Anatomically shaped breast prosthesis in vivo: a change of dimension?

The Breast Implant ARC: An Algorithm for Determining the Position of the IMF in Breast Augmentation Planning

In breast augmentation surgery, many techniques have been developed and advocated to achieve the best possible results in incision planning. The standard dimensions on which most algorithms are based are width, height and the projection of the silicone gel-filled implants. The ARC is introduced as a new dimension instead of the currently used anatomical silicone gel-filled implants parameters. The algorithm presented in this article is based on the amount of breast parenchyma (P) and the ARC of an anatomical silicone gel-filled implant to obtain an exact positioning of the incision at the new inframammary fold. A patient case is presented to demonstrate the use of the algorithm. To date, this technique has been used in over 1200 patients with reproducible and consistent results. LEVEL OF EVIDENCE IV : This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266.

Round versus Anatomical Implants in Primary Cosmetic Breast Augmentation: A Meta-Analysis and Systematic Review

BACKGROUND

Choosing implant shape (round or anatomical) is one of the most essential yet controversial decisions in cosmetic breast augmentation. Many surgeons choose implant shape based on personal experience or expert opinion. This is the first systematic review and meta-analysis comparing the aesthetic effect between anatomical and round implants in primary cosmetic breast augmentation.

METHODS

The authors searched the PubMed, MEDLINE, Embase, ScienceDirect, Web of Knowledge, Scopus, and Cochrane Central Register of Controlled Trials databases for studies that compared anatomical and round implants in primary cosmetic breast augmentation. Primary outcomes were postoperative aesthetic effect and correct identification rate of implant shape. Random effects models were used to obtain pooled standardized mean difference and 95 percent confidence intervals.

RESULTS

One randomized comparative and four observational comparative studies met the inclusion criteria. No aesthetic superiority was found in the anatomical implant group with regard to overall appearance (standardized mean difference, 0.06; 95 percent CI, -0.40 to 0.53), naturalness (standardized mean difference, 0.18; 95 percent CI, -1.51 to 1.15), projection, upper pole contour, and lower pole contour. Pooled correct identification rate of implant shape by plastic surgeons was 52 percent (95 percent CI, 0.46 to 0.58).

CONCLUSIONS

Generally, anatomical implants do not seem to have an aesthetic superiority compared to round implants. Plastic surgeons seemed to be unable to accurately differentiate the two implant shapes in vivo. Further studies should focus on identifying the specific indications for the use of anatomical implants.

Transition from Round to Shaped Implants in Immediate Breast Reconstruction: Our Preferred Approach and Clinical Outcomes

BACKGROUND

Smooth, round, silicone implants predominate device-based breast reconstruction in the USA; despite their prevalence, complications can include bottoming out, superior contour deformity, rippling, and/or lateral malposition. This complication profile increases the need for revision surgery and subsequent patient dissatisfaction. With the resurgence of shaped, textured, silicone implants in the USA, we report the senior author's success with these devices and outline a strategy to optimize outcomes in breast reconstruction surgery.

METHODS

A retrospective chart review was conducted on a prospectively collected IRB-approved database of nipple-sparing mastectomies (NSMs) with immediate breast reconstruction with smooth, round, silicone implants (Group A) in 2011 in comparison to textured, shaped, silicone implants (Group B) in 2012. Changes in operative technique were highlighted and extrapolated. Outcomes were reviewed.

RESULTS

In Group A, 128 NSMs were performed in 76 patients. In Group B, 109 NSMs were performed in 59 patients. Thirteen percent of patients in Group A had direct to implant reconstruction as compared with 21% in Group B. Patients with textured, shaped implants were more likely to have acellular dermal matrix (61 vs 34%, p < 0.0001) than those with smooth, round implants. Patients who had smooth, round implants were more likely to have postoperative nipple malposition (18 vs 0%, p < 0.0001,) and rippling (29 vs 0%, p < 0.0001.) Patients with textured, shaped implants had fewer operative revision reconstructions as compared with those with smooth, round implants (36.71 vs 12.8%, p < 0.0001) Based on these results, our technique has evolved and has eight key technical modifications.

CONCLUSION

With a few adaptations in surgical technique, the transition to textured, shaped, silicone devices for breast reconstruction can be seamless with superior breast contour and reduced complications/revision rates.

LEVEL OF EVIDENCE IV

This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Characterization of Breast Implant Surfaces, Shapes, and Biomechanics: A Comparison of High Cohesive Anatomically Shaped Textured Silicone, Breast Implants from Three Different Manufacturers

Several companies offer anatomically shaped breast implants but differences among manufacturers are often misunderstood. The shell texture is a crucial parameter for anatomically shaped implants to prevent rotation and to decrease the risk of capsular contracture, even though concerns have recently been raised concerning the complications associated with textured breast implants. The aim of this study was to characterize differences in terms of texture, cell adhesion, shape, and stiffness between some commonly used anatomically shaped implants from three different manufacturers.

METHODS

Five commercially available anatomically shaped breast implants from 3 different manufacturers (Allergan, Mentor, and Sebbin) were used. Scanning electron microscopy, X-ray microtomography, and scanning mechanical microscopy were used to characterize the shell texture. Human fibroblast adhesion onto the shells was evaluated. 3D models of the implants were obtained using CT-scan acquisitions to analyze their shape. Implant stiffness was evaluated using a tractiometer.

RESULTS

Major differences were observed in the topography of the textures of the shells, but this was not conveyed by a statistically significant fibroblast adhesion difference. However, fibroblasts adhered better on anatomically shaped textured implants than on smooth implants (p < 0.01). Our work pointed out differences in the Biocell® texture in comparison with older studies. The 3D analysis showed significant shape differences between the anatomically shaped implants of the 3 companies, despite similar dimensions. Implant stiffness was comparable among the 3 brands.

CONCLUSIONS

Each texture had its specific topography, and this work is the first description of Sebbin anatomic breast implant texturation. Moreover, major discrepancies were found in the analysis of the Biocell® texture when comparing our results with previous reports. These differences may have clinical implications and are discussed. This study also highlighted major shape differences among breast implants from different manufacturers, which is quite counterintuitive. The clinical impact of these differences however needs further investigation.

NO LEVEL ASSIGNED

This journal requires that authors assign a level of evidence to each submission to which Evidence-Based Medicine rankings are applicable. This excludes Review Articles, Book Reviews, and manuscripts that concern Basic Science, Animal Studies, Cadaver Studies, and Experimental Studies. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266.

Evaluation of the effects of silicone implants on the breast parenchyma

BACKGROUND

Despite being the cosmetic procedure most performed worldwide, there are still few objective measurements of postoperative volumetric analysis of breast augmentation available in the literature.

OBJECTIVE

The aim of this study was to evaluate volumetric changes in the breast parenchyma after the placement of silicone implants in the subglandular plane.

METHODS

Thirty-four women were randomly allocated to the intervention group (n = 24), who underwent breast augmentation in the subglandular plane, or to the control group (n = 10), who received no intervention. Volumetric magnetic resonance imaging was performed at inclusion, and after 6 and 12 months in all participants. The non-parametric Friedman's test was used for statistical analysis.

RESULTS

There was a significant reduction in glandular volume (mean, 22%) at 12 months postoperatively in patients who underwent breast augmentation.

CONCLUSIONS

Breast augmentation caused reduction in the volume of the breast parenchyma.

LEVEL OF EVIDENCE

3 Therapeutic.

Assessing the augmented breast: a blinded study comparing round and anatomical form-stable implants

BACKGROUND

Controversy persists as to whether round or anatomical form-stable breast implants provide the most aesthetically pleasing results, and there is a paucity of evidence comparing cosmetic outcomes of these two implants. A blinded study comparing aesthetic outcomes was conducted in an attempt to address this issue.

OBJECTIVES

The authors compare aesthetic outcomes between round and anatomical form-stable breast implants.

METHODS

Pre- and postoperative photographs of 60 consecutive patients undergoing breast augmentation (33 round, 27 anatomical) by a single surgeon were reviewed by 22 plastic surgeons. Photographs were graded on a modified Likert scale (1, poor; 4, excellent) for overall aesthetic result, upper pole contour, and natural appearance. The panel was asked to determine implant shape.

RESULTS

Anatomical implants scored higher for upper pole contour: anatomical 2.80 (±0.44 - standard deviation) vs round 2.60 (±0.38). With regard to natural appearance and overall aesthetic results, anatomical implants scored higher: 2.89 (±0.42) vs 2.56 (±0.36) and 2.86 (±0.41) vs 2.72 (±0.37), respectively. None of these differences achieved statistical significance, and 62.7% of round and 49% of anatomical implants were correctly identified. There was no significant difference in the body mass index (BMI) between the 2 groups (P = .21).

CONCLUSIONS

No significant difference (P > .05) in the general and specific cosmetic points between round and anatomical implants was demonstrated; many on the panel were unable to identify implant shape correctly. Both techniques seem to yield good cosmetic results. Clearly the decision on which implant to use must be made on an individual patient basis because many factors influence overall aesthetic outcome. Anatomical implants should not be assumed to produce a more natural result.

LEVEL OF EVIDENCE

4 Therapeutic.

Prediction of prone-to-supine tumor displacement in the breast using patient position change: investigation with prone MRI and supine CT

BACKGROUND

One of the challenges for clinical use of preoperative breast magnetic resonance imaging (MRI) is how to transfer prone MRI information to the operating theater with a supine surgical position. The aim of this study was to retrospectively evaluate tumor displacement in the breast by changing the patient position from prone to supine (prone-to-supine tumor displacement), using preoperative prone MRI and supine computed tomography (CT).

METHODS

Preoperatively, 55 Japanese women with 57 breast cancer lesions underwent breast MRI in the prone position and breast CT in the supine position. Tumor positions in both the prone and supine positions were measured on X-, Y-, and Z-coordinates by fixing the nipple to the origin (0, 0, 0). As an indicator of the mobility of the breast, the ratio of the breast projection between the prone MRI and supine CT (prone-to-supine projection ratio) was calculated. The direction and distance of prone-to-supine tumor displacement was analyzed by dividing the breast into four quadrants according to the tumor position.

RESULTS

When changing the patient position from prone to supine, tumors located in the inner-upper and inner-lower quadrants tended to move radially toward the center of the nipple. The movement distance of the tumors in the inner-lower and outer-lower quadrants was very strongly correlated with the prone-to-supine breast projection ratio (r ≥ 0.8, p < 0.05). Conversely, in the outer-upper quadrant, the direction of tumor displacement was variable, and the distance of tumor displacement did not correlate with the prone-to-supine projection ratio.

CONCLUSIONS

The present study showed that prone-to-supine tumor displacement in the breast differs depending on tumor location. The inner-lower quadrant of the breast may be the most predictable area for prone-to-supine tumor displacement.

[Optimization of primary aesthetic breast augmentation using implants: an evidence-based level approach]

The primary aesthetic breast augmentation has been the most performed cosmetic surgery procedure in the world for over 40 years. The current literature focuses on the new concept of "process of breast augmentation" and the importance of non-surgical part (patient selection, preoperative planning and personalized management of postoperative care) in potentiating the cosmetic results and reducing the rate of complications and reoperations. This review of literature discusses, through an analysis of scientific evidence levels, every step of the whole process of breast augmentation in order to determine the current best practices tailored to each patient to optimize satisfactory and durable cosmetic outcomes.

Silicone breast phantoms for elastographic imaging evaluation

PURPOSE

Breast cancer is a major public health issue for women, and early detection significantly increases survival rate. Currently, there is increased research interest in elastographic soft-tissue imaging techniques based on the correlation between pathology and mechanical stiffness. Anthropomorphic breast phantoms are critical for ex vivo validation of emerging elastographic technologies. This research develops heterogeneous breast phantoms for use in testing elastographic imaging modalities.

METHODS

Mechanical property estimation of eight different elastomers is performed to determine storage moduli (E') and damping ratios (ζ) using a dynamic mechanical analyzer. Dynamic compression testing was carried out isothermally at room temperature over a range of 4-50 Hz. Silicone compositions with physiologically realistic storage modulus were chosen for mimicking skin adipose, cancerous tumors, and pectoral muscles and 13 anthropomorphic breast phantoms were constructed for ex vivo trials of digital image elastotomography (DIET) breast cancer screening system. A simpler fabrication was used to assess the possibility of multiple tumor detection using magnetic resonance elastography (MRE).

RESULTS

Silicone materials with ranges of storage moduli (E') from 2 to 570 kPa and damping ratios (ζ) from 0.03 to 0.56 were identified. The resulting phantoms were tested in two different elastographic breast cancer diagnostic modalities. A significant contrast was successfully identified between healthy tissues and cancerous tumors both in MRE and DIET.

CONCLUSIONS

The phantoms presented promise aid to researchers in elastographic imaging modalities for breast cancer detection and provide a foundation for silicone based phantom materials for mimicking soft tissues of other human organs.

Three-dimensional evaluation of breast augmentation and the influence of anatomic and round implants on operative breast shape changes

BACKGROUND

Currently, postoperative outcome analysis in breast augmentation is essentially subjective, and objective evaluation of treatment efficacy is lacking. This study evaluates the influence of anatomic and round implant parameters on breast contour changes after subpectoral breast augmentation using three-dimensional (3D) surface imaging.

METHODS

3D surface breast scans of 17 patients (34 breasts) undergoing subpectoral breast augmentation with round implants and of ten patients (20 breasts) receiving anatomic implants via an axillary approach under endoscopic assistance or a submammary fold incision were obtained before and 6 months postoperatively. 3D linear distance, breast volume, and surface measurement were correlated with the implanted round and anatomic implant parameters, and the resulting breast shape changes were evaluated.

RESULTS

Total breast volume changed in correlation with the implant size (2.4% difference; r=0.894; p<0.001). Implant volume and type influence the nipple-to-inframammary fold distance (N-IMF). Every inserted 100 ml implant volume enlarges the N-IMF distance by 0.8 cm (anatomic>round; p=0.01). Postoperatively, the IMF dropped by an average of 1.3 cm for round implants and by 1.1 cm for anatomic implants, without relevant differences between the applied surgical incision and the selected implants (p>0.05). Breast projection increased significantly more with anatomic implants (2.4 cm) than with round implants (1.7 cm) (p=0.01). The breast projection increase was 22% less than expected for round implants and 25% less than expected for anatomic implants based on the manufacturer implant parameters (p<0.01), without essential differences regarding the surgical incision.

CONCLUSIONS

3D breast shape changes induced by round and anatomic implants after subpectoral augmentation mammaplasty are objectively documented including breast projection, volume, and N-IMF distance changes. 3D surface imaging may have a potential clinical contribution to objective surgical outcome research.

LEVEL OF EVIDENCE III

This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors at www.springer.com/00266.

Breast augmentation: Part III--preoperative considerations and planning

The past four decades since the introduction of silicone mammary prostheses have seen significant improvements in their quality and durability. Advances in our understanding of the aetiopathology and prevention of adverse capsular contracture (ACC) have occurred such that surgical technique itself has now probably become the single most important determinant of both immediate and long-term outcome. Considered a simple, and in some quarters mindless, procedure it has evolved such that high-quality short- and stable long-term results are now expected. Whilst the fundamentals of breast augmentation (BA) remain, evolutionary philosophies confront today's surgeon with a wealth of options. Of fundamental importance has been the paradigm shift from a purely, or predominantly, volumetric, through biodimensional to a tissue-based approach. With BA, more than any other aesthetic procedure, possessing more variables, choice and influential external factors a thorough understanding of the myriad options available is essential. This review seeks to cover the key elements in obtaining an optimal primary result. It provides a rational basis for the selection of an option tailored to both the patient and the individual tissue characteristics in addition to the pertinent medico-legal issues.

Form stability of the Style 410 anatomically shaped cohesive silicone gel-filled breast implant in subglandular breast augmentation evaluated with magnetic resonance imaging

BACKGROUND

In this study, the authors evaluated the form stability of the Style 410 anatomically shaped cohesive silicone gel-filled breast implant after subglandular implantation.

METHODS

Nine women who had undergone bilateral subglandular breast augmentation using Style 410 implants were examined in the prone and supine positions with magnetic resonance imaging.

RESULTS

In the supine position, the dimensions of the implants were similar to those specified by the manufacturer. In the prone position, there was a mean increase of 29.5 percent (range, 9.7 to 53.3 percent) in implant projection. All implants had their point of maximal projection positioned in the lower pole in both positions.

CONCLUSIONS

The Style 410 implant is described as a form-stable, anatomically shaped, cohesive, silicone gel-filled implant. However, its shell and the degree of silicone gel cohesivity allow for a change in form depending on body posture. Compared with the supine position, there was a marked increase in implant projection in the prone position. The Style 410 implant keeps its lower pole fullness after subglandular implantation in both the supine and prone positions.

Round gel breast implants or anatomic gel breast implants: which is the best choice?

BACKGROUND

Since their introduction in 1993, anatomic implants have been popularized by numerous surgeons, but very little literature compares the precise indications, advantages, and disadvantages between round implants and anatomic implants.

METHODS

A retrospective analysis was performed for all the patients who underwent breast implantation by the main author over a 15-year period. The number of implanted patients, the shape of the implants placed, the approach routes, and the placement plane were determined as well as the relationship between the shape of the implant and the approach route. The aesthetic results obtained were analyzed in detail based on the shape of the implant used.

RESULTS

Over a 15-year period, 932 patients underwent surgery for breast implants. During the first 6 years, only round implants were used, and during the last 9 years, both anatomic and round implants were used. A total of 787 pairs of round implants and 145 pairs of anatomic implants were placed. The indications based on the postoperative aesthetic analysis suggest the use of implants according to their shape.

CONCLUSIONS

The use of anatomic implants is suggested for patients with significant differences in chest height and width measurements, for cases of significant mammary asymmetry, for patients with a small breast volume or a prominent thorax, and for breasts with a significant deficit of inferior mammary volume or significant shortening of the breast. The authors recommend round implants for patients with a superior pole deficit or moderate breast pseudoptosis, for patients who have a breast that will cover the implant, and for patients who present with a small asymmetry.

Three-dimensional laser imaging as a valuable tool for specifying changes in breast shape after augmentation mammaplasty

BACKGROUND

Three-dimensional (3D) terrestrial laser scanning (TLS) is a valuable method for measuring shapes of objects and for obtaining quantitative measurements. These qualities of the 3D laser scanner have proved to be useful in reconstructive breast surgery. This study investigated various 3D parameters to obtain an optimal objective visualization of the breast after cosmetic augmentation mammaplasty.

METHODS

The objects are represented in a point cloud, which comprises millions of x, y, and z coordinates representing a virtual image. The quantification of 3D points shows changes in height (z coordinate) at any chosen point on the augmented breast (x and y coordinates). To give visual feedback on the change in dimensions, a color elevation scheme was applied on the reconstructed surface of the breast. As a quantifying description, a sagittal B-spline was chosen in a plane through the nipple to obtain the breast shape via the lateral profile.

RESULTS

Pre- and postoperative clear images were obtained. The color elevation model showed an increased projection and upper pole fullness after augmentation. The B-spline showed the gain in projection in a sagittal plane through the nipple.

CONCLUSIONS

Three-dimensional TLS is capable of objectifying changes in shape after augmentation mammaplasty. This imaging technique represents superior visualization of the breast shape and can serve as a valuable tool to determine the changing dimensions of the breasts after augmentation mammaplasty.