Asian Breast Augmentation: A Systematic Review

Racial disparities in surgical outcomes after mastectomy in 223 000 female breast cancer patients: a retrospective cohort study

BACKGROUND

Breast cancer mortality and treatment differ across racial groups. It remains unclear whether such disparities are also reflected in perioperative outcomes of breast cancer patients undergoing mastectomy.

STUDY DESIGN

The authors reviewed the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) database (2008-2021) to identify female patients who underwent mastectomy for oncological purposes. The outcomes were stratified by five racial groups (white, Black/African American, Asian, American Indian/Alaska Native, and Native Hawaiian/Pacific Islander) and included 30-day mortality, reoperation, readmission, surgical and medical complications, and non-home discharge.

RESULTS

The study population included 222 947 patients, 68% ( n =151 522) of whom were white, 11% ( n =23 987) Black/African American, 5% ( n =11 217) Asian, 0.5% ( n =1198) American Indian/Alaska Native, and 0.5% ( n =1018) Native Hawaiian/Pacific Islander. While 136 690 (61%) patients underwent partial mastectomy, 54 490 (24%) and 31 767 (14%) women received simple and radical mastectomy, respectively. Overall, adverse events occurred in 17 222 (7.7%) patients, the largest portion of which were surgical complications ( n =7246; 3.3%). Multivariable analysis revealed that being of Asian race was protective against perioperative complications [odds ratio (OR)=0.71; P <0.001], whereas American Indian/Alaska Native women were most vulnerable to the complication occurrence (OR=1.41; P <0.001). Black/African American patients had a significantly lower risk of medical (OR=0.59; P <0.001) and surgical complications (OR=0.60; P <0.001) after partial and radical mastectomy, respectively, their likelihood of readmission (OR=1.14; P =0.045) following partial mastectomy was significantly increased.

CONCLUSION

The authors identified American Indian/Alaska Native women as particularly vulnerable to complications following mastectomy. Asian patients experienced the lowest rate of complications in the perioperative period. The authors' analyses revealed comparable confounder-adjusted outcomes following partial and complete mastectomy between Black and white races. Their findings call for care equalization in the field of breast cancer surgery.

Harmonic Scalpel Versus Monopolar Electrotome in Endoscopic-Assisted Transaxillary Dual-Plane Augmentation Mammaplasty: A Retrospective Study in 122 Patients

BACKGROUND

The transaxillary approach of breast augmentation is the most popular method in Asia, but longer period of recovery was observed in spite of the assistance of endoscope.

OBJECTIVES

Introducing the ultrasonic dissection devices might be a solution to minimizing tisue damage thus relieving pain and shortening the period of recovery.

METHOD

Between March 2020 and September 2022, we retrospectively reviewed the cases of 122 patients underwent endoscopic augmentation mammoplasty via the transaxillary approach using either the monopolar electrotome (ME) alone or assisted with Harmonic Scalpel (HS) in defining the retropectoral pocket and severing the pectoralis major muscle.

RESULT

The total drainage volume was significantly lower in the HS group than ME group (74.33 ± 48.81 vs. 180.30 ± 125.10 mL; p < 0.0001). VAS score of the first 24 hour after surgery of the ME group was significantly higher than that of the HS group (6.10 ± 1.27 vs. 2.88 ± 1.29, p < 0.0001). Operation time in HS group was reduced compared to ME group (113.1 ± 14.46 mins vs. 131.3 ± 35.51 mins, p < 0.001). The duration of drainage placement (1.08 ± 0.27 vs. 2.72 ± 1.18 days) and hospital stay after surgery (3.08 ± 0.42 vs. 5.64 ± 2.78 days; p < 0.0001) were largely reduced in HS group.

CONCLUSION

The assistance of Harmonic Scalpel significantly reduced total postoperative drainage, relieved pain and shortened operation time, length of drainage placement and hospital stay compared to using monopolar electrotome alone in endoscopic-assisted transaxillary dual-plane augmentation mammaplasty.

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 .

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.

Does Surgeon Training Affect Patient Perception of Surgeon Skill in DIEP Flap Breast Reconstruction?

BACKGROUND

 The aim of this study is to investigate whether a surgeon's training background and years of experience advertised on a social media platform influences perception of surgeon competence, patient recruitment likelihood, and referral likelihood.

METHODS

 A mockup of an Instagram post was created using a before and after picture of a deep inferior epigastric perforator (DIEP) flap patient. The caption under each post was changed to reflect one of six possible training categories: 1 year of experience, 10 years of experience, 20 years of experience, fellowship, Ivy League training, and a null case (with no training information against which all other cases were compared). Surveys asked female responders to evaluate surgeon competence, likelihood of becoming a patient, and likelihood of making a referral to their friends or family. Amazon MTurk crowdsourcing platform was used to distribute the survey.

RESULTS

 A total of 1,878 responses were recorded, with the majority identifying as Caucasian (59%). The surgeon with 20 years of experience had the highest patient recruitment scores when compared with the null, 1 year, 10 year, and Ivy League training backgrounds (p = 0.0314, p = 0.0065, p = 0.0207, and p = 0.0244, respectively). The majority of responders (67%) preferred a female surgeon. Responders with a history of breast reconstruction assigned lower surgeon competence scores compared with women without a history of breast cancer (p <0.0001). Women who underwent breast reconstruction were also less likely to make referrals to their family and friends (p <0.0001).

CONCLUSION

 Surgeon's experience influences whether a patient is likely to seek care from a plastic surgeon. Personal history of breast cancer has a negative impact on perceived surgeon competence as well as patient recruitment likelihood and referral likelihood. Emphasizing fewer years of training or Ivy League training did not make an appreciable difference in patient perception of competence or likelihood of recruiting a new patient.

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.

Protocol for a multicentre, prospective, cohort study to investigate patient satisfaction and quality of life after immediate breast reconstruction in Japan: the SAQLA study

INTRODUCTION

The aim of breast reconstruction (BR) is to improve patients' health-related quality of life (HRQOL). Therefore, measuring patient-reported outcomes (PROs) would clarify the value and impact of BR on a patient's life and thus would provide evidence-based information to help decision-making. The Satisfaction and Quality of Life After Immediate Breast Reconstruction study aimed to investigate satisfaction and HRQOL in Japanese patients with breast cancer who undergo immediate breast reconstruction (IBR).

METHODS AND ANALYSIS

This ongoing prospective, observational multicentre study will assess 406 patients who had unilateral breast cancer and underwent mastectomy and IBR, and were recruited from April 2018 to July 2019. All participants were recruited from seven hospitals: Okayama University Hospital, Iwate Medical University Hospital, The Cancer Institute Hospital of Japanese Foundation for Cancer Research, Showa University Hospital, University of Tsukuba Hospital, Osaka University Hospital and Yokohama City University Medical Center. The patients will be followed up for 36 months postoperatively. The primary endpoint of this study will be the time-dependent changes in BREAST-Q satisfaction with breast subscale scores for 12 months after reconstructive surgery, which will be collected via an electronic PRO system.

ETHICS AND DISSEMINATION

This study will be performed in accordance with the Ethical Guidelines for Medical and Health Research Involving Human Subjects published by Japan's Ministry of Education, Science and Technology and the Ministry of Health, Labour and Welfare, the modified Act on the Protection of Personal Information and the Declaration of Helsinki. This study protocol was approved by the institutional ethics committee at the Okayama University Graduate School of Medicine, Dentistry, on 2 February 2018 (1801-039) and all other participating sites. The findings of this trial will be submitted to an international peer-reviewed journal.

TRIAL REGISTRATION NUMBER

UMIN000032177.

Endoscopic Transaxillary Versus Inframammary Approaches for Breast Augmentation Using Shaped Implants: A Matched Case-Control Study

PURPOSE

The incision for breast augmentation can be chosen from the transaxillary, inframammary fold, periareolar, or transumbilical approaches. While the inframammary fold approach is commonly used worldwide, the transaxillary approach is more popular in Asia due to the more conservative location of the scar. In this study, we performed augmentation mammoplasty using anatomically shaped implants via the endoscopic transaxillary and inframammary fold incisions and compared the outcomes.

METHODS

Three hundred sixty-four patients who underwent breast augmentation with shaped implants were enrolled. All were primary and bilateral cases. In total, 728 shaped implants were used. Patients' demographics, incision type, and complications were documented. Complications such as capsular contracture, hematoma, infection, implant malposition, wound problem, and chronic seroma were observed during the average 27 months of follow-up period and analyzed.

RESULTS

One hundred ninety-five patients underwent augmentation mammoplasty via the inframammary approach, whereas 169 patients underwent the endoscopic transaxillary approach. Implant type and size were matched between the two groups. Complication rates were 1.8% and 2.7% in the inframammary and transaxillary approach, respectively. There was no significant difference between the two approaches in terms of surgical complications (p = 0.593).

CONCLUSION

This study demonstrates that the endoscopic transaxillary approach is not inferior to the inframammary approach when shaped implants are used for augmentation mammoplasty. Therefore, the transaxillary approach may be an alternative method when using shaped implants for augmentation mammoplasty, especially for women who wish to avoid a visible scar on the inframammary fold.

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 .

Breast augmentation surgery using an inframammary fold incision in Southeast Asian women: Patient-reported outcomes

Background

This analysis presents patient-reported outcomes of breast augmentation procedures performed in Singapore using an inframammary fold incision and the “5 Ps” best practice principles for breast augmentation. These data are the first of their kind in Southeast Asian patients.

Methods

Through a retrospective chart review, patients who underwent primary breast augmentation with anatomical form-stable silicone gel breast implants using an inframammary fold incision were followed for ≥6 months postoperatively. The BREAST-Q Augmentation Module (scores standardized to 0 [worst] – 100 [best]) and Patient and Observer Scar Assessment Scale (POSAS; 1 [normal skin] to 10 [worst scar imaginable]) were administered. Responses were summarized using descriptive statistics. Patient-reported events were collected.

Results

Twenty-two Southeast Asian patients (mean age, 35.1 years) completed ≥1 postoperative BREAST-Q and POSAS assessment and were assessed 11 months to 5.5 years postoperatively. The mean postoperative BREAST-Q satisfaction with breasts and psychosocial well-being scores were 69.2 and 84.0, respectively. The mean POSAS score for their overall opinion of the scar was 4.2; the mean scores for all scar characteristics ranged from 1.2 to 4.2. Over 90% of patients (20/22) said that they would recommend the procedure. Patient complaints following surgery included anisomastia (possibly pre-existing; n=2), sensory loss at the nipple (n=2) or around the nipple (n=3), scarring (n=4), and slight capsular contracture (n=1). No patients required reoperation.

Conclusions

Southeast Asian patients reported high long-term satisfaction scores on the BREAST-Q scale and with their scar characteristics following breast augmentation using an inframammary fold incision, and nearly all said they would recommend this procedure. No reoperations were necessary in patients assessed for up to 5.5 years postoperatively.

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.

Experience of Breast Augmentation in Pakistani Females

BACKGROUND

Breast augmentation is an elective surgery used to increase the size of the breast in females. This study was undertaken to determine the breast augmentation in Pakistani females.

METHODS

From 2006 to 2011, 43 female patients who underwent breast augmentation via infra-mammary, periareolar, trans-umbilical and fat transfer were enrolled. For augmentation, saline-filled or gel-filled implants were used in the supine position under general anesthesia and local infiltration of adrenaline (1:100,000 dilution) on each side. After the surgery, postoperative dressing was changed after 3-5 days and post-op bra was used for next 3-4 weeks. The patients were followed up for any complications too.

RESULTS

The majority of patients (60.4%) were less than 30 years (mean age: 27.51 years). Most of patients (70%) had infra-mammary incision, 13.9% had periareolar, 9.3% had trans-umbilical and 4.7% had fat transfer. Saline-filled implants were used in 30.2%, whereas gel-filled implants in 69.8% of patients. Implant volume in infra-mammary, periareolar, trans-umbilical and fat transfer approaches was 278.9, 291.7, 277.5 and 325 mL, respectively. Only two cases of infection were recorded in early postop period. One patient responded to conservative treatment and in 2^nd patient, implants were removed. There was only one case of hypertrophic scar. No case of capsular contracture was seen. Quality of scar was satisfactory in infra-mammary and periareolar incisions. Changes in sensations were noted in 6 cases, 4 of them had periareolar incision.

CONCLUSION

Properly performed breast augmentation results in restoration of physical and psychological well-being of the patient and less complication rates.