Breast augmentation – Breast implants
Definition and principles
Breast augmentation surgery aims at putting in place breast implants to increase the volume of the breast seen as too small by the patient. Breasts may not have developed sufficiently since adolescence or may have become smaller as a result of considerable weight loss or a pregnancy followed by breast feeding.
The decision to undergo a breast increase must never be taken lightly. The act in itself is certainly not technically more complicated to perform for a competent surgeon, but many decisions need to be taken. Their coherence and understanding are imperative for the patient to be happy after the operation. The longterm consequences of the operation also need to be discussed and accepted so as to avoid decisions that are too rash and not properly thought out.
Two alternatives treatments are currently proposed in order to increase mammary volume without implants: the fat transfer: lipomodelling and filler injection.
Fat remodelling is a local application of the fat transfer technic called lipostructure or lipofilling (see in section lipostructure). The fat tissue is removed from excess non-aesthetic areas of the patient and then transfered by injections into her breasts.
In favorable cases, the technique presents two major advantages:
1. It provides obtaining breast augmentation, though moderate, without implants placement, is utterly natural, without any foreign body, and not causing the breasts to look artificial.
2. At the same time, it provides for reducing the excess fat from one or several collecting sites.
However, it can be performed only in a very precise setting:
1. As with lipostructure, it is mandatory that the patient presents sufficient good quality fat to allow for fat tissue collection (or collections) under adequate conditions. Namely, one must take into account the partial resorption of the fat implants.
2. This technique is not recommended for significant breasts augmentation requests.
3. Since it concerns implants of a living fat tissue derived from localised excess fat masses, the latter retains its natural sensitivity to weight variations. Good weight stability is therefore mandatory to ensure the stability of the results.
4. Lastly, the patient must be ready to accept the possibility that a second or even a third operation be required to obtain the desired result. Although these do not constitute any real threat in terms of complications, or risk of surgical errors, localized imperfections may occur: insufficient correction, asymmetry, irregularities. Such risks of imperfect result are inherent to the engraftment process. The number of visits for « surgical touch-ups » is not limited, except as indicated by health reasons, good sense and the quantities of fat tissue available for collection.
For the breasts, lipomodeling was first proposed only in reconstructive surgery, where it permitted an amazing upturn and seen as inadvisable for aesthetic purpose since, at medium-term, part of the implanted fat degradation was difficult to differentiate from cancer–related micro-calcifications. Thanks to recent improvements in medical imagery, this process now proves not to have negative effects on the detection of cancer.
Besides, improvement of fat transfer techniques permits a more harmonious distribution of implanted fat, hence reducing the risk of oily cyst formation or of poor engraftment (cytostéatonécrose).
Nevertheless, some surgeons still worry about potential interactions between the injected fatty tissue and the mammary gland. The SOFCPRE specifies, therefore, as of 26.12.2007: « Pending additional data, the SOFCPRE does not guarantee the injection of autologous fat tissue into the mammary gland outside of clinical research protocols providing namely for medium and long-range patient follow-up ».
Even if there is not, to date, any convincing element in favor of an increased risk for breast cancer following lipomodelling, it remains nonetheless true that every woman is at risk depending on her age, her family history, health habits…
It is therefore necessary that the female candidates for this operation understand that all precautions should be taken to limit the risk of having any occurrence of cancer coincide with the lipomodelling. In keeping with this, the patient requesting lipomodelling of the breasts must be committed to having pre-operative screening tests (mammography, ultrasonography and MRI if need be) performed by an expert breast radiologist, and especially to having follow-up examinations carried out at 1, 2 and even 3 year intervals, if possible by the same specialist, and to heeding to his prescriptions (mammography, ultrasonography).
It should be known that a product that would be definitively neutral, stable and flexible to palpation does not exist yet.
In the past, one used to propose silicone oil injections as an alternative to implant placement, but this technique is absolutely prohibited today regarding the risk of migration and major subsequent inflammatory reactions induced.
Since then, other filler products have been suggested, such as poly-acrylamides which also seem questionable in the mammar localisation, at least from the point of view of long–term safety.
Lastly, Macrolane-type reticulated hyaluronic acids have come out recently and seem less risky than the above-mentioned products for mammary treatment, but it should be known that although they are absorbable, these products:
1. have not been sufficiently tested in esthetic mammary treatment in terms of radiolucency, migration risk and carcinogenic risk;
2. may cause a non-homogeneous sensation to palpation (like glass beads);
3. yield non-final results (1 to 3 years) for a relatively high cost (the product itself is expensive);
4. require fairly painful injections (warranting namely the use of « empowered » local anesthestics ), and the post-operative sequelae are not as non-existant as the press would have us believe.
Therefore, as a precautionary measure, Doctor Le Louarn does not propose to his patients, the use of fillers in the indication of breast augmentation for the time being.
The choices to be made before the operation:
The desired volume and shape
The discussion concerning the volume is essential in the decision to operate. The proportions that the patient is looking for in relation to her body must be determined:
– An average, “natural” size for soft seduction.
– A larger than average size, perhaps sexier, but certainly less “natural” in appearance.
– A very large size – an unusual appearance with a remarkable “hot” look for aggressive seduction.
Do not let the fear of “what people might say” or a criticism hold you back from explaining to the doctor exactly what change you would like to see in your appearance: not with the aim of satisfying this desire, whatever it might be, but to be able to determine with him the best compromise between your “dream body” and other considerations, such as the way other people see you or the daily practising of an intensive sport…This discussion at the beginning of the process enables good mutual understanding, thereby reducing the risk of disappointment after the operation.
The type of implant to use
All implants are made up of an envelope and of a filling product, but the range is very varied as are the results and the consequences of each are very different. The advantages and disadvantages of each element must be perfectly understood before any decision can be taken.
The envelope is always made of silicon. The surface can be smooth (for a firmer result that limits creases risk) or textured (to reduce capsular contracture risk)
The filling product
Currently silicon gel, saline or hydrogel are proposed, depending on the regulations in place.
Silicon is a more or less cohesive gelatinous chemical substance. Silicon has an advantage over saline in that it limits creases. If the gel used is supple, the breasts look more natural, but there is also the risk of the silicone migration inside the body over time in case of a leak due to wearing or in case of implant bursting after a trauma. The more cohesive the gel, the lower the risk of deflation or leaks and the firmer the breast.
Giving an overall more natural look than saline implants, silicon gel implants have been widely used over the past 30 years. But it has been said that they cause autoimmune illnesses in certain patients. After an initial period during which they were not allowed to be used, the AFSSAPS reauthorized them in France since scientific research showed that there is no higher risk in women with silicon implants. As for splitting, saline implants have the advantage of being easily absorbed by the body, whilst a silicon leak can lead to foreign body granulomas (siliconomas) or inflammatory reactions.
Hydrogel offers a third solution between saline and silicone. It appears a more “biological” answer than silicone since it is made of sugar while keeping the advantage of a more “natural sensation” to palpation. The main disadvantage of these implants is to offer less restrospect and the possible instability of the gel with time (it can turn more liquid and thus the result appears closer to saline implant)
Inflatable or pre-filled
The implants are “pre-filled” with saline or silicon when the envelope is filled at the factory and are “inflatable” when the surgeon fills the implants during the operation. Only saline implants can be inflated. Pre-filled implants therefore are of a volume fixed by the manufacturer, whilst the surgeon can adapt the filling of inflatable implants to a certain degree during the operation. However, the inflatable implants present a higher risk of partial or total, slow or rapid deflation, due to the potential problems of water tightness of their filling valves.
The shape: round or anatomic
Depending on each individual patient and the desired shape of the breast, it can be preferable to use either round or anatomic implants.
Anatomic implants are shaped like a water drop and are very useful for breast reconstructions and for women wanting a very natural look (more pear-shaped than round). However, these implants have the disadvantage of making very firm breasts (and are therefore much more noticeable to the touch) and of reversing in the mid-term, a complication that renders the result totally inharmonious.
Round implants can protrude to a greater or lesser degree. They can look less natural than anatomic ones, but are more stable over time since they do not run the risk of reversal.
Position of the implant
During the operation, the implant can be positioned directly behind the mammary gland (retro-glandular)
Implant in retro-glandular position
or behind the large pectoral muscle (retro-pectoral).
Implant in retro-pectoral position
The position behind the gland has the advantage of being less painful after the operation, but the implants are clearly more visible through the skin. This position is therefore reserved to smaller volumes implanted in women with thick subcutaneous tissue.
The position behind the muscle is much more discreet when at rest. However, muscle movement can be visible during muscular contraction, which is not the case with natural breasts. Therefore it would be necessary to wear a t-shirt to work the pectorals discreetly. Moreover, this position requires part of the muscle to be removed; this is not recommended for certain high-level sportswomen whose performance could negatively affected (tennis, javelin, etc…)
Position of incisions and thus of the scars
1: trans-areolar 2: peri-areolar
The scar can be situated under the armpits (axillary incision) or on the areola (peri-areolar or trans-areolar incision) or the crease below the breast (infra-mammary incision).
Certain types of implants dictate the choice of incision. For example, anatomic implants usually require incisions under the breast to ensure a sufficient opening and good visibility for the surgeon.
Other implants can be used indifferently in one way or the other. For these implants other considerations are taken into account:
- With axillary incisions, when the patient lifts her arms wearing a vest top, 2 scars will be visible in the armpits. Moreover, this type of incision gives the least access and least visibility to the surgeon during the operation and thus enables the least prevention of secondary haemorrhages.
- Areolar incisions are not practiced for sizeable implants and when nipples are small or only slightly coloured.
Should ptosis or asymmetry be corrected at the same time?
In the case of breast ptosis (drooping breast and low areola), an associated correction is often an option, indeed advisable. Supplementary incisions will therefore be necessary to reduce the slackened skin envelope, to remodel the breasts and return the areolas to their correct position at the same time as the breast increase. This would entail a greater scarring.
Unpredictability of implant longevity and secondary interventions
The longevity of an implant, whether filled will silicon gel or saline, cannot be predicted since it depends on possible complications. The longevity of implants cannot be guaranteed. A woman with an implant should expect to have other operations to maintain the benefits of the implant. However, the implant does not have a limited longevity and, in the absence of complications, a patient can keep an implant as long as is desired.
Since implants can affect X-rays, women with breast implants must tell radiologists of the implant so that the X-ray technique can be adapted (digital echograms and mammograms).
The implant does not have any repercussions on breastfeeding. However, it is recommended not to have implants if a pregnancy is envisaged in the short-term, nor is it recommended to have large implants in before pregnancies, since the slackening of the tissues can cause stretch marks.
Risk of cancer and self-immune illnesses
The link between breast cancer and implants has been researched but has never been proven. Cancer treatment centres even use implants in reconstructive surgery.
As for autoimmune illnesses and silicon gel implants, today’s scientific studies are reassuring: there is no significant increase of risk with implants.
Practical recommendations for before the operation
Apart from the usual pre-operation assessment and anaesthetic consultation, it can be useful to check mammary scanning before the operation.
Do not arrive too morally or physically tired to the operation. Let us know about any change in your state of physical or mental health and do not forget that there is never any urgency to carry out an aesthetic operation.
Medicines that cause bleeding are prohibited during the days leading up to the operation: Aspirin, Anti-inflammatory drugs, Anticoagulants, Vitamin E….
It is imperative that all aesthetic operations be foregone if you are ill or, if you are pregnant on the day of the operation. You must not drink or eat during the 6 hours prior to the operation. You must stop smoking due to the risk of necrosis.
The operation will be cancelled if preoperative advices are not adhered to.
When preparing your belongings, DO NOT FORGET YOUR MEDICAL FILE.
Where possible, do not bring any valuable jewellery with you (or put it in the safe at the clinic with your other valuables during the operation.)
Have a shower or bath before coming to the clinic and wash your hair; women should obviously not wear nail varnish or make-up.
Prior to the anaesthetic contact lenses, dentures and hearing aids must imperatively be removed.
Anaesthetics and hospitalisation
The operation is performed in the clinic and always under general anaesthetic.
Dr Le Louarn will prepare the pre-op drawings with you.
The operation lasts from 1 to 2 hours.
Upon waking up, you will have drains, to limit the risk of haematomas, and a bandage. Please note that due to action on the muscle, more pain will be experienced when the implants are placed behind the muscle (retro pectoral).
You will spend one to two nights in hospital after the operation.
From the day after the operation you will be asked to get up to reduce the risk of embolism.
Prepare an outfit for when you leave the hospital that is not put on over your head and that is wide enough around the chest. A lycra bra or body is often best before going to buy a bra suited to your new chest. Avoid chains or heavy brooches on the chest.
For the first days spent at home you must relax as much as possible and avoid any over exertion. However, you must walk around, a few times a day, to prevent the risk of embolisms and should eat enough to help the healing process.
Initially, the breasts will be larger than planned due to post-op swelling, the extent of which varies from patient to patient. This can continue for up to two months.
You will have difficulty lifting your arms and as such, it will be hard for you to reach objects placed high-up.
For 15 days you must avoid wearing bras that lift the chest and could lift the implant higher than the desired position.
Note down the telephone number of the office (from France 01 45 53 27 17 and for international call 33 1 45 53 27 17), and of the clinic near your home telephone and in your mobile phone. Do not hesitate to call us if you are worried. Call us if you have a temperature, experience weeping, pain or other symptoms that give you cause to worry.
Leave from work 8 to 10 days, but we recommend that you take it easy for 15 days
Stitches will either be absorbable or taken out 10 – 15 days after the operation
Bruises will remain for 15-20 days in theory
Swelling is at its most acute on the 3 rd – 4 th day after the operation, then fades progressively
Scars : 6 to 9 months until they whiten
Exercise that causes jolts or tension on the pectoral muscle is prohibited for 2 months (horse riding, tennis…)
In most cases, operations are smooth and patients are pleased with the result. However, before taking a decision, you should be aware of the risks and possible complications.
General risks inherent to all surgical operations: infections, haematomas, healing problems and anaesthetic-related risks.
If an operation is performed under normal conditions and post-op care and advice are adhered to, infections are very seldom. You will be notably asked to initially wash daily to keep scars clean and to respect the antiseptic and antibiotic prescriptions. In the case of breast surgery, infections can sometimes require surgical draining.
This is quite a rare complication but needs to be evacuated quickly. Haematomas occur most often in the hours following the operation. The risk of haematoma rises considerably when medicines that can cause bleeding are taken pre and post-op. Cases of haematomas have also been reported after airplane journeys too soon after surgery, due to the changes in atmospheric pressure and also violent contact or repeated jolts in the short-term following an operation (being hit in the back by a ball or a very long journey in a small car less than15 days after the operation).
Immediately after the operation, the scar may become inflamed or weep; this requires specific, local treatment that can often be long. In this regard, the respect of cleanliness advice, stopping smoking and attending follow-up appointments are decisive.
In the midterm, the scar can sometimes develop unfavourably: thicken, expand, form keloids. That depends on the type of skin (problems increase on red and black skins) and on life behaviour (smoking and the contraceptive pill increase this risk.)
Anaesthetic techniques and monitoring methods have improved immensely and safety is high when an operation is performed in non-emergency conditions on a person in good health, when the anaesthetist is competent and working in a recognised establishment. However, the effect of anaesthetics on the body can be difficult to predict and treat. Therefore there are still risks and hazards inherent to all anaesthetics before and after the operation. This is why it is imperative that you consult the anaesthetist prior to the operation and fully inform him of the state of your health. In function of your health and the planned operation, he will assess the risks related to anaesthetics and tell you of any potential precautions to take. If the anaesthetist objects to the operation, this decision is final.
(see in chapter ” Before surgery ” section “Check up and anaesthetic consultation“)
Risks during any aesthetic operation: asymmetry, a result judged as insufficient or excessive, need to touch up results, sensitivity issues
The way in which tissues react to an operation is always specific and, to a certain extent, unpredictable. It depends on the patient correctly following the doctor’s recommendations, but luck also plays a role. This is why all risks of asymmetry, unsatisfactory or excessive results and the need to touch up are evoked prior to any aesthetic operation.
Breasts are never perfectly symmetrical and augmentation surgery does not treat pre-existing asymmetries without specific action. However, just like after any cosmetic operation, it is normal for the patient to look at and analyse herself more than before and, furthermore, once the features to be treated as a priority have been corrected, some patients become embarrassed about a pre-existing asymmetry that they saw as insignificant prior to the operation. Therefore, it may be useful to discuss possible asymmetry corrections during pre-op consultations. Also, mammary surgery can lead to posture changes giving the appearance of asymmetry, even if the implants are of the same size. This risk rises in patients with vertebral column deformities.
Problems of inappropriate size are the result of decisions taken without due consideration
This risk can be limited by careful consideration prior to the operation. However, a patient who had asked for certain size implants may be very happy with the size when the breasts are swollen and thus may request a second operation to maintain that temporary size.
Problems of sensitivity
Notably of the nipples, can occur, but usually disappear after 12 – 18 months.
The risk of touching up results is unfortunately inherent to all types of cosmetic surgery.
Risks specific to breast enlargement
When an implant is too supple, envelope creases can be visible under the skin, giving a “wave” appearance, especially in the upper breast. This complication, primarily cosmetic, can cause splitting by premature wearing of the envelope on a crease.
This phenomenon is clearly more common when the implant is filled with saline or a little-cohesive silicon gel (more supple). The risk also rises when textured implants are used to combat the inverse phenomenon of capsular spasms.
Creases may appear that are not very noticeable but can be felt when touched. These creases can become more visible when the patient bends forward, more particularly in case of fine skin.
Capsular spasms (fibrous scarring reaction):
The formation of a capsule around the implant is a normal reaction by the body that builds a sort of membrane around any foreign body in order to isolate it and protect itself.
In certain cases, this membrane develops in a negative way: it becomes thicker, retracts and forms a veritable fibrous wall around the implant. This is a capsular spasm. There are 4 stages of firmness ranging from a normal appearance that is undetectable, to more severe forms – hard, round, fixed and sometimes painful breasts.
The frequency of this complication cannot be estimated since it varies in function of the type and quality of the implant and the conditions of implantation. The risk is higher for silicon implants, lower with saline implants and almost nil with hydro-gel implants. The position of the implant behind the muscle reduces the frequency. It can also be limited by massaging implants each day.
Dr Le Louarn and his colleagues J. Buis and E. Auclair have recently introduced (and published) the idea to use a locally active antiinflammatory patch (Flector Tissugel). They noted excellent results (after 3 weeks of treatment) on many cases of early contracture. Unfortunately, it has been a quite less effective in case of established contractures (application started later than 3 months after the onset of capsular contracture). It is very important that patients refer to their surgeon, as soon as they have a suspicion of beginning of contracture, in order to start an early treatment if necessary.
The contracture does not increase the risk of splitting, but poses an aesthetic complication and, in the most serious cases, of pain. Surgical intervention (capsulotomy) may be necessary to correct functional complications.
This is leads most often to more or less complete deflation of the breast. There are factors that can bring this on, such as a violent traumatism and the age of the implant.
In case of splitting, saline has the advantage that it can be naturally absorbed by the body, but the splitting or the leaks can be brutal. This is why patients choosing this type of implant must be warned that they are exposing themselves to the risk of brusque deflation of an implant – this can be socially or personally upsetting.
When silicon gel implant splits, the gel either remains in the fibrous envelope surrounding the implant and can go unnoticed, or it diffuses through the fibrous shell and causes the body to react as when it reacts against a foreign body in the form of nodules (siliconomas) or inflammation. Hydro-gel implants can either deflate or attract more water from the body and cause the breast to swell.
Gel must be systematically monitored every 3 years after 10/15 years and/or after a direct and significant knock. If in doubt, we can carry out a digital echogram and a mammogram to see if it is necessary to change the implants. When gel implants split, it is best to have an explantation and if desire a reimplantation of the implants.
Two to three months after the operation, it is possible to make an initial evaluation of the result. The breast is suppler and post-op swelling usually disappears by this time. However, the scars and the tissues can experience a peak of inflammation at that time, which is why it is often necessary to wait for nine to twelve months before seeing the definitive result.
In the vast majority of cases an appreciable aesthetic effect is accompanied by veritable psychological benefits.
The amount of final scarring depends on the reaction specific to each patient. Cessation of smoking does affect this (and can be decisive, especially in operations on ptosis.)
For breast implants, the longevity of the result depends mostly on life behaviour. The effect will be longer lasting on two conditions: limited significant weight loss and injuries. Pregnancies are possible but obviously can harm the aesthetic result.
By way of conclusion, we remind you that precise and detailed information, an in-depth analysis of the reasons for the operation, teamwork between the patient and the surgeon during the preparatory phase, the search for surgical excellence coupled with a good analysis of benefits and risks, the respect of pre-op and post-op advice and regular monitoring of the patient are all key elements for aesthetic surgery to be a success.
You can also general information in english regarding the breast augmentation surgery in the « Breast Augmentation » of the ISAPS’website (International Society of Aesthetic plastic Surgery) chapter: « Info for patients ».
You may also find general information in french about this surgery, in section « prothèses mammaires» of the SOFCPRE’s website : www.plasticiens.org
Specific informations appearing on this website are based on Doctor Le Louarn’s practice and on his scientific works:
1 – LE LOUARN C., BUIS J., AUCLAIR E. : Flector Tissugel Used to Treat Capsular Contracture After Breast Augmentation Surgery
Aesthetic Plast. Surg. 2008 Apr 4
2 – LE LOUARN S. & LE LOUARN C. : La chirurgie mammaire et l’esthétiquement correct: Le sein et les medias – Mammaplasty and the aesthetically correct: breast and medias
Ann Chir Plast Esthet. 2005 Oct;50(5):378-93.
3 – LE LOUARN C. : La technique du sillon latéral dans la plastie mammaire – The lateral fold mammaplasty
Ann Chir Plast Esthet. 2004 Aug;49(4):366-72.
4 – LE LOUARN C. : Une voie d’abord pour les plasties mammaires d’augmentation – An approach for augmentation mammaplasties
Ann Chir Plast Esthet.1989 34(3) : 289.
In this field, the following publications and works can also be listed (this list is obviously not exhaustive and may be amended):
1 – BOTTI G. : Aesthetic Mammaplasties
Practical Atlas of Plastic Surgery – Edited by SEE – Firenze 2008
2 – GOSSET J., FLAGEUL G., TOUSSON G., GUERIN N., TOURASSE C., DELAY E. : Lipomodelage et correction des séquelles du traitement conservateur du cancer du sein: Aspects médicolégaux. Le point de vue de l’expert à partir de cinq cas cliniques délicats – Lipomodelling for correction of breast conservative treatment sequelae. Medicolegal aspects. Expert opinion on five problematic clinical cases.
Ann. Chir. Plast. Esthet. 2007 Dec 2
3 – GOSSET J., GUERIN N., TOUSSON G., DELAPORTE T., DELAY E. : Aspects radiologiques des seins traités par lipomodelage après séquelles du traitement conservateur du cancer du sein – Radiological evaluation after lipomodelling for correction of breast conservative treatment sequelae.
Ann. Chir. Plast. Esthet. 2007 Dec 3
4 – DELAY E., GROLLEAU J.L ., SITBON E . : Les implants mammaires en chirurgie esthétique et reconstructrice
50ème Congrès national de la SOF.CPRE (rapport annuel) sous la présidence du Dr G. FLAGEUL
Ann Chir Plast Esthet. 2005 Oct
5 – DELAY E., DELAPORTE T., SINNA. : Alternatives aux prothèses mammaires
Breast implant alternatives
Ann. Chir. Plast. Esthet. 2005 Oct Vol 50 N(6)
6 – CHAVOIN J.P. , TEYSSEYRE A., GROLLEAU J.L. : « Morphosein » : gestion d’une base de données patients pour le choix objectif du volume de l’implant dans les hypotrophies mammaires – « Morphobreast » : Patient’s data bank management for objective selection of implant’s volume in hypotrophic breasts
7 – AUCLAIR E., STAUB S. : Prothèses mammaires rondes ou anatomiques. Avantages et inconvénients respectifs – Round and anatomical mammary implants. Respective advantages and disadvantages
Ann. Chir. Plast. Esthet. 2005 Oct Vol 50 N(6)
8 – MULLER G.H. : Breast implants and silicone: silicone crisis’ history
Ann Chir Plast Esthet. 2005 Oct ;50(5):350-6
9 – MULLER G.H. : Les prothèses mammaires pré-remplies d’hydrogel – Breast prostheses prefilled with hydrogel
Ann Chir Plast Esthet. 1994 Dec;38(6):721-5
10 – BAKER J.L. : Augmentation mammaplasty
Chapter 9 in Complications and Problems in Aesthetic Plastic Surgery
Edited by George C. PECK – Gower Medical Publishing 1992 : ISBN 0-397-44613-6
11 – BIGGS T.M. : Augmentation mammaplasty: a comparative analysis
Plast Reconstr Surg. 1990 Mar;85(3):368-72
12 – BOSTWICK III J. : Aesthetic and reconstructive breast surgery
C.V. Mosby Company 1983 : ISBN 0-8016-0731-0
13 – ASTON S.J. , REES T.D. : Mammary augmentation, correction of asymmetry, and gynecomastia
Chapter 34 Volume II in Aesthetic Plastic Surgery
Edited by Thomas D. REES Saunders 1980 : ISBN 0-7216-7521