Quantifying Dynamic Deformity After Dual Plane Breast Augmentation

Pectoral Muscle Re-Attachment with Breast Implant Removal

Breast implant removal is an increasingly requested procedure. An uncommon but important reason for this is breast animation deformity (BAD). Although methods such as the split muscle have been used for prevention and correction of animation deformity successfully for many years, [1, 2] we occasionally see patients who have undergone explantation and present with unresolved animation. These patients have had prior unsuccessful attempts at correction by further muscle release, and explantation was done as a final attempt at resolution. We regard muscle re-attachment as key to correction of animation. Herein we present illustrative cases and discuss technical points.

Layered Mastopexy with Augmentation in Muscle Splitting Biplane: A Modification for Lower Pole Safety and Stability

BACKGROUND

Single-stage mastopexy with augmentation is a commonly performed procedure. The single-stage procedure can be performed in primary cases or a secondary procedure in patients with previous history of augmentation, mastopexy or mastopexy with augmentation. The procedure is challenging and not without its risks.

METHODS

A retrospective chart review of all consecutive cases of layered mastopexy with augmentation mammoplasties, carried out from September 2015 to August 2019, was performed. All patients had their implants placed in muscle splitting pocket first and access for the pocket was closed prior to the commencement of mastopexy.

RESULTS

During the period of 4 years, 102 consecutive layered mastopexy with augmentations were performed in muscle splitting plane. Of these 102 patients, 74 (72.5%) patients had it as a primary and 28 (27.5%) as a secondary procedure. Of these 102 patients, 53 (52.0%) had textured, 37 (36.3%) had smooth and 12 (11.8%) had microtextured implants and 72 (70.6%) patients had high profile and 30 (29.4%) had medium profile implants. Same size implant was used in 89 patients with a mean of 298 cc, and 13 patients had different size implants with a mean of 362 cc on the right and 395 cc on the left. In current study, bilateral periareolar, vertical scar cat's tail and Wise pattern mastopexies were performed in 11, 51 and 27 patients, respectively. Of the 102 patients, 5 had unilateral right periareolar, 5 unilateral right vertical scar cat's tail, 2 unilateral left periareolar and 1 patient had a combination of periareolar and vertical scar combination. There was no nipple loss or periprosthetic infection. There was a minor wound breakdown seen in 4 (3.9%), haematoma in 2 (2.1%), nipple sensation loss in 2 (2.1%) and 12 (11.8%) had layered mastopexy as a part of a combined procedure. Revision was performed in 6 (6.5%), drains were used in 14 (13.7%), and 92 (90.2%) had the procedure performed as a day case.

CONCLUSION

Layered mastopexy with augmentation is a safe procedure with added stability and safety to lower pole of the breast as well as nipple-areolar complex.

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 .

Muscle-Splitting Transaxillary Revision Breast Augmentation-A Single Surgeon's Experience

BACKGROUND

Well discussed in a previous article published by the senior author, primary transaxillary breast augmentation drawbacks include the need to correct complications arising from reuse of the axillary incision which the literature is sparse on. We here discuss a technique in patients who underwent a secondary transaxillary breast augmentation procedure.

OBJECTIVES

This study aims to present a technique for transaxillary revision breast augmentation with conversion to a muscle-splitting plane which has the advantage of good upper and medial pole coverage and adequate lower pole expansion.

METHODS

We performed a retrospective chart review of 41 women with previous silicone gel implants placed through a transaxillary incision who presented with rippling or a desire for larger implants (January 2016-July 2020). Inclusion criteria were age 18 years or older and having undergone breast augmentation surgery. Exclusion criteria were active smoking and body mass index (BMI) greater than 30 kg/m². At one year postoperatively patients were asked a "yes or no" question regarding satisfaction with the overall result and with the scar quality.

RESULTS

A total of 41 patients were included in this study; no patients were excluded. The patients' age ranged from 32 to 47 years, the average being 38 years old. All participants were female. Mean BMI was 21.9 kg/m² and all patients had a pinch test <2cm. Indications for surgery included rippling (all patients) and a desire for larger implant size (n = 5). Size of new implants ranged from 325cc to 430cc; all were of a larger size than those used in the primary surgery. Operative time was on average 53 min. [4483 min.]. Mean follow-up was 13 months, ranging from 12 to 15 months. There was no additional cost related to operative time. Regarding patient satisfaction, 100% replied they were pleased with the overall results and scar quality. There were no major complications.

CONCLUSION

The transaxillary approach for muscle splitting breast augmentation revision surgery offers a safe and reproducible technique. Despite having a mean follow-up of only 13 months, we demonstrate a low rate of complication as well as high degree of patient satisfaction with no extra cost when compared to other techniques.

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 .

Development and Psychometric Validation of the BREAST-Q Animation Deformity Scale for Women Undergoing an Implant-Based Breast Reconstruction After Mastectomy

BACKGROUND

To assess the impact of animation deformity on health-related quality of life, a content-specific, valid, and reliable patient-reported outcome measure is needed. This report describes the development and validation of the BREAST-Q Animation Deformity scale.

METHODS

Women with breast cancer who had an implant-based reconstruction provided data. In phase 1 (January 2017 and December 2018), qualitive and cognitive patient interviews and expert input were used to develop and refine scale content. In phase 2 (March to June 2019), a field test study with members of the Love Research Army (LRA) was conducted. Rasch Measurement Theory (RMT) analysis was used to examine psychometric properties.

RESULTS

In phase 1 of the study, qualitative (n = 11) and cognitive (n = 4) interview data and expert input (n = 9) led to the development of a 12-item scale measuring animation deformity. In phase 2, 651 LRA members provided data and 349 participated in a test-retest study. In the RMT analysis, the data fit the Rasch model (X²(96) = 104.06; p = 0.27). The scale's reliability was high, with person separation index and Cronbach alpha values with/without extremes of ≥ 0.84 and ≥ 0.92 respectively, and an intraclass correlation coefficient of 0.92 (95% confidence interval, 0.90-0.94). Mean scores on the Animation Deformity scale varied as predicted across subgroups of participants who reported differing amounts of change in breast appearance when their arms were lifted overhead or when they lifted something heavy, and for increasing happiness with the overall outcome of their breast reconstruction.

CONCLUSION

The 12-item Animation Deformity scale forms a new scale in the BREAST-Q Reconstruction Module that can be used in comparative effectiveness research or to inform clinical care.

Use of the Subfascial Plane for Gender-affirming Breast Augmentation: A Case Series

Transgender women seeking gender-affirming breast augmentation often present with differences in preoperative chest measurements and contours in comparison with cisgender women. These include a more robust pectoralis muscle and limited glandular tissue, raising important considerations in determining the optimal anatomical plane for implantation. Abundant literature has described advantages and drawbacks of the available planes for breast augmentation in cisgender women. Certain drawbacks may be more pronounced for transgender women, given their distinct anatomy. The subfascial plane offers lower complication rates than the subglandular plane when using smooth implants, and avoids implant animation and displacement associated with the subpectoral plane. To our knowledge, existing studies have not yet addressed this discussion in the transfeminine population. The goal of this article is to highlight potential benefits of the subfascial plane for gender-affirming breast augmentation, utilizing a case series of 3 transfeminine patients, and to review the literature on surgical techniques and outcomes in this population.

SMS-Split Muscle Support: A Reproducible Approach for Breast Implant Stabilization

BACKGROUND

Recent concerns regarding the association between macrotextured breast implants and anaplastic large cell lymphoma (ALCL) have led to renewed interest in the use of devices with less texturing. Smooth implants appear to have a decreased risk of ALCL; however, low implant adherence has led to questions about implant stabilization and bottoming-out. The senior author has used a split muscle support (SMS) technique to help support the implant infero-laterally in over 380 breast augmentations and augmentation-mastopexy using smooth implants, with a low complication and reoperation rate.

METHODS

A retrospective chart review of 387 consecutive breast augmentation and augmentation-mastopexy patients operated on by the senior author over 24 months was performed. The SMS technique was classified in three grades according to amount of implant support by the pectoralis major muscle.

RESULTS

Patients were followed for an average of 13 months. Major complications occurred in seven (1.9%) patients, of which five (1.4%) were considered implant-related. There were one case of implant rotation and three cases of malposition during the transition from microtexture to nanotexture implants and one case of capsular contracture in a previously irradiated breast. Three post-massive weight loss patients required reoperation for further skin adjustment, and one patient requested upsizing of her implants at 3 months.

CONCLUSIONS

The SMS technique is easily reproducible, adjustable intraoperatively according to patient characteristics, and helps stabilize breast implants. With increasing patient awareness regarding ALCL, the association of smooth implants along with the varying degrees of implant support afforded by SMS can help achieve a low complication and reoperation rate.

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.

The Triple Plane, the Bra-Flap, and the Inverted Bra-Flap Modified Dual Plane Techniques for Breast Augmentation

BACKGROUND

Breast augmentation (BA) is a very common procedure performed for a wide range of indications. The short-term and long-term outcomes are strongly correlated with the choice of the correct implant pocket, which should be tailored to the anatomic features of the breast.

OBJECTIVES

The aim of this study was to report the safety and efficacy of the triple-plane technique and Bra-flap modified dual-plane techniques for BA.

METHODS

From January 1995 to January 2016, 605 patients underwent BA procedures that utilized the triple-plane technique or Bra-flap modified dual-plane techniques. Patient evaluation was performed preoperatively and postoperatively at 6 and 12 months and every 5 years thereafter. The occurrence of ptosis and implant malposition, as well as breast animation deformity, were assessed. Patient satisfaction was evaluated with the BREAST-Q Augmentation Module.

RESULTS

The average patient age was 39.3 years. The follow-up period ranged from 24 months to 20 years. The triple-plane technique was performed in 450 patients, the Bra-flap modified dual-plane technique in 97, and the inverted Bra-flap modified dual-plane technique in 58. No cases of double-bubble deformity or implant bottoming-out were observed. Regarding animation deformity, 209 patients presented with mild to moderate distortion, whereas no patients presented with severe distortion. The BREAST-Q questionnaire reported significant postoperative improvements in all scales.

CONCLUSIONS

In over 20 years of experience, the triple-plane technique has proven to be a reliable procedure that offers natural and long-lasting results. The Bra-flap and inverted Bra-flap modified dual-plane techniques are efficient options to expand the range of breast conditions treated.

LEVEL OF EVIDENCE: 4

A simple clinical assessment of breast animation deformity following direct-to-implant breast reconstruction

BACKGROUND

A high incidence of breast animation deformity (BAD) has been reported following immediate breast reconstruction with subpectorally placed implants. The aim of this study was to assess and compare the incidence of BAD in women who underwent either subpectoral or prepectoral immediate breast reconstruction. Therefore, we developed a grading tool and tested its reproducibility in a clinical setting.

METHODS

Video recordings of 37 women who had undergone unilateral or bilateral immediate breast reconstruction were evaluated by two consultant plastic surgeons. The degree of BAD was assessed by our grading tool, named the Nipple, Surrounding Skin, Entire Breast (NSE) grading scale, which evaluates the degree of tissue distortion in three areas of the breast. Blinded assessments were performed twice by each observer.

RESULTS

Eighteen patients were reconstructed with subpectoral implant placement and 19 with prepectoral implant placement. Using the NSE grading scale, we found a significant difference in the degree of BAD between the groups, in favor of patients who underwent prepectoral immediate breast reconstruction (0.2 vs. 4, P=0.000). Inter- and intraobserver agreement was moderate (74%) to strong (88%).

CONCLUSIONS

The incidence and severity of BAD was significantly lower in women reconstructed with a prepectorally placed implant than in those who underwent subpectoral immediate breast reconstruction. All patients reconstructed using the subpectoral technique had some degree of BAD. The inter- and intraobserver agreements were high when using the NSE grading scale, suggesting it is an easy-to-use, reproducible scale for assessing BAD in women who undergo immediate breast reconstruction.

The Relationship between Animation Deformity and Patient-Reported Outcomes: Application of the BREAST-Q to a Quantitative Stratification of Animation Severity

BACKGROUND

Animation deformity can occur following subpectoral breast reconstruction and is an oft-touted rationale for prepectoral reconstruction. Despite increasing recognition, there is a paucity of patient-reported outcome studies in women with animation deformity.

METHODS

Women presenting after subpectoral implant-based breast reconstruction were evaluated for animation deformity. Video analysis and quantitative deformity assessment were performed in conjunction with BREAST-Q surveys. BREAST-Q data were compared to our quantitative animation grading scale to assess the relationship between animation severity and patient-reported outcomes.

RESULTS

One hundred forty-one subpectoral breast reconstructions met inclusion criteria. Average scores were 67.8 ± 17.9 of 100 for satisfaction with breasts and 78.3 ± 14.1 of 100 for physical well-being. Animation deformity severity did not correlate with satisfaction with breasts (p = 0.44). Physical well-being, particularly pain-related questions, increased with increasing animation (p = 0.01); specifically, patients reported significantly less pulling, nagging, and aching in the breast (p = 0.01, p = 0.001, and p = 0.004, respectively). Patients with the least and most severe animation deformity had significantly higher numbers of revision procedures (0.89 and 1.03 procedures, respectively) compared with patients with intermediate deformity (0.49 procedures; p = 0.01 and p = 0.009, respectively).

CONCLUSIONS

Although pectoralis release creates a more mobile-and more animating-reconstruction, this same release may lead to less pain because muscle is no longer contracting against a fixed space. This may lead to two distinct origins of subpectoral revision: (1) patients in pain (but low animation) and (2) patients with visibly distorted animation (but low pain).

CLINICAL QUESTION/LEVEL OF EVIDENCE

Risk, II.

An overview of animation deformity in prosthetic breast reconstruction

Animation deformity is an unsightly complication after sub-pectoral breast reconstruction characterized by implant displacement with pectoralis muscle contraction. Recent increased awareness of this phenomenon has driven interest in pre-pectoral breast reconstruction but research is limited regarding the causes and implications of animation deformity. Specifically, no patient-specific risk factors have been identified as contributing to animation deformity. Placement in a sub-pectoral plane and division of the pectoralis are the only peri-operative factors associated with severity of animation deformity. Our own quantitative analysis of animation deformity has further refined our understanding of this phenomenon, which we present here along with a review of current grading scales. We also more broadly review the current literature surrounding animation deformity, including its causes, risk factors, impact on patient outcomes and current treatment options. Overall, patients find this to be an emotionally distressing complication and most patients would like to be educated on alternative surgical options to avoid animation deformity. Treatment options range from conversion to a pre-pectoral plane to muscle-splitting techniques to selective nerve ablation to Botox injections. Further research into causes, implications and ways to enhance pre-pectoral reconstruction are needed to improve patient outcomes with this phenomenon.