Definition, objectives and principles

Breast hypoplasia is characterized by an insufficiently developed breast volume in relation to the patient’s morphology. It may result from insufficient development of the mammary gland at puberty, or appear secondarily due to loss of glandular volume (pregnancy, weight loss, hormonal disturbances, etc.).

Lack of volume can also be associated with ptosis (drooping breasts, with sagging glands, distended skin and low areolas). The procedure can be performed at any age, from 18 upwards.

This hypotrophy is often physically and psychologically unpleasant for the patient, who perceives it as an attack on her femininity, which can affect her self-confidence and provoke a sometimes profound malaise, even leading to a real complex. This is why the procedure aims to increase the volume of breasts deemed too small by implanting prostheses.

These sometimes marked physical alterations, as well as the psychological suffering involved, lend a therapeutic dimension to this restorative surgical procedure.

A minor patient is generally not considered suitable for cosmetic breast augmentation. However, it may be considered in cases of severe hypoplasia or malformative anomalies such as tuberous breasts or breast agenesis.

This purely cosmetic surgery is not covered by health insurance, except in rare cases of true breast agenesis (total absence of breast development), where a contribution from social security may be considered after prior agreement.

Today’s breast implants consist of a silicone elastomer shell, which can be smooth or micro-textured. Textured (rough) shells are no longer used, as they can cause inflammation.

The implant’s content is the filling product. Fluid-filled implants, approved in France from 1995 to 2001, contain saline (salt water), which is completely safe. They can be pre-filled at the factory or inflated by the surgeon during the operation, allowing a certain degree of volume adaptation.

Today, silicone gel-filled prostheses are in widespread use. They give the breast a supple feel, close to a natural consistency. Gels are more or less cohesive, limiting gel transpiration through the wall, which reduces the risk of shell formation in the event of rupture.

Prostheses come in a variety of shapes, from round ones for a beautiful décolleté, to anatomically contoured ones for a more natural breast shape. The wide variety of shapes and volumes enables an almost customized choice, according to the patient’s morphology and personal expectations.

Constant development is aimed at improving the sealing and solidity of the walls, the naturalness to the touch and to the eye, and the lifespan and tolerance of the materials. All implants available in France are subject to precise and rigorous standards: CE marking and ANSM authorization.

What’s more, since November 2016, the French administrative authorities and the Ministry of Health have set up a national breast implant registry. This registry will remain perfectly anonymous and aims to list all implants implanted on French territory, ensuring that all implants are monitored for greater patient safety.

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Other types of implants

• Hydrogel-filled prostheses: This is an aqueous gel, approved since 2005, composed mainly of water gelled with a cellulose derivative. More natural in consistency than saline, it is also resorbable by the body in the event of envelope rupture.
• There are also prostheses whose silicone shell is covered with polyurethane foam, but these have been withdrawn from the French market since 2019.

In all cases, the choice of the type of prosthesis will be the result of a discussion with the surgeon, who will advise you on the most appropriate option for your specific situation.

Before the operation

The surgeon will carry out a careful examination, taking into account all the parameters that make each patient a special case (height, weight, pregnancy, breastfeeding, thoracic and breast morphology, skin quality, amount of fat and glandular tissue, musculature, etc.).

Based on this anatomical context, the surgeon’s preferences and habits, and the patient’s expressed wishes, an operative strategy will be defined. The location of scars, the type and size of implants, and their positioning in relation to the muscle will all be predetermined.

A pre-operative blood test will be carried out as prescribed. The anaesthetist must be consulted at least 48 hours before the operation. A breast X-ray (mammogram, ultrasound) will also be prescribed.

You should not take any medication containing aspirin for ten days prior to the operation. You will probably be asked to fast (eat and drink nothing) for six hours before the operation.

Type of anesthesia and hospitalization arrangements

Type of anesthesia

In most cases, this is a classic general anaesthetic, during which you sleep completely. In rare cases, a “vigile” anesthesia (local anesthesia deepened by intravenous tranquilizers) may be used, to be discussed with the surgeon and anesthesiologist.

Hospitalization arrangements

The procedure usually requires a one-day hospital stay. The patient is usually admitted in the morning (or sometimes the afternoon of the day before) and discharged the following day. In some cases, however, the procedure can be performed on an outpatient basis, meaning that the patient can be discharged the same day after a few hours of monitoring.

The intervention

Each surgeon adopts his or her own technique, adapting it to each case to achieve the best results. However, there are some common basic principles:

Skin incisions

There are several possible approaches:

• Areolar approach: incision in the lower segment of the areola’s circumference, or horizontal opening around the nipple from below.
• Axillary route: incision under the arm, in the armpit.
• Sub-mammary route: incision made in the fold under the breast.

These incisions correspond to the location of future scars, which will be hidden in natural folds or junctions.

Fitting prostheses

Through the incisions, the implants can be inserted into the implant sockets. Two positions are possible:

• Premuscular: the prostheses are placed directly behind the gland, in front of the pectoral muscles.
• Retromuscular: the prostheses are placed deeper, behind the pectoral muscles.

The choice between these two locations, with their respective advantages and disadvantages, will have been discussed with your surgeon.

Complementary gestures

In the case of associated breast ptosis (drooping breasts, low areolas), it may be advisable to reduce the skin envelope of the breast in order to lift it (mastopexy). This skin resection will result in larger scars (around the areola ± vertical ± horizontal in the submammary fold).

Drains and dressings

A small drain may be inserted, depending on the surgeon’s habits and local conditions. This is a device designed to evacuate any blood that may accumulate around the prostheses.

At the end of the procedure, a shaping dressing is applied with an elastic bandage. Depending on the surgeon, the approach and the need for additional procedures, the procedure can last from one to two and a half hours.

After the operation: post-operative care

The post-operative period can sometimes be painful for the first few days, especially when the implants are large in volume and particularly if they are placed behind the muscles. A painkiller adapted to the intensity of the pain will be prescribed for a few days. In the best-case scenario, the patient will feel a strong sensation of tension.

Edema (swelling), bruising and discomfort when raising the arms are common in the early stages.

The first dressing is removed after a few days. It is then replaced by a lighter dressing. A bra may be recommended day and night for several weeks.

In most cases, the sutures are internal and absorbable. If not, they will be removed after a few days.

A convalescence period of five to ten days is recommended. We recommend waiting one to two months before resuming sporting activities.

The result

It takes two to three months to appreciate the final result. This is the time needed for the breasts to regain their full suppleness and for the prostheses to stabilize.

The procedure generally improves the volume and shape of the breasts. Scars are usually very discreet. The gain in breast volume has a positive impact on the overall silhouette, offering greater freedom of dress. Beyond these physical improvements, the restoration of full femininity often has a very beneficial effect on the psychological level.

The aim of this surgery is improvement, not perfection. If your expectations are realistic, the result should bring you great satisfaction.

Stable earnings

Regardless of the lifespan of the prostheses (see below), and except in the case of major weight variations, breast volume will remain stable over the long term.

However, in terms of breast shape and “fit”, augmented breasts will, like natural breasts, undergo the effects of gravity and aging, with a variable speed depending on age, quality of skin support and implant volume.

Result imperfections

Some imperfections may appear occasionally:

• Residual volume asymmetry, incompletely corrected despite different implant sizes.
• Slightly too firm, with insufficient flexibility and mobility (especially with large implants).
• A slightly artificial appearance, particularly in very thin patients, with excessive visibility of the prosthesis edges, especially in the upper segment.
• It is always possible to feel the implants, especially when the thickness of the tissue cover (skin + fat + gland) over the prosthesis is low. Direct palpation of the prosthetic membrane, or even of folds, is more frequent in slender patients with large-volume, saline-filled implants in a prepectoral position.
• A worsening of breast ptosis may be observed, especially when large implants are used.
• Breast deformity due to pectoral muscle contracture can sometimes occur with retromuscular implants.

In the event of dissatisfaction, some of these imperfections may benefit from surgical correction after a few months.

Other business

Pregnancy/breastfeeding

After breast prosthesis insertion, pregnancy is possible without danger to the patient or child. However, it is advisable to wait at least six months after the operation. Breast-feeding is not dangerous, and remains possible in most cases.

Autoimmune diseases

Numerous large-scale international scientific studies have unanimously demonstrated that there is no greater risk of this type of rare disease in patients with implants (particularly silicone implants) than in the general female population.

Prostheses and cancer

Until recently, the state of science suggested that the implantation of breast implants, including silicone implants, did not increase the risk of breast cancer. This is still the case for the most common breast cancers (adenocarcinomas), whose incidence is not increased by the fitting of a breast prosthesis.

However, in the context of post-implant cancer screening, clinical examination and palpation may be impaired, especially in the case of periprosthetic shells or siliconomas. Similarly, the presence of implants can interfere with the performance and interpretation of regular screening mammograms. It is therefore imperative to specify that you have breast implants. Certain specialized radiological techniques (special incidences, digitized images, ultrasound, MRI, etc.) may be used depending on the case. And if you have any doubts about the diagnosis of breast cancer, it’s important to know that the presence of implants may require more invasive exploration to achieve diagnostic certainty.

Large-cell anaplastic lymphoma (LAGC) associated with breast implants (LAGC-AIM) is a very rare clinical entity, observed since 2010 (around 1 in 10,000 cases). This pathology is mostly associated with macro-textured (rough) implants, which have been withdrawn from the market in 2019. It is almost always accompanied by obvious symptoms, such as recurrent periprosthetic effusions, redness of the breast, a significant increase in breast volume or the presence of a palpable mass.

In almost 90% of cases, this condition has a good prognosis, curing with removal of the prosthesis and periprosthetic capsule. However, in around 10% of cases, the pathology is more severe, requiring treatment with chemotherapy and/or radiotherapy.

Intracapsular squamous cell carcinoma is an extremely rare entity (only a handful of cases have been published worldwide). It occurs in complex cases requiring multiple interventions and prosthesis changes.

Implant life

Although some patients can keep their implants for several decades without major modification, breast implants should not be considered as something definitive “for life”. A patient with implants can expect to have to replace them one day to maintain the beneficial effect.

The life expectancy of any implant is uncertain and impossible to estimate precisely, as it depends on variable wear phenomena. The lifespan of implants can therefore never be guaranteed. The average lifespan is estimated at around 10 years.

It should be noted that new-generation implants have made great strides in terms of strength and reliability. After the tenth year, the prostheses should be replaced if any change in consistency occurs.

Monitoring

It is essential to comply with the check-ups scheduled by your surgeon in the weeks and months following implantation. Thereafter, the presence of implants does not exempt you from the usual medical surveillance (gynecological monitoring and breast cancer screening), even if it does not require any additional examinations beyond those linked to this surveillance. Nevertheless, it is essential to inform your doctors that you are wearing breast implants.

We recommend that you consult your plastic surgeon every two to three years for implant-specific follow-up. Apart from this follow-up, it is essential to consult your surgeon as soon as any change in one or both breasts is detected, or after any violent trauma.

Ultrasound examination of the breast is a non-irradiating and highly effective means of assessing prosthesis integrity. Ultrasound should be performed at the slightest clinical doubt, and for some patients, systematically once a year. Prosthesis replacement is only considered in the event of clinical or radiological abnormality, or at the patient’s request. After a certain period, replacement is not systematic.

Possible complications

Although performed for essentially aesthetic reasons, breast augmentation with prostheses is nonetheless a genuine surgical procedure, with the risks inherent in any medical procedure, however minimal.

This procedure is subject to the vagaries of living tissue, whose reactions are never entirely predictable.

A distinction must be made between complications related to anesthesia and those related to the surgical procedure:

Anesthesia-related complications

During the obligatory pre-operative consultation, the anaesthetist will inform the patient of the risks of anaesthesia. It’s important to remember that anaesthesia of any kind induces reactions in the body that are sometimes unpredictable, and more or less easy to control.

However, when performed by a skilled anesthetist in a truly surgical setting, the risks involved are statistically very low. Techniques, anaesthetics and monitoring methods have progressed considerably over the last thirty years, offering optimum safety, especially when the procedure is performed in a non-emergency situation and on a healthy patient.

Surgical complications

By choosing a qualified and competent plastic surgeon, trained in this type of procedure, you will limit these risks as much as possible, without, however, eliminating them completely.

In practice, the vast majority of breast augmentations performed in accordance with the rules are problem-free, the postoperative period is straightforward and patients are fully satisfied with their results. However, complications can sometimes arise after the operation, some inherent to breast surgery and others specifically linked to the implants:

• Hematoma: The accumulation of blood around the prosthesis is an early complication that can occur within the first few hours. If the hematoma is significant, it is preferable to return to the operating room to evacuate the blood and stop the bleeding at its source.
• Serous effusion: an accumulation of lymphatic fluid around the prosthesis is a fairly frequent phenomenon in the immediate post-operative period. It results in a transient increase in breast volume. It disappears spontaneously and gradually. If you experience seroma after surgery, you should consult your surgeon.
• Infection: Rare after this type of surgery, an infection may not be resolved by antibiotic treatment alone, and may require repeat surgery for drainage and implant removal for a few months (the time required before a new prosthesis can be fitted without risk).
• Skin necrosis: This very rare but dreaded complication results from a lack of tissue oxygenation due to insufficient localized blood supply, encouraged by excessive tension, hematoma, infection or heavy smoking. It can expose the prosthesis, notably by disuniting the sutures. Revision surgery is often necessary, sometimes requiring temporary removal of the implant.
• Scarring abnormalities: Scars are sometimes not as inconspicuous as hoped, taking on a variety of appearances: enlarged, retractile, adherent, hyper- or hypopigmented, hypertrophic (puffy), or even, exceptionally, keloids.
• Alterations in sensitivity: These are frequent in the first few months, but usually subside. However, a certain degree of dysesthesia (reduced or exaggerated sensitivity to touch) may persist, particularly around the areola and nipple.
• Galactorrhea/milk discharge: Rare cases of unexplained postoperative hormonal stimulation, resulting in milk discharge (galactorrhea), have been reported, sometimes associated with fluid collection around the prosthesis.
• Pneumothorax: Rare, it will benefit from specific treatment.
• Rupture: As we have seen, implants cannot be considered definitive, with an average lifespan of around 10 years. Eventually, the envelope may lose its watertightness.
• Malpositioning, displacement: Secondary malpositioning or displacement of implants, affecting the shape of the breast, can sometimes justify surgical correction.
• Rotation/turning over : Although relatively rare, the pivoting of an anatomical prosthesis or the reversal (recto/verso) of an implant remains possible and can affect the aesthetic result.
• Chest wall deformity: In rare cases, prostheses with fibrous shells left in place for long periods can imprint themselves on the tissue, leaving a chest wall deformity that is difficult to correct when the prosthesis is removed.
• Late periprosthetic seroma: Fluid accumulation may occur late around the prosthesis. Late periprosthetic effusion, especially if associated with other clinical breast abnormalities, requires a breast assessment by a specialist radiologist. Ultrasound puncture may be required for analysis. In the event of a breast mass or recurrent effusion, surgical exploration will enable histological analysis of the periprosthetic capsule in order to rule out anaplastic large-cell lymphoma associated with breast implants (LAGC-AIM), or an even more exceptional intracapsular pathology such as intracapsular squamous cell carcinoma.
• ASIA syndrome: ASIA syndrome (autoimmune/autoinflammatory syndrome induced by adjuvants) is a rare syndrome characterized by varied and diffuse symptoms, with no known precise etiology. Some breast implant patients have attributed this syndrome to their implants. However, no scientific evidence has demonstrated a precise link between breast implants and the onset of this syndrome. It could be a coincidence with the onset of fibromyalgia syndrome in patients with prostheses.