Cadaveric Study of Breast Measurements during Augmentation with Implants:

The Position of the Nipple-Areola Complex in Breast Augmentation

BACKGROUND

There is some controversy regarding whether the nipple-areola complex (NAC) is elevated, remains stable, or is lowered in breast augmentation. There is a general belief that one can modulate its position depending on the implant chosen. In addition, many preoperative markings include elevating the arms to predict the final position of the NAC.

OBJECTIVES

The aim of this study was to investigate changes in the position of the NAC and determine whether the postoperative position of the NAC can be predicted preoperatively by elevating the arms.

METHODS

The study included 45 patients. A 3-dimensional scan was performed to take basal (preoperative) and 12-month measurements with the patient's arms in abduction and elevated over the head. The distances measured were the sternal notch-nipple (SN-Ni), nipple-nipple (Ni-Ni), and nipple-inframammary fold (Ni-IMF) distances.

RESULTS

With arms abducted, the SN-Ni distance increased by 6% when measured linearly, 8.5% when measured on the skin surface, and 1% to 2% when measured on the sternal line. The Ni-Ni distance increased by 9% (linear) and 15% (over the surface). The Ni-IMF increased by 44%. With arms adducted, the SN-Ni distance increased by 9% (linear), 12% (on the skin surface), and 0.5% at the sternal midline projection. The Ni-Ni distance increased 11% (linear) and 19% (on the surface). The Ni-IMF distance increased by 53%. The postoperative position of the NAC with the arms abducted increased by 17% compared with the preoperative position in adduction.

CONCLUSIONS

Implants do not elevate the NAC; its position remains nearly unaltered. The SN-Ni distance was increased in 90% of the patients. Lifting the arms for preoperative markings does not help to predict the postoperative position of the NAC.

LEVEL OF EVIDENCE: 4

An Analysis of Ptosis following Subfascial Breast Augmentation: Calculations That Explain Dogma

BACKGROUND

Implant placement can improve ptosis due to the position of the nipple, inframammary crease, and base of the breast acting together. The interrelationship between these was quantified via changes in morphometry following subfascial augmentation, and explains the circumstances under which dogma holds true.

METHODS

One hundred seventy-five patients underwent a series of static measurements before and 3 months after subfascial breast augmentation. Ptosis in the nipple and base of the breast was calculated before and after surgery.

RESULTS

All measurements except that of the the lateral sternal margin increased after surgery. All grades of ptosis reduced following surgery. There was lowering of the base in grade 1 patients, but not for other grades. Increased base ptosis correlated with reduced lateral sternal margin (1.9 cm compared with 2.9 cm; left, H5 = 24.7, p < 0.01; right, H5 = 24.5, p < 0.01). Implant volume did not correlate with change in ptosis at the nipple or base. Reduced ptosis was associated with implants that are a narrow match of implant to breast (0.52 to 0.95) (left, H5 = 28.3, p < 0.01; right, H5 = 24.9, p < 0.01). Decreasing ptosis correlated with lower lateral sternal margin compared to breasts that increased ptosis. Change in ptosis following surgery does not correlate with having children.

CONCLUSIONS

Subfascial placement has varying effects on ptosis. Non-ptotic or mildly ptotic breasts appear to improve due to a disproportionate descent of the inframammary crease relative to the nipple and base. Patients with little breast tissue are more susceptible to an increase in "bottoming out," particularly if broad implants are used. A ratio matching implant to the base width has predictive value on outcome.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Therapeutic, IV.

An anthropometric evaluation of the augmented breast: differences between cis-and transgender women and possible clinical implications

Background

The morphometric results after breast augmentations are generally understood to be clinically different between trans(gender) and cis(gender) women. The objective of this study was to establish these morphometric differences between the augmented breasts of trans and cis women and their implications for preoperative planning and expectation management of trans women.

Methods

A single-center, observational cross-sectional study was conducted. Three-dimensional images (VECTRA) of the chest were taken and used to measure preset morphometric parameters. Subsequently, several proportional morphometric outcome variables were calculated. We compared body, breast, and nipple dimensions and their interdependence between trans and cis women. The main outcome sets were (1) the relative dimensions of the chest, (2) the position of the breasts relative to the chest, (3) and the position of the nipple relative to the breast and nipple size.

Results

A total of 22 transgender and 22 cisgender women were included. The results showed that the breasts of the trans women were positioned more cranial. Furthermore, the nipple-areola complexes (NAC) were significantly smaller and positioned relatively more latero-cranial on the breasts.

Conclusions

Morphological characteristics of augmented breasts differ significantly between trans and cis women. The results of this study identified distinct differences between the augmented breasts of trans and cis women. Because of the apparent differences in results, surgical considerations, expectation management, and shared decision-making should play an even more pronounced role in breast augmentations in trans women.

Level of evidence: Level III, risk/prognostic study.

A Prospective Study of Breast Morphological Changes and the Correlative Factors After Periareolar Dual-Plane Augmentation Mammaplasty with Anatomic Implant

BACKGROUND

Dual-plane breast augmentation is a popular cosmetic procedure. However, objective evaluations on the effects of dual-plane breast augmentation on breast morphology are lacking. This study evaluated the breast morphological changes and correlative factors after dual-plane anatomic implant augmentation with a periareolar incision via a Vectra 3-dimensional (3D) scanning technique.

METHODS

The dynamic changes in linear distance, breast projection, nipple position, and breast volume and surface over time (preoperatively; 1 month, 3 months, 6 months, and 12 months after surgery) were analyzed in 21 patients with the Vectra 3D scanning technique. In another group of 65 patients, the influence of the implant parameters and tissue characteristics of the patients on breast morphological changes were evaluated.

RESULTS

The breast measurements changed significantly up to 6 months postoperatively and remained stable thereafter. The inframammary fold dropped by 0.8 cm at 1 month postoperatively and by 0.5 cm in the following 11 months. The preoperative implant volume and a lower pole skin elasticity lead to an increase in the nipple-to-inframammary fold distance. Compared with the expected values, the final volume was 10.9% smaller, and the projection was 25% smaller. Both the reduced volume and projection were correlated with the implant parameters and preoperative values. The nipple level was slightly elevated by approximately 0.8 cm.

CONCLUSIONS

This study provides objective information regarding the breast morphological changes and correlative factors after dual-plane breast augmentation. These information may help to further understand the operation effects of dual-plane breast augmentation and to guide medical practice.

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 .

Anthropometric Aspects in the Breast Augmentation

BACKGROUND

Studies have demonstrated the importance of anthropometric measurements of the breasts, based on linear measurements for the selection of the volume of breast implants, their positioning, and surgical planning.

OBJECTIVES

The objective of this study is to evaluate the main changes in anthropometric measurements in breast augmentation.

METHODS

A prospective, randomized clinical study with 74 female candidates for breast augmentation. All the individuals were split into five groups, according to the implant volume. The implants used were of different textures, from three different brands (LifeSil, Politech, and Silimed). The following measures were taken: distance from the nipple to the inframammary fold (N-IMF), inter-nipple-areolar complex distance (N-N), distance from the Sternal notch to the Nipple (SN-N), areola diameter, and breast projection.

RESULTS

The most significant breast anthropometric alteration after mammoplasty was the N-IMF distance; that is, an expansion of the lower pole of the breast, followed by an increase in the areolar diameter. Mostly of measurements showed stability between 3rd and 6th months after the surgery. The projection was the most interesting measure due to presenting two patterns of behavior according to the analysis criteria performed. When comparing the implant projection and the final breast projection, it was observed that the implant profile represented a 27% increase in the final breast projection.

CONCLUSIONS

This study provides an essential comparative analysis between anthropometric changes in breast augmentations and serves as a predictive tool in the preoperative evaluation of the patient during surgical planning.

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 .

Geometric Measurements of Nipple Position in Breasts Reconstructed with Transverse Rectus Abdominis Musculocutaneous Flap: A 5-Year Prospective Study

BACKGROUND

After breast reconstruction, nipple position and other long-term changes in the reconstructed breast relative to the contralateral breast remain poorly understood. In this prospective cohort study, the authors performed serial nipple position measurements over 5 years in patients who had undergone breast reconstruction with a transverse rectus abdominis musculocutaneous (TRAM) flap. The effects of adjuvant radiotherapy on nipple position over time were also investigated.

METHODS

The authors studied 150 patients who had undergone nipple-sparing mastectomy, using radial incision followed by immediate unilateral pedicled TRAM flap breast reconstruction. Measurements of sternal notch-to-nipple, midline-to-nipple, and inframammary fold-to-nipple distances were performed 1 day before reconstruction and 6, 12, 36, and 60 months after surgery, on patients' reconstructed and nonoperated breasts.

RESULTS

The average sternal notch-to-nipple distance increased in both reconstructed and nonoperated breasts at every follow-up visit, with an average difference of 0.393 cm at the 60-month visit (p < 0.0001). Comparing the pattern of distance change, reconstructed breasts tend to change more slowly than nonoperated breasts until 36 months postoperatively. In irradiated breasts, the sternal notch-to-nipple distance was significantly smaller than in nonirradiated breasts, and nipple position changed minimally between 1 and 3 years after surgery.

CONCLUSIONS

Nipple position in TRAM flap-reconstructed breasts changed over time compared with that in nonoperated breasts, especially along the vertical axis. The pattern of nipple position change in reconstructed breasts became similar to nonoperated breasts 3 years after surgery. In patients who had undergone adjuvant radiation therapy, nipple position remained consistent for 1 to 3 years.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Therapeutic, IV.

The Effect of Implant Type on Nipple Position Geometry and Aesthetics Following Tissue Expander Reconstruction After Nipple Sparing Mastectomy

BACKGROUND

While recent studies have reported modest to no difference in breast aesthetics for shaped and round implant types in breast augmentations, the anatomy and biomechanics in the setting of breast reconstruction is different.

OBJECTIVES

Accordingly, we endeavored to evaluate whether two implant types impacted nipple position and aesthetic features in prosthetic breast reconstruction.

METHODS

A retrospective chart review was carried out on patients who underwent nipple-sparing mastectomy (NSM) with immediate tissue expander breast reconstruction. Patients were divided into two cohorts: smooth round implants and textured shaped implants. Postoperative photographs were evaluated to assess nipple displacement vis-à-vis a vector of maximal projection and aesthetic outcome for features of breast shape.

RESULTS

Of 102 breasts meeting the inclusion criteria, 41 had tissue expander-implant reconstruction with anatomical shaped implants, and 61 had reconstruction with smooth round implants. The shaped implant cohort had less nipple deviation from the point of maximal projection (3.69 ± 6.24 vs 7.52 ± 10.50; P < 0.0001). Graded semi-quantitative aesthetic scores were also higher (4.04 ± 0.67 vs 3.72 ± 0.93; P = 0.0044) in the shaped implants than in the round cohort.

CONCLUSIONS

Unlike breast augmentation, there is a paucity of overlying breast tissue and larger dissected spaces in prosthetic breast reconstruction. Our analysis suggests that in this setting, textured anatomic implants result in less nipple deviation from the point of maximum projection and improved aesthetic outcomes compared to round implants. When considering implant choice in NSM reconstruction, the manifold risks of shaped textured implants must thus be informed by potential aesthetic benefits with respect to shape and enhanced nipple sensation.

LEVEL OF EVIDENCE 4

Intraoperative Comparison of Anatomical versus Round Implants in Breast Augmentation: A Randomized Controlled Trial

BACKGROUND

The purpose of this randomized controlled trial was to determine whether anatomical implants are aesthetically superior to round implants in breast augmentation.

METHODS

Seventy-five patients undergoing primary breast augmentation had a round silicone implant of optimal volume, projection, and diameter placed in one breast and an anatomical silicone device of similar volume and optimal shape placed in the other. After intraoperative photographs were taken, the anatomical device was replaced by a round implant to complete the procedure. A survey designed to measure breast aesthetics was administered to 10 plastic surgeon and 10 lay reviewers for blind evaluation of the 75 cases.

RESULTS

No observable difference in breast aesthetics between anatomical and round implants was reported by plastic surgeons in 43.6 percent or by lay individuals in 29.2 percent of cases. When a difference was perceived, neither plastic surgeons nor lay individuals preferred the anatomical side more often than the round side. Plastic surgeons judged the anatomical side superior in 51.1 percent of cases and the round side superior in 48.9 percent of cases (p = 0.496). Lay individuals judged the anatomical side superior in 46.7 percent of cases and the round side superior in 53.3 percent (p = 0.140). Plastic surgeons identified implant shape correctly in only 26.5 percent of cases.

CONCLUSIONS

This study provides high-level evidence supporting no aesthetic superiority of anatomical over round implants. Given that anatomical implants have important and unique disadvantages, a lack of proven aesthetic superiority argues against their continued use in breast augmentation.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Therapeutic, I.