Breast augmentation

Surgical Management of Breast Capsular Contracture-A Multi-institutional Data Analysis of Risk Factors for Early Complications

BACKGROUND

Capsular contracture (CC) is a common complication following implant-based breast surgery, often requiring surgical intervention. Yet, little is known about risk factors and outcomes following CC surgery.

METHODS

We reviewed the American College of Surgeons National Surgical Quality Improvement Program database (2008-2021) to identify female patients diagnosed with CC and treated surgically. Outcomes of interest included the incidence of surgical and medical complications at 30-days, reoperations, and readmissions. Confounder-adjusted multivariable analyses were performed to establish risk factors.

RESULTS

5,057 patients with CC were identified (mean age: 55 ± 12 years and mean body mass index [BMI]: 26 ± 6 kg/m2). While 2,841 (65%) women underwent capsulectomy, capsulotomy was performed in 742 patients (15%). Implant removal and replacement were recorded in 1,160 (23%) and 315 (6.2%) cases, respectively. 319 (6.3%) patients experienced postoperative complications, with 155 (3.1%) reoperations and 99 (2.0%) readmissions. While surgical adverse events were recorded in 139 (2.7%) cases, 86 (1.7%) medical complications occurred during the 30 day follow-up. In multivariate analyses, increased BMI (OR: 1.04; p = 0.009), preoperative diagnosis of hypertension (OR: 1.48; p = 0.004), and inpatient setting (OR: 4.15; p < 0.001) were identified as risk factors of complication occurrence.

CONCLUSION

Based on 14 years of multi-institutional data, we calculated a net 30 day complication rate of 6.3% after the surgical treatment of CC. We identified higher BMI, hypertension, and inpatient setting as independent risk factors of postoperative complications. Plastic surgeons may wish to integrate these findings into their perioperative workflows, thus optimizing patient counseling and determining candidates' eligibility for CC surgery.

LEVEL OF EVIDENCE III

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

Twelve Years and over 2400 Implants Later: Augmentation Mammoplasty Risk Factors Based on a Single Plastic Surgeon's Experience

Background

Breast augmentation is one of the most commonly performed aesthetic surgery procedures. Yet, few reports in the literature analyze individual surgeon experiences with a unified surgical method on a large group of patients. This study aimed to analyze a single surgeon's complications rate and experience with the Akademikliniken augmentation mammaplasty method from the beginning of his career.

Methods

A retrospective outcome analysis of all patients (n = 1646) who underwent breast augmentation between 2009 and 2021 performed by a single surgeon was conducted. Complications and reoperation rates were evaluated. In addition, correlations with the patient and implant characteristics and insertion-method-related risk factors were analyzed.

Results

In total, 1212 female patients (mean age, 31.47 years) were analyzed. The minimal follow-up for every patient was 6 months (mean follow-up, 18.35 months). The total complication rate was 7.1%, and the most common complication (2.64%) was capsular contracture (Baker scale III/IV). Implant insertion with a funnel significantly lowered the overall risk of complications (P = 0.009). Statistical analysis indicates that the single independent risk factors for primary breast augmentation are patient age younger than 27 years, initial breast size B and C, and tobacco smoking.

Conclusions

This study indicated that capsular contracture and implant rotation are the most common complications of analyzed primary augmentation mammoplasty. It also identifies various risk and protection factors, such as funnel usage, which should be considered by the surgeon when performing this type of procedure.

Impact of Incisional Access Site in Primary Breast Augmentation: Evaluation of Patient Satisfaction with SCAR-Q

BACKGROUND

Scarring at the incision site represents one of the most impactful outcomes in breast augmentation surgery for both the patient and the surgeon. Few studies exist with the aim of assessing patient perception of scarring outcomes in primary breast augmentation. The aim of this study was to evaluate the impact on quality of life of scars by submitting the SCAR-Q in patients who underwent primary augmentation mammoplasty.

METHODS

The SCAR-Q was administered at one and at 6 months after surgery to 54 consecutive patients underwent primary breast augmentation with inferior hemi-periareolar or inframammary incision. A total of 50 patients were divided into two groups of 21 patients with inferior hemi-periareolar incision and 29 patients with inframammary fold incision, respectively. Statistical analysis was performed with Prism 9.

RESULTS

All mean values of the three SCAR-Q scales tend to decrease at the second administration meaning that the perception of the scar is better at time 6 from the patient perspective. In the "Psychosocial scale," lower values at both 1 month and 6 months for group 2 compared to group 1 were shown. Unpaired T tests with Welch's correction showed significance for delta values variations between the two groups with P values <0.0001.

CONCLUSION

Data show that patients undergoing primary breast augmentation have a scar that has no significant impact. Patients with inframammary fold scar have less psychosocial impact than those with inferior hemi-periareolar scar. There were no statistically significant differences in scar-related symptoms and scar appearance between scar along the inframammary groove and inferior hemi-periareolar scar.

LEVEL OF EVIDENCE IV

Case series study. 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 .

Main Factors Influencing Patient Satisfaction After Primary Breast Augmentation: A Prospective Study Based on Patient-Reported Outcome Measures

BACKGROUND

Primary breast augmentation is one of the most sought-after procedures in cosmetic surgery. It is generally related to a high degree of patient satisfaction, but it is not always obvious which factors have greater influence on patient satisfaction.

OBJECTIVES

The aim of this prospective study was to evaluate how anthropometric, psychological, and social parameters, in association with the main surgical variables, influenced patients' satisfaction with their breasts after surgery.

METHODS

Patients undergoing primary breast augmentation between October 2018 and February 2022, who completed a 12-month follow-up without complications, were enrolled in the study. For each patient we recorded: BMI, pinch test (upper pole of the breast), surgical access, implant pocket, implant volume, bra size increase, age, smoking habit, civil status, education level, pregnancies, and psychiatric disorders. Each variable was statistically correlated with patient's satisfaction, assessed by BREAST-Q questionnaire preoperatively and 12 months postoperatively.

RESULTS

Analyzing the data of the 131 patients, we found 3 factors affecting their satisfaction (P<.05); BMI: underweight patients were less satisfied than normal and overweight patients; pinch test: patients with a pinch test >2 cm were more satisfied; volume of the implant and bra size increase: patients with implant volume <300 cc and a less than 2 bra size increase were less satisfied than patients with larger augmentation.

CONCLUSIONS

BMI, pinch test, implant volume, and extent of volumetric enhancement should be taken into careful consideration by the surgeon during preoperative consultation and surgical planning, because they can be critical to patient satisfaction.

LEVEL OF EVIDENCE: 3

The Incidence and Outcomes of Breast Implants Among 1696 Women over more than 50 Years

OBJECTIVE

To investigate the incidence of women with breast implants in 1964-2017 MATERIALS AND METHODS: All women with breast implants in Olmsted County, MN between January 1, 1992 and December 31, 2017 were identified, and a comprehensive review of individual medical records was performed, adding to a previously identified cohort of women with breast implants in 1964-1991. Incidence rates were calculated and were age- and sex-adjusted to the US white female 2010 population.

RESULTS

In 1992-2017, 948 women with breast implants were identified, totaling 1696 Olmsted County, MN women with breast implants in 1964-2017. Overall incidence was 63.3 (95% CI 60.2-66.4) per 100,000 women, but incidence varied significantly over time. Women in 1964-1991 were more likely to have implants for cosmetic reasons and more likely to have silicone implants compared to the 1992-2017 cohort. The overall standardized mortality ratio was 1.17 (95% CI 0.99-1.38) in 1964-1991 and 0.94 (95% CI 0.66-1.29) in 1992-2017. In 1992-2017, breast reconstruction patients had a significantly elevated risk of implant rupture and implant removal versus breast augmentation patients.

CONCLUSION

The incidence of breast implants among women in Olmsted County, MN has varied drastically over the past five decades, with significant changes in the trends for implant type and reason. The findings of this study may provide further insight regarding how risks associated with implants may vary over time.

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

Evaluating Chatbot Efficacy for Answering Frequently Asked Questions in Plastic Surgery: A ChatGPT Case Study Focused on Breast Augmentation

BACKGROUND

The integration of artificial intelligence (AI) and machine learning (ML) technologies into healthcare is transforming patient-practitioner interaction and could offer an additional platform for patient education and support.

OBJECTIVES

This study investigated whether ChatGPT-4 could provide safe and up-to-date medical information about breast augmentation that is comparable to other patient information sources.

METHODS

ChatGPT-4 was asked to generate 6 commonly asked questions regarding breast augmentation and respond to them. Its responses were qualitatively evaluated by a panel of specialist plastic and reconstructive surgeons and reconciled with a literature search of 2 large medical databases for accuracy, informativeness, and accessibility.

RESULTS

ChatGPT-4 provided well-structured, grammatically accurate, and comprehensive responses to the questions posed; however, it was limited in providing personalized advice and sometimes generated inappropriate or outdated references. ChatGPT consistently encouraged engagement with a specialist for specific information.

CONCLUSIONS

Although ChatGPT-4 showed promise as an adjunct tool in patient education regarding breast augmentation, there are areas requiring improvement. Additional advancements and software engineering are needed to enhance the reliability and applicability of AI-driven chatbots in patient education and support systems.

Breast Augmentation: A Cross-Sectional Survey of UK and Irish Aesthetic Surgeons

Background

Breast augmentation surgery is the most frequently performed aesthetic surgical procedure within the United Kingdom year on year. However, many variations exist among surgeons regarding various aspects of implant usage and technique.

Objectives

The aim of this study was to evaluate current trends and practices in breast augmentation, within the United Kingdom and correlate them to evidence-based literature.

Methods

An electronic survey of 41 questions was sent to 201 surgeons performing breast augmentation within the United Kingdom and Republic of Ireland. The survey inquired about the surgeons themselves, their practice, implant choice, surgical technique, post-op care, revision surgery, and impact of breast implant-associated anaplastic large cell lymphoma among several other questions.

Results

There were a total of 166 respondents, with 146 completing the survey fully, equaling a response rate of approximately 73%. Overall, there were specific trends in certain aspects such as type of practice, number of augmentations performed per surgeon per year, preferred implant manufacturer, and implant characteristics. That said, there has been a change in other aspects such as implant texture with an increase in the use of smooth implants. The United Kingdom and Ireland concur with certain internationally dominant practice preferences, including the use of inframammary incisions and post-op bra use.

Conclusions

This survey suggests that many aspects of breast augmentation surgery in the United Kingdom are approaching standardization. There are, however, some variations in practice and controversies remaining as expected. It is our belief that further standardizing this very common aesthetic surgical procedure according to evidence-based guidelines will help to improve outcomes for patients.

Defining Cognitive Competencies for Breast Augmentation Surgery

BACKGROUND

Breast augmentation is the most performed aesthetic procedure in the United States yet one that surgical trainees have limited exposure to. This creates a lack of confidence in performing this key procedure among graduates. It is imperative to develop novel curricula and objective measures to standardize acquiring competency.

OBJECTIVE

This qualitative study establishes various cognitive competencies and pitfalls in augmentation mammoplasty.

METHODS

Using a priori established task analysis, literary sources and operative observations, a total of 20 cognitive vignettes were developed to conduct cognitive task analyses (CTA) for breast augmentation through semistructured interviews of experts. Interviews were itemized, and verbal data were recorded, transcribed verbatim, and thematically analyzed by reviewers.

RESULTS

Eight experts were interviewed (median age 39 years, 87.5% males, with a median of 7 years in practice). A conceptual framework for breast augmentation was developed and divided into 5 operative stages containing 208 competencies and 41 pitfalls. Pitfalls were mapped to deficits in shared decision making, proper informed consent, prospective hemostasis, and awareness of anatomical landmarks and markings.

CONCLUSIONS

This work provided an inclusive framework of cognitive competencies in breast augmentation surgery to facilitate their assessment. This model guides the analysis of other procedures to transfer cognitive competencies to learners. In a transition toward competency-based education, this provides a primer to assessments that include all aspects of a surgeon's skill set.

Advances on Capsular Contracture-Prevention and Management Strategies: A Narrative Review of the Literature

Capsular contracture (CC) is the most relevant complication of both aesthetic and reconstructive breast implant surgery. For many years, experimental and clinical trials have attempted to analyze CC risk factors, clinical features, and appropriate management strategies. It is commonly accepted that a multifactorial etiology promotes CC development. However, the heterogeneity in patients, implants and surgical techniques make it difficult to suitably compare or analyze specific factors. As a consequence, discordant data are present in literature, and a true systematic review is often limited in its conclusions. Hence, we decided to present a comprehensive review of current theories on prevention and management strategies, rather than a specific "solution" to this complication.

Methods

The PubMed database was searched for literature regarding CC prevention and management strategies. Pertinent articles in English, published before December 1, 2022, were compared with selection criteria and eventually included in this review.

Results

Through the initial search, 97 articles were identified, of which 38 were included in the final study. Several articles explored different medical and surgical preventive and therapeutic strategies, showing numerous controversies on appropriate CC management.

Conclusions

This review provides a clear overview of the complexity of CC. The wide variety of clinical situations in term of patients, implants, and surgical techniques prevent the standardization of CC management strategies. By contrast, a patient-customized approach should be preferred, and different strategies should be considered depending on the specific case. Further research is desirable to better ascertain evidence-based protocols with regard to CC prevention and treatment.

Comparison of the effect of the harmonic scalpel and monopolar cautery in transaxillary endoscopic dual-plane breast augmentation

BACKGROUND

Transaxillary endoscopic dual-plane breast augmentation is becoming increasingly mature. The intraoperative separation of the implant into the space is often performed using monopolar cautery. The use of the harmonic scalpel has proved more beneficial in several surgeries. However, no study has ever addressed the effects of harmonic scalpel usage compared to monopolar cautery in transaxillary endoscopic dual-plane breast augmentation.

METHODS

In this randomized controlled study, we enrolled patients (n = 78) who underwent breast augmentation in our hospital from January to October 2022. Participants were randomized with an intentional unequal allocation ratio (2:1 in the harmonic scalpel group: monopolar cautery group). Outcome measures included: total postoperative drainage volume, postoperative drainage volume for the first 24 h, number of postoperative drainage days, daily pain scored through the visual analog scale, operative time, and reoperation rate.

RESULTS

A total of 51 patients in the harmonic scalpel group and 24 patients in the monopolar cautery group were analyzed. Overall, in comparison to the monopolar cautery group, the harmonic scalpel group showed improved total postoperative drainage volume, postoperative drainage volume for the first 24 h, number of postoperative drainage days, and postoperative pain scores. No differences were found regarding operative time and reoperation rate.

CONCLUSION

Compared with monopolar cautery, harmonic scalpel usage in transaxillary endoscopic breast augmentation has evident advantages regarding postoperative drainage and patients' pain scores, making it an instrument worth of recommendation.

Multiplanar (4-Dimension) Breast Augmentation-A Personal Surgical Concept for Dynamic Implant-Tissue Interaction Providing Sustainable Shape Stability

BACKGROUND

In esthetic breast augmentation long-term shape stability and natural appearance remain an ongoing challenge. The authors found that to reduce the incidence of secondary deformity and increase the natural feel and appearance, a standard multiplanar procedure combining a subfascial and dual plane approach with fasciotomies will provide long-term stability and esthetic quality.

PATIENTS AND METHODS

The technique involves a submuscular dissection, release of the infranipple portion of the pectoralis muscle combined with the wide subfascial release of the breast gland, and scoring of the deep plane of the superficial glandular fascia. For long-term stability, a firm fixation of the glandular fascia at the inframammary fold to the deep layer of the abdomino-pectoral fascia is critical. Long-term results were analyzed for up to 10 years.

RESULTS

Postoperative measurements proved the intrinsic balance of the breasts without significant changes over time. The overall complication rate was <5%. Shape stability was observed over 10 years in more than 95% of the patients. Unsightly muscular animation could be avoided in almost every patient.

CONCLUSIONS

Our results indicate that a technique of multiplane breast augmentation provides long-term stability and esthetic quality. By combining the benefits of well-established techniques of a submuscular dual plane, additional shaping through a controlled deep fasciotomy and stable inframammary fold fixation some of the existing tradeoffs of the different methods can be avoided.

Clinical use of perioperative magnetic resonance imaging-based breast volumetric analysis in final implant volume prediction for two-stage breast reconstruction

Purpose

Breast volume is an important factor in breast reconstruction; however, the surgeon is expected to deliver the volume expectation with his aesthetic inspiration. Therefore, objective volumetry must be developed. This study aimed to conduct an MRI-based breast volumetric analysis. With periodic analysis of 2-stage breast reconstruction, we suggest the possibility of clinical use of breast volumetry in implant volume prediction.

Methods

This retrospective study included 140 patients who underwent unilateral 2-stage breast reconstruction (tissue expander followed by implant insertion) between January 1, 2017 and December 31, 2019. The MRI image was converted into a 3-dimensional image with a reconstruction program (A-VIEW, Coreline Soft). MRI image was obtained before the surgery and then at 1, 3, 6, 12, and 24 months postoperatively. The volume was automatically calculated.

Results

Compared with the preoperative volume, maximized volume and differences were noted at 1 month and minimized at 1 year. The correlation between MRI-based preoperative breast volumetry and the mastectomy specimen volume was 0.611. Volume difference between the MRI-based preoperative state and the implant volume showed a minimal difference at 1 year. The final implant size prediction formula was calculated using the 1-year postoperative volume (P < 0.001, R² = 0.594).

Conclusion

To avoid breast reconstruction based solely on the surgeon’s subjective assessment, MRI-based breast volumetry could be a useful method to develop more scientific and objective breast reconstruction planning. We suggest a volume prediction formula that describes the relationship between the postoperative breast volume and the final breast implant size.

Preoperative Risk Factors and Complication Rates of Breast Augmentation With Fat Grafting

BACKGROUND

The current literature on the complications and risk factors of autologous fat grafting (AFG) for breast augmentation is scant and inconclusive.

OBJECTIVES

The aim of this study was to use a large, multicenter database to determine the major complications and risk factors of patients undergoing breast augmentation with AFG in comparison to breast augmentation with implants.

METHODS

Patients undergoing breast augmentation with AFG as well as with implants between January 2, 2017 and July 31, 2019 were identified from the CosmetAssure database (Birmingham, AL). The primary outcome was the occurrence of major complication(s) requiring emergency department visit, hospital admission, or reoperation within 45 days postoperatively. Age, gender, BMI, smoking, diabetes, facility, ASA class, and anesthetic type were evaluated as risk factors.

RESULTS

Among the 76,128 patients enrolled in CosmetAssure, 789 (1.0%) underwent breast augmentation with AFG, in comparison to 18,544 (24.3%) patients with implants. The incidence of any major complication in the AFG cohort and implant cohort was 3.2% and 2.3%, respectively. Infection was significantly higher in the AFG cohort (1.1% vs 0.5%). Tobacco users were more likely to have any complication, infection, and pulmonary dysfunction/hypoxia on univariate analysis. ASA Class III/IV was more likely to have any complication and infection. On multivariate analysis, smoking was an independent risk factor for any complication (relative risk = 17.1) and infection (relative risk = 20.2).

CONCLUSIONS

Infection and hematoma are the most common major complications in breast augmentation with AFG. Tobacco use is the only independent risk factor for overall complications and infection. Breast augmentation with AFG has a higher infection rate than augmentation with implants.

LEVEL OF EVIDENCE: 4

Assessment of Patient Satisfaction Using a New Augmented Reality Simulation Software for Breast Augmentation: A Prospective Study

Background: Breast augmentation is one of the most frequently performed plastic surgery procedures. Providing patients with realistic 3D simulations of breast augmentation outcomes is becoming increasingly common. Until recently, such programs were expensive and required significant equipment, training, and office space. New simple user-friendly programs have been developed, but to date there remains a paucity of objective evidence comparing these 3D simulations with post-operative outcomes. The aim of this study is to assess the aesthetic similarity between a pre-operative 3D simulation generated using Arbrea breast simulation software and real post-operative outcomes, with a focus on patient satisfaction. Methods: The authors conducted a prospective study of patients requiring breast augmentation. Patients were asked to assess how realistic the simulation was compared to the one-year post-operative result using the authors’ grading scale for breast augmentation simulation assessment. Patient satisfaction with the simulations was assessed using a satisfaction visual analogue scale (VAS) ranging from 0 (not at all satisfied) to 10 (very satisfied). Patient satisfaction with the surgical outcome was assessed using the BREAST-Q Augmentation Module. Results: All patients were satisfied with the simulations and with the attained breast volume, with a mean VAS score of 8.2 ± 1.2. The mean simulation time took 90 s on average. The differences between the pre-operative and one-year post-operative values of the three BREAST-Q assessments were found to be statistically significant (p < 0.001). Conclusions: Three-dimensional simulation is becoming increasingly common in pre-operative planning for breast augmentation. The present study aimed to assess the degree of similarity of three-dimensional simulations generated using Arbrea Breast Software and found that the use of the software provided a very satisfying representation for patients undergoing breast augmentation. However, we recommend informing patients that only the volume simulation is extremely accurate. On the other hand, it is necessary to not guarantee an absolute correspondence regarding the breast shape between the simulation and the post-operative result.

Single Center and Surgeon's Long-Term (15-19 Years) Patient Satisfaction and Revision Rate of Round Textured Eurosilicone Breast Implants

BACKGROUND

Breast augmentation is one of the most commonly performed aesthetic plastic surgical procedures, with over 250,000 procedures in the United States in 2020 alone. However, the safety of breast implants should be closely researched and monitored, especially in the long term.

OBJECTIVES

This study was undertaken to evaluate the long-term results of round micro-textured Eurosilicone (Eurosilicone S.A.S, Apt Cedex, France) Cristalline Paragel breast implants from a single-center, single-surgeon experience regarding both patient-reported outcome measures and revisions.

METHODS

A retrospective cohort study was undertaken of 84 patients who underwent primary breast augmentation with round micro-textured Eurosilicone Cristalline Paragel breast implants, either submuscular (dual-plane) or subglandular placed, between 2001 and 2004. All patients were contacted for informed consent, and after approval, the validated BREAST-Q questionnaire was sent and utilized to analyze patient satisfaction. In addition, objective data regarding revisions, including capsular contracture, rupture rate, pain, and/or aesthetic causes needing revision surgery, were analyzed.

RESULTS

High BREAST-Q scores (67%-100% for 0-100 scale variables and 66.0%-77.3% of the patients scored "very satisfied" on categorical variables) were found without clinically significant differences between patients with dual-plane-placed implants and subglandular-placed implants. The overall revision rate was 29.8%, also with no significant differences between groups (P = 0.317).

CONCLUSIONS

This study showed high patient satisfaction and relatively low revision rates after 15 to 19 years of follow-up of round micro-textured Eurosilicone Cristalline Paragel breast implants. No clinically relevant significant differences were found between dual-plane and subglandular placement of the implants.

LEVEL OF EVIDENCE: 4

The Key of Pocket Dissection in Transaxillary Dual-plane Breast Augmentation: How to Control Inferior Malposition of Smooth Implants

BACKGROUND

Inferior implant malposition after breast augmentation is the second most common reason for revision surgery. This article introduces the new concept of dual-plane pocket formation in transaxillary breast augmentation to prevent inferior implant malposition by preserving the continuity of the superficial layer of the deep pectoralis fascia.

METHODS

Patients who underwent transaxillary endoscopic breast augmentation performed from January 2017 to December 2019 were retrospectively reviewed. With the aid of the endoscope, dissection proceeded. During pectoralis muscle origin detachment, the superficial layer of deep pectoralis fascia was preserved. After making the pocket, silicone gel implants were inserted. A retrospective chart review was done to collect data on postoperative complications.

RESULTS

A total of 251 patients were performed, and the mean follow-up time was 20.6 months. In a total of 28 cases of complications (9.6%), there were 2 cases of reoperations. In a total of three patients (1.2%) of implant malposition, one patient (0.4%) developed mild bilateral bottoming-out deformity.

CONCLUSIONS

Meticulous dissection by endoscopy could avoid the destruction of the superficial layer of the deep pectoralis fascia during pocket dissection and produce an intact fascial system with its own continuity at the inframammary fold (IMF). A well-controlled envelope over the implant and a supporting structure underneath it are important in breast augmentation to prevent inferior implant malposition.

Reoperative Augmentation Mammoplasty: An Algorithm to Optimize Soft-Tissue Support, Pocket Control, and Smooth Implant Stability with Composite Reverse Inferior Muscle Sling (CRIMS) and its Technical Variations

BACKGROUND

Reoperative augmentation mammoplasty (RAM) is a challenging procedure, with the highest rates of complications and revision. Complications include implant malposition, lateral displacement, bottoming out, and rotation. These deformities can be addressed with various procedures, but the pocket control and stability of the new smooth implant surface may present limitations.

OBJECTIVES

This study revisits a previously described predictable approach in primary breast augmentation and defines a surgical treatment algorithm for RAM technique selection.

METHODS

Between 2017 and 2021, 72 patients (144 breasts) underwent RAM with composite reverse inferior muscle sling (CRIMS) technique and its technical variations (types I-IV). CRIMS technique involves placing a silicone gel implant into the submuscular (SM) pocket with an inferior sling of the pectoralis major muscle based on the dimensions of the implant, in combination with support points/dermal bridge sutures to stabilize the implant and glandular tissue at the lower breast pole (LBP). Reasons for surgery were ptosis (92%), implant and malposition (59.6%). Patients were followed for at least 6 months in 5 cases (6.9%), at least 12 months in 50 cases (69.4%), for at least 36 months in 10 cases (13.8%), and more than 36 months in 7 cases (9.7%) (mean 34 months; range 6-48 months). Patients were evaluated in terms of resolution of symptoms, satisfaction, and complications. Three-dimensional imaging (3DI) obtained from the Divina scanner system was used and followed up for 1 year to evaluate breast position, lower pole stretch (LPS), and intermammary distance (IMD).

RESULTS

Eleven cases of minor complications were observed in 9 patients (12.5%): hypertrophic scarring in 4 (5.5%), wound dehiscence in 4 (5.5%), Baker II/III capsular contracture in 1 (1.3%). SmoothSilk surface silicone implants were used in all cases, with an average volume decrease of 120 cc. Sixty-eight patients (94.4%) were either very satisfied/satisfied with their aesthetic result. Breast images were performed in a group of 65 patients (90.2%), and in 7 breasts (10.7%), localized oil cysts were observed. The value for LPS was 7.87% (p <0.0001) between 10 days and 1 year, with the majority occurring early in the first 3 months, indicating that the LBP/implant remains steady during the last months of follow-up. No cases of fat necrosis/seroma were observed. There were no signs of intra/extracapsular ruptures, capsular contracture. There were 2 cases (3%) of minimal implant displacement and no cases of rotation.

CONCLUSIONS

CRIMS and its variations can be performed successfully in RAM. An algorithmic approach can facilitate the pre- and intraoperative decision-making process and provide the new pocket control and implant stability with acceptable complication rates. Further accurate evaluation is recommended to understand the benefits or disadvantages of CRIMS compared to other RAM 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 .

A new oncoplastic technique for removal of centrally located malignant tumors and reconstruction by a local dermo-glandular flap in conservative breast surgery

AIM

To evaluate the local dermo-glandular flap as a new reconstructive oncoplastic technique after removal of central malignant tumors of the breast, in terms of patient satisfaction and local recurrence.

PATIENTS AND METHODS

This study included 60 females with centrally located breast cancer who underwent central quadrantectomy and local dermo-glandular flap with either sentinel lymph node biopsy or axillary clearance.

RESULTS

The mean age of the patients was 49.68 ± 8.52 years. The duration of the operation ranged from 68-105 minutes, with a mean of 79.77 ± 9.41 minutes. Local recurrence was observed in three patients (5.00%) with no distant metastasis. Forty-seven patients (78.33%) reported satisfaction after the operation. Ugly scarring and the existence of tissue defects were the main factors affecting patient satisfaction. Correction of these complications increased overall satisfaction to 88.33%.

CONCLUSIONS

For small- and medium-sized breasts, the use of a local dermo-glandular flap for the management of centrally located malignant tumors seems to be a simple and easy technique with good oncological outcomes and acceptable few minor complications. This technique offers an immediate reconstruction of a new areola with fewer scars that will be hidden later after areola tattooing. Most of the patients reported satisfaction three months after areola reconstruction.

Split Inferior Pedicle: The 1-Stage Augmentation Mastopexy for Grade 3 Ptosis

In this article, the authors describe the 1-stage surgical technique that has been used by the senior author since 1990 for all his primary grade 2 and grade 3 augmentation-mastopexies. The article provides a safe, simple, and reproducible approach to a challenging procedure, one that tends to be the most litigious in aesthetic breast surgery. The key points of this technique are simple preoperative markings; the augmentation is performed with a true submuscular placement of smooth implants; and the mastopexy is performed with an inferior pedicle technique with unlimited skin flap undermining and no limitation of nipple elevation. Seventy-eight consecutive cases of augmentation mastopexy performed since 1999 by a single surgeon (V.S.) using the same technique were reviewed. The age range was 26-62 years old; the range of implant volume was 150-375 cc; and the follow-up time period was from 1 year to 22 years. After an extensive patient case review, the authors enforce true extended submuscular augmentation (TESMA) as a reliable augmentation technique that can be used as the first procedure in any grades 2 and 3 ptosis, 1-stage augmentation-mastopexies including bariatric cases. The authors believe that the split inferior pedicle for the mastopexy in combination with the TESMA is a breakthrough approach that eliminates the second stage for any augmentation mastopexy procedure. No major complications such as nipple necrosis, implant bottoming, malpositioning, or extrusions were observed. It is a safe, simple, and reproducible procedure.

Level of Evidence 4

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.

Current Challenges in Breast Implantation

Breast implantation (BI) is the most common plastic surgery worldwide performed among women. Generally, BI is performed both in aesthetic and oncoplastic procedures. Recently, the prevalence of breast implant-associated anaplastic large cell lymphoma (BIA-ALCL) or breast implant illness (BII) has aroused concerns. As a result, several countries, like Australia, Korea or the United Kingdom, introduced national registries dedicated to the safety and quality of BI surgeries. This narrative review aimed to focus on the clinical challenges, management and the current state of knowledge of BI. Both short and long-term outcomes of BI are determined by various alternatives and differences, which surgeons must consider during the planning and performing breast augmentation along with further complications or risk of reoperation. Proper preoperative decisions and aspects of surgical technique emerged to be equally important. The number of performed breast reconstructions is increasing, providing the finest aesthetic results and improving patient’s quality of life. Choice of prosthesis varies according to individual preferences and anatomical variables. A newly diagnosed cases of BIA-ALCL with lacking data on prevention, diagnosis, and treatment are placing it as a compelling medical challenge. Similarly, BII remains one of the most controversial subjects in reconstructive breast surgery due to unspecified diagnostic procedures, and recommendations.

Post-Mastectomy Surgical Pocket Irrigation With Triple Antibiotic Solution vs Chlorhexidine Gluconate: A Randomized Controlled Trial Assessing Surgical Site Infections in Immediate Tissue Expander Breast Reconstruction

BACKGROUND

Post-mastectomy pocket irrigation solution choice is debated and primarily surgeon dependent. We compare triple antibiotic solution (TAS) with 0.05% chlorhexidine gluconate (CHG).

OBJECTIVES

The purpose of this study was to determine surgical site infection (SSI) rates after utilizing TAS vs CHG for breast pocket irrigation in immediate tissue expander (TE) breast reconstruction.

METHODS

A prospective, blinded, randomized controlled trial was performed in patients (18-81 years old) who underwent bilateral mastectomy with TE reconstruction. In each patient, 1 mastectomy pocket was randomized to TAS and the other to CHG. Both the TE and the pocket were irrigated in the respective solution. The primary outcome was the incidence of SSI. Secondary outcomes were rates of mastectomy flap necrosis, hematoma, and seroma.

RESULTS

A total of 88 patients who underwent bilateral immediate breast reconstruction were enrolled. Demographic and operative characteristics were equivalent because each patient served as their own control. Between the TAS and CHG groups, the incidence of SSI did not differ (5 [4.5%] vs 7 [8.0%], P = 0.35), including minor infections (2 [2.3%] vs 1 [1.1%], P = 0.56), major infections (2 [2.3%] vs 6 [6.8%], P = 0.15), and those resulting in explantation (2 [2.3%] vs 5 [4.5%], P = 0.25). Necrosis, hematoma, or seroma formation also did not differ. No patients who developed SSI received radiation.

CONCLUSIONS

This study does not demonstrate a statistically significant difference in SSI between TAS and CHG irrigation, though TAS approached statistical significance for lower rates of infectious complications.

LEVEL OF EVIDENCE: 2

Evaluating the Quality of Systematic Reviews and Meta-Analyses About Breast Augmentation Using AMSTAR

BACKGROUND

Breast augmentation is one of the most commonly performed cosmetic surgeries worldwide. Therefore, it is imperative to have evidence with high methodological quality to guide clinical decision making.

OBJECTIVES

To evaluate the methodological quality of the systematic reviews (SRs) focused on breast augmentation.

METHODS

A comprehensive search of MEDLINE, Embase, and the Cochrane Library of Systematic Reviews was performed. SRs that have a particular focus on breast augmentation and were published in the top 15 plastic and reconstructive surgery journals were included. Quality assessment was performed using a measurement tool to assess systematic reviews (AMSTAR). Study characteristics were extracted including journal and impact factor, year of publication, country affiliation of the corresponding author, reporting adherence to Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines, number of citations, and number of studies included.

RESULTS

Among the 22 studies included for analysis, the mean AMSTAR score was moderate (5.55), with no SR achieving good quality (AMSTAR score of ≥9). There were no significant associations between AMSTAR score and journal impact factor, number of citations, year of publication, or number of included studies. Studies that reported adherence to PRISMA guidelines on average scored higher on the AMSTAR tool (P = 0.03).

CONCLUSIONS

The methodological quality of reviews about breast augmentation was found to be moderate, with no significant increase in studies or quality over time. Adherence to PRISMA guidelines and increased appraisal of SRs about breast augmentation using methodological assessment tools would further strengthen methodological quality and confidence in study findings.

Hybrid mastopexy: improving outcomes on implant-based augmentation mastopexy with fat

Background

Autologous fat transplantation for breast augmentation represents an increasingly interesting technique in plastic surgery. Only a few standardized procedures are available. Hybrid augmentation mastopexy combines the benefits of autologous fat transplantation and implant-based breast augmentation mastopexy, reducing implant-related complications and prothesis size. Herein, we describe our surgical approach as a “hybrid aesthetic surgery.”

Methods

A retrospective analysis of all patients who underwent hybrid breast augmentation and lifting with simultaneous fat grafting was carried out. Clinical outcomes, ultrasound evaluation of upper pole fullness, aesthetic postoperative results, and complications were examined.

Results

Eighteen patients with a mean age of 33 years (range: 24–52 years) and mean BMI of 25.8 kg/m2 (range: 21.4–32.1 kg/m2) were included in this study. Mean injected fat volume per breast was 115 cc (range: 78–144 cc). Patients were followed up for a mean of 9.4 months (range: 6–24 months). No fat necrosis or major complications were encountered during the follow-up. Patient satisfaction was high in terms of breast shape, size, and coverage of the breast implant. No recurrence of ptosis was observed yet and no secondary revision surgery was performed.

Conclusions

Hybrid mastopexy augmentation is an effective and safe procedure that combines the benefits of autologous fat grafting and implant-based breast augmentation. The transfer of autologous soft tissue allows obtaining a natural breast shape, reducing the onset of rippling and prothesis size. The reduction of prothesis size prevents ptosis recurrence but provides the desired projection. This reliable option improves long-term breast shape with elevated patient’s satisfaction.

Level of evidence: Level IV, therapeutic study.

Revision Breast Augmentation

Breast augmentation is consistently one of the most commonly performed aesthetic operations every year. Unfortunately, revision rates following primary augmentation remain as high as 36%. There are several causes for revision breast augmentation; however, the most common and challenging of these include capsular contracture, implant malposition, and ptosis of the aging breast following augmentation. Successful management of these problems requires knowledge on how to best treat the implant and capsule with the corresponding soft tissue simultaneously. While surgical management is important, understanding the pathological causes of these entities during the primary operation can reduce the need for revision. This article utilizes the most up-to-date literature to review the appropriate clinical evaluation and surgical management of these complex cases.

3D images of the silicone implants in capsular contracture after breast augmentation using magnetic resonance imaging with SPACE sequence

BACKGROUND

Capsular contracture is a common complication after breast augmentation. However, no objective methods are available to assess capsular contracture at present. The goal of the present study was to evaluate the correlation between capsular contracture and 3D images of the silicone implants by using magnetic resonance imaging (MRI) with sampling perfection with application optimized contrast using different flip angle evolutions (SPACE) sequence.

METHODS

Twenty-one patients (42 breasts) underwent breast augmentation, had postoperative MRI examinations with SPACE sequence, and the evaluation of the Baker grade by two trained plastic surgeons. Capsular thickness was measured on the T2-weighted images. The software ITK-SNAP was used to reconstruct 3D images of the implants. The fold characteristics such as number, depth, direction, and distribution were compared with the Baker grade.

RESULTS

Of the 42 breasts, 14, 8, 12, and 8 breasts were classified as Baker grade I, II, III, and IV, respectively. The MRI images of breasts with Baker grade III or IV revealed a thicker capsule (mean of 2.29 mm) as compared to the capsule with the lower Baker grades (mean of 1.58 mm). The 3D images of implants showed no difference in the number of folds between the groups with different Baker grades. The fold direction and fold distribution differed between grade I to II and grade III to IV.

CONCLUSION

The 3D image of an implant with pathological folds is a potential and feasible diagnostic indication of capsular contracture.

LEVEL OF EVIDENCE

IV.

Implant to Fat: A Breast Augmentation Technique Validated by BREAST-Q

Supplemental Digital Content is available in the text.

Implant-based breast augmentation is the number one cosmetic procedure performed in the United States. However, it is associated with relatively high revision rates, reaching up to 24% at 4 years. This case series presents our experience in implant explantation with simultaneous breast augmentation using fat.

Prospective Study of Saline versus Silicone Gel Implants for Subpectoral Breast Augmentation

Background

Silicone gel implants are regarded as esthetically superior to saline implants, offering a more natural consistency. They are also considered less susceptible to rippling. However, objective measurements and patient-reported outcome studies are lacking. Similarly, minimal data are available quantitating animation deformity.

Methods

A 3-year prospective study was undertaken among 223 women undergoing primary subpectoral breast augmentation using either saline (n = 145) or silicone gel (n = 78) implants. Photographs obtained included frontal views with the patient flexing the pectoral muscles. Images were matched, and vertical differences in nipple position were measured. Breast implants were evaluated using high-resolution ultrasound to detect any ripples or folds at least 3 months after surgery. Outcome surveys were administered. Statistical analysis included the χ² test, point-biserial correlations, and a power analysis.

Results

Respondents reported visible rippling in 18% of women and palpable rippling in 32% of patients, with no significant difference between women treated with saline and silicone gel implants. Ripples were detected on ultrasound scans in 24% of women with saline implants and in 27% of women with silicone gel implants (difference not significant). Ripples were more common in women with lower body mass indices. Fifty percent of patients demonstrated nipple displacement <1 cm on animation. Nipple displacement occurred either up or down with equal frequency and a mean overall nipple displacement of zero.

Conclusions

Saline and silicone breast implants produce similar degrees of rippling, as determined on outcome surveys and ultrasound examination. Animation deformities tend to be minor and well-tolerated.

D-SUN Method to Prevent Double-Bubble Deformity in Broad Base Breasts with High-Rising Inframammary Fold

Breast augmentation is the most commonly performed plastic surgery among women worldwide. With time, implant selection shifted from arbitrary implantation to precise planning. Different methods address the dimensional planning process. Many of them are complex to put into practice, focusing mainly on the breast base. Constricted, short lower pole breasts are morphologically predisposed to complication such as double-bubble deformity. Yet, by focusing on the distance between the nipple on stretch and the inframammary fold, the D-SUN method guides the surgeon to find the most appropriate implant volume for anatomical form-stable silicon implants and IMF incision to avoid complications.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.

Safe autologous rib harvest in patients with breast implants; technique and review

INTRODUCTION

Autologous rib harvest is a useful technique for rhinoplasty when septal cartilage is inadequate. For patients who have previously undergone augmentation mammoplasty, however, there is theoretical concern about the risk to breast implant integrity during costal cartilage harvest. The true risk to patients and their implants from autologous rib harvest is poorly studied. Herein, we review our technique and experience with autologous rib harvest after augmentation mammoplasty.

METHOD

We performed a retrospective review of patients who underwent autologous rib harvest after augmentation mammoplasty between February 1998 and February 2017 at a tertiary care hospital and private practice. We identified basic demographics, implant type, approach to implantation, and any post-operative complications following rib harvest. Surgery was performed using an inframammary approach with a boat-technique for cartilage harvest.

RESULTS

A total of 109 individuals, aged 19-64, were included in our study. There was a 2% rate of post-operative seroma development; no patients developed long-term complications. There was a 5% rate of incidental intraoperative discovery of implant dehiscence or implant entry, all of which were repaired primarily at the time of surgery, and none of which developed post-operative sequelae. There were no cases of pneumothorax, post-operative breast malposition, or other major complications.

CONCLUSION

Herein, we present the largest cohort of patients to undergo autologous rib harvest after augmentation mammoplasty. Routine intra-operative drain placement and perioperative imaging is unnecessary. Our technique allows harvest of a suitable amount of cartilage, is very cosmetically acceptable to this cosmetically-conscious population, and is safe for patients and their implants.

Drainage Collection After Endoscopic-Assisted Transaxillary Dual-Plane Augmentation Mammaplasty Using Cold or Electrosurgical Separation of Interpectoral Space

BACKGROUND

Endoscopic transaxillary augmentation mammaplasty breast augmentation offers several advantages over other augmentation methods. Nonetheless, this procedure is fraught with some problems, including greater surgical trauma due to the longer separation area. We hypothesized that cold separation of the interpectoral space could reduce surgical injury in comparison to the electrosurgical method. This study aimed to compare the outcomes of endoscopic-assisted transaxillary augmentation mammaplasty using cold separation versus electrosurgical separation of the interpectoral space.

METHODS

In this prospective clinical trial, cold and electrosurgical separation of the interpectoral space were achieved using a separation shovel and monopolar electrotome, respectively. A total of 20 patients who visited our department in Beijing, China, for primary breast augmentation surgeries from October 1, 2017, and May 31, 2018, were included. The primary outcome was total postoperative drainage volume. The secondary outcomes were operative time, daily drainage volume, daily pain as assessed using the visual analogue scale (VAS), and reoperation rate. Quantitative data were compared using independent-samples t test. Chi-square test was used to compare 2 classified indexes.

RESULTS

The total drainage volume was significantly lower in the cold separation group than in the electrosurgical separation group (170.45 ± 75.40 mL vs 281.05 ± 148.43 mL; P = .005). The VAS score on the first postoperative day was significantly lower in the cold separation group than in the electrosurgical separation group (6.45 ± 1.93 vs 7.55 ± 1.43; P = .048). Two (20%) reoperations owing to postoperative pain or implant stiffness were performed in the electrosurgical separation group.

CONCLUSIONS

Cold separation is more conducive to reducing drainage, relieving postoperative pain, and causing less damage than the electrosurgical method in endoscopic-assisted transaxillary dual-plane augmentation mammaplasty.

A comparative assessment of three planes of implant placement in breast augmentation: A Bayesian analysis

BACKGROUND

Techniques based on three planes of implant placement, including the subglandular (SG), subpectoral (SP), and subfascial (SF) planes are used for breast augmentation. The placement that offers the greatest balance of risks and benefits is unclear. This study presents a systematic review with a Bayesian network meta-analysis to compare different implant placement techniques for augmentation mammaplasty.

METHODS

A systematic literature search was performed. We estimated the odds ratios (ORs) for capsular contractures, hematomas, seromas, infections, reoperation rates, rippling, nipple numbness, malplacements, ruptures, and asymmetry among the different interventions. Muscle movement events and satisfaction rates were also evaluated.

RESULTS

A total of 19 studies (25,744 cases) were included. SG placement significantly increased the incidence of capsular contractures (SP vs. SG: OR 0.42; 95% credible interval [CrI] 0.28-0.63; SF vs. SG: OR 0.41; 95% CrI 0.17-0.97), hematomas (SF vs. SG: OR 0.22; 95% CrI 0.06-0.63), and seromas (SF vs. SG: OR 0.04; 95% CrI 0.00-0.81) compared to other placement techniques. Muscle movement only occurred in the SP group, but it did not increase the risk of subsequent malplacements, asymmetries, or ruptures. Most patients were highly satisfied with their surgical results. Comparisons did not show significant differences in the remaining results.

CONCLUSIONS

Our evidence suggests that SG placement increases the risk of capsular contractures, hematomas, and seromas. The SP and SF planes were safe and effective for controlling total complication rates and achieving high satisfaction rates; however, the long-term benefits of the SF technique require further research.

Winged Ribs: An Underestimated Problem That May Compromise Breast Augmentation Outcomes

Chest wall shape is an important aspect to consider when planning a breast augmentation. Minor chest wall deformities are usually underestimated by the patient and surgeon and may compromise postoperative outcomes. Lower costal cartilage dysmorphia or winged rib is one of these minor underestimated chest wall deformities characterized by a visible and palpable cartilaginous prominence under the inframammary fold and causes discomfort in patients decreasing the satisfaction with the breast augmentation surgery. For these patients, the author utilized an innovative surgical technique that allows resection of the protruding cartilages and placement of breast implants through the same surgical incision. Six patients with winged ribs underwent breast augmentation and costal cartilage resection via this method and there were no intraoperative or early postoperative complications, and all patients were satisfied with the aesthetical result after 6 months of follow-up. The presented surgical technique has a short learning curve with excellent postoperative results. Cases are presented to demonstrate the improved postoperative chest wall contour combined with breast augmentation outcome.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 .

Can It Be Safe and Aesthetic? An Eight-year Retrospective Review of Mastopexy with Concurrent Breast Augmentation

Supplemental Digital Content is available in the text.

Background:

The safety of concurrently performing mastopexy and breast augmentation is controversial, due to the risk of breast tissue and nipple neurovascular compromise and overall potential high complications rates. This article describes a concurrent procedure of augmentation with implants and a “Tailor-Tack” mastopexy that consistently achieves an aesthetically pleasing breast with acceptable complication rates.

Methods:

This is a retrospective chart review of all consecutive breast augmentations performed concurrently with mastopexy using the “Tailor-Tack” technique by the 2 senior authors (M.M. and O.T.) over an 8-year period. Independent variables were patient demographics, surgical approach, implant type, shape, size, duration of follow-up, and complications. Complications were categorized as “early” (ie, first 30 days) or “late” (ie, after 30 days). Potential early complications include hematoma, skin necrosis, infection, and nipple loss. Potential late complications include recurrent breast ptosis, poor shape of the nipple areolar complex, hypertrophic scarring, implant rupture, capsular contracture, decreased nipple sensation, implant extrusion, reoperation, and scar revisions. The key principle of the technique is to place the breast implant in the dual plane first, and then perform the tailor tacking of the skin for the mastopexy second.

Results:

Fifty-six consecutive patients underwent augmentation and mastopexy over 8 years with this technique. The average age of the studied patients was 41.2 years. The average follow-up time period was 2.1 years (±8.9 months). Fifty-four patients (96.4%) had implants placed through the periareolar approach, 2 patients (3.6%) had implants placed via the inframammary approach. All implants were placed in a dual plane. Fifty-two patients (92.9%) received silicone implants and 4 patients (7.1%) received saline implants. Patient preference determined implant choice. All but 5 patients had textured implants. Average implant size was 277 cm³ (range 120–800 cm³). Ten patients had complications (17.9%). Complications included hypertrophic scarring in 5 (8.9%) patients; poor nipple-areola complex shape in 4 patients (7.1%); implant ruptures in 3 patients (5.4%); capsular contracture in 3 patients (5.4%); and recurrent ptosis in 2 patients (3.6%). There were no reported early complications such as nipple loss, breast skin necrosis, decreased nipple sensation, implant infections, or extrusions. However, 6 patients (10.7%) required return trips to the operating room for revisions, and 1 patient (1.8%) had a nipple areolar complex scar revised in the office, yielding a 12.5% surgical revision rate for the late complications.

Conclusions:

It is safe to concurrently perform mastopexy and breast augmentation. In our 8-year review, there were no early catastrophic complications such as skin loss, nipple loss, implant extrusion, or infection. The complications that occurred were the same complications known to occur with the independent performance of mastopexy alone or breast augmentation alone, and they occurred at rates comparable to or less than the national averages for those procedures when they are performed independently. The paramount principle for the success of this technique is to first adjust breast volume and then perform an intraoperatively determined skin resection to fit the new breast volume.

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 .

Current Trends in Breast Augmentation: Analysis of 2011-2015 Maintenance of Certification (MOC) Tracer Data

BACKGROUND

Breast augmentation is the most common aesthetic surgery performed in the United States. Despite its popularity, there is no consensus on many aspects of the procedure.

OBJECTIVES

The authors assessed current trends and changes in breast augmentation from January 1, 2011 to December 31, 2015.

METHODS

A retrospective cross-sectional study of 11,756 women who underwent breast augmentation based on the American Board of Plastic Surgery (ABPS) Maintenance of Certification Tracer Database was performed.

RESULTS

There were clearly dominant trends in how ABPS-certified plastic surgeons performed breast augmentations. Most surgeries were performed in freestanding outpatient (47.3%) or office operating room (33.7%). The inframammary fold incision was most popular (75.1%), followed by periareolar (17.8%) and transaxillary approaches (4.1%). Implants were more commonly placed in a submuscular pocket (30.6%) compared with dual plane (26.7%) or subglandular (6.7%). Silicone implants (66.8%) were favored over saline (25.1%), with a statistically significant increase in silicone prostheses from 2011 to 2015. Data were "not applicable" or "other" in the remainder of cases. Administration of both preoperative antibiotics (3.8% in 2011, 98.7% in 2015, P < 0.05) and deep venous thromboembolism (DVT) prophylaxis (3.8% in 2011, 90.6% in 2015, P < 0.05) dramatically increased during the study period. Overall adverse events (7.4%) and reoperation rates (2.2%) were low.

CONCLUSIONS

Changes in standard of care for breast augmentation are reflected by the evolving practice patterns of plastic surgeons. This is best evidenced by the dramatic increase in use of antibiotic and DVT prophylaxis from 2011 to 2015.

LEVEL OF EVIDENCE: 4

Breast Implant Selection: Consensus Recommendations Using a Modified Delphi Method

Background:

Geographical differences in breast implant selection approaches exist, and clinical data to guide the process are limited. Developing knowledge of implant-related risk factors further complicates the process. This analysis aimed to establish expert consensus on considerations for breast implant selection in Australia and New Zealand based on practice patterns in those countries.

Methods:

A modified Delphi method was used to gain consensus from experts in breast augmentation surgery in Australia and New Zealand. Panelists anonymously completed an initial questionnaire on current considerations in implant selection, discussed a summary of their responses in a live meeting, and completed a final consensus survey based on their live recommendations.

Results:

Seven panelists completed the final consensus survey. Consensus recommendations included ensuring consideration of proper surgical technique (pocket formation, positioning of implant) and patient tissue and anatomical characteristics, weighing relative expected results of various surface textures, sizes, and degrees of cohesivity, and careful contemplation of the migration risk.

Conclusions:

This modified Delphi exercise provided consensus recommendations on the key factors involved in implant selection from the perspective of plastic surgeons with practices in Australia and New Zealand. A primary recommendation was that the choice of implant for each patient should be individualized to patient tissue and anatomical characteristics.

Getting the Most Out of Augmentation-Mastopexy

LEARNING OBJECTIVES

After reviewing the article, the participant should be able to: 1. Understand the tenets of proper patient selection. 2. Be familiar with the assessment of patients for augmentation-mastopexy. 3. Be able to plan an operative approach and execute the critical steps. 4. Be able to recognize common complications and have a basic understanding of their management. 5. Be aware of emerging adjunctive techniques and technologies with respect to augmentation-mastopexy.

SUMMARY

Despite being a multivariable and complex procedure, augmentation-mastopexy remains a central and pivotal component of the treatment algorithm for ptotic and deflated breasts among plastic surgeons. Careful preoperative planning, combined with proper selection of approach and implant, can lead to success. Physicians need to understand that there is a high frequency of reoperation cited in the literature with regard to this procedure, and discussions before the initial operation can help alleviate common misunderstandings and challenges inherent in this operation.

Silicone breast prostheses: A cohort study of complaints, complications, and explantations between 2003 and 2015

BACKGROUND

Complications after silicone implantation, with silicone extravasation being the most severe, remain a safety issue in breast implantation surgery. The purpose of our study was to determine the incidence of medium- and long-term postoperative complaints and complications and indications for explantation in patients with a silicone breast implant.

METHODS

This is a retrospective cohort study consisting of patients who received silicone breast implants of the fourth or fifth generation between 2003 and 2015. Long-term outcomes (> 3 months after initial placement) were derived from medical records. The association with indication of breast surgery, method of placement, and type of reconstruction was determined.

RESULTS

In total, 448 patients (n = 738 silicone breast implants) met the inclusion criteria with a median follow-up of 330 days. Overall, 18% of the implants resulted in postoperative complaints, with discomfort or pain being the most common complaint (12%), significantly more frequent in reconstructive cases and significantly associated with subglandular placement in cosmetically augmented breasts. Physical examination revealed in 14% one or more postoperative complications, with capsular contracture being the most common complication. A total of 12% of the implants were eventually explanted within a median time of 568 days. Predominant reasons were cosmetic dissatisfaction, capsular contracture, and pain (in 37%, 21%, and 15%, respectively). Macroscopic leakage was demonstrated in 3% of the explanted prostheses.

CONCLUSIONS

Explantation of breast implants occurred in 12%, within a median time of 1.6 years, wherein macroscopic leakage was rarely seen. Cosmetic dissatisfaction, capsular contracture, and pain were the most common indications.

Case of late hematoma after breast augmentation

We present a case report of a patient who experienced a late, spontaneous breast hematoma 26 years after primary breast augmentation. Late hematomas are a rare complication of breast augmentation with uncertain etiology. In this case, there was no trauma, calcifications, or implant rupture. We believe the patient’s hematoma was secondary to erosion of a capsular vessel due to capsular contracture.

Current Trends in Breast Augmentation: An International Analysis

BACKGROUND

Breast augmentation surgery remains the most frequently performed aesthetic surgical procedure worldwide. However, many variations exist regarding preoperative planning, surgical management, and postoperative care.

OBJECTIVES

The goal was to evaluate current trends and practices in breast augmentation, with a focus on international variability.

METHODS

A questionnaire was sent to over 5000 active breast surgeons in 44 countries worldwide. The survey inquired about current controversies, new technologies, common practices, secondary procedures, and surgeon demographics. The findings and variations were evaluated and correlated to evidence-based literature.

RESULTS

There were a total 628 respondents equaling a response rate of approximately 18%. While certain approaches and common practices prevail also on an international basis, there exist several geographic controversies. For example, while almost fifty percent of surgeons in the United States and Latin America never use anatomically shaped implants, in Europe and Oceania most surgeons use them. Similarly, in Latin America, Europe, Asia, and Oceania, over 80% of surgeons use silicone implants only, whereas in the United States only 20% use them - meanwhile US surgeons use the largest implants (78% > 300 cc). Internationally dominant practice preferences include preoperative sizing with silicone implants, as well as the use of inframammary incisions and partial submuscular pockets.

CONCLUSIONS

Significant differences exist when comparing most common surgical breast augmentation approaches on an international basis. While certain techniques seem to be universal standards, there still remain several controversies. Further standardizing this most common aesthetic surgical procedure according to evidence-based guidelines will help to improve outcomes.

Antibiotic Irrigation of Pocket for Implant-Based Breast Augmentation to Prevent Capsular Contracture: A Systematic Review

Background

In vitro and in vivo studies have described a number of different antibiotic solutions for irrigation of the pocket in implant-based breast augmentation in an attempt to prevent the formation of capsular contracture (CC). Our objective was to evaluate the evidence that antibiotic irrigation reduced the rate of CC.

Methods

A systematic search of MEDLINE, EMBASE, and CENTRAL was conducted from inception to January 2016. We included studies which examined the use of intraoperative antibiotic irrigation in women undergoing primary breast augmentation. Our primary outcome was the rate of CC. Included studies were assessed for methodological quality using validated tools.

Results

Seven studies were included in the final analysis: 1 randomized controlled trial (RCT) and 6 non-randomized studies. The mean follow-up ranged from 14 to 72 months. The rate of CC was less than 2% in 8 studies, between 3% and 6% in 4 studies, and 13.9% in 1 study. Included studies demonstrated significant clinical and methodological heterogeneity. The solitary low-quality RCT concluded that antibiotic irrigation was superior to saline irrigation. Three non-randomized studies demonstrated no significant difference in the rate of CC with the use of antibiotics. One non-randomized controlled study showed that the use of mixture of antibiotic and povidone-iodine significantly lowered the rate of CC.

Conclusions

The available evidence on the use of antibiotic irrigation to prevent CC is weak and it is based on studies with high risk of bias. Methodologically robust studies are necessary to answer the question whether antibiotic breast pocket irrigation prevents CC.

Evidence-Based Medicine: Breast Augmentation

LEARNING OBJECTIVES

After reading this article, the participant should be able to: 1. Understand the key decisions in patient evaluation for cosmetic breast augmentation. 2. Cite key decisions in preoperative planning. 3. Discuss the risks and complications, and key patient education points in breast augmentation.

SUMMARY

Breast augmentation remains one of the most popular procedures in plastic surgery. The integral information necessary for proper patient selection, preoperative assessment, and surgical approaches are discussed. Current data regarding long term safety and complications are presented to guide the plastic surgeon to an evidence-based approach to the patient seeking breast enhancement to obtain optimal results.