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Breast augmentation using anatomic implants
Breast Augmentation Using Anatomic Implants Dennis C. Hammond, MD
Breast augmentation has been traditionally performed with round smooth implants. However, the recent introduction of a host of anatomically designed devices has significantly increased the options available to both the patient and the surgeon to achieve the best results possible. In particular, the results obtained with textured, anatomically shaped silicone gel devices have been particularly promising. This article will outline the rationale behind choosing a particular device, describe the operative technique involved in using these devices, and show representative results in patients undergoing augmentation with anatomic implants. Copyright 9 2000 by W.B. Saunders Company
he aesthetic contours of an attractive breast remain largely
T a matter of personal and cultural preference. However, it is
reasonable to appreciate the contours of the youthful, full breast and to use these contours as a guideline to assess the results of breast augmentation. This requires careful evaluation of these aesthetic contours and the forces that cause them to occur. The upright shape of the breast is determined by the effect of gravity on the mobile breast mound. As the mound is drawn slightly downward, a smooth straight-line contour extending down from the clavicle to the most projecting part of the breast is created. As the volume of the breast increases, the propensity of this line to become slightly concave increases as well. It is important to note that this contour becomes convex only in cases of significant hypertrophy (Fig 1). In a youthful, aesthetic breast, the nipple and areola are located directly at the point of maximal projection and not below. Also, a significant portion of the mound remains positioned above the inframammary fold, giving a pleasing fullness and projection to the breast. It is these contours that breast augmentation is attempting to restore or enhance. This creates a potentially conflicting mismatch with regards to breast augmentation because, despite the mildly ptotic appearance of the breast, the most commonly used device to augment the breast is round. Therefore, placement of a round implant under a slightly ptotic breast m o u n d creates the potential for m o u n d distortion and excess fullness in the upper pole of the breast and an alteration of "normal" breast contours. Despite this seeming mismatch, the results of breast augmentation with round devices are most often acceptable, and the round breast implant, either silicone or saline-filled, remains the most c o m m o n l y used device for this purpose. From the Hand and Plastic Surgery Centre, Grand Rapids, MI. Address reprint requests to Dennis C. Hammond, MD, The Hand and Plastic Surgery Centre, 245 Cherry SE Suite 302, Grand Rapids, MI 49503. Copyright 9 2000 by W.B. Saunders Company 1071-0949/00/0703-0005535.00/0 doi:l 0.1053/otpr.2000.22059
However, accurate evaluation of the effect of a round device on the shape of the breast remains difficult to assess because other factors impact on the results of breast augmentation, including implant location, implant settling within the pocket, degree of implant fill, breast parenchymal characteristics, skin elasticity, implant shell stiffness, implant fill material (silicone vs saline), as well as the physician's and patient's goals. Taken together, it becomes difficult to identify which factors are responsible in those instances when poor results are obtained after breast augmentation. What is clear is that the poor result is often characterized by too much upper pole fullness, irregular upper pole contour, and an exaggerated and rounded fullness to the breast (Fig 2). In an attempt to better control the contour of the upper pole of the breast and to provide more consistency and an overall improved aesthetic result, anatomically shaped implants were developed. Although initially developed for breast reconstruction, these devices have been shown to have great utility in breast augmentation as well. The concept of anatomically distributing the volume of an implant to provide for an improved breast shape is one that has been embraced by many surgeons, and excellent results are being achieved using a wide variety of anatomically shaped devices.
Anatomic Implants Several different shapes and sizes of anatomically configured silicone and saline implants are now, or soon will be, available for use in breast augmentation (Fig 3). The variables involved in the design of these devices include measurements of the base diameter and longitudinal length, projection, fill volume, outer shell characteristics including several different textured surfaces, and various fill materials including silicone, saline, and other t y p e s of materials such as hydrocolloid. Although these variables and measurements are important when choosing an implant for an individual patient, one critical difference between the various types of anatomic devices depends on whether the device is filled with saline or silicone. This is important because of the differing fluid characteristics between these two substances. Saline, being of relatively low viscosity, does not support the outer shell of the implant to the same extent, as does the higher viscosity silicone gel. This is particularly true of the newer silicone gel materials that are more cohesive and resemble a semi-solid. As a result, saline devices need to be filled completely to resist shell deformation and wrinkling. 1 Such filling, when excessive, can overcome the anatomic design of the shell and result in the opposite of what was intended, that being excessive upper pole fullness. Silicone gel, because of its higher viscosity, resists wrinkling and maintains an anatomic shape without the need for excessive filling of the device. As well, the newer, more cohesive gels allow the shape to be manu-
Operative Techniques in Plastic and Reconstructive Surgery, Vol 7, No 3 (August), 2000: pp 125-130
125
Fig 1. (A) The youthful, aesthetic breast demonstrates a smooth straight line contour extending down from the clavicle to the nipple. (B) As the breast becomes larger and more ptotic, the upper pole contour becomes variably concave. (C) As the size of the breast increases, the superior portion of the upper pole contour is concave and the lower portion, which is filled out by the increased volume of breast parenchyma, is convex.
factured in a more aggressive manner, particularly in the upper pole. As a result, anatomically shaped implants, and in particular anatomically shaped silicone gel implants, have proven to be very effective in shaping the breast after augmentation 2,3 and to an even greater degree in breast reconstruction. 4-7
Indications It bears repeating that the average patient undergoing breast augmentation, that being a woman with a proportionately small breast and possessing a reasonable body habitus, can
achieve an aesthetic result with a round breast implant. 2 As well, the patient with an already full breast who desires further increase in volume can achieve an excellent result with round implants because the tendency toward upper pole distortion is totally masked by the relative volume of the existing breast. However, thin patients or patients with mild to marked under-filling of the skin envelope, or patients with an element of preexisting ptosis, may benefit to a greater degree from an anatomic implant. With the volume of the device more anatomically distributed, there is a,diminished tendency toward upper pole distortion and greater volume support to the lower pole of the breast. Taken together, these
Fig 2. (A, B) Anteroposterior and lateral view after augmentation with a round device. The rounded upper pole contour accentuates the deformity caused by superior malposition of the implant.
126
)ENNIS C. HAMMOND
Fig 3. Types of anatomic implants including (A) a full height textured saline implant (Style 468, McGhan Medical Corporation, Santa Barbara, CA), (B) a short height textured saline implant (Style 163, McGhan), (C) a full height textured saline implant with a more contoured upper pole designed for breast reconstruction (Style 163, McGhan), (D) a short height textured saline device emphasizing projection (Contour profile, Mentor Corporation, Santa Barbara, CA), (E) a full height textured silicone gel implant (Style 153, McGhan), (F) a more aggressively shaped full height textured cohesive silicone gel implant (Style 410, McGhan), (G) and a textured silicone gel device with an inner saline reservoir in the lower pole for volume adjustment (Style 150, McGhan).
BREAST AUGMENTATION USING ANATOMIC IMPLANTS
127
Fig 4. (A, B) Preoperative appearance of a thin 40-year-old woman with significant hypomastia. (C, D) Postoperative appearance after partial subpectoral placement of a 230-mL full height anatomic textured saline implant filled to 240 mL shows a proportionate and symmetric enlargement of the breast without the creation of excess upper pole fullness.
factors can combine to provide greater consistency and improved aesthetic results in these patients.
Operative Technique No matter what incision is used, or whether the implant is above or below the muscle, the two most important technical maneuvers to be respected when using anatomically shaped devices are accurate pocket development and proper placement of the device. These maneuvers may require alteration of ex!sting or familiar technique. It is advisable to avoid blunt pocket dissection and instead develop the pocket using direct vision during dissection. This not only enhances hemostasis, but allows direct control of the dimensions of the pocket, particularly laterally where over-dissection is easily done. If a pocket is dissected that is larger than the dimensions of the implant, the chances for rotation or malposition of the device are enhanced. When using a transaxillary approach, it is advisable to use endoscopic assistance to allow accurate pocket dissection and release of the pectoralis major muscle. Silicone and saline anatomic implants are easily placed through inframammary or periareolar incisions. It may be difficult to place an anatomic silicone implant through a transaxillary incision, and saline may be the preferred option in these patients. Because of the blind nature of the technique, use of anatomic devices is contraindicated
128
when using the periumbilical approach, because they cannot be positioned with certainty. It is important to place the implant precisely at the level of the proposed inframammary fold, because accurate determination of this contour is vital for proper positioning of the implant under the breast mound.1 Because of the inherent asymmetry of these devices, it is imperative that the less full, superior aspect of the implant be positioned in the upper pole of the breast and, likewise, the fuller lower pole is located in the inferior aspect. The longitudinal axis of the device can be tipped toward or away from the midline slightly to provide more fullness medially or laterally as desired. To facilitate accurate implant positioning, it is sometimes helpful to mark the center midline of the device with a surgical marker before placement. Alternatively, some manufacturers have placed orientation tabs or dots on the implant to facilitate positioning.
Textured Versus Smooth It is imperative that the shaped implant maintains its orientation once it is placed under the breast. For this reason, all shaped devices that are currently available have a textured surface. Although these roughened surfaces seem to play a role in the reduction of capsular contracture, 3 they also serve to resist implant migration caused by the interaction of the DENNIS C, HAMMOND
Fig 5. (A, B) Preoperative appearance of a 36-year-old woman in preparation for augmentation mammaplasty. The patient demonstrates a lax skin envelope with significant hollowing out of the upper and upper, lateral portion of the breast. Attempted augmentation in a patient such as this using a round implant risks the creation of upper pole irregularity and persistent upper pole convexity. (C, D) Appearance 8 months after partial subpectoral augmentation using a full height 360-mL anatomic textured silicone gel implant. Smooth, proportionate filling out of the breast is shown with a pleasing and even upper pole contour.
textured surface with the capsule. 1,2 With aggressive texturing, there can be actual ingrowth of the capsule into the interstices of the texture, essentially locking the device into position. 3 With the less aggressive textures, tissue ingrowth does not occur. However, the roughened surface increases the friction between the implant and the capsule, thus resisting implant migration or rotation.
Clinical Results Thus far, the results obtained using these devices have been encouraging. Several different shaped saline implants are available to meet specific needs, and the results obtained using these devices can be outstanding (Fig 4). Some shaped saline implants have been noted to retain slightly more upper pole fullness than desired; however, this finding is potentially due to many factors, with superior malposition and mild capsular contracture being common. In fact, recent examination of the results of augmentation using shaped saline devices has been shown via mammogram to differ little when compared with augmentation using round saline implants, although the results of this study remain controversial. 8 However, there is little doubt as to the utility of shaped silicone gel devices in creating a more natural breast BREAST AUGMENTATION USING ANATOMIC IMPLANTS
contour, particularly in thin patients or patients with a lax skin envelope. The more aggressive shape and thicker consistency combine to provide predictable and aesthetic resuits, particularly in difficult cases (Figs 5, 6). Although reported, rotation after augmentation with an anatomic device has not been observed. This may be the result of adherence to the guidelines discussed under operative technique. Despite this, rotation with shape distortion does remain a possible adverse event, and patients should be cautioned about the possibility. It is recommended that notation of this possibility be documented in the informed consent.
Summary
Although controversial, breast augmentation with anatomically shaped implants has proven to be an effective technique for providing excellent aesthetic results in thin or ptotic patients. With appropriate manipulation of implant choice, pocket dissection and implant positioning, excellent results can be obtained predictably and reliably. Use of these devices, particularly anatomically shaped silicone gel devices, is recommended as an excellent option in properly selected patients. 129
Fig 6. (A, B) Preoperative appearance of a 30-year-old woman with ptosis and loss of breast volume after breast feeding. (C, D) Postoperative appearance after partial subpectoral augmentation using a full height 360-mL anatomic textured silicone gel implant. A pleasing shape is shown without excess upper pole fullness. By differentially filling out the lower portion of the skin envelope with the shaped device, a mastopexy was successfully avoided.
References 1. Tebbetts JB: What is adequate fill? Implications in breast implant surgery. Plast Reconstr Surg 97:1451-1454, 1996 2. Tebbetts JB: Use of anatomic breast implants: Ten essentials. Aesthetic Surg J 18:377-384, 1998 3. Spear SL, EImaraghy M, Hess C: Textured-surface saline-filled silicone breast implants for augmentation mammaplasty. Plast Reconstr Surg 105:1542-1552, 2000 4. Maxwell GP, Falcone PA: Eighty-four consecutive breast reconstructions using a textured silicone tissue expander. Plast Reconstr Surg 89:1022-1034, 1992 5. McGeorge DD, Mahdi S, Tsekouras A': Breast reconstruction with
130
anatomical expanders and implants: Our early experience. Br J Plast Surg 49:352-357, 1996 6. Spear SL, Majidian A: Immediate breast reconstruction in two stages using textured, integrated-valve tissue expanders and breast implants: A retrospective review of 171 consecutive breast reconstructions from 1989 to 1996. Plast Reconstr Surg 101:53-63, 1998 7. Rimareix F, Masson J, Couturaud B, et ah Reconstruction mammaire par prothese anatomique gonflable. Ann Chir Plast Esthet 44:239-245, 1999 8. Hamas RS: The postoperative shape of round and teardrop salinefilled breast implants. Aesthetic Surg J19:369-374, 1999
DENNIS C. HAMMOND
Breast augmentation has been traditionally performed with round smooth implants. However, the recent introduction of a host of anatomically designed devices has significantly increased the options available to both the patient and the surgeon to achieve the best results possible. In particular, the results obtained with textured, anatomically shaped silicone gel devices have been particularly promising. This article will outline the rationale behind choosing a particular device, describe the operative technique involved in using these devices, and show representative results in patients undergoing augmentation with anatomic implants. Copyright 9 2000 by W.B. Saunders Company
he aesthetic contours of an attractive breast remain largely
T a matter of personal and cultural preference. However, it is
reasonable to appreciate the contours of the youthful, full breast and to use these contours as a guideline to assess the results of breast augmentation. This requires careful evaluation of these aesthetic contours and the forces that cause them to occur. The upright shape of the breast is determined by the effect of gravity on the mobile breast mound. As the mound is drawn slightly downward, a smooth straight-line contour extending down from the clavicle to the most projecting part of the breast is created. As the volume of the breast increases, the propensity of this line to become slightly concave increases as well. It is important to note that this contour becomes convex only in cases of significant hypertrophy (Fig 1). In a youthful, aesthetic breast, the nipple and areola are located directly at the point of maximal projection and not below. Also, a significant portion of the mound remains positioned above the inframammary fold, giving a pleasing fullness and projection to the breast. It is these contours that breast augmentation is attempting to restore or enhance. This creates a potentially conflicting mismatch with regards to breast augmentation because, despite the mildly ptotic appearance of the breast, the most commonly used device to augment the breast is round. Therefore, placement of a round implant under a slightly ptotic breast m o u n d creates the potential for m o u n d distortion and excess fullness in the upper pole of the breast and an alteration of "normal" breast contours. Despite this seeming mismatch, the results of breast augmentation with round devices are most often acceptable, and the round breast implant, either silicone or saline-filled, remains the most c o m m o n l y used device for this purpose. From the Hand and Plastic Surgery Centre, Grand Rapids, MI. Address reprint requests to Dennis C. Hammond, MD, The Hand and Plastic Surgery Centre, 245 Cherry SE Suite 302, Grand Rapids, MI 49503. Copyright 9 2000 by W.B. Saunders Company 1071-0949/00/0703-0005535.00/0 doi:l 0.1053/otpr.2000.22059
However, accurate evaluation of the effect of a round device on the shape of the breast remains difficult to assess because other factors impact on the results of breast augmentation, including implant location, implant settling within the pocket, degree of implant fill, breast parenchymal characteristics, skin elasticity, implant shell stiffness, implant fill material (silicone vs saline), as well as the physician's and patient's goals. Taken together, it becomes difficult to identify which factors are responsible in those instances when poor results are obtained after breast augmentation. What is clear is that the poor result is often characterized by too much upper pole fullness, irregular upper pole contour, and an exaggerated and rounded fullness to the breast (Fig 2). In an attempt to better control the contour of the upper pole of the breast and to provide more consistency and an overall improved aesthetic result, anatomically shaped implants were developed. Although initially developed for breast reconstruction, these devices have been shown to have great utility in breast augmentation as well. The concept of anatomically distributing the volume of an implant to provide for an improved breast shape is one that has been embraced by many surgeons, and excellent results are being achieved using a wide variety of anatomically shaped devices.
Anatomic Implants Several different shapes and sizes of anatomically configured silicone and saline implants are now, or soon will be, available for use in breast augmentation (Fig 3). The variables involved in the design of these devices include measurements of the base diameter and longitudinal length, projection, fill volume, outer shell characteristics including several different textured surfaces, and various fill materials including silicone, saline, and other t y p e s of materials such as hydrocolloid. Although these variables and measurements are important when choosing an implant for an individual patient, one critical difference between the various types of anatomic devices depends on whether the device is filled with saline or silicone. This is important because of the differing fluid characteristics between these two substances. Saline, being of relatively low viscosity, does not support the outer shell of the implant to the same extent, as does the higher viscosity silicone gel. This is particularly true of the newer silicone gel materials that are more cohesive and resemble a semi-solid. As a result, saline devices need to be filled completely to resist shell deformation and wrinkling. 1 Such filling, when excessive, can overcome the anatomic design of the shell and result in the opposite of what was intended, that being excessive upper pole fullness. Silicone gel, because of its higher viscosity, resists wrinkling and maintains an anatomic shape without the need for excessive filling of the device. As well, the newer, more cohesive gels allow the shape to be manu-
Operative Techniques in Plastic and Reconstructive Surgery, Vol 7, No 3 (August), 2000: pp 125-130
125
Fig 1. (A) The youthful, aesthetic breast demonstrates a smooth straight line contour extending down from the clavicle to the nipple. (B) As the breast becomes larger and more ptotic, the upper pole contour becomes variably concave. (C) As the size of the breast increases, the superior portion of the upper pole contour is concave and the lower portion, which is filled out by the increased volume of breast parenchyma, is convex.
factured in a more aggressive manner, particularly in the upper pole. As a result, anatomically shaped implants, and in particular anatomically shaped silicone gel implants, have proven to be very effective in shaping the breast after augmentation 2,3 and to an even greater degree in breast reconstruction. 4-7
Indications It bears repeating that the average patient undergoing breast augmentation, that being a woman with a proportionately small breast and possessing a reasonable body habitus, can
achieve an aesthetic result with a round breast implant. 2 As well, the patient with an already full breast who desires further increase in volume can achieve an excellent result with round implants because the tendency toward upper pole distortion is totally masked by the relative volume of the existing breast. However, thin patients or patients with mild to marked under-filling of the skin envelope, or patients with an element of preexisting ptosis, may benefit to a greater degree from an anatomic implant. With the volume of the device more anatomically distributed, there is a,diminished tendency toward upper pole distortion and greater volume support to the lower pole of the breast. Taken together, these
Fig 2. (A, B) Anteroposterior and lateral view after augmentation with a round device. The rounded upper pole contour accentuates the deformity caused by superior malposition of the implant.
126
)ENNIS C. HAMMOND
Fig 3. Types of anatomic implants including (A) a full height textured saline implant (Style 468, McGhan Medical Corporation, Santa Barbara, CA), (B) a short height textured saline implant (Style 163, McGhan), (C) a full height textured saline implant with a more contoured upper pole designed for breast reconstruction (Style 163, McGhan), (D) a short height textured saline device emphasizing projection (Contour profile, Mentor Corporation, Santa Barbara, CA), (E) a full height textured silicone gel implant (Style 153, McGhan), (F) a more aggressively shaped full height textured cohesive silicone gel implant (Style 410, McGhan), (G) and a textured silicone gel device with an inner saline reservoir in the lower pole for volume adjustment (Style 150, McGhan).
BREAST AUGMENTATION USING ANATOMIC IMPLANTS
127
Fig 4. (A, B) Preoperative appearance of a thin 40-year-old woman with significant hypomastia. (C, D) Postoperative appearance after partial subpectoral placement of a 230-mL full height anatomic textured saline implant filled to 240 mL shows a proportionate and symmetric enlargement of the breast without the creation of excess upper pole fullness.
factors can combine to provide greater consistency and improved aesthetic results in these patients.
Operative Technique No matter what incision is used, or whether the implant is above or below the muscle, the two most important technical maneuvers to be respected when using anatomically shaped devices are accurate pocket development and proper placement of the device. These maneuvers may require alteration of ex!sting or familiar technique. It is advisable to avoid blunt pocket dissection and instead develop the pocket using direct vision during dissection. This not only enhances hemostasis, but allows direct control of the dimensions of the pocket, particularly laterally where over-dissection is easily done. If a pocket is dissected that is larger than the dimensions of the implant, the chances for rotation or malposition of the device are enhanced. When using a transaxillary approach, it is advisable to use endoscopic assistance to allow accurate pocket dissection and release of the pectoralis major muscle. Silicone and saline anatomic implants are easily placed through inframammary or periareolar incisions. It may be difficult to place an anatomic silicone implant through a transaxillary incision, and saline may be the preferred option in these patients. Because of the blind nature of the technique, use of anatomic devices is contraindicated
128
when using the periumbilical approach, because they cannot be positioned with certainty. It is important to place the implant precisely at the level of the proposed inframammary fold, because accurate determination of this contour is vital for proper positioning of the implant under the breast mound.1 Because of the inherent asymmetry of these devices, it is imperative that the less full, superior aspect of the implant be positioned in the upper pole of the breast and, likewise, the fuller lower pole is located in the inferior aspect. The longitudinal axis of the device can be tipped toward or away from the midline slightly to provide more fullness medially or laterally as desired. To facilitate accurate implant positioning, it is sometimes helpful to mark the center midline of the device with a surgical marker before placement. Alternatively, some manufacturers have placed orientation tabs or dots on the implant to facilitate positioning.
Textured Versus Smooth It is imperative that the shaped implant maintains its orientation once it is placed under the breast. For this reason, all shaped devices that are currently available have a textured surface. Although these roughened surfaces seem to play a role in the reduction of capsular contracture, 3 they also serve to resist implant migration caused by the interaction of the DENNIS C, HAMMOND
Fig 5. (A, B) Preoperative appearance of a 36-year-old woman in preparation for augmentation mammaplasty. The patient demonstrates a lax skin envelope with significant hollowing out of the upper and upper, lateral portion of the breast. Attempted augmentation in a patient such as this using a round implant risks the creation of upper pole irregularity and persistent upper pole convexity. (C, D) Appearance 8 months after partial subpectoral augmentation using a full height 360-mL anatomic textured silicone gel implant. Smooth, proportionate filling out of the breast is shown with a pleasing and even upper pole contour.
textured surface with the capsule. 1,2 With aggressive texturing, there can be actual ingrowth of the capsule into the interstices of the texture, essentially locking the device into position. 3 With the less aggressive textures, tissue ingrowth does not occur. However, the roughened surface increases the friction between the implant and the capsule, thus resisting implant migration or rotation.
Clinical Results Thus far, the results obtained using these devices have been encouraging. Several different shaped saline implants are available to meet specific needs, and the results obtained using these devices can be outstanding (Fig 4). Some shaped saline implants have been noted to retain slightly more upper pole fullness than desired; however, this finding is potentially due to many factors, with superior malposition and mild capsular contracture being common. In fact, recent examination of the results of augmentation using shaped saline devices has been shown via mammogram to differ little when compared with augmentation using round saline implants, although the results of this study remain controversial. 8 However, there is little doubt as to the utility of shaped silicone gel devices in creating a more natural breast BREAST AUGMENTATION USING ANATOMIC IMPLANTS
contour, particularly in thin patients or patients with a lax skin envelope. The more aggressive shape and thicker consistency combine to provide predictable and aesthetic resuits, particularly in difficult cases (Figs 5, 6). Although reported, rotation after augmentation with an anatomic device has not been observed. This may be the result of adherence to the guidelines discussed under operative technique. Despite this, rotation with shape distortion does remain a possible adverse event, and patients should be cautioned about the possibility. It is recommended that notation of this possibility be documented in the informed consent.
Summary
Although controversial, breast augmentation with anatomically shaped implants has proven to be an effective technique for providing excellent aesthetic results in thin or ptotic patients. With appropriate manipulation of implant choice, pocket dissection and implant positioning, excellent results can be obtained predictably and reliably. Use of these devices, particularly anatomically shaped silicone gel devices, is recommended as an excellent option in properly selected patients. 129
Fig 6. (A, B) Preoperative appearance of a 30-year-old woman with ptosis and loss of breast volume after breast feeding. (C, D) Postoperative appearance after partial subpectoral augmentation using a full height 360-mL anatomic textured silicone gel implant. A pleasing shape is shown without excess upper pole fullness. By differentially filling out the lower portion of the skin envelope with the shaped device, a mastopexy was successfully avoided.
References 1. Tebbetts JB: What is adequate fill? Implications in breast implant surgery. Plast Reconstr Surg 97:1451-1454, 1996 2. Tebbetts JB: Use of anatomic breast implants: Ten essentials. Aesthetic Surg J 18:377-384, 1998 3. Spear SL, EImaraghy M, Hess C: Textured-surface saline-filled silicone breast implants for augmentation mammaplasty. Plast Reconstr Surg 105:1542-1552, 2000 4. Maxwell GP, Falcone PA: Eighty-four consecutive breast reconstructions using a textured silicone tissue expander. Plast Reconstr Surg 89:1022-1034, 1992 5. McGeorge DD, Mahdi S, Tsekouras A': Breast reconstruction with
130
anatomical expanders and implants: Our early experience. Br J Plast Surg 49:352-357, 1996 6. Spear SL, Majidian A: Immediate breast reconstruction in two stages using textured, integrated-valve tissue expanders and breast implants: A retrospective review of 171 consecutive breast reconstructions from 1989 to 1996. Plast Reconstr Surg 101:53-63, 1998 7. Rimareix F, Masson J, Couturaud B, et ah Reconstruction mammaire par prothese anatomique gonflable. Ann Chir Plast Esthet 44:239-245, 1999 8. Hamas RS: The postoperative shape of round and teardrop salinefilled breast implants. Aesthetic Surg J19:369-374, 1999
DENNIS C. HAMMOND