Chinese women's preferences and concerns regarding incision location for breast augmentation surgery: a survey of 216 patients

Transaxillary Capsulorrhaphy with Reimplantation to Correct Bottoming-Out Deformity in Breast Mycobacterial Periprosthetic Infection: A Case Report with Literature Review

Augmentation mammoplasty is one of the most popular cosmetic surgeries, but there is a high reoperation rate (29.7%) commonly due to capsular contracture, implant malpositioning, infection, and unsatisfactory size. Although infection only accounts for 2% of cases, its management is very challenging, especially with nontuberculous mycobacteria (NTM) infection. Breast prosthetic NTM infection is a rare but is a disastrous condition with an incidence of approximately 0.013%. Immediate salvage reimplantation is usually not suggested, and most studies recommend a gap of 3 to 6 months after combination antibiotics therapy before reimplantation. However, delayed reimplantation often leads to great psychological stress and struggle between the doctor and patient. We present the case report of successful reimplantation in treating prosthetic NTM infections in a 28-year-old female. We discuss a novel technique "transaxillary capsulorrhaphy" to correct the bottoming-out deformity. One year after the combination of antibiotics and surgery, the follow-up computed tomography scan showed complete remission of NTM without recurrence. We discuss the surgical technique in detail. The 1-year follow-up assessment (photos and dynamic video) revealed good cosmesis and reliable correction using the new technique. This report is the first formal description and discussion of one-stage reimplantation following NTM infections. Transaxillary capsulorrhaphy allows for a successful salvage operation when an implant is displaced. This approach provides highly favorable result in eastern women undergoing revision augmentation mammoplasty. This study reflects level of evidence V, considering opinions of respected authorities based on clinical experience, descriptive studies, or reports of expert committees.

Comparison of Total and Nontotal Endoscopic Transaxillary Breast Augmentation Techniques: A Retrospective Study

BACKGROUND

The aim of this retrospective study was to compare the clinical outcomes of total endoscopic transaxillary (TET) breast augmentation with those of non-TET (NTET) breast augmentation. For the purposes of this study, the term NTET refers to the combination of blunt dissection and endoscopic techniques, whereas TET did not involve blunt dissection.

METHODS

We conducted a retrospective review of 119 consecutive cases of primary breast augmentation from May 1, 2020, to August 31, 2020. The primary outcomes were the number of drainage days and pain scores as assessed using the visual analog scale on the first postoperative day. The secondary outcomes were the daily drainage volume recorded during the postoperative drainage days, the presence of postoperative daily pain that required the administration of tramadol for relief, reoperation rate, and operative time.

RESULTS

The number of drainage days was significantly lower in the TET group than in the NTET group (TET vs NTET: 2.56 ± 0.57 vs 3.78 ± 1.30 days, P = 0.000). The visual analog scale score on the first postoperative day was significantly lower in the TET group than in the NTET group (TET vs NTET: 4.96 ± 0.63 vs 5.93 ± 0.93, P = 0.000).

CONCLUSIONS

We observed that the major outcomes of the TET group were more favorable than those of the NTET group. Based on our results, we recommend the avoidance of blunt dissection during endoscopic transaxillary breast augmentation.

LEVEL OF EVIDENCE

III.

Breast Morphological Comparison Between Anatomic and Round Implant Augmentation: A Prospective Study

BACKGROUND

The choice of implant shape (anatomic or round) is one of the most critical issues for breast augmentation. Determining whether there are differences in the postoperative breast morphology of the 2 implants is pivotal for surgical planning. This issue has been controversial and lacking in evidence. The aim of this study was to provide reference for implant selection by comparing breast morphology after dual-plane augmentation with anatomic and round implants using 3-dimensional scanning technology.

METHODS

Patients with implant volume less than 300 mL who underwent transaxillary dual-plane augmentation were included in this study and were grouped according to implant shape. Three-dimensional scans were performed preoperatively and 6 months postoperatively. Postoperative breast height (BH), breast width (BW), BH of upper pole (BHUP), BH of lower pole (BHLP), breast projection (BP), BP of upper pole (BPUP), and BP of lower pole (BPLP) were measured separately, resulting in corresponding ratios (BH/BW, BHUP/BHLP, BP/BH, BPUP/BPLP). Breast volume, and the volumes of each pole (breast volume of upper pole [BVUP], breast volume of lower pole [BVLP]) and its ratio (BVUP/BVLP) were calculated. Correlation and regression analysis on the influencing factors of breast volume were performed.

RESULTS

Thirty patients with anatomic implants and 26 with round implants were enrolled in this study. The mean volumes of anatomic and round implants were 260.5 ± 26.7 and 267.9 ± 21.7 mL (P = 0.192). The ratios of BH/BW in the 2 groups were 1.39 ± 0.12 and 1.37 ± 0.19, respectively (P = 0.582). The BHUP/BHLP values of 2 groups were 1.35 ± 0.22 and 1.41 ± 0.25 (P = 0.160). Two sets of BPUP/BPLP were 0.68 ± 0.19 and 0.73 ± 0.17 (P = 0.133). The ratios of BP/BH in the 2 groups were 0.39 ± 0.08 and 0.39 ± 0.06 (P = 0.830). The BVUP/BVLP ratios for both groups were 0.75 ± 0.11 and 0.77 ± 0.12 (P = 0.287). There was a volume loss rate of 13.3% ± 3.9% and 13.9% ± 5% (P = 0.489). The postoperative volume showed a positive correlation with both the preoperative volume and the implant volume.

CONCLUSIONS

For patients with breast dysplasia undergoing transaxillary dual-plane augmentation with anatomic or round implants less than 300 mL, the difference in postoperative breast morphology is not obvious. Using these 2 shapes of implants results in a similar degree of volume loss.

A non-manufacturer-sponsored, retrospective study to assess 2-year safety outcomes of the BellaGel® SmoothFine as compared with its competitors in the context of the first Korean case of a medical device fraud

BACKGROUND

We conducted this study to assess preliminary 2-year safety outcomes of an implant-based augmentation mammaplasty using the BellaGel® SmoothFine in the context of the first Korean case of a medical device fraud.

METHODS

Our clinical series of the patients (n = 579; 1,158 breasts) received augmentation using the BellaGel® SmoothFine, Naturgel™, Motiva Ergonomix™, Eurosilicone Round Collection™, Natrelle® INSPIRA™, Natrelle® 410, Mentor® MemoryGel Xtra or Microthane®. The patients were evaluated for incidences of postoperative complications and Kaplan-Meier survival and hazards.

RESULTS

Overall, there were a total of 101 cases (17.4%) of postoperative complications; these include 31 cases (5.4%) of shape deformity, 21 cases (3.6%) of CC, 18 cases (3.1%) of early seroma, 8 cases (1.4%) of infection, 5 cases (0.9%) of early hematoma, 1 case (0.2%) of delayed hematoma, 1 case (0.2%) of rupture and 1 case (0.2%) of ripping. Moreover, there were also 15 cases (2.6%) of other complications. There were significant differences in incidences of postoperative complications between the breast implants from different manufacturers (P = 0.034). The Natrelle® 410 showed the longest survival (333.3±268.2 [141.5-525.1] days). A subgroup analysis showed that there were no significant differences in incidences of postoperative complications between the breast implants (P = 0.831). Moreover, the Natrelle® INSPIRA™ showed the longest survival (223.7±107.1 [-42.3-489.6] days).

CONCLUSIONS

Here, we describe preliminary 2-year safety outcomes of an implant-based augmentation mammaplasty using the BellaGel® SmoothFine in the context of the first Korean case of a medical device fraud.

A Preliminary Retrospective Study to Assess the Short-Term Safety of Traditional Smooth or Microtextured Silicone Gel-Filled Breast Implants in Korea

Background and objectives: We conducted this preliminary retrospective study to assess the short-term safety of silicone gel-filled breast implants (SGBIs) that are commercially available in Korean women. Materials and methods :The current retrospective, observational study was conducted in a total of 2612 patients (n = 2612) who underwent augmentation mammaplasty using breast implants at our hospitals between 1 January 2017 and 31 August 2021. Results: Overall, there were a total of 248 cases (9.49%) of postoperative complications; these include 112 cases of early seroma, 52 cases of shape deformation, 32 cases of CC, 12 cases of early hematoma, 12 cases of rupture, 12 cases of infection, 12 cases of stretch deformities with skin excess and 4 cases of rippling. Overall complication-free survival of the breast implant was estimated at 1564.32 ± 75.52 days (95% CI 1416.39–1712.32). Then, the Motiva Ergonomix™ SilkSurface showed the longest survival (1528.00 ± 157.92 days [95% CI 1218.48–1837.56]), followed by the BellaGel® SmoothFine (1458.4 ± 65.76 days [95% CI 1329.56–1587.28]), the Sebbin® Sublimity (1322.00 ± 51.20 days [95% CI 1221.64–1422.32]), the BellaGel® Smooth (1138.72 ± 161.28 days [95% CI 822.6–1454.84), the Mentor® MemoryGel™ Xtra (698.4 ± 52.64 days [95% CI 595.28–801.52]) and the Natrelle® INSPIRA™ (380.00 ± 170.88 days [95% CI 45.04–714.96]) in the decreasing order. On subgroup analysis, both the Motiva ErgonomixTM and Mentor® MemoryGel™ Xtra showed no postoperative complications. However, the BellaGel® SmoothFine, Sebbin® Sublimity and BellaGel® Smooth showed incidences of 8.87%, 4.84% and 1.61%, respectively. A subgroup analysis also showed differences in incidences of postoperative complications between microtextured and smooth breast implants (15.18% vs. 16.67%). Conclusions: In conclusion, our results indicate that diverse types of an SGBI are commercially available and their safety profile varies according to the manufacturer. Plastic surgeons should consider the safety profile of each device in selecting the optimal types of the device for Korean women who are in need of an implant-based augmentation mammaplasty. However, this warrants a single-surgeon, single-center study with long periods of follow-up.

Comparison Of Endoscopic Transaxillary And Peri-areolar Approaches In Breast Augmentation With Smooth Implants

INTRODUCTION

The most common surgical approaches for breast augmentation in Asia have traditionally been peri-areolar and transaxillary. In recent years, transaxillary approach has become increasingly popular with the use of endoscopic methods, which result in safer and better outcomes. In the literature, there are no comparison studies of endoscopic transaxillary and peri-areolar approaches.

METHODS

This prospective study compared the outcomes of 275 women undergoing primary breast augmentation (endoscopic transaxillary n=205, peri-areolar n=70). All procedures were performed by a single surgeon using smooth round silicone implants and dual-plane pockets from April 2013 to March 2016. Every patient was monitored for a minimum of 4 years for minor and major complications.

RESULTS

Types and percentage of patients experiencing minor complications among transaxillary and peri-areolar patients were localized fluid collection in the wound (1% transaxillary, 7.1% peri-areolar), hypertrophic scarring or keloids (1% transaxillary, 8.6% peri-areolar), and areolar and nipple deformity (0% transaxillary, 8.6% peri-areolar). Major complications were postoperative bleeding (0% transaxillary, 2.9% peri-areolar) and capsular contracture, Baker Group III or IV (1% transaxillary, 5.7% peri-areolar).

CONCLUSIONS

Endoscopic transaxillary breast augmentation had better outcomes, with lower rates of complications than the peri-areolar approach. Reviewing the literature, our study is the first direct comparison of peri-areolar and endoscopic transaxillary incisions using smooth implants. With the risk of anaplastic large cell lymphoma associated with certain macrotexture implants, endoscopic transaxillary approach using smooth implants is the safer technique and very good alternative choice for Asian women who do not want any scarring on their breasts.

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.

Effects of general anesthesia on quality of recovery after transaxillary endoscopic breast augmentation: A randomized controlled trial

BACKGROUND

Types of general anesthesia may affect the quality of recovery, but few studies have investigated the quality of postoperative recovery, and none has focused on patients undergoing breast augmentation.

METHODS

This prospective, parallel, randomized controlled study enrolled 104 patients undergoing transaxillary endoscopic breast augmentation. Eligible patients were randomly assigned to receive inhalation anesthesia (IH, n = 52) or total intravenous anesthesia (TIVA, n = 52). Quality of recovery was assessed on the first and on the second postoperative days using the 15-item Quality of Recovery questionnaire (QoR-15). Baseline demographic, clinical characteristics, and operative data were also collected.

RESULTS

The IH and TIVA groups had similar QoR-15 total scores on the first postoperative day (P = .921) and on the second postoperative day (P = .960), but the IH group had a significantly higher proportion of patients receiving antiemetics than the TIVA group (53.6% vs 23.1%, P = .002). Multivariate analysis revealed that the type of general anesthesia was not significantly associated with QoR-15 total scores on the first postoperative day (β = 0.68, P = .874) and with QoR-15 total scores on the second postoperative day (β = 0.56, P = .892), after adjusting for age, BMI, operation time, steroids use, and antiemetics use.

CONCLUSION

For the patients undergoing transaxillary endoscopic breast augmentation, the type of general anesthesia did not significantly impact the quality of recovery. Both IH or TIVA could provide good quality of recovery demonstrated by high QoR-15 total scores. The results suggested that the type of general anesthesia may not be the most critical factors of quality of recovery in the patients undergoing transaxillary endoscopic breast augmentation.

Personal Approach to Optimizing Inframammary Fold Incision for Asian Augmentation Mammoplasty

BACKGROUND

The rates of aesthetic breast augmentation have risen substantially in Asia. Outcomes of various breast augmentation approaches in Asia have not been comprehensively studied. In the past, the inframammary approach to breast augmentation was not popular because of conspicuous scarring. In this article, the authors review academic articles related to the use of an inframammary incision for breast augmentation in Asian women and present our recommendations for the available techniques.

METHODS

A literature search was performed for articles published after 2015 on Asian women with augmentation mammoplasty describing techniques, incision sites, outcomes, and complications. The search was performed using the MEDLINE, Embase, and Cochrane databases. We also included our own technique to demonstrate the outcome of augmentation mammoplasty through inframammary incision.

RESULTS

Eight articles satisfied our inclusion criteria. Evidence indicates that with proper preoperative design and surgical techniques, scarring resulting from the inframammary approach is not inferior to that resulting from the transaxillary approach in Asian patients. Long-term satisfaction with the inframammary approach to breast augmentation is high in Asian patients.Eight articles reported the outcomes of 1168 women receiving breast augmentation. Inframammary incisions were used in 45.29% of patients (529 patients). After the 2015 publication of Zelken's review paper on Asian breast augmentation, the rate of inframammary incisions increased from 3.1% to 45.29%.

CONCLUSIONS

With precise design of the new inframammary fold, accurate wound suture fixation, and postoperative scar care, the inframammary approach to breast augmentation offers optimal operative visualization, reduced pain, fewer complications, and desirable esthetic outcomes even in Asian patients. This study demonstrates that the percentage of inframammary fold approach of Asian esthetic mammoplasty grows rapidly after 2015.

A Randomized Controlled Trial to Assess the Use of a Virtual Decisional Aid to Improve Knowledge and Patient Satisfaction in Women Considering Breast Reconstruction Following Mastectomy

Background

The decisional process of navigating breast reconstruction surgery is very challenging for patients with a breast cancer diagnosis. This study aims to assess the impact of a virtual breast reconstruction decision aid program on the decision-making process of breast cancer patients considering breast reconstruction. 

Methods

A two-arm, randomized, controlled trial was conducted at the University of Pittsburgh. Patients were blindly assigned to one of two arms: Emmi Decide (Emmi Solutions LLC, Chicago, IL) program prior to traditional consultation (intervention) and traditional consultation alone (control). All patients completed a baseline pre- and post-intervention questionnaire to evaluate knowledge, patient satisfaction, and psychological status. Surgeons' satisfaction and consultation time were also recorded.

Results

A total of 26 patients participated in the study (n=13 in each arm). Patients in the intervention group reported a greater BREAST-Q reconstruction module score (control=47.9±8.2, intervention=56.8±4.2, p=0.0017), lower decisional conflict scale score (control=30.2±11.8, intervention=14.5±8.8, p=0.017), and improved patient knowledge (control=70.8±15.5%, intervention=83.1±13.8%, p=0.018). No difference was noted in consultation time (control=51.0±7.8 min, intervention=47.8±13.7 min, p=0.46) and psychological testing (control=49.7±16.0, intervention=44.6±15.2, p=0.26). However, surgeons reported greater satisfaction with their consultations with interventional group participants (control=3.4±0.7, intervention=4.8±0.4, p=0.000056).

Conclusions

The use of a virtual decisional aid program to assist the decision-making of breast reconstruction patients was shown to significantly benefit both patients and surgeons, by improving patient knowledge and satisfaction without placing an additional psychological burden on them. This supports the notion that this resource is a promising tool that can improve the difficult process of breast reconstruction in the vulnerable population of breast cancer patients. 

Endoscopic transaxillary capsulectomy with immediate reimplantation performed as a single-operator outpatient procedure

Capsulectomy is a standard treatment for capsular contracture after breast augmentation. Incision via the endoscopic transaxillary approach is generally preferred by Asian women, but relevant literature addressing endoscopic transaxillary capsulectomy is limited. This study described the techniques of endoscopic transaxillary capsulectomy with reimplantation performed as a single-operator outpatient procedure. This retrospective study included patients with diagnosis of capsular contracture underwent endoscopic transaxillary capsulectomy with immediate reimplantation between January 1, 2013 and December 31, 2017. Data regarding history, implant type, operation time, duration of postoperative drainage, and complications were collected and analyzed. A total of 42 patients with a mean age of 36 years were included (11 unilateral and 31 bilateral capsulectomy). Total capsulectomy was performed on four (10%) patients for previous subglandular augmentation, and anterior capsulectomy was performed on 38 (91%) patients for previous submuscular augmentation. Mean sizes of previous and new (or reused) implants were 268 ml (median 283 ml, SD 57) and 317 ml (median 307 ml, SD 49), respectively. Mean operation time for unilateral and bilateral procedures were 4 h 15 min and 6 h 28 min, respectively. Postoperatively, mean duration of wound drainage was 10 (SD 3) days. Six (14%) patients experienced complications, including two (5%) patients with seroma, two (5%) with hematoma, one (2%) with infection, and four (10%) with recurrent capsular contracture. The four recurrent cases underwent repeat endoscopic transaxillary capsulectomy. All of the 42 patients had satisfactory clinical and esthetic outcomes. This study demonstrated the feasibility of endoscopic transaxillary capsulectomy with immediate reimplantation performed as an ambulatory surgery by a single surgeon who is in a stable and comfortable sitting position without the aid of a surgical assistant.

Transaxillary Endoscopic Approach to Capsular Contracture Following Previous Breast Augmentation: Operative Technique and Clinical Outcome

BACKGROUND

Capsular contracture (CC) is a complication of breast augmentation that frequently requires revision surgery. The axillary approach reduces the visibility of the postoperative scar. It is unclear whether the previous incision can be used to repair the deformity caused by CC.

METHODS

This study analyzed 21 patients (42 breasts) with grade III-IV CC during 2012-2017. The mean age of the patients was 32 years (range 23-48). Previous axillary scars were used to expose, and CCs were taken out completely or partially. Breast implants were removed. The dissection was performed with endoscopic assistance, using electrocautery under direct visualization.

RESULTS

The mean follow-up period was 13 months (range 6-24 months). The dissection plane was changed to dual plane. Thirty-five CCs were taken out completely. Thirty-eight breast implants taken out remained intact. None of the patients required additional surgery.

CONCLUSION

Endoscopic-assisted treatment may be an effective technique for treating CC and avoiding the additional scar.

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.

Short-term Safety of Augmentation Mammaplasty Using the BellaGel Implants in Korean Women

Supplemental Digital Content is available in the text.

Asian women are stereotypically characterized by a slim body, smaller breasts and areolae, and larger nipples when compared with White women. They would therefore be vulnerable to displacement of a breast implant if they receive larger implants. They are also prone to hypertrophic and prolonged hyperemic scars. Surgeons should therefore be aware of Asian women’s breast anatomy, healing tendency, and preferences. We conducted this multicenter, retrospective study to assess the short-term safety of the BellaGel implants in Korean women.

The Comparison of Scars in Breast Implantation Surgery with Inframammary Fold Incision Versus Axillary Incision: A Prospective Cohort Study in Chinese Patients

BACKGROUND

A prospective cohort study was developed to compare the surgical scars in the axilla and the inframammary fold at short-, medium- and long-term time periods after surgery.

METHODS

Patients who underwent primary breast augmentation with implants in our department were divided into two groups based on the incision location they chose and were followed up for scar assessment at 1 month, 6 months and 12 months post-surgery from June 2012 to March 2016. Each scar was evaluated by the Vancouver Scar Scale (VSS) and patient satisfaction score. The data were analyzed with Wilcoxon rank-sum tests, Cochran-Armitage trend tests and Fisher's exact probability tests based on the data type.

RESULTS

One hundred and sixty-three patients were completely investigated three times. Ninety-four patients underwent breast augmentation surgeries with implants through axillary approaches and 69 patients through IMF approaches. At 1 month after surgery, the median total VSS score was 6 in the axillary incision group and 4 in the IMF group, with statistically significant differences (P < 0.05). Larger proportions of high scores in terms of vascularity and height were found in the axillary incision group (P < 0.05). At 6 months after surgery, the median total VSS score was 4 in the axillary incision group and 3 in the IMF group, with statistical significance (P < 0.05). The axillary group still had a larger proportion of high scores in terms of vascularity and height than that of the IMF group (P < 0.05). At 12 months after surgery, the median total VSS score was 2 in both groups. The median patient satisfaction score was 9 in both groups. No significant differences were noted in the total VSS and patient satisfaction scores between the two groups. However, the axillary group had a larger proportion of high scores in terms of vascularity and low scores in terms of pliability.

CONCLUSIONS

The total VSS score for the axillary incision group was significantly higher than that for the IMF incision group one and 6 months after surgery, mainly on the subscales of vascularity and height. At 12 months after surgery, the total VSS scores were not different between the two groups, and patients with both kinds of incisions were highly satisfied with scar appearance. The research confirmed that the scars at two locations can achieve comparable appearance in the long term after surgery.

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 www.springer.com/00266 .

A Low-Cost Simulator for Training in Endoscopic-Assisted Transaxillary Dual-Plane Breast Augmentation

BACKGROUND

Endoscopic-assisted transaxillary dual-plane (EATD) technique is a popular procedure for breast augmentation, especially for Chinese women. However, frustration is often expressed by plastic surgeons when first attempting EATD surgery. Simulation-based teaching is beneficial for EATD training, but it is expensive. This study presents a low-cost simulator to help plastic surgeons exercise psychomotor skills during EATD surgery.

METHODS

The low-cost simulator was invented by Dr Jie Luan (the senior author) and made of some easily available materials including a mannequin, a T-shirt printed the bottom anatomical structure of the chest, the order of dissection, and the potential bleeding spot, and an elastic compression garment printed the upper anatomical structure and the cut-off position to sever the pectoralis major muscle. The first-year residents of plastic surgery assessed their improvement by completing a 5-item evaluation questionnaire at the beginning and at the end of the simulation.

RESULTS

Fifty participants enrolled in this study. There was a significant difference (P < 0.05) before and after the training regarding candidate confidence, anatomical awareness, and endoscope control including the dexterity and hand-to-eye coordination.

CONCLUSIONS

The low-cost and simple maintenance simulator may help plastic surgeons, especially those in developing countries, to improve gradually their EATD breast augmentation skills with no risks in a way. Further randomized controlled trials are needed to test its validity and reliability.

Lateral Inframammary Approach for Asian Augmentation Mammaplasty

Background:

The inframammary fold (IMF) approach for augmentation mammaplasty is less popular in Asia. The incision was modified to lateral IMF(L-IMF) for easy access and better outcome. The aim of this study was to evaluate if L-IMF approach is feasible in Asian women.

Methods:

Between 2002 and 2016, 53 patients with 96 augmentation mammaplasties were performed using lateral (L-IMF, 31 cases, 56 breasts) and traditional IMF approaches (T-IMF, 22 cases, 40 breasts). Surgical outcome was compared between L-IMF and T-IMF groups. Scar was assessed using photographic images by 4 assessors with a modified Manchester Scar Score, and telephone surveys available in L-IMF group.

Results:

The average age was 41 ± 10.7 years (range, 20–73 years). There were no statistical differences in demographics in both groups besides of implant type (P < 0.01). At a follow-up of 80.1 months (range, 20–173 months), the capsular contracture rate and overall complication rate were statistically lower in L-IMF group, 3.6%, and 3.6%, than in T-IMF group, 15%, and 20% (P = 0.05, and P < 0.01, respectively). The modified Manchester Scar for L-IMF scars was 8.47 ± 2.4. The average score of 24 of 31 patients with L-IMF incision was 3.8 ± 0.96/5 points with patient-reported questionnaire. Nineteen patients (79.2%) would recommend or strongly recommend the procedure to friends.

Conclusions:

The scar of L-IMF group healed satisfactorily with lower capsular contracture and overall complication rates than T-IMF group. Patients were satisfied with the outcome of breast augmentation and scar appearance using L-IMF approach.

Comparison between different methods of breast implant volume choice and degree of postoperative satisfaction

OBJECTIVES

to assess the degree of patient satisfaction after undergoing breast augmentation and compare three different, easy, inexpensive and universal methods of preoperative choice of breast implant volume.

METHODS

a prospective study was carried out at University Hospital Pedro Ernesto of State University of Rio de Janeiro, in 94 women from Rio de Janeiro, aged 18 to 49 years, submitted to breast augmentation mammaplasty with breast implant due to hypomastia. All implants were textured, with a round base and high projection and were introduced into the retroglandular space through an inframammary access. The patients were divided into three groups: Control, Silicone and MamaSize®, with 44, 25 and 25 patients, respectively. Satisfaction questionnaires were applied in the pre and postoperative periods by the same evaluator, through the visual analogue scale, in which '0' meant very unsatisfied and '100' very satisfied for the four variables: shape, size, symmetry and consistency. The degree of satisfaction with the surgical scar was also assessed in the postoperative period.

RESULTS

when the preoperative and postoperative satisfaction levels were compared, there was a difference in all variables for the three groups, with statistical significance. However, when the postoperative data were compared with each other, there was no significant difference. The degree of satisfaction with the surgical scar was high.

CONCLUSION

the augmentation mammaplasty with breast implant had a high index of satisfaction among patients. However, there was no difference in the degree of satisfaction in the postoperative period between the three methodologies of breast volume measurement.

Scar Assessment After Breast Augmentation Surgery with Axillary Incision versus Inframammary Fold Incision: Long-Term Follow-Up in Chinese Patients

BACKGROUND

The inframammary fold (IMF) incision is widely used in Western countries for breast augmentation surgery, whereas the axillary incision is the dominant approach used in China, because many Chinese surgeons believe that the Asian population has a higher risk of developing hypertrophic scars. However, comparative data of scar assessment through different incisions in Chinese patients are scarce. The aims of the study were as follows: (1) to evaluate the outcomes of scar assessment using the Vancouver scar scale (VSS), combined with patient satisfaction scoring, in the scar assessment after breast augmentation surgery; (2) to compare the long-term cosmetic effects of surgical scars between axillary and IMF incisions.

METHODS

Consecutive patients coming to our department for follow-up care at least 1 year after primary breast augmentation surgeries with axillary and IMF incisions between January 1, 2014 and December 31, 2014 were included in the research. Internal consistency, inter-rater reliability, and convergent validity were examined for the VSS and patient satisfaction scoring. The baseline characteristics and scar scores were tested using the Mann-Whitney U-test and Student's t test between the two groups.

RESULTS

Sixty-one patients underwent implantation surgeries through the axillary incisions, and 17 patients through the IMF incisions. There were no significant differences in age, follow-up time, body mass index, implant volume, or implant projection between groups. Reliability and validity of the VSS and patient satisfaction scoring were satisfactory. The scores of pigmentation were higher in the IMF group than those in the axilla group with statistical significance (P < 0.05). The scores of other subscales, overall VSS scores, and patient satisfaction were not statistically significant. The scars were significantly longer in the axilla group compared with the IMF group (P < 0.05).

CONCLUSIONS

The VSS combined with patient satisfaction scoring constitutes an effective tool to evaluate incision scars after augmentation mammaplasty. Scars in the axilla and IMF can achieve comparable cosmetic effects and patient satisfaction in Chinese women. Chinese patients with proper indications can receive breast augmentation surgery through the IMF incision, with fewer risks and less trauma, and get satisfactory scar appearance as through the axillary incision.

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 www.springer.com/00266 .

Response to the Comments of Dr. Chen on Chinese Women's Preferences and Concerns Regarding Incision Location for Breast Augmentation Surgery: A Survey of 216 Patients

In our previous article, preoperative education material regarding different incisions for breast augmentation surgery was compiled to help Chinese patients fully understand the characteristics of different incisions and make informed choices. Dr. Chen argued that some key indicators were missing in the instrument. However, the preoperative education material was compiled based on existing literature to provide patients with valid information. The items listed were proven to be directly connected to incision choices. The items unlisted were unconfirmed or not related to incision choices.

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.

Shared Decision-Making in Cosmetic Medicine and Aesthetic Surgery

Shared decision-making (SDM) invokes the bidirectional communication between physicians and patients required to involve the patient's preference in the eventual treatment choice. This paper will explain what SDM is, why it is important, and how it is performed in clinical practice. It is an essential part of evidence-based medicine, as it helps determine whether the available evidence on the possible benefits and harms of treatment options match the patient's characteristics and preferences. Cosmetic medicine and aesthetic surgery seem to be obvious fields of medicine in which SDM should be applied to achieve high-quality care.

Asian Breast Augmentation: A Systematic Review

BACKGROUND

Economic, cultural, and regulatory phenomena may explain recent popularization of implant-based augmentation in Asia; but the collective Eastern experience remains limited. Asian surgeons and their patients rely on evidence-based medicine that originates elsewhere and may not be entirely relevant. Distinct anatomic and cultural features of Asian women warrant a tailored approach to breast augmentation. We explore the Asian experience with a thorough exploration of the recent literature.

METHODS

A literature search was performed for articles written after 2000, of Asian women who underwent augmentation mammoplasty using MEDLINE, Embase, and Pubmed Databases. Technique and outcomes data were summarized.

RESULTS

Twelve articles reported outcomes of 2089 women. Korea contributed most series (English language, 7), followed by China (3), Taiwan (1), and Japan (1). Silicone implants were used in 82.1% of women studied, and almost exclusively after 2009. More round (68.9%) than anatomic implants (31.1%) were placed. Non-inframammary (axillary, areolar, and umbilical) incisions were used in 96.9% of cases. Nearly all implants were positioned below the muscle or fascia; subglandular placement accounted for 1.1% of cases. Implant/nipple malposition (1.3%), capsular contracture (1.9%), hematoma (0.6%), and infection (0.2%) rates were reported in most series. Undesirable scarring was the most frequent complication (7.3%), but was reported only in 4 of 12 series.

CONCLUSIONS

Studies of Asian women undergoing augmentation mammoplasty are limited, often with ill-defined outcomes and inadequate follow-up. As experience accumulates, an expanding literature relevant to Asian women will provide evidence-based guidelines that improve outcomes and patient satisfaction, and foster innovation.

Comment on Chinese Women's Preferences and Concerns Regarding Incision Location for Breast Augmentation Surgery: A Survey of 216 Patients

The recent article by Sun et al. regarding a preoperative instrument to aid patients' decision-making on different incision sites in breast augmentation was reviewed. Some key indicators are missing in the instrument.

LEVEL OF EVIDENCE IV

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