Breast augmentation

Background history

The four types of breast-implant prostheses available for surgical breast reconstruction, breast augmentation, and the aesthetic enhancement (size, shape, texture) of the breasts of a woman are:

1. Saline breast prosthesis filled with sterile saline solution.
2. Silicone breast prosthesis filled with viscous silicone gel.
3. Alternative-composition breast prosthesis filled with various fillers (soy oil, polypropylene string); now discontinued.
4. Structured breast prosthesis constructed of nested shells, made of elastomer silicone, with saline solution filling the space between the silicone shells; now discontinued.^[5]

Breastfeeding and the prosthetic breast

The breasts of a woman are apocrine glands that produce breastmilk with which to feed an infant child.^[20] A woman with implanted prosthetic breasts can breastfeed an infant, yet the breast implants can interfere with the breastfeeding function, especially in the case of a woman whose breast augmentation surgery accidentally cut into the nipple-areola complex (NAC) and might either have damaged the lactiferous ducts or damaged the nerves that serve the nipple-areola complex.

The breast augmentation procedures realised by way of IMF augmentation (through the inframammary fold), of the TABA augmentation via the armpit (trans-axillary breast augmentation), and of the TUBA augmentation via the navel (trans-umbilical breast augmentation) avoid the nipple-areola complex in order to preserve the tactile sensitivity of the areola and the breastfeeding functions. Moreover, two conditions most affect and interfere with the functioning of the lactiferous ducts: (i) the subglandular implantation of the prosthetic breast, and (ii) the implantation of oversized prosthetic-breasts. Therefore, the implantation of small prosthetic breasts and a submuscular implant-pocket are the breast-augmentation surgeries that least thwart the breastfeeding function.^[21][22][23]

Platinum toxicity

The industrial manufacture of silicone breast prostheses employs the metallic element platinum (Pt, 78) as a catalyst for chemically transforming liquid silicone oil into viscous silicone gel, the elastomer material for making breast-implant shells.^[26] Occasionally, trace quantities of platinum leak from a prosthetic breast into the woman's body and accumulate in the bone marrow, from where red blood cells would deposit the trace-platinum upon nerve endings and consequently cause disorders of the nervous system, such as blindness, deafness, and nervous tics (involuntary muscle contractions).^[26]

The FDA's review of the trace-platinum-toxicity data about the silicone-gel used for making prosthetic breasts said that the type of platinum used in modern silicone breast implants is not ionized platinum, and so not a biological risk to women with such prosthetic breasts.^[27] That there were no reports of trace-platinum-toxicity and no causal relation between the metal in the silicone-gel and the occurrence of trace-platinum-toxicity among women with silicone-gel prosthetic breasts.^[28]

Types of surgical incision

To realise the emplacement of a prosthetic breast (saline-solution or silicone-gel) into the implant-pocket of the woman patient, plastic surgeons employ five types of surgical incision:^[29]

Quick facts Inframammary fold ...

Inframammary fold
Cross section of the breast of an adult, female human
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1. Inframammary incision: The plastic surgeon makes a long cut at the inframammary fold (IMF) — the bottom border of the breast — for maximal access to the interior of the breast hemisphere. The inframammary incision allows for the precise cutting of tissues in order to securely emplace the prosthetic breast into the implant-pocket cut into the chest muscle. Moreover, according to the skin-type of the woman, the emplacement of a prosthetic breast by way of an IMF-incision can result in noticeable surgical scars.^[30]
2. Periareolar incision: The surgeon makes a short incision (5.0 cm.) along the areolar periphery (outside border of the areola) which allows for the symmetrical adjustment of the position of the inframammary fold (IMF) of the augmented breast. The periareolar incision is made at the medial-half (bottom half) of the outside border of the nipple-areola complex (NAC) of the breast to be augmented. Given the narrow access allowed into the skin-envelope of the breast hemisphere, the short, five-centimetre length of the periareolar incision makes difficult the surgeon's emplacement of a voluminous breast-implant made of silicone gel. Moreover, as a surgical approach, the periareolar incision (cutting along the outside border of the NAC) allows the plastic surgeon to also do a breast-lift procedure that has been included to an initial, primary mammoplasty procedure. In the therapeutic long term, the emplacement of a prosthetic breast through a periareolar incision tends to a greater rate of incidence of capsular contracture, and also risks severing the breastmilk ducts and the nerves of the NAC, which would impede breastfeeding.^[31]
3. Transaxillary incision: The plastic surgeon makes an incision at the axilla area (armpit) that allows tunnelling medially (cutting across) under the skin of the thorax — from the armpit to the bust area of the chest — in order to emplace the breast prosthesis into the implant-pocket of the breast to be augmented. The surgeon emplaces the prosthetic breast by cutting the cross-wise tunnel either bluntly (by hand) or mechanically (with an endoscope). The surgical approach of the transaxillary incision avoids cutting and scarring the skin envelope of the breast. The technical challenge is determining the ideal position of the prosthetic-breast within the implant-pocket in order to achieve a symmetrical breast hemisphere.^[32]
4. Transumbilical incision: To realise an endoscopic TUBA procedure (trans-umbilical breast augmentation), the surgeon makes an incision at the navel to allow tunneling superiorly (cutting upwards) under the abdominal skin — from the waist to the chest — in order to emplace the saline prosthetic breast into the implant-pocket of the breast to be augmented. The endoscopic surgical approach of the TUBA incision avoids cutting and scarring the skin envelope of the breast.^[33]
5. Transabdominal incision: To realise an endoscopic TABA procedure (transabdominal breast augmentation), the plastic surgeon makes an incision at the navel that will allow tunneling superiorly (cutting upwards) under the abdominal skin — from the waist to the chest — in order to emplace the prosthetic breast into the bluntly-cut implant-pocket of the breast to be augmented, whilst the patient simultaneously undergoes an abdominoplasty procedure.^[34]

Implant-pocket placement

The four surgical approaches for the emplacement of a prosthetic breast into the implant-pocket are described in anatomical relation to the pectoralis major muscle, the major muscle of the chest.

1. Subglandular implant-pocket: The plastic surgeon emplaces the breast implant to the retromammary space — between the breast tissue and the pectoralis major muscle — which is the orientation that most approximates the normal plane of the breast. Although this surgical approach to emplacing a prosthetic breast yields the most aesthetic results, in women with a small volume of soft-tissue in the breast, the subglandular emplacement of the implant is likelier to ripple and wrinkle the skin-envelope of the breast.
2. Subfascial implant-pocket: The surgeon emplaces the prosthetic breast beneath the fascia (the membrane that covers and encloses the pectoralis major muscle) to augment the size and volume of the breast hemisphere, for subsequent contouring and anatomic symmetry.^[35]
3. Subpectoral implant-pocket: In this dual-plane surgical approach, the surgeon emplaces the breast implant beneath the pectoralis major muscle (after partially cutting the inferior attachments of that muscle) with or without the partial cutting of the subglandular plane of the breast. Resultantly, the upper-half of the breast-implant is partially beneath the pectoralis major muscle, while the lower-half of the implant is in the subglandular plane of the breast being augmented. This emplacement technique achieves maximal coverage of the upper-half of the breast implant, whilst allowing the maximal expansion of the lower-half of the implant to achieve maximal breast-volume; however, there exists the risk of animation deformity, the breast-implant moving in place beneath the subpectoral plane.^[36]
4. Submuscular pocket: The plastic surgeon emplaces the prosthetic breast beneath the pectoralis major muscle without cutting the inferior origin of that muscle. The total coverage of the prosthetic breast can be achieved by releasing the lateral muscles of the chest wall (either the serratus muscle or the pectoralis minor muscle) and then attach those lateral muscles to the pectoralis major muscle to augment the breast.

Post-surgical recovery

The surgical scars of a breast augmentation mammoplasty heal at 6-weeks post-operative, and fade within several months, according to the skin type of the woman. Depending upon the daily physical activity the woman might require, the augmentation mammoplasty patient usually resumes her normal life activities at about 1-week post-operative. The woman who underwent submuscular implantation (beneath the pectoralis major muscles) usually has a longer post–operative convalescence, and experiences more pain, because of the healing of the deep-tissue cuts into the chest muscles for the breast augmentation. The patient usually does not exercise or engage in strenuous physical activities for about six weeks. Moreover, during the initial convalescence, the patient is encouraged to regularly exercise (flex and move) her arms to alleviate pain and discomfort; and, as required, analgesic medication catheters for alleviating pain.^[37][38]

Medical complications

The emplacement of a prosthetic breast presents the risks of medical complication usual to undergoing surgery, such as: an adverse reaction to anesthesia, a breast hematoma (post-operative bleeding), a seroma (fluid accumulation), and infection of the surgical wound.^[39] The medical complications of breast augmentation include: pain in the breast, altered tactile sensation, wrinkling and asymmetry of the breast hemisphere, thinning of the breast skin, impeded breastfeeding functions, and symmastia, the bread-loafing of the bust, which condition elevates the natural plane (cleavage) between the breast hemispheres.

The functional complications of the prosthetic breast — capsular contracture and capsular rupture — are managed with periodic, preventative physical examinations and MRI examinations. Medical complications from the emplacement surgery and complications (scarring) from the application of tissue expanders (place-holder prosthetics) occur in approximately six to seven per cent (6–7%) of breast-augmentation patients. ^[40][41][42] Statistically, twenty per cent (20%) of women with prosthetic breasts for aesthetic enhancement, and fifty per cent (50%) of women with prosthetic breasts for breast reconstruction, required the explantation of their failed breast-prostheses at the ten-year mark.^[43] In 2019, upon identification of a causal relation between Allergan Biocell breast prostheses (with a textured surface) and an immune-system cancer [anaplastic, large-cell lymphoma (BIA-ALCL)], the FDA recalled every model of prosthetic breast made by the Allergan Biocell company.^[44]

Rupture of the prosthetic breast

Because the prosthetic breast is an inorganic foreign object in the body of the woman, her immune system defensively responds by encapsulating the breast prosthesis (saline solution or silicone gel) in a hard-shell capsule of fibrous collagen.^[45] In time, the body's continual thickening of the fibrous capsule exerts mechanical compression forces upon the prosthetic breast that cause two ruptures that will leak filler-material: (i) the intracapsular rupture of the prosthesis, wherein the leaked filler-material remains within the fibrous capsule that contains the ruptured prosthetic breast, and (ii) the extracapsular rupture of the prosthesis, wherein the filler-material leaks out of the ruptured fibrous capsule and into the implant-pocket, from where that leaked filler-material will migrate into the thorax of the woman.^[46]

As a medical-device failure, the rupture of a breast implant usually is not immediately noticed by or is evident to the woman, because the prosthetic filler-material — saline solution or silicone gel — is biologically inert and is not absorbed by her body, and thus causes her no immediate sickness. The migration of the filler-material that has leaked from the breast-implant into the woman's thorax usually provokes medical complications in the pectoral area (the bust) area and in the axillary area (the armpit), and occur are as granulomas (inflamed nodules) and as lymphadenopathy (enlarged lymph nodes in the armpit).^[47]

The mechanisms of breast-implant rupture are

• Damage during the emplacement surgery
• Damage during a thoracic surgery
• Chemical degradation of the silicone shell of the prosthesis
• Trauma: blunt trauma, penetrating trauma, blast trauma
• Mechanical pressure, e.g. capsular contracture and mammogram breast examination^[48]

As a Class III medical device, the breast implant is an industrial product that eventually fails because of age and design flaws of material and manufacture; thus the rupture-and-deflation of a prosthetic breast is a medical-device failure resolved with the surgical explantation and replacement of the failed prosthetic breast with a new model of prosthetic breast.^[49] In that light, the Food and Drug Administration informed the women of the U.S. that breast implants are medical devices of finite shelf-life that wear out and fail. That the longer a woman has breast implants in her body — either saline solution or silicone gel — the greater the statistical likelihood of her experiencing the medical complications of the rupture-and-deflation failure of her prosthetic breasts.^[50]

For Second-generation prosthetic breasts (silicone shell, single-lumen) designed in the 1970s, the rupture-deflation defect occurred at the rate of eight to fifteen per cent (8–15%) at the ten-year mark after the surgery; which occurred among fifteen to thirty per cent (15–30%) of the cohort of mammoplasty patients.^{[51][52][53][54]} The study Safety and Effectiveness of Mentor's MemoryGel Implants at 6 Years (2009) reported a medical-device rate of failure of one-point-one per cent (1.1%) at the six-year mark after the surgery.^[55] Moreover, the data for failed breast prostheses indicated a rupture-and-deflation rate of one-point-zero per cent (1.0%) at the six-year, median age of the medical device.^[56]

Regarding the detection of rupture-and-deflation defects, The Diagnosis of Silicone Breast-implant Rupture: Clinical Findings Compared with Findings at Magnetic Resonance Imaging (2005) indicated that, in women without the symptoms of a medical-device failure, the physician's manual examination identified and confirmed only thirty per cent (30%) of breast-implant ruptures, whereas MRI examinations detected eighty-six per cent (86%) of breast-implant ruptures.^[57][58] Consequently, the FDA recommended that women schedule an MRI examination of their prosthetic breasts to detect rupture-and-leakage defects, at the three-year mark after the surgery; and afterwards schedule a defect-detection MRI examination every two years: (i) for the woman with a suspected breast-implant rupture; and (ii) for the confirmation of mammographic and ultrasonic studies that indicate the presence of a ruptured breast implant.^[40][59]

Regarding the detection-and-confirmation of a failed breast-implant, the study Natrelle Saline-filled Breast Implants: a Prospective 10-year Study (2009) reported a rupture-and-deflation rate of three to five per cent (3–5%) at the three-year mark, and a rupture-and-deflation rate of seven to ten per cent (7–10%) at the ten-year mark after the surgery for breast augmentation.^[60] The study Does Overfilling Smooth Inflatable Saline-filled Breast Implants Decrease the Deflation Rate? Experience with 4,761 Augmentation Mammaplasty Patients reported that overfilling the prosthetic breast with saline solution (by approx. 10–13%) reduced the rate of rupture-and-deflation to one-point-eighty-three per cent (1.83%) at the eight-year mark after the surgery.^[61]

Capsular contracture

The human body's immune response to a surgically-implanted foreign object (prosthetic breast, cardiac pacemaker, orthopedic prosthesis) is to biologically isolate the foreign object with a capsule of tightly-woven collagen fibres. Afterwards, the capsular contracture occurs over time when the thickened, collagen-fibre capsule has compressed inwards, against the breast-implant with great mechanical pressure that deforms and breaks the implant, and so disfigures the breast; the causes of capsular contracture include bacterial contamination, shell-rupture of the medical device, leakage of the prosthetic filler-material, and hematoma.

The prosthetic-breast implantation surgeries that have a low-rate of capsular contractures include surgical approaches that feature the submuscular emplacement of the breast-implant and the use of breast implants with a textured surface;^[62] limited handling of the breast implants before the surgery, limited contact with and handling of the skin of the implant-pocket, and irrigation of the surgical site with antibiotic solutions.^[63][64]

To correct a capsular contraction, the plastic surgeon realises an open capsulotomy procedure to loosen and release the collagen-fibre capsule from the implant-pocket, for removal and replacement with a new model of prosthetic breast. Moreover, non-surgical therapies for treating collagen-fibre capsules include massage, external ultrasonic therapy^[65], pharmaceutic therapy with leukotriene pathway inhibitor medications^[66][67], and Diapulse therapy (Pulsed Electromagnetic Field Therapy, PEMFT).^[68]

Systemic sickness

Since the 1990s, reviews of studies for causal relations between silicone-gel prosthetic breasts and systemic disease reported no causal relation to the occurrences of either systemic or autoimmune diseases; nonetheless, many women reported suffering neurological and rheumatological illnesses caused by failures of their prosthetic breasts.^{[59][71][72][73]} The study Long-term Health Status of Danish Women with Silicone Breast Implants (2004), reported that in relation to women of the general population, women with prosthetic breasts did not have a greater rate of incidence and diagnosis of autoimmune disease; that their rate of incidence for musculoskeletal disease was lower than the rate of incidence among women who had undergone other types of cosmetic surgery.^[74][75]

Follow-up longitudinal studies of women with prosthetic breasts indicated no causal relation between the presence of a breast prosthesis and the occurrence of either a systemic disease or an autoimmune disease.^[76] European and North American studies reported that women who had undergone an augmentation mammoplasty tended to be healthier than the general population; that plastic surgery patients had a lower standardized mortality ratio than did other types of surgery patient; and that women with prosthetic breasts faced a greater rate of incidence for lung cancer than did other types of plastic-surgery patient.

Moreover, because only the study Long-term Cancer Risk among Swedish Women with Cosmetic Breast Implants: an Update of a Nationwide Study (2006) controlled for tobacco smoking, the data were insufficient to establish verifiable statistical differences between smokers and non-smokers and the greater incidence of death by lung cancer for women with prosthetic breasts.^[77][78] The long-term study of 25,000 women, Mortality among Canadian Women with Cosmetic Breast Implants (2006), reported that breast prostheses do not directly increase mortality in women.^[79]

The study Silicone-gel Breast Implant Rupture, Extracapsular Silicone, and Health Status in a Population of Women (2001) reported an increased rate of incidence of fibromyalgia among women who had suffered a capsular contracture that leaked silicone-gel, than among women whose prosthetic breasts had neither ruptured nor leaked.^[80] That study was criticized as methodologically flawed, and had presented no evidence of a causal relation between the presence of a prosthetic breast and the occurrence of systemic disease. Upon investigation, the FDA concluded that the epidemiological evidence in the medical literature does not support an association between fibromyalgia and breast implants.^[81][82] Likewise, the review study, Silicone Breast implants and Connective tissue Disease: No Association (2011) reported that the scientific literature does not support any claims about a causal relation between prosthetic breasts and connective-tissue disease.^[83]

Fat grafting techniques

The centrifugal refinement of the harvested adipocyte tissues removes blood products and free lipids to produce autologous breast-filler. The injectable filler-fat is obtained by centrifuging the syringes with body-fat in order to separate the serum, blood, and liquid fat components by density, to produce refined, injection-quality body-fat.^[96] For facial injection quality, the fat-filled syringes are centrifuged for 1.0 minute at 2,000 RPM.^[97] Moreover, centrifugation at 10,000 RPM for 10 minutes produces a collagen graft, the histologic composition of which is cellular residues, collagen fibres, and 5.0 percent intact fat cells. Because the woman's body absorbs some of the fat grafts, the breasts retain their contours and volumes for 18–24 months.^[98][99]

The study Fat Grafting to the Breast Revisited: Safety and Efficacy (2007) indicates that the autologous fat was harvested by liposuction with a 10-ml. syringe attached to a two-hole Coleman harvesting cannula; after centrifugation, the refined breast filler-fat was transferred to 3-ml. syringes. Blunt infiltration cannulas were used to inject the body-fat through 2-mm. incisions; the blunt cannula injection method allowed greater dispersion of small aliquots (equal measures) of body-fat, and reduced the possibility of intravascular fat injection. The 2-mm. incisions were positioned to allow the injection of the fat-grafts from two injection sites; a 0.2 ml fat volume was injected with each withdrawal of the cannula.^[100]

The breast-contours were realized by layering the fat-grafts at different levels within the breast hemisphere. The fat-graft injection technique allows the plastic surgeon to accurately define the contour of the breast — from the chest wall to the breast-skin envelope— with subcutaneous fat-grafts to the superficial planes of the breast. The greater control in sculpting the contour of the breast is unlike the global augmentation realised with an implant below the breast or below the pectoralis major muscle, respectively expanding the retromammary space and the retropectoral space. The greatest proportion of the grafted fat usually is infiltrated to the pectoralis major muscle, then to the retropectoral space, and to the prepectoral space (before and behind the pectoralis major muscle). Moreover, fat-grafting to the breast parenchyma increases the degree of projection of the bust.^[94]

Fat-graft injection

The biologic survival of autologous fat tissue depends upon the correct handling of the fat graft, of its careful washing (refinement) to remove extraneous blood cells, and of the controlled, blunt-cannula injection (emplacement) of the refined fat-tissue grafts to an adequately vascularized recipient site. Because the body resorbs some of the injected fat grafts (volume loss), compensative over-filling aids in obtaining a satisfactory breast outcome for the patient; thus the transplantation of large-volume fat grafts greater than required, because only 25–50 percent of the fat graft survives at 1-year post-transplantation.^[101]

The correct technique maximizes fat graft survival by minimizing cellular trauma during the liposuction harvesting and the centrifugal refinement, and by injecting the fat in small aliquots (equal measures), not clumps (too-large measures). Injecting minimal-volume aliquots with each pass of the cannula maximizes the surface area contact, between the grafted fat-tissue and the recipient breast-tissue, because proximity to a vascular system (blood supply) encourages histologic survival and minimizes the potential for fat necrosis.^[94] Transplanted autologous fat tissue undergoes histologic changes like those undergone by a bone transplant; if the body accepts the fat-tissue graft, it is replaced with new fat tissue, if the fat-graft dies it is replaced by fibrous tissue. New fat tissue is generated by the activity of a large, wandering histocyte-type cell, which ingests fat and then becomes a fat cell.^[102] When the breast-filler fat is injected to the breasts in clumps (too-large measures), fat cells emplaced too distant from blood vessels might die, which can lead to fat tissue necrosis, causing lumps, calcifications, and the eventual formation of liponecrotic cysts.

The operating room time required to harvest, refine, and emplace fat to the breasts is greater than the usual 2-hour OR time; the usual infiltration time was approximately 2 hours for the first 100 cm³ volume, and approximately 45 minutes for injecting each additional 100 cm³ volume of breast-filler fat. The technique for injecting fat grafts for breast augmentation allows the plastic surgeon great control in sculpting the breasts to the required contour, especially in the correction of tuberous breast deformity. In which case, no fat-graft is emplaced beneath the nipple-areola complex (NAC), and the skin envelope of the breast is selectively expanded (contoured) with subcutaneously emplaced body-fat, immediately beneath the skin. Such controlled contouring selectively increased the proportional volume of the breast in relation to the size of the nipple-areola complex, and thus created a breast of natural form and appearance; greater verisimilitude than is achieved solely with breast implants. The fat-corrected, breast-implant deformities, were inadequate soft-tissue coverage of the implant(s) and capsular contracture, achieved with subcutaneous fat-grafts that hid the implant-device edges and wrinkles, and decreased the palpability of the underlying breast implant. Furthermore, grafting autologous fat around the breast implant can result in softening the breast capsule.^[103]

Post-mastectomy procedures

Surgical post-mastectomy breast reconstruction requires general anaesthesia, cuts the chest muscles, produces new scars, and requires a long post-surgical recovery for the patient. The surgical emplacement of breast implant devices (saline or silicone) introduces a foreign object to the patient's body (see capsular contracture). The TRAM flap (Transverse Rectus Abdominis Myocutaneous flap) procedure reconstructs the breast using an autologous flap of abdominal, cutaneous, and muscle tissues. The latissimus myocutaneous flap employs skin fat and muscle harvested from the back, and a breast implant. The DIEP flap (Deep Inferior Epigastric Perforators) procedure uses an autologous flap of abdominal skin and fat tissue.^{[106][full citation needed]}

Technical limitations

When the patient's body has insufficient adipocyte tissue to harvest as injectable breast filler, a combination of fat grafting and breast implants might provide the desired outcome. Although non-surgical breast augmentation with fat graft injections is not associated with implant-related medical complications (filler leakage, deflation, visibility, palpability, capsular contracture), the achievable breast volumes are physically limited; the large-volume, global bust augmentations realised with breast implants are not possible with the method of structural fat grafting. Global breast augmentation contrasts with the controlled breast augmentation of fat-graft injection, in the degree of control that the plastic surgeon has in achieving the desired breast contour and volume. The controlled augmentation is realised by infiltrating and diffusing the fat grafts throughout the breast; and it is feather-layered into the adjacent pectoral areas until achieving the desired outcome of breast volume and contour. Nonetheless, the physical fullness-of-breast achieved with injected fat-grafts does not visually translate into the type of buxom fullness achieved with breast implants; hence, patients who had plentiful fat-tissue to harvest attained a maximum breast augmentation of one bra cup size in one session of fat grafting to the breast.^[94]

Psychology

The psychological studies Body Image Concerns of Breast Augmentation Patients (2003) and Body Dysmorphic Disorder and Cosmetic Surgery (2006) indicate that women who seek breast-augmentation surgery usually have a mental-health background that features treatments of psychotherapy, who suffer many occurrences low self-esteem and of psychological depression, in comparison with the general population of women. Moreover, women who sought breast augmentation also suffered body dysmorphia, which is an extreme dissatisfaction and preoccupation with perceived physical defects in her personal appearance, which misperceptions often lead to significant impairment of her mental ability to function socially.

Post-operative patient surveys about the mental health and the quality of life of the women, reported improved physical health, physical appearance, social life, self-confidence, self-esteem, and satisfaction sexual functioning. Furthermore, most of the women reported long-term satisfaction with their breast implants; some despite having had medical complications that required surgical revision, either corrective or aesthetic. In Denmark, 8.0 percent of breast augmentation patients had a pre-operative history of psychiatric hospitalization.^{[113][114][115][116][117][118][119][120][40][121][excessive citations]}

Women bodybuilders

The Cosmeticsurgery.com article They Need Bosoms, too – Women Weight Lifters (2013) reported that women weight-lifters have resorted to breast augmentation surgery to maintain a feminine physique, and so compensate for the loss of breast mass consequent to the increased lean-body mass and decreased body-fat consequent to lifting weights.^[122]

Mental health

The longitudinal study Excess Mortality from Suicide and other External Causes of Death Among Women with Cosmetic Breast Implants (2007), reported that women who sought breast implants are almost 3.0 times as likely to commit suicide as are women who have not sought breast implants. Compared to the standard suicide-rate for women of the general populace, the suicide-rate for women with augmented breasts remained alike until 10-years post-implantation, yet it increased to 4.5 times greater at the 11-year mark, and so remained until the 19-year mark, when it increased to 6.0 times greater at 20-years post-implantation. Moreover, additional to the suicide risk, women with breast implants also faced a trebled death risk from alcoholism and drugs abuse (prescription and recreational).^[123][124] Although seven studies have statistically connected a woman's undergoing a breast augmentation procedure to a greater suicide rate, the research indicates that augmentation^[125][126] surgery does not increase the suicide rate; and that, in the first instance, it is the psychopathologically inclined woman who is likelier to undergo breast augmentation.^{[127][128][129][79][130][131]}

Moreover, the study Effect of Breast Augmentation Mammoplasty on Self-Esteem and Sexuality: A Quantitative Analysis (2007), reported that the women attributed their improved self-esteem, self-image, and increased, satisfactory sexual functioning to having undergone breast augmentation; the cohort, aged 21–57 years, averaged post-operative self-esteem increases ranging from 20.7 to 24.9 points on the 30-point Rosenberg self-esteem scale, which data supported the 78.6 percent increase in the woman's libido, relative to her pre-operative level of libido. Therefore, before agreeing to any surgical procedure, the plastic surgeon evaluates and considers the woman's mental health to determine if breast implants can positively affect her self-esteem and sexual functioning.^[132]