Prospective Analysis of the Outcome of Subpectoral Breast Augmentation: Sensory Changes, Muscle Function, and Body Image

Long-Term Satisfaction with Breast Augmentation and Augmentation Mastopexy in the Latin American Population

OBJECTIVE

The primary objective of this study was to determine the long-term satisfaction levels of women who have undergone breast augmentation and augmentation mastopexy procedures, while identifying the factors influencing patient satisfaction.

METHODS

A self-reported retrospective case study design was used to collect data from women with breast implants. The study employed a survey that included demographic information, preoperative diagnosis, implant details, and patient-reported outcomes measured using the Breast-Q Instrument, which evaluates satisfaction with breasts, self-esteem, sexual well-being, and physical symptoms. Statistical analyses were conducted to identify correlations and differences in outcomes between the different variables.

RESULTS

The survey was completed by 1022 women from 19 countries, with Chile, Mexico, and Colombia being the most represented. Augmentation was performed on 72.2% of the patients, while 27.7% underwent augmentation mastopexy. Patient satisfaction with breast size and shape varied significantly between the two procedures, with patients undergoing augmentation mastopexy showing less satisfaction. In addition, patients who were unaware of their implant shape or placement reported lower satisfaction scores. The study also found that patient satisfaction decreased over time in the augmentation mastopexy cases and that patients with high body mass index had lower satisfaction.

CONCLUSION

Augmentation mastopexy in patients with breast ptosis yields lower satisfaction than augmentation alone. Dissatisfaction escalates with overweight/obesity (BMI), post-surgery time, and misinformation. Implant pocket (pre-vs. subpectoral), shape (round vs. anatomical), and size did not impact satisfaction.

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 .

Sensory Evaluation of the Nipple-Areolar Complex Following Primary Breast Augmentation: A Comparison of Incision Approaches

BACKGROUND

The central inframammary incisional approach for breast augmentation surgery disrupts the fifth anterior intercostal nerve-artery-vein-plexus. The authors hypothesized that preservation of the fifth anterior intercostal neurovascular pedicle might completely preserve nipple-areola complex (NAC) sensitivity after implant breast augmentation.

OBJECTIVES

The aim of the study was to analyze if the use of a laterally displaced incision achieves better sensitivity results than the conventional median submammary incision in females who underwent primary breast augmentation surgery.

METHODS

A group of 25 female patients (50 breasts) underwent a surgical protocol for primary prepectoral implant breast augmentation with a laterally displaced submammary incision. This group was compared to a similar group of 25 patients (50 breasts) who underwent breast augmentation through a conventional submammary central approach. Sensitivity testing with Semmes-Weinstein monofilaments was performed in both groups preoperatively and on postoperative days 2, 14, and 30, and after 6 months.

RESULTS

Both groups were similar in age, BMI, comorbidities, and implant volumes. Preoperatively, all patients reported normal sensory function in both breasts. Postoperatively, in the laterally displaced incision group, sensory function remained normal in NAC areas, whereas in the conventional incision group, all cases presented the same degree of sensitivity diminution at Days 2, 14, and 30 (P = .000). At 6 months, all values were the same as at Day 30.

CONCLUSIONS

Preservation of the fifth AIC pedicle resulted in complete preservation of preoperative NAC sensitivity. The laterally placed inframammary incision should be considered for patients undergoing primary prepectoral implant breast augmentation.

LEVEL OF EVIDENCE: 4

A Comparison of BREAST-Q Scores between Prepectoral and Subpectoral Direct-to-Implant Breast Reconstruction

BACKGROUND

Subpectoral breast implant placement has in recent history predominated in breast reconstruction, but there has been more recent adoption of prepectoral implant reconstruction. There has been limited study to date of patient-reported outcomes comparing the two techniques.

METHODS

Patients who underwent direct-to-implant breast reconstruction between 2013 and 2018 were included in this retrospective cohort study. Eligible patients were asked to complete BREAST-Q domains comparing quality of life and satisfaction. Descriptive, t test, chi-square test, and multivariate linear regression analyses were performed to compare BREAST-Q scores. Significance was defined as p ≤ 0.05.

RESULTS

There were 64 patients (114 breasts) who underwent prepectoral reconstruction and 37 patients (68 breasts) who underwent subpectoral reconstruction. Among the 101 women (182 breasts), there were no significant differences between BREAST-Q scores and implant position for the Satisfaction with Breasts domain (adjusted p = 0.819), Psychosocial Well-being domain (adjusted p = 0.206), or Physical Well-being Chest domain (adjusted p = 0.110). The subpectoral implant cohort was associated with higher scores, 53 versus 47, for the Sexual Well-being module (adjusted p = 0.001).

CONCLUSIONS

Patients undergoing direct-to-implant breast reconstruction had comparable BREAST-Q satisfaction scores for most modules regardless of implant plane. The subpectoral implant cohort scored higher for sexual well-being.

Two-person screening of mental well-being before primary breast augmentation: Can we do more?

Patients choosing aesthetic surgery are asymptomatic individuals opting for surgery. Psychologists and surgeons have been interested in identifying characteristics of these individuals' preoperative as well as postoperative psychological changes. It was identified that a small number of patients have a primary issue with self-body image, which resulted in altered perceptions and attitudes such that the preoccupation with perceived deficiencies continued even after surgery. The recommended course is to attempt to screen for the patients' mental well-being, as surgery alone does not improve the patients' symptoms. In the first author's practice, each prospective patient is reviewed by two individuals on separate occasions in order to discuss surgery and assure their mental and physical suitability. However, we encountered four patients who exhibited a strong negative reaction to their new shape, to the point that it necessitated explanation in the immediate postoperative phase in two of them. To our knowledge, this situation has not been described in the literature. We discuss the available literature as well as our consent process for breast augmentation. The first author has since introduced BREAST-Q to assess general patient well-being in the pre- and post-operative phases as a result of this experience. We also discuss the results for each of its domains and offer our thoughts about the management of such a situation.

BellaGel breast implant: 6-Year results of a prospective cohort study

Background

This is the first clinical study conducted among Asian women using breast implants manufactured by an Asian company. Four-year data regarding the safety and efficacy of BellaGel breast implants have already been published, and we now report 6-year data.

Methods

This study was designed to take place over 10 years. It included 103 patients who underwent breast reconstruction or augmentation using BellaGel breast implants. The rates of implant rupture and capsular contracture were measured and analyzed to evaluate the effectiveness of the breast implant.

Results

At patients’ 6-year postoperative visits, the implant rupture and capsular contracture rates were 1.15% and 2.30%, respectively. The implant rupture rate was 3.77% among reconstruction cases and 0% among augmentation cases. The capsular contracture rate was 5.66% among reconstruction cases and 0.83% among augmentation cases.

Conclusions

The 6-year data from this planned 10-year study suggest that the BellaGel cohesive silicone gel-filled breast implant is an effective and safe medical device that can be used in breast reconstruction and augmentation.

Comprehensive management of breast augmentation with polyacrylamide hydrogel injection based on 15 years of experience: a report on 325 cases

Background

As a permanent soft tissue filler, the use of polyacrylamide hydrogel (PAAG) has been banned due to its myriad complications. However, a large number of symptomatic and asymptomatic patients whose breasts were augmented with the gel injection have continued to seek medical advice. This study aimed to explore standardized clinical management of breast augmentation with PAAG.

Methods

The authors retrospectively collected the data of a total of 325 patients following PAAG injection for breast augmentation from 2003 to 2018. Magnetic resonance imaging (MRI) was performed preoperatively to disclose the general distribution of the gel and its infiltration into the muscle and gland. Debridement surgery, including the PAAG evacuation, pathologic tissue excision, and pocket irrigation via the periareolar incision, was performed. Immediate breast reconstruction (IBR) using silicone prostheses was carried out on 86 patients and delayed breast reconstruction (DBR) was performed on 35 patients.

Results

Most of the patients in the group were satisfied with their surgical outcome, their symptoms disappeared after the debridement surgery, and they experienced no relapse or recurrence. Unfortunately, for most of the cases, it was extremely difficult to remove the PAAG completely-however, improved quality of life as seen through the BREAST-Q evaluation.

Conclusions

With the guidance of MRI images, surgery, including PAAG evacuation, pathologic tissue excision, and pocket irrigation via the periareolar incision, was a reliable method to ensure the maximal removal of the PAAG. Immediate or secondary breast reconstruction with sub-glandular placement of silicone prostheses showed a satisfactory mid-term effect.

Body image, cosmetic surgery, and minimally invasive treatments

Over the past 60 years, a growing body of research has investigated the psychological aspects of cosmetic surgery and related minimally-invasive treatments. While the earliest studies were influenced by psychoanalytic thinking, much of the work over the past several decades has been influenced by Thomas Cash's cognitive-behavioral theory of body image and has focused on the appearance concerns of patients who seek these procedures. The majority of individuals interested in the procedures report heightened dissatisfaction typically focused on the feature being considered for treatment. Studies from around the world also have suggested that between 5-15% of patients who present for cosmetic procedures meet diagnostic criteria for body dysmorphic disorder (BDD). While individuals with BDD typically do not report a reduction in their BDD symptoms following a cosmetic procedure, the great majority of patients without the disorder do report improvement in body image. The paper reviews this literature and also discusses the role of body image in three newer areas of plastic surgery-body contouring after massive weight loss, genital procedures (either for cosmetic purposes or as part of gender reassignment), and vascularized composite allotransplantation, including face and hand transplantation.

Patient related outcome measures for breast augmentation mammoplasty: a systematic review

We review the current literature for validated patient related outcome measures (PROM) in breast augmentation mammoplasty (BAM). Using Medline search between 1966 to 2018, using the search strategy ("patient reported outcome measure" OR "surveys or questionnaires") AND "breast" AND ("augment" OR "implant") was performed. A manual search with Google Scholar using the search term "Patient Reported Outcome Measures in Bilateral Augmentation Mammaplasty" was also performed. Once the search yielded its results, a further search of bibliographic references within the articles was also performed. The Medline computer search produced 72 results, with a Google Scholar search yielding two results and a bibliographic search of all articles revealing a further single result. Ten studies were included as they used validated PROM. Three articles used the same PROM (Breast-Q) and seven used different PROM, therefore 8 validated PROM were discovered. Bilateral augmentation mammoplasty has been demonstrated to confer an increase in patient reported outcomes in domains of satisfaction with breasts and psychological well-being. There is some decrease in physical well-being following this procedure. Validated PROMs provide objective data relating to different aspects of BAM. Combined with traditional surgeon-based outcome measures and implant registry data, they may provide a more comprehensive insight into the patient journey.

Two-Staged Implant-Based Breast Reconstruction: A Long-Term Outcome Study in a Young Population

Background and objectives: Differences in patient anatomy and physiology exist between young and older patients undergoing breast reconstruction after mastectomy. Breast cancer has been described as being more aggressive, more likely to receive radiation, contralateral mastectomy, as well as bilateral reconstruction in young patients. Our purpose is to report long-term experience on two-staged implant-based breast reconstruction (IBR) in young females, with complication sub-analysis based on obesity and adjuvant radiation. Materials and Methods: Retrospective chart review of all consecutive young patients who underwent two-staged IBR at our institution, between 2000 and 2016, was performed. Patients between 15 and 40 years old with least 1-year follow-up were included. Univariate logistic regression models and receiver operating characteristic (ROC) curves were created. Results: Overall 594 breasts met our inclusion criteria. The mean age was 34 years, and the median follow-up was 29.6 months. Final IBR was achieved in 98% of breasts. Overall, 12% of breasts had complications, leading to explantations of 5% of the devices. Adjuvant radiation was followed by higher rates of total device explantations (p = 0.003), while obese patients had higher rates of total complications (p < 0.001). For each point increase in BMI, the odds of developing complications increased 8.1% (p < 0.001); the cutoff BMI to predict higher complications was 24.81 kg/m². Conclusions: This population demonstrates high successful IBR completion and low explantation rates. These data suggest that obese women and those with planned adjuvant radiation deserve special counseling about their higher risk of complications.

Prepectoral Site Conversion for Animation Deformity

A signifcant disadvantage of subpectoral breast reconstruction procedures is animation deformity during pectoralis major contraction. In this study, we discuss one surgeon’s experience with elective subpectoral to prepectoral implant site conversion as a definitive solution to animation deformity..

Surgical Outcomes of Prepectoral Versus Subpectoral Implant-based Breast Reconstruction in Young Women

Background:

Two-staged implant-based reconstruction (IBR) is the most common breast reconstructive modality. Recently, technological and surgical advances have encouraged surgeons to revisit prepectoral IBR. Data comparing prepectoral against subpectoral IBR in women under the age of 40 are lacking.

Methods:

Retrospective chart review of patients under the age of 40 years old, who underwent immediate 2-staged IBR at our institution, was performed. Patient’s demographics, clinical characteristics, operative details, and early surgical outcomes of prepectoral and subpectoral reconstruction were compared. Data with values of P < 0.05 were considered statistically significant.

Results:

Between 2012 and 2016, 100 patients (187 breasts) who underwent prepectoral and 69 patients (124 breasts) who underwent subpectoral IBR were included. Median follow-up was 17.9 and 17.5 months in the prepectoral and subpectoral groups, respectively. Total number of complications including both stages of reconstruction was 20 (10.7%) and 19 (15.3%) in the prepectoral and subpectoral groups, respectively (P = 0.227). Specific complications, including hematoma, seroma, skin flap necrosis, wound dehiscence, and breast infections, were not significantly different among groups. Ten (5.4%) devices, including implants and tissue expander, required explantation in the prepectoral group and 8 (6.5%) in the subpectoral group (P = 0.683). Explantation was most commonly due to infection (n = 14), and all of them occurred during the first stage (P < 0.001).

Conclusions:

Early complications and implant explantation rates are comparable among prepectoral and subpectoral breast reconstruction in women under 40 years old. Based on these results, we believe that prepectoral IBR is a safe, reliable, and promising reconstructive option.

Single stage, direct to implant pre-pectoral breast reconstruction

BACKGROUND

Given the current trends in skin preservation during mastectomy, improved biofilm reduction algorithms, and advancements in tissue bioengineering and perfusion assessment, acellular dermal matrix (ADM)-reinforced single stage, direct to implant insertion in the pre-pectoral space has become a viable alternative to two-stage expander-based, sub-pectoral reconstruction.

METHODS

The authors performed a retrospective review of their pre-pectoral cases evaluating outcomes for all single stage, direct to implant procedures. Outcomes reviewed included hematoma, seroma, infection, device loss or change, animation deformity and revisional procedures such as fat grafting. The anterior tenting surgical technique is also reviewed.

RESULTS

The authors have carried out 305 direct to implant pre-pectoral breast reconstructions using an anterior tenting technique with low complication rates and superior clinical and functional outcomes. The benefits of this technique include less patient discomfort, no need for postoperative expansion, virtually no subjective negative impact on upper extremity function and elimination of animation deformity. Longer-term follow-up demonstrates maintenance of the integrity and quality of the reconstructions over time.

CONCLUSIONS

The authors consider single stage, pre-pectoral direct to implant breast reconstruction to be a state-of-the-art breast reconstruction technique and have found it to be safe and reproducible. This technique is their primary choice for immediate implant-based reconstruction following mastectomy.

Breast animation deformity

Breast animation deformity (BAD) has been reported to occur after submuscular implant placement following breast augmentation and immediate breast reconstruction. Despite its apparent impact on patients' quality of life, BAD has only recently become a topic of general concern. Its incidence and etiology have yet to be established. The aim of this systematic review was to identify papers that clearly defined and classified BAD and described how the degree of animation was assessed. We performed a search in PubMed and Embase. Studies meeting the inclusion criteria that described BAD after implant-based breast augmentation or immediate breast reconstruction were included. After screening 866 publications, four studies were included: three describing BAD after breast augmentation and one describing BAD after immediate breast reconstruction. The median percentage of patients with some degree of BAD was 58%. The highest percentages were found in patients operated on using the Regnault technique or the dual-plane technique (73%-78%). The lowest percentages were found following the dual-plane muscle-splitting technique (30%) and the triple-plane technique (33%). We found no studies meeting the inclusion criteria that analyzed BAD after prepectoral implant placement. This review of the current literature suggests that the degree of BAD is proportional to the degree of muscle involvement. Evidence is scarce, and the phenomenon seems to be underreported. Future comparative studies are warranted.

Cohort Study to Assess the Impact of Breast Implants on Breastfeeding

BACKGROUND

The objective of this study was to evaluate the impact of breast implant surgery and its approaches on lactation by comparing women with and without breast implants at the time of childbirth.

METHODS

Between April of 2013 and July of 2014, in Rosario (Sanatorio de la Mujer and Centro Quirúrgico Rosario), Argentina, a prospective cohort study of women with and without breast implants was performed. Of a total of 3950 births that occurred during this period, 200 patients with similar anthropometric characteristics (maternal and newborn) were selected. Breastfeeding (exclusive or mixed) was compared with artificial feeding at 24 and 48 hours and 30 days in both groups, and the type of incision was also compared.

RESULTS

Breastfeeding at 30 days showed a nonsignificant trend favoring the control group (OR, 7.39; 95 percent CI, 0.92 to 339.2). The percentage of women with implants who succeeded in establishing breastfeeding (exclusive or mixed) was very high (93 percent). In the control group, 99 percent of the women were breastfeeding at 30 days. In a comparison of the submammary and areola incision, breastfeeding showed odds ratios of 0.78 (95 percent CI, 0.33 to 1.87) at 24 hours, 1.10 (95 percent CI, 0.48 to 2.56) at 48 hours, and 0.18 (95 percent CI, 0.36 to 1.82) at 30 days.

CONCLUSIONS

This study shows that most patients with breast implants were able to establish breastfeeding. However, there is a higher number of women without implants that established exclusive breastfeeding. No significant difference was found between the different surgical approaches.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Therapeutic, II.

Objective Sensory Changes Following Subfascial Breast Augmentation

BACKGROUND

Sensory changes occur following breast augmentation, and describing the incidence, pattern, and course of deficit is important for informed consent.

OBJECTIVES

To examine sensory changes following subfascial breast augmentation, and the influence of change in breast volume caused by an implant.

METHODS

One hundred and sixty-two consecutive patients undergoing subfascial breast augmentation were assessed for sensory changes using a Semmes Weinstein monofilament test before surgery, 2, 6, and 12 weeks postoperatively. Morphometric measurements allowed a breast volume to be calculated and the percentage change in volume produced by the implant.

RESULTS

Most women (92.5%) regained preoperative levels of sensation in all areas of the breast, excepting the lower-outer quadrants (16.15%) by 12 weeks following surgery. Four percent of nipple-areolar complexes (NAC) failed return to preoperative levels of sensitivity by 12 weeks after surgery. Younger patients or those who have a high BMI and a measurably thicker soft tissue envelope were more likely to experience sensory deficits. Breast augmentation in this series produced calculated volume changes by an implant of between 12.1% and 102.7%. Within these limits there is no association between percentage increase in breast volume and sensory deficits.

CONCLUSIONS

The study demonstrates that for calculated volume increases of up to 102% of the initial breast volume, sensory loss at 12 weeks after surgery is 4% at the NAC. The commonest area of diminished sensitivity is the lower-outer quadrant (16.15%), relating to the use of the inframammary crease incision. It provides a useful adjunct in monitoring patient recovery following subfascial breast augmentation. LEVEL OF EVIDENCE 4: Therapeutic.

Does Liposuction Improve Body Image and Symptoms of Eating Disorders?

Background:

Unpleasant attention to unfavorable fat may have harmful psychological effects in terms of body dissatisfaction. As a consequence, this may cause abnormal eating regulation. It has been noted that women interested in liposuction self-report more eating problems. As far as we know, there are no prospective studies with standardized instruments providing sufficient data regarding the effects of aesthetic liposuction on various aspects of quality of life. Nevertheless, publications on the effects of eating habits are lacking.

Methods:

Sixty-one consecutive women underwent aesthetic liposuction. Three outcome measures were applied at baseline and at follow-up: the eating disorder inventory, Raitasalo's modification of the Beck depression inventory, and the 15-dimensional general quality of life questionnaire.

Results:

The mean age at baseline was 44 years, and the mean body mass index was 26.0. Thirty-six (59%) women completed all outcome measures with a mean follow-up time of 7 months. A significant improvement from baseline to follow-up was noted in women's body satisfaction, and their overall risk for developing an eating disorder decreased significantly.

Conclusion:

Aesthetic liposuction results in a significantly reduced overall risk for an eating disorder in combination with improved body satisfaction.

Perinipple Broken Line Incision: a Novel Approach for Breast Augmentation

OBJECTIVE

To investigate reliability of the infra-nipple broken line incision for breast augmentation.

METHODS

From January 2012 to January 2013, 15 patients underwent primary bilateral retromuscular breast augmentation with round textured silicone-gel implants and a novel infra-nipple broken line incision. Preoperatively, a semicircular incision was marked along the inferior base of the nipple. It was then extended bilaterally using two transverse right-angled geometric broken lines within the pigmented areolar skin. Follow-up was performed to evaluate the sensation of nipple-areolar complex, the scar, and the shape and texture of the breasts.

RESULTS

The average follow-up was 6.7 months. Most of the patients complained of paresthesia of the nipple or breast skin, but transient decreased sensation improved within 3 months. No patients showed permanent sensory changes of the nipple areolar complex at a minimum follow-up of 4 months. The scars were imperceptible in all patients.

CONCLUSION

We believe that for selected patients, the infra-nipple broken line incision is a practical and reliable method to achieve aesthetic result.

Physical attractiveness and self-assessment before and after breast augmentation

BACKGROUND

This study verifies selected opinions on breast cosmetic surgery in the population of Polish women.

MATERIALS AND METHODS

A total of 78 women aged 20 to 48 years were surveyed between 2008 and 2010 before and after breast augmentation surgery using a questionnaire. The χ and Wilcoxon signed rank tests were used for statistical analysis. Most were married and single women aged approximately 30 years and residents of large cities.

RESULTS

The significance of professional success in the hierarchy of values and the level of self-assessment increased after surgery (P = 0.0000 and 0.0213, respectively). The distribution of responses concerning the expectations of surgery and the evaluation of their fulfillment changed significantly (P = 0.0031). In general, the satisfaction with one's life after surgery also increased (P = 0.0000).

CONCLUSIONS

A well-thought-out decision on breast cosmetic surgery positively affects at least several spheres of psychosocial functioning and fulfills most women's expectations.

Nerve Injuries in Aesthetic Breast Surgery: Systematic Review and Treatment Options

BACKGROUND

The risk of nerve injuries in aesthetic breast surgery has not been well explored.

OBJECTIVES

The authors conducted a systematic review to provide evidence-based information on the incidence and treatment of nerve injuries resulting from aesthetic breast surgery.

METHODS

A broad literature search of Medline, Embase, and the Cochrane Database of Systematic Reviews was undertaken to identify studies in which nerve injury occurred after breast augmentation or mastopexy. Specific inclusion and exclusion criteria were established before the search was performed.

RESULTS

The initial 4806 citations were narrowed by topic, title, and abstract to 53 articles. After full-text review, 36 studies were included. The risk of any nerve injury after breast augmentation ranged from 13.57% to 15.44%. Specific nerve injury rates were calculated for the intercostal cutaneous nerves, branches to the nipple-areola complex, intercostobrachial nerve, long thoracic nerve, and brachial plexus. Also calculated were the total estimated risks of chronic pain, hyperesthesia, hypoesthesia, and numbness. The meta-analysis showed no associations between the rates of breast nerve injury or sensation change and implant size, incision type, or implant position in patients who underwent breast augmentation. The data were insufficient to determine rates of nerve injury in mastopexy.

CONCLUSIONS

The possibility of nerve injury, sensation change, or chronic pain with breast augmentation is real, and estimating the incidences of these conditions is useful to both patients and surgeons. Optimizing patient outcomes requires timely treatment by a multidisciplinary team and may include peripheral nerve surgery.

LEVEL OF EVIDENCE

3.

Cosmetic and reconstructive breast surgery in adolescents: psychological, ethical, and legal considerations

Cosmetic and reconstructive breast surgery has increased in popularity among adolescents in the United States. As more adolescents pursue these procedures, an understanding of the psychological aspects of these surgeries becomes increasingly important for the benefit of both patients and providers. The authors review the psychological aspects of cosmetic and reconstructive surgical breast procedures as they pertain to adolescents, including augmentation mammoplasty, gynecomastia correction, breast reduction, and asymmetry correction. They include a discussion of the medicolegal and ethical implications of these procedures and recommendations for clinical management.

[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.

The effects of aesthetic breast augmentation on quality of life, psychological distress, and eating disorder symptoms: a prospective study

BACKGROUND

There are only a few studies that provide sufficient data regarding the effects of aesthetic breast augmentation on various aspects of quality of life. Significant improvement in body image, satisfaction with appearance, sexual attractiveness, and self-esteem has been observed in these studies. In contrast, however, a somewhat impaired general health-related quality of life has been reported at follow-up. Nevertheless, when considering the effects of aesthetic breast augmentation on eating habits, publications are lacking. We therefore decided to assess the effects of aesthetic breast augmentation on quality of life, psychological distress, and eating disorder symptoms.

METHODS

This study included 79 consecutive women who underwent bilateral aesthetic augmentation mammaplasty. The women completed three outcome measures at baseline and at follow-up: the Eating Disorder Inventory, Raitasalo's modification of the Beck Depression Inventory, and the 15D general quality-of-life questionnaire.

RESULTS

The mean age at baseline was 35 years (range = 18-52). The mean body mass index was 21.3 (range = 17.5-27.3). Sixty-five (82 %) women completed the outcome measures with a mean follow-up time of 7 months (range = 4-13). A significant improvement was observed in self-esteem and depression scores as well as body satisfaction from baseline to follow-up. Interpersonal trust also improved, and after the operation the women were more able to tolerate and understand their own feelings and sensations. A significant decrease in the overall risk for an eating disorder was also noted.

CONCLUSIONS

Aesthetic breast augmentation results in significant improvement in women's body satisfaction and self-esteem. The level of risk for an eating disorder is also significantly reduced.

LEVEL OF EVIDENCE III

This journal requires that authors assign a level of evidence to each article.

The "triple-plane technique" for breast augmentation

Breast augmentation is one of the most frequently performed aesthetic surgery procedures. In the United States, it is the second most commonly performed aesthetic surgery procedure among women, according to the American Society of Aesthetic Plastic Surgery statistics. Different choices available to the surgeon deal with the pocket plane, the skin incisions, and the type of implant. This report describes the results from a retrospective review of the authors' experience with the "triple-plane technique" and its different indications according to breast types. Findings have shown that this technique is suitable for many different types, shapes, and sizes of breasts; that it offers very good and natural results; and particularly, that these results last over time.

Transaxillary subpectoral augmentation mammaplasty: a single surgeon's 20-year experience

BACKGROUND

Transaxillary subpectoral augmentation mammaplasty (TASPA) is not widely accepted due to perceived limitations in pocket access, visualization, control, and subsequent risk for postoperative complications. Current published data do little to substantiate or refute those claims.

OBJECTIVE

A retrospective chart review of a single surgeon's 20-year experience with the TASPA technique was undertaken to assess the incidence of total secondary procedures, implant-related revisions, and reoperations unrelated to the implant.

METHODS

The senior author (DCM) performed 1776 primary TASPA procedures from January 1989 through December 2008. Of those, 94 patients did not meet inclusion criteria, leaving a total of 1682 records for analysis. Data reviewed included age, date of surgery, race, implant size and type, manufacturer, and reasons for reoperation.

RESULTS

Average age was 32.7 ± 8.1 years (range, 16-62). Average implant size was 438.5 ± 51.5 cc (range, 270-630). Implants from Allergan/Inamed/McGhan (Irvine, CA), Dow-Corning (Midland, MI), Mentor (Santa Barbara, CA), and Surgitek (Racine, PA) were inserted (n = 2094 saline, n = 1270 silicone). Mean follow-up time was 37.9 ± 45.4 months (range, one month to 19.8 years). Excluding staged mastopexies and treatment for breast cancer, total secondary procedures were required in 225 patients (13.4%). Implant-related revisions included malposition (2.97%), size change (2.5%), and capsular contracture (1.9%). Perioperatively, no infections occurred, and two patients (0.12%) experienced hematoma. Most reoperations (62.8%) were performed through the axilla. Comparison to published data showed an equal or lower rate of capsular contracture, hematoma, and infection with the TASPA approach.

CONCLUSIONS

Given its advantages of an inconspicuous scar, decreased infection, and decreased capsular contracture, TASPA can be safely offered to patients as an option in breast augmentation.

Predicting consideration of cosmetic surgery in a college population: a continuum of body image disturbance and the importance of coping strategies

Elective cosmetic surgeries are increasing in the American population with reasons linked to body image disturbance and body dysmorphic disorder (BDD). Little research exists documenting the continuum of body image disturbance and its relationship to seeking surgery. The present research examined data from 544 participants, 55 of whom were diagnosable with BDD. Using assessments for body image disturbance, problematic coping strategies, and BDD symptomatology, results provided evidence for a continuum of body image distress. Logistic regression analysis supported the hypothesis that increased levels of body image disturbance and one type of problematic coping strategy (Appearance Fixing) predicted consideration of cosmetic surgery. Of participants diagnosable with BDD, those who considered cosmetic surgery showed more severe body image disturbance and problematic coping than those who did not consider surgery. These results have implications for pre-surgical assessment as well as psychological interventions rather than invasive medical interventions.

Body dysmorphic disorder in patients who seek appearance-enhancing medical treatments

Most patients who seek appearance-enhancing medical treatments report some degree of body image dissatisfaction, which is believed to motivate the pursuit of these treatments. However, patients with extreme body image dissatisfaction may be suffering from a psychiatric disorder known as body dysmorphic disorder (BDD). This article reviews BDD, including its clinical features and prevalence in medical settings. Although patients with BDD frequently seek cosmetic treatments to address their appearance-related distress, such treatments are rarely beneficial. The article concludes with recommendations for patient and provider safety.

Hyperesthesia one year after breast augmentation surgery increases the odds for persisting pain at four years A prospective four-year follow-up study

In this long-term follow-up study of 175 women, we investigated the prevalence of and factors associated with persisting pain and sensory changes four years after augmentation mammoplasty. Previously the women had participated in an acute postoperative pain study, and follow-up investigations at 6 weeks and 1 year after surgery. In the present study, the women were mailed questionnaires about pain, sensory changes, and affection of daily life, quality of life and pain catastrophizing 4 years after surgery.

One hundred and sixteen women answered the questionnaire. The fraction of women reporting evoked- and/or spontaneous pain during the last 24 h had declined from 20% at 1 year to 14% at 4 years. Hyperesthesia had declined from 46% at 1 year to 32% at 4 years, while the change in hypoesthesia was small, 47% at 1 year to 51% at 4 years. Methylprednisolone and parecoxib given pre incisionally reduced acute postoperative pain and reduced the prevalence of hyperesthesia after 6 weeks/1 year, but after 4 years we found no significant differences between the test drug groups. Those having concomitant pain and hyperesthesia at 6 weeks and 1 year had high odds for persisting pain at 4 years (OR 7.8, 95% CI 2.1–29.8, P = 0.003; OR 13.2, 95% CI 2.5–71.3, P = 0.003). In patients without pain but with hyperesthesia at 1 year, the hyperesthesia increased the odds for pain at 4 years (OR 2.6 95% CI 1.1–6.1, P = 0.03). Hypoesthesia at 6 weeks or at 1 year did not affect the odds for pain at 4 years. A good general health condition (mental and physical) was associated with reduced odds for pain at 4 years (OR = 0.56, 95% CI 0.35–0.88, P = 0.01). However, using the Short Form health survey, SF-12, the Mental Component Summary Score seemed to affect the odds for chronic pain more than the Physical Component Summary Score.

To conclude, the prevalence of pain and hyperesthesia after breast augmentation declined from 1 to 4 years. Nevertheless, the most striking finding in the current trial was that pain coinciding with hyperesthesia at 6 weeks and 1 year resulted in highly increased odds for persistent postoperative pain. Even hyperesthesia alone, without pain, increased the odds for chronic postsurgical pain. Thus, the present study suggests hyperesthesia as an independent risk factor for chronic postsurgical pain.

Psychological considerations in cosmetic breast augmentation

Within the past decade, the popularity of cosmetic breast augmentation has surged and, with it, the interest in the psychological aspects of the procedure. Investigations of women who seek cosmetic breast augmentation have examined both their psychosocial characteristics and their motivations for surgery. Dissatisfaction both with body image and with breast size and/or shape are thought to be primary motivators for surgery. It is common for women seeking cosmetic breast augmentation to have some body image dissatisfaction. However, a considerable minority may suffer from excessive dissatisfaction consistent with the psychiatric diagnosis of body dysmorphic disorder, which is believed to contraindicate cosmetic surgery. Following breast augmentation, most women report satisfaction with the aesthetic result and improvements in body image. The impact of the procedure on other areas of functioning, such as self-esteem and quality of life, is less clear. These positive outcomes have been tempered by recent epidemiological studies that have identified a relationship between cosmetic breast implants and suicide. This article reviews this literature and provides recommendations to plastic surgical nurses regarding the psychological assessment and management of patients seeking breast augmentation.

Psychological issues associated with breast augmentation

The American Society of Plastic Surgeons (ASPS) reported that 329,396 women have undergone breast augmentation in the United States, an increase of 55% between 2000 and 2006, making it the most frequent US surgical cosmetic procedure for 2006 (ASPS, 2007). Although many studies have explored psychological aspects of this type of surgery, the consistently dramatic increase in numbers of breast augmentations, some that result in adverse psychological outcomes, remains a serious concern for health care providers. Surprisingly, very little is known about either the psychological characteristics of cosmetic surgery patients or the psychological impact of the surgical procedures. This literature review focuses on psychological issues in relation to breast augmentation procedures, including recent suicide findings related to this procedure. Conclusion of this review supports the necessity by health care providers to consistently screen patients for psychological disorders, such as Body Dysmorphic Disorder (BDD), prior to conducting cosmetic surgical procedures, specifically breast augmentation.

Aesthetic breast surgery: consulting for the future--proposals for improving doctor-patient interactions

This report summarizes the opinions advanced by an international panel of acknowledged expert plastic surgeons convened to discuss women's attitudes about aesthetic breast surgery. To inform the discussions, a survey was undertaken to explore women's attitudes and opinions. The survey showed that significant numbers of women take the initial steps but do not proceed to surgery. This represents a failure to meet the needs of many women who stand to benefit from surgery. It also represents a waste of resources. Cost and fear are important factors, but a crucial consideration for women is whether they can find a surgeon they can trust. The panel recommends using standard consultation procedures, ensuring good clinic organization, managing expectations, dispelling myths, and providing adequate patient education to build trust and contribute to the successful treatment of women who desire breast surgery.

Long-term safety and effectiveness of style 410 highly cohesive silicone breast implants

Background

In 2006, a single-center Swedish study demonstrated a low rupture rate and high patient satisfaction with the Style 410 shaped, form-stable gel implant. The current study aimed to validate the accuracy of the previously published results across multiple European sites.

Methods

A total of 163 subjects (~70% had augmentation [n = 112], 15% had reconstruction [n = 25], and 15% had revision [n = 26]) underwent a physical examination followed by breast magnetic resonance imaging (MRI) for rupture detection. These subjects had been implanted for 5 to 11 years with at least one Style 410 shaped gel breast implant before examination. The secondary end points included lactation, reproductive and breast disease history before and after implantation, and quality-of-life measurements and complications after implantation.

Results

The implant rupture rate was 1.7% a median of 8 years after implantation. Capsular contracture was the most common complication noted at the physical examination, occurring for 5.3% of implants, and there were no cases of grade 4 capsular contracture. The postimplantation rates for lactation and reproductive problems and breast disease were lower than the preimplantation rates. Breast implantation surgery was considered advantageous by 91% of the subjects, demonstrating high patient satisfaction.

Conclusions

The Style 410 anatomically shaped, form-stable gel breast implants demonstrated long-term safety and effectiveness.

Areola-nipple perception threshold to faradic electricity: a new measure of sensibility of the breasts

BACKGROUND

We describe a new method to study the sensibility of the nipple-areola complex of the breast with faradic electricity delivered through an electromyographic device used to monitor peripheral nerve conduction.

METHODS

The objective results of faradic pulses (2-50 mA per pulse) delivered to the nipple-areola complex of the breast through a Nihon-Kohden II machine (Evoked potential/Electromyographs, Nihon-Kohden Co., Japan) were evaluated in normal volunteers to get a basal measure that was defined by the patient as "a soft electric discharge." The measures were recorded and their output discharges averaged (at least 5 to each complex).

RESULTS

Twenty-eight volunteers with normal breasts, 28 patients with breast hypertrophy before and after breast reduction, and 28 patients before and after breast augmentation were studied. The faradic pulses were perceived from 1.5 to 3.5 mA in the areola and from 3 to 5.5 mA in the nipple in the control group and from 4.5 to 7.0 mA in the areola and from 6.5 to 9.5 mA in the nipple in the breast hypertrophy group with no significant changes before and after surgery. In the breast augmentation group the faradic pulses were very similar to the volunteers that had normal breasts, but 13 months after breast augmentation with silicone gel prosthesis, a difference was found because all the patients had a higher threshold and three cases had lost sensibility of the nipple-areola complex.

CONCLUSION

In normal breasts the areola had a lower threshold for faradic pulses compared to the nipple. Hypertrophic breasts had a higher threshold to the faradic stimulation than normal subjects in the pre- and postoperative period. Hypoplastic breasts before breast augmentation had a perception threshold similar to that of the normal volunteers but after breast augmentation this perception was much higher.

Transareolar incision with geometric broken line for breast augmentation: a novel approach

Along with implant location and size, incision location is an important variable that influences the final result of breast augmentation. The transareolar approach is not popular because of reported lactational difficulties, higher rates of capsular contracture, visibility of scars, and potential changes in nipple sensation. We describe a geometric zigzag transareolar incision for breast augmentation that can achieve imperceptible scarring. We believe that in selected patients the transareolar zigzag incision has its place among the different approaches used in breast augmentation today.

Body dysmorphic disorder and appearance enhancing medical treatments

This article reviews the literature on body dysmorphic disorder (BDD) in persons who seek appearance enhancing medical treatments such as cosmetic surgery and dermatological treatment. We begin with a discussion of the growing popularity of cosmetic surgical and minimally invasive treatments. The literature investigating the psychological characteristics is briefly highlighted. Studies investigating the rate of BDD among persons who seek appearance enhancing treatments are detailed and, collectively, suggest that approximately 5-15% of individuals who seek these treatments suffer from BDD. Retrospective reports suggest that persons with BDD rarely experience improvement in their symptoms following these treatments, leading some to suggest that BDD is a contraindication to cosmetic surgery and other treatments. The clinical management of patients with BDD who present for these treatments is briefly described and directions for future research are provided.

The psychological aspects of cosmetic breast augmentation

BACKGROUND

The psychological aspects of cosmetic breast augmentation have been the focus of a great deal of empiric study over the past 40 years.

METHODS

Studies investigating the preoperative characteristics and psychosocial status of women interested in breast augmentation are reviewed. Investigations of postoperative satisfaction and psychosocial changes are discussed. The results of the seven epidemiologic studies that have identified a relationship between cosmetic breast augmentation and suicide are detailed.

RESULTS

Methodologic limitations of the studies investigating the preoperative psychosocial status of breast augmentation candidates make it difficult to draw firm conclusions about the potential psychological differences between these women and those not interested in breast augmentation. Postoperative satisfaction rates are high, and several studies suggest that patients experience improvements in body image following surgery. The effects of breast augmentation on other areas of psychological functioning are less clear. Based on the seven epidemiologic studies published to date, the suicide rate among women with cosmetic breast implants is two to three times the expected rate.

CONCLUSIONS

The literature in this area should be used to guide the psychosocial assessment and management of cosmetic breast augmentation patients. There currently is little evidence to support a recommendation that all women who present for cosmetic breast augmentation be required to undergo a psychiatric evaluation before surgery. Given the relationship between breast implants and suicide, however, it is recommended that women with a history of psychopathology who present for breast augmentation, or those who are suspected by the plastic surgeon of having some form of psychopathologic abnormality, should undergo a mental health consultation before surgery.

Psychological considerations in cosmetic breast augmentation

Within the past decade, the popularity of cosmetic breast augmentation has surged and, with it, the interest in the psychological aspects of the procedure. Investigations of women who seek cosmetic breast augmentation have examined both their psychosocial characteristics and their motivations for surgery. Dissatisfaction both with body image and with breast size and/or shape are thought to be primary motivators for surgery. It is common for women seeking cosmetic breast augmentation to have some body image dissatisfaction. However, a considerable minority may suffer from excessive dissatisfaction consistent with the psychiatric diagnosis of body dysmorphic disorder, which is believed to contraindicate cosmetic surgery. Following breast augmentation, most women report satisfaction with the aesthetic result and improvements in body image. The impact of the procedure on other areas of functioning, such as self-esteem and quality of life, is less clear. These positive outcomes have been tempered by recent epidemiological studies that have identified a relationship between cosmetic breast implants and suicide. This article reviews this literature and provides recommendations to plastic surgical nurses regarding the psychological assessment and management of patients seeking breast augmentation.

Relative implant volume and sensibility alterations after breast augmentation

BACKGROUND

Recent studies have provided diverging results regarding the factors that may affect sensibility after primary breast augmentation. Implant volume is believed to be an important factor, but the relation of implant size to breast volume has not been adequately addressed. In addition, the literature shows that a conflict exists when the periareolar and inframammary approaches are compared. This study aimed to refine the volumetric analysis comparing the implant and final breast size as well as the intrinsic association of these two factors with postoperative sensory alteration of the breast.

METHODS

A prospective study investigated patients who underwent aesthetic breast augmentation between June 2004 and October 2005 (i.e., a 16-month period) at the Ivo Pitanguy Institute. The sensibility in nine regions of the breast was tested before and after surgery using Semmes-Weinstein monofilaments. Breast sizers were used to compare the pre- and postoperative breast volumes. Statistical analysis of the data took into consideration the relative volume of the implant, the surgical approach, the presence of minor complications, the breast-feeding history, and the subjective evaluation of sensory changes in the patients.

RESULTS

A total of 37 patients who underwent breast augmentation were examined preoperatively. The relative volume of the implant was found to be associated with sensibility alterations. No difference was found between the periareolar and inframammary incision approaches. Other factors such as previous breast-feeding, minor complications, and subjective alterations were not associated with sensory alterations.

CONCLUSIONS

The study findings suggest that larger implants and smaller breasts show an increased association with postoperative sensory alterations of the breast. Plastic surgeons and their patients should be aware of this possibility. Implant volume should be considered together with breast size to avoid sensory complications, and this is summarized in the concept of relative volume.

Effect of breast augmentation mammoplasty on self-esteem and sexuality: a quantitative analysis

Although not extensively researched, psychologic factors have attributed to the growing number of performed breast augmentation procedures. The reported a 293% increase in the cases of cosmetic surgery since 1997. The percent increase in breast augmentation procedures performed in 2003 was up 12 (280 procedures up to 401). As the number of women seeking breast augmentation surgery continues to rise, an increasing number of healthcare professionals are likely to be confronted with questions, concerns, and complications that often accompany the procedure. Consequently, it is important that healthcare providers comprehend the degree to which self-esteem and/or sexuality may affect their patients' outcomes. Healthcare professionals must ascertain specific nursing skills and attitudes while caring for the cosmetic surgical patient. Therefore, the purpose of this research is to gain an understanding of the changes that occur in the levels of self-esteem and sexuality following the breast augmentation. Test of the study hypotheses 1 through 4 failed to be rejected, thereby supporting significant positive relationships between the variables. Statistical analysis of Hypothesis 5 found positive significance between breast augmentation, self-esteem, and the demographic variables-educational level and history of previous cosmetic surgery.