Things We Cannot Control: Wound Healing, Tissue Stretch And Gravity

• Wound healing
• Tissue stretching and thinning
• Influence of gravity on the implant and breast tissues

One would look at this list and say “Wow, I sure have the majority of the control of the outcome of this operation!” My reply to that is “Wrong!” Let me go into a bit more detail:

Wound healing: By wound healing, most people think I am referring to the quality of the scar. While this is absolutely true, the quality of the mature (healing is completed) scar is only a small part of the process. Wound healing is a complex, only partially understood dynamic process that varies considerably among inidividuals. After a breast augmentation is performed, the surgical wound, specifically the incision in the skin, and the pathway down through the fat, to the muscle and ending at the pocket where the implant resides is healing by different processes and rates depending upon what tissues are uniting: muscle to muscle or fascia, fascia to fascia, fat to fat, skin to skin. For those curious, fascia is the thin layer of tough connective tissue that lines the surface of muscles and the underside of skin. This is the thin, but strong layer that holds sutures, allowing us to secure different tissues together. While the patient is focused only upon how the scar looks, much more is going on inside the breast.

Let’s also not forget one other minor detail. The implant is now sitting in a pocket. Before this space was a pocket, it was two layers of tissue that lay one above the other. The muscle and breast lie above, and the chest wall lies below (in the case of a submuscular augmentation). In the case of a subglandular augmentation, the breast lies above and the muscle and chest wall lies below. In either case, these new exposed planes of tissue are also healing. But healing to what? They certainly do not grow into and attach to the implant? What happens is that in the human body, anytime a foreign body is placed inside our body, be it a pacemaker, artificial joint, twig, bullet or a breast implant, the adjacent tissues react by encapsulating the foreign body with a layer of scar tissue. I would look at this as a self-defense mechanism somewhat akin to how an oyster creates a pearl around a piece of sand that enters its oral cavity. The question then becomes how thick is this scar tissue? What is the quality of this scar tissue? Why is this important if you do not see it?

The scar tissue that forms around a breast implant is typically very thin and pliable. It is inconsequential to the look and feel of the breast. That is a good thing. Sometimes, and for reasons only partially understood, this scar tissue thickens and actually contracts. As it contracts, it makes the implant feel firmer. There is no actual change in the implant, it just feels firmer. If you squeeze a water balloon in your hands, you can simulate this effect. Now we have a problem: the breast feels hard, looks rounder, and the implant even rides upwards on the chest. This is called a capsule contracture. Fortunately, this does not commonly occur. As we do understand some of the factors that cause capsule contracture to happen, there are definitely interventions done during surgery that have been proven to dramatically reduce the risk of this from happening, but unfortunately, we cannot eliminate that risk 100%. You can read more about capsule contracture, what causes it and how it is treated here.

Tissue stretching and thinning: This is conceptually a lot easier to understand than wound healing. Skin is living tissue. It is made up of, among other things, collagen and elastin which are proteins that give skin both strength and elasticity. Every elastic material, living or otherwise, has its limits. If you apply a force to an elastic material, it will deform in response to that force. Once that force is removed, the material will revert to its former dimensions. If you apply too great a force, and exceed the elastic limits of that material, then it can break down, and lose the ability to revert back to its former dimensions. This is especially true with skin and other living tissue. If an excessive force is applied, there is breakdown of the collagen and elastic matrix, resulting in permanent stretching of that tissue. The placement of a breast implant is essentially a deforming force on the breast tissues. The larger the implant, the greater the deforming force on the tissues. A smaller implant – small amount of force. A larger implant – a greater amount of force. Some tissue stretch to accommodate the implant is both desirable and expected. When I place an implant, there is almost always a distortion in the contour of the breast, at least initially. The breast is not used to accommodating that implant, so the tight lower breast tissue envelope pushes back against the implant, causing it to shift its contents (saline or silicone gel) upwards. This is what causes the “hump” that we observe after just about every breast augmentation. Then, over the next few months, the breast tissue stretches, and as the tissues now accommodate that implant, the implant itself can now have a more desirable distribution of its contents, resulting in the breast attaining a more pleasing contour. This is illustrated in the case below: