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

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.

Reoperative Transaxillary Subfascial Breast Augmentation and Fat Grafting: Technical Highlights and a Step-by-Step Video Guide

SUMMARY

Reoperative procedures after breast augmentation are frequently more complex than primary cases because of local complications and insufficient soft-tissue coverage. Although the transaxillary incision is often indicated in primary breast augmentation, limitations of this approach include secondary surgery and correcting complications after using this approach via the same incision. Combining the transaxillary technique with a subfascial pocket has been suggested to avoid breast scarring and the limitations of submuscular pockets represented by breast animation. With advances in autogenous fat grafting (AFG) techniques, implant coverage alternatives and more natural outcomes have been reported from more superficial implant pockets. Simultaneous AFG with silicone implants (defined as hybrid breast augmentation) has been evaluated recently as an attractive procedure. These two techniques combine to provide breast projection and natural cleavage while camouflaging implant edges. AFG is also important to reduce the intermammary distance and achieve a smoother transition between the breasts. The transaxillary approach can be useful in reoperative breast augmentation and avoids additional scarring on the breast. This article and the accompanying videos provide a detailed, step-by-step guide to reoperative hybrid breast augmentation using a subfascial transaxillary approach, with a predictable and optimized surgical outcome.

Comparison of Total and Nontotal Endoscopic Transaxillary Breast Augmentation Techniques: A Retrospective Study

BACKGROUND

The aim of this retrospective study was to compare the clinical outcomes of total endoscopic transaxillary (TET) breast augmentation with those of non-TET (NTET) breast augmentation. For the purposes of this study, the term NTET refers to the combination of blunt dissection and endoscopic techniques, whereas TET did not involve blunt dissection.

METHODS

We conducted a retrospective review of 119 consecutive cases of primary breast augmentation from May 1, 2020, to August 31, 2020. The primary outcomes were the number of drainage days and pain scores as assessed using the visual analog scale on the first postoperative day. The secondary outcomes were the daily drainage volume recorded during the postoperative drainage days, the presence of postoperative daily pain that required the administration of tramadol for relief, reoperation rate, and operative time.

RESULTS

The number of drainage days was significantly lower in the TET group than in the NTET group (TET vs NTET: 2.56 ± 0.57 vs 3.78 ± 1.30 days, P = 0.000). The visual analog scale score on the first postoperative day was significantly lower in the TET group than in the NTET group (TET vs NTET: 4.96 ± 0.63 vs 5.93 ± 0.93, P = 0.000).

CONCLUSIONS

We observed that the major outcomes of the TET group were more favorable than those of the NTET group. Based on our results, we recommend the avoidance of blunt dissection during endoscopic transaxillary breast augmentation.

LEVEL OF EVIDENCE

III.

Augmentation-Mastopexy: Analysis of 95 Consecutive Patients and Critical Appraisal of the Procedure

Single-stage mastopexy-augmentation has been demonstrated to be a safe procedure. However, revisions may still be necessary. We evaluate 95 consecutive patients undergoing mastopexy-augmentation and introduce a new surgical technique for the procedure: the modified dual plane technique. In this retrospective study, 95 patients (mean age 34 ± 11 years) underwent mastopexy-augmentation between 2009 and 2019. The procedures were classified as subglandular, dual plane, or modified dual plane technique. The outcome measures included major and minor complications. A total of 19 patients underwent a subglandular procedure, 32 patients a dual plane procedure, and 44 patients a modified dual plane procedure. We observed a high overall complication rate in the subglandular group (n = 12, 63%), dual plane group (n = 15, 47%), and modified dual plane group (n = 10, 23%). Complications leading to implant loss/change occurred in seven patients in the subglandular group (37%), six patients in the dual plane group (19%), and no patient in the modified dual plane group. While we observed a high complication rate in patients undergoing mastopexy-augmentations, the modified dual plane technique was associated with a lower complication rate.

How Big Is Too Big? Exploring the Relationship between Breast Implant Volume and Postoperative Complication Rates in Primary Breast Augmentations

There is no consensus regarding implant size as an independent risk factor for complications in primary breast augmentation. Choosing appropriate implant volume is an integral part of the preoperative planning process. The current study aims to assess the relationship between implant size and the development of complications following augmentation mammaplasty.

Methods

A retrospective chart review of patients undergoing primary breast augmentation at the Westmount Institute of Plastic Surgery between January 2000 and December 2021 was conducted. Demographics, implant characteristics, surgical technique, postoperative complications, and follow-up times were recorded. Univariate logistic regression was used to identify independent predictors, which were then included in multivariate logistic regressions of implant volume and implant volume/body mass index (BMI) ratio regarding complications.

Results

A total of 1017 patients (2034 breasts) were included in this study. The average implant volume used was 321.4 ± 57.5 cm³ (range: 110-605). Increased volume and volume/BMI ratio were associated with a significant increase in risk of implant rupture (odds ratio = 1.012, P < 0.001 and 1.282, P < 0.001 respectively). Rates of asymmetry were significantly associated with increases in implant volume and volume/BMI ratio (odds ratio = 1.005, P = 0.004 and 1.151, P < 0.001, respectively). No single implant volume or volume/BMI ratio above which risks of complications significantly increase was identified.

Conclusions

Implant rupture and postoperative asymmetries are positively correlated with bigger implant volumes. Implant size could likely be a useful independent predictor of certain complications, especially in patients with high implant to BMI ratios.

Immediate Prepectoral Breast Reconstruction Using an ADM with Smooth Round Implants – A Prospective Observational Cohort Study

Prepectoral breast reconstruction using acellular dermal matrices (ADMs) is well established and used in candidates for nipple/skin-sparing mastectomies; it is based on many different matrices and a great variability in breast implant selection. We describe our experience and clinical outcomes using Braxon® ADMs and smooth round breast implants. Females aged 18-80 years who underwent mastectomies with immediate prepectoral reconstruction between April 2019 and April 2021 were prospectively included. Complications were classified as mastectomy-related (hematoma, necrosis) or reconstruction-related (seroma, infection, red breast syndrome). Binary logistic regression analysis was performed to assess correlation between complication rate and selected variables, which were analyzed per breast with Kruskal-Wallis H test. Fifty-eight patients (102 breasts) received 45 bilateral and 12 unilateral procedures. Drains collected 485.9 cc [range: 100-1260] and were removed 15.7 days [range: 6-29] postoperatively. We report 41 complications (40.2%): 33 mastectomy-related, 8 reconstruction-related. Reoperation occurred in 14 patients: 7 wound debridement and revisions under local anesthesia; and 7 explantation. Implant loss rate was 6.8%. Mastectomy and reconstruction complications were not correlated with any variable. In conclusion, we found prepectoral reconstruction with Braxon® ADMs and smooth round implants to be associated with acceptable complication rates that are not influenced by any patient- or surgery-related factors. Drainage volume is comparable to other breast implant reconstructive techniques, but drains are left in place for longer.

Subfascial Ergonomic Axillary Hybrid (SEAH) Breast Augmentation: A Surgical Approach Combining the Advantages of Incision, Pocket, Silicone Gel, and Fat Grafting in Primary and Revision Breast Augmentation Surgery

BACKGROUND

Simultaneous application of the axillary approach (AA) with the subfascial pocket (SF) has been proposed for breast augmentation (BA) surgery. New silicone implant technology and recent improvements in autologous fat grafting (AFG) have ushered in a new era for BA.

OBJECTIVES

The aim of this study was to present the combined subfascial ergonomic axillary hybrid (SEAH) method and evaluate its aesthetic benefits after primary/secondary BA.

METHODS

In total, 42 patients (84 breasts) underwent BA with the SEAH technique; this approach was indicated when the overlying tissue was insufficient to adequately cover the implant.

RESULTS

Mean patient age was 34.6 years (range, 28-56 years), mean BMI was 18.8 kg/m2 (range, 14.4-26.1 kg/m2). The most common implant (Motiva SmoothSilk surface Ergonomix style) volume was 255 cc (range, 175-355 cc), patients received a mean fat volume of 96 mL (range, 60-145 mL) per breast in the subcutaneous tissue. The average lower pole stretch value was 40.5% (21.75 mm) and 13.1% (9.9 mm) for preoperative to 10 days postprocedure and 10 days to 18 months postprocedure, respectively. Postoperative complications included subcutaneous banding in the axilla (n = 3, 7.1%), small wound dehiscence (n = 1, 2.3%), and hypertrophic scarring (n = 1, 2.3%). No rippling, implant malposition, infection, or fat necrosis was observed during a mean follow-up of 18 months (range, 6-32 months).

CONCLUSIONS

SEAH is a useful and versatile technique combining the benefits of AFG and implant-based augmentation, particularly with regard to soft tissue coverage, and avoids the limitations of the submuscular position. The combination of ergonomic gel implants and a SF pocket can yield satisfactory aesthetic outcomes.

LEVEL OF EVIDENCE: 4

Safety and Effectiveness of Silicone Gel-Filled Breast Implants in Primary Augmentation Patients

Background

Results from the MemoryGel Breast Implants Core Clinical Study suggest these devices are safe and effective at 10 years after implantation. Although clinical trials are essential for measuring the safety and effectiveness of a device, real-world evidence can supplement clinical trials by providing information on outcomes observed in diverse clinical settings for a more heterogeneous population, without fixed treatment patterns, and without continuous patient monitoring, such that follow-up is more representative of normal clinical practice.

Objectives

The aim of this study was to measure real-world outcomes, including safety and effectiveness, in patients who underwent primary breast augmentation with smooth MemoryGel implants.

Methods

This was a case series looking at patients, age 22 years and older, who underwent primary breast augmentation at a single site between December 2006 and December 2016 and who had a minimum of 2 years of follow-up. Descriptive statistics were used to summarize baseline characteristics and outcomes. Kaplan-Meier models were used to estimate safety outcomes for capsular contracture (Baker grade III/IV), infection, and rupture.

Results

A total of 50/777 (6.4%) patients reported a complication, with an average time to complication of 3.9 years (range, 19 days-11.8 years) postprocedure. Kaplan-Meier estimates of the 10-year cumulative incidence of capsular contracture (Baker grade III/IV), infection, and rupture were 4.7%, 0.1%, and 1.6%, respectively.

Conclusions

Analyses of a large population from a single site provide further support for the long-term safety and effectiveness of MemoryGel breast implants in a primary augmentation cohort.

Level of Evidence: 4

Reoperative Transaxillary Approach Algorithm: Extending the Surgical Alternatives for Secondary Breast Augmentation in the Era of Scarless Surgery

BACKGROUND

Although the transaxillary approach (TAA) is useful in primary breast augmentation (BA) surgery, drawbacks of this technique include the need to correct complications arising from reuse of the axillary incision.

OBJECTIVES

The purpose of this study was to assess the outcomes of secondary BA procedures performed via the TAA in a cohort of patients operated on by a single surgeon and to provide an algorithm for reoperative TAA technique selection.

METHODS

Sixty-two patients (122 breasts) underwent secondary TAA BA, which was indicated for capsular contracture (CC) in 35 patients (56.4%). Periods for analysis included less than 10 days, 1, 3, 6, and 12 months, and then at 2-year intervals postprocedure.

RESULTS

Forty-three patients (69.3%) had a previous premuscular (PM) pocket; in 35 (81.3%) of these patients the new pocket was kept in the same position. Nineteen patients (30.7%) had a previous submuscular pocket, and 15 patients (78.9%) had the new pocket transferred to the PM plane. Ten cases of complications were observed in 8 patients (16.1%), Baker grade II/III CC in 3 (4.8%), and axillary banding in 2 (3.2%), during a mean follow-up of 72 months (range, 6-170 months). Fifty-nine patients (95.1%) were either very satisfied or satisfied with their aesthetic result.

CONCLUSIONS

Recent progress in surgical techniques has led to significant improvements in aesthetic outcomes following BA. The TAA can play a useful role in secondary BA cases and our results show this procedure to be useful, with acceptable complication rates, and the added bonus of avoiding additional scarring on the breast.

LEVEL OF EVIDENCE: 4

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.

Epidemiologic Characteristics and Postoperative Complications following Augmentation Mammaplasty: Comparison of Transgender and Cisgender Females

Breast augmentation in transgender women can be an important first step in addressing gender incongruence and improving psychosocial functioning. The aim of this study was to compare postoperative outcomes of augmentation mammoplasty in transgender and cisgender females.

Eight-Year Safety Data for Round and Anatomical Silicone Gel Breast Implants

BACKGROUND

The safety and efficacy of all medical devices, including breast implants, is important and consistent performance is best shown by undertaking long-term clinical and vigilance studies. Local complications such as capsular contracture and rupture are risks often associated with breast implant surgery.

OBJECTIVES

The authors investigate and evaluate the safety and performance of Eurosilicone's (Eurosilicone S.A.S, Apt Cedex, France) Cristalline Paragel breast implants at 8 years postimplantation.

METHODS

In this prospective clinical study, 995 Eurosilicone textured cohesive Cristalline Paragel mammary implants were implanted in 526 women undergoing augmentation and reconstructive surgery at 17 centers across France. Complications were recorded at 3 months and annually thereafter for 8 years. Descriptive statistics were used and key complications were analysed using the Kaplan-Meier method.

RESULTS

Capsular contracture was reported in 8.5% of implants across all cohorts through 8 years. The Kaplan-Meier risk of capsular contracture (Baker Grade III/IV) per implant was 8.4% in the primary augmentation cohort and 18.0% in the primary reconstruction cohort. Eight implant ruptures were identified by surgeon examination during this follow-up period. The Kaplan-Meier risk of rupture occurring within 8 years postimplantation, across all cohorts, was 1.4% per patient and 0.9% per implant. Actual implant removal rate (explantation/exchange) was 6.0% and 13.8% for primary augmentation and primary reconstruction, respectively. Actual rates of local complications including infection and seroma were low with risk rates of 0.6% and 0.2% by subject.

CONCLUSIONS

This multicenter clinical study involving Eurosilicone's silicone gel breast implants in both round and shaped profiles demonstrates an excellent safety and efficacy profile through 8 years.

Five-Year Outcomes of Breast Augmentation with Form-Stable Implants: Periareolar vs Transaxillary

BACKGROUND

Form-stable 410 implants have the potential advantage of maintaining their anatomic form thanks to the cohesiveness of the gel. Furthermore, Biocell texturing appears to maximize adhesion and to allow for implant immobility.

OBJECTIVES

To compare the rate of reoperations for transaxillary and periareolar approaches for breast augmentation.

METHODS

This retrospective study consisted of 373 patients with a 5-year follow up. Patient demographics, self-perception and esteem, surgical technique, and implant characteristics were documented. The reasons for reoperation for both approaches were reviewed.

RESULTS

Transaxillary breast augmentation was used in 302 patients (81%) and periareolar breast augmentation in 71 patients (19%). In the axillary group, 210 had subfascial placement (69.5%), and 92 patients had submuscular placement (30.5%). In the nipple-areolar complex group, 50 were subfascial (70.4%), and 21 were submuscular (29.6%). The reoperation rate for the patients operated on during this time and followed for 5 years was 11% (8 patients) for the nipple-areolar complex approach and 8.3% (25 patients) in the axillary group. Capsular contracture grade III or IV were the main causes for reoperation for any technique (4.2% nipple-areolar complex vs 3.3% axillary). Other reasons were implant rupture, seroma, infection, implant malrotation, implant malposition, and rippling.

CONCLUSIONS

The rate of reoperations was similar to those described in the literature for this type of implant. There were no statistically significant differences between the various techniques, although the reoperation rate was significantly higher when a periareolar subfascial technique was used.

LEVEL OF EVIDENCE

3 Therapeutic.

The Process of Breast Augmentation with Special Focus on Patient Education, Patient Selection and Implant Selection

Breast augmentation remains one of the most commonly performed plastic surgical procedures worldwide; however, Food and Drug Administration clinical trials have suggested that this procedure has a reoperation rate of 14% to 24% after 3 years. Recent literature has proposed that breast augmentation should not only be a surgical procedure but ultimately a surgical process to reduce postoperative complications and enhance patient satisfaction. The process of breast augmentation has been documented to optimize postsurgical outcomes and includes the following 4 steps: patient education, tissue-based planning, refined surgical techniques, and defined postoperative management.

Response to the Comments of Dr. Chen on Chinese Women's Preferences and Concerns Regarding Incision Location for Breast Augmentation Surgery: A Survey of 216 Patients

In our previous article, preoperative education material regarding different incisions for breast augmentation surgery was compiled to help Chinese patients fully understand the characteristics of different incisions and make informed choices. Dr. Chen argued that some key indicators were missing in the instrument. However, the preoperative education material was compiled based on existing literature to provide patients with valid information. The items listed were proven to be directly connected to incision choices. The items unlisted were unconfirmed or not related to incision choices.

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.

Transaxillary endoscopic breast augmentation with shaped gel implants

BACKGROUND

At its inception, transaxillary breast augmentation was a blind technique associated with complications and unpredictable outcomes. The transaxillary approach now involves electrocautery dissection with direct endoscopic visualization and yields excellent aesthetic outcomes with a concealed scar. Shaped implant devices can be combined with transaxillary augmentation for natural-appearing results that can be individualized to the patient.

OBJECTIVES

The authors sought to improve the results of transaxillary endoscopic breast augmentation by placing shaped gel implants in patients with an indistinct or absent inframammary fold (IMF), who wished to avoid a breast scar.

METHODS

One hundred sixteen Asian women underwent transaxillary endoscopic breast augmentation with electrocautery dissection and were evaluated in a prospective study. A partial retropectoral plane pocket was created in 4 sequential dissection steps with direct endoscopic visualization and careful control of bleeding. Shaped cohesive gel implants were placed to produce smooth, natural-appearing breast mounds and well-defined IMFs.

RESULTS

Patients were monitored for 6 to 24 months after surgery (mean, 10 months; median, 12 months). There were no instances of pneumothorax, instrument-related skin burns, or severe implant deformation due to rotation or displacement of the implants postoperatively. Three of 116 patients (2.6%) experienced Baker 3 unilateral capsular contracture. One patient developed a unilateral hematoma at 3 weeks after surgery.

CONCLUSIONS

Endoscopic breast surgery is associated with shortened recovery times, a reduced need for drainage, and excellent outcomes, including a well-defined and symmetric IMF. This approach, combined with shaped gel implants, can yield natural-appearing results of transaxillary breast augmentation.

LEVEL OF EVIDENCE

4 Therapeutic.

Asian Outcomes of Primary Breast Augmentation in 162 Consecutive Cases by a Single Surgeon

In 162 Asian patients, primary breast augmentation was performed by a single surgeon during 5 years. The purpose of this study evaluates Asian outcomes in primary breast augmentation using single antibiotic breast irrigation by a single surgeon's practice and examines the comparison of Asian and Western outcomes in primary breast augmentation.

METHODS

A retrospective chart review was performed to examine a total of 162 patients who received the same brand of implants for primary breast augmentation under sedative anesthesia (propofol infusion) in a single surgeon's practice. Asian patients' demographics, preoperative and postoperative measurements, surgical technique (single antibiotic breast irrigation), implant type, size, texture, soft tissue coverage, implant placement, incision approach, complications, and incidence of reoperation were documented.

RESULTS

This study presents data for 162 primary breast augmentation who received a total of 324 implants. The mean length of follow-up for all patients was 25.1 months (range, 6-60 months). The difference between Tebbetts and Adams' reoperation proportion (ρ0 = 0.028) and this article's reoperation proportion (ρ0 = 0.0185) is not statistically significant (P value = 0.3707). Reoperation rate and complications are not related with implant type, implant placement, body mass index, and incision approach.

CONCLUSIONS

By comparison, the reoperation rates between Asian and Western patients are equal due to adequate preoperative evaluation and surgical procedure. The differences are found somewhat in the average measurements of age, body mass index, and implant size. The technique of the use of blunt dissection with fingers under tumescent infiltration and single antibiotics irrigation provides an alternative way to surgeons for breast augmentation.

Understanding the Etiology and Prevention of Capsular Contracture: Translating Science into Practice

Capsular contracture remains a common and preventable complication of implanted breast prostheses. As our understanding of the pathophysiology continues to develop, it is prudent to reexamine existing beliefs in a contemporary context. This article presents a current summary of clinical and laboratory evidence, expressed as an interaction between potentiating and suppressing factors, and how this understanding can be applied to practice.

Chinese women's preferences and concerns regarding incision location for breast augmentation surgery: a survey of 216 patients

BACKGROUND

The axillary approach is the dominant incision used in China for breast augmentation. Systematic preoperative education regarding incision locations for breast augmentation is scarce in China. In this study, we surveyed Chinese patients to ascertain their preferences and concerns for incision location based on a comprehensive understanding of different incisions.

METHODS

We used a literature review, patient interviews, and expert panels to develop the preoperative education material and questionnaire regarding different incision locations. The respondents were requested to choose one incision location before and after they received the preoperative education. Their initial choices and final decisions as well as the reasons for these choices were recorded and analyzed. Multinomial logistic regression was preformed to analyze the affecting factors on the incision choice.

RESULTS

A total of 216 Chinese women participated in the study between 2012.5 and 2014.1. Initially, 176 (81.48%) women chose axillary incision, 27 (12.50%) chose periareolar incision, and 13 (6.02%) chose inframammary fold (IMF) incision. After they received preoperative education on incisions, the axillary and periareolar approaches decreased to 117 (54.17%) and 13 (6.02%), respectively, while IMF increased to 86 (39.81%). The easily hidden scar (43.98%), lower capsular contracture rate (23.15%), and lower possibility of injury to the breast parenchyma (17.13%) ranked as the top 3 reasons for the incision choice. Patients with a preoperative cup size of AA were 12.316 times more likely to choose the axillary approach relative to the IMF approach compared with those with a B cup (P = 0.044; 95% confidence interval [CI] 1.069-141.923). For each one-unit increase in BMI, the odds that a patient would choose the axillary versus the periareolar approach decreased by 32.4% (P = 0.049; 95% CI 0.457-0.999).

CONCLUSIONS

The systematic and objective preoperative education material and questionnaire regarding different incision locations helped the Chinese patients make truly informed decisions and express their personal requirements. The axillary approach was the first option for more than half of Chinese women mainly because an easily hidden scar was considered the primary concern during the decision-making process. The patients with a low BMI and a small preoperative breast cup size were more likely to choose an axillary incision. However, a considerable number of Chinese women would choose the IMF incision and value its superiority in terms of a lower capsular contracture rate, less tissue trauma, and lower possibility of injury to the breast parenchyma.

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.

Utility of video-assisted endoscopy in transaxillary breast augmentation

BACKGROUND

Breast augmentation through incisions in the axillae is an option for patients who wish to avoid scars on the breasts. The axillary approach also preserves the mammary parenchyma and lactiferous ducts. The utility of video-assisted endoscopy during this procedure as a means to improve safety and aesthetic outcomes remains debatable.

OBJECTIVES

The authors compared outcomes of transaxillary breast augmentation with and without video-assisted endoscopy.

METHODS

Thirty-four women who underwent transaxillary breast augmentation with or without video-assisted endoscopy were evaluated in a prospective, randomized study. Patients received high-profile silicone implants in the subglandular plane and were monitored for an average of 25 months. Operating time, complication rates, postoperative pain, patient satisfaction, and aesthetic parameters were evaluated.

RESULTS

Operative time were significantly longer for patients who underwent transaxillary breast augmentation with video-assisted endoscopy compared with patients who underwent nonendoscopic surgery.

CONCLUSIONS

Video-assisted endoscopy increased operating time but did not improve the safety of transaxillary breast augmentation or yield better aesthetic outcomes.

LEVEL OF EVIDENCE

3 Therapeutic.

Shoelace Breast Cast

Implant malposition after breast augmentation surgery remains a common complication. Several surgical options exist to correct the resultant deformity; however, all involve additional risks, costs, and the increased potential for patient dissatisfaction. In my practice, I have developed a nonsurgical therapy using shoelaces, which, when tied and placed in a certain fashion, can correct this deformity. When worn continuously, the shoelaces act as an external breast cast that allows the inframammary fold to be set and heal in the correct position. I have achieved great success in using this nonsurgical technique, and it allows me to be aggressive in cases where I need to raise the inframammary fold because I know that I can easily correct if the fold is lowered too much.

Transaxillary Nonendoscopic Subpectoral Augmentation Mammaplasty: A 10-Year Experience With Gel vs Saline in 2000 Patients-With Long-Term Patient Satisfaction Measured by the BREAST-Q

BACKGROUND

Transaxillary augmentation mammaplasty (TAM) is an option for patients who wish to avoid a visible breast incision from breast augmentation (BA).

OBJECTIVES

The authors compared TAM outcome data for gel and saline implants and evaluated patient satisfaction using the BREAST-Q patient-reported outcome measure (BQ).

METHODS

In this 10-year retrospective, comparative, and cross-sectional study, the authors reviewed results of saline implants placed with TAM in a surgeon's practice during the final 5 years of the moratorium of the US Food and Drug Administration (phase 1) and compared them with results for gel and saline implants placed with TAM during the 5 years after the moratorium (phase 2). Outcomes were assessed for the entire BA study population (n = 2430 for primary BA; 4860 implants); 670 patients completed and returned the BQ, from which postoperative satisfaction was evaluated.

RESULTS

BQ responses demonstrated a high rate of patient satisfaction, with outcomes comparable to those of other studies. The differences between the median BQ-assessed breast satisfaction and outcome satisfaction scores in the axillary and nonaxillary surgical groups were statistically significant, favoring axillary over nonaxillary. The difference in mean satisfaction scores was marginally significant between the 2 types of implants, favoring silicone gel. The incidence of surgical revision was 7.5% for the entire BA study population and 6.8% for the patients who underwent TAM.

CONCLUSIONS

TAM produces long-term patient satisfaction as measured by the BQ. Complication rates are similar to those of other studies. In the present study, patients who underwent TAM and thus had hidden incisions were more satisfied than patients whose incisions were visible.

LEVEL OF EVIDENCE

3.

Breast augmentation

LEARNING OBJECTIVES

After studying this article, the participant should be able to: 1. Assess patient physical characteristics that influence implant selection. 2. Adopt a system to aid in implant size selection. 3. Become cognizant of the advantages and disadvantages of incision, pocket plane, and implant options. 4. Understand implant positioning concepts and aseptic implant handling methods. 5. Manage untoward postoperative sequelae 6. Understand secondary surgery concepts.

SUMMARY

Breast augmentation is the most commonly performed aesthetic surgical procedure. Choices of incisions, pocket plane, and myriad implant characteristics constitute the basis for surgical planning. Analysis of physical characteristics and inclusion of the patient in implant selection contribute to overall satisfaction and reduce requests for secondary surgery. Technical expertise in implant positioning and aseptic handling helps to prevent capsular contracture, implant malposition, and other shape problems. Despite the need for secondary surgery in some, patient satisfaction is high.

Five-year Safety Data for Eurosilicone's Round and Anatomical Silicone Gel Breast Implants

BACKGROUND

Multicenter prospective studies assessing the safety and efficacy of silicone gel breast implants are relatively rare. Eurosilicone S.A.S. present their safety and efficacy data herein for the largest European silicone gel breast implant study published to date.

METHODS

One thousand and ten of Eurosilicone's textured cohesive Cristalline Paragel range of mammary implants was implanted in women undergoing augmentation and reconstructive surgery at 17 centers throughout France. Physical examinations and complications were recorded by physicians at 3 months and annually thereafter until 10 years postimplantation. Descriptive statistics were used and key complications were analyzed using the Kaplan-Meier analysis method.

RESULTS

Two ruptures were observed within 5 years postimplantation, one of which was subject to mechanical trauma during reoperation and the other was identified during routine screening. Capsular contracture, one of the most common complications associated with breast implants, was reported in 6.6% implants across all indications through 5 years. The Kaplan-Meier risk of capsular contracture (Baker III/IV) was 10.7% (95% confidence interval, 7.2-14.2%) and 17.2% (95% confidence interval, 5.4-29%) in the primary augmentation and primary reconstruction patient cohorts, respectively. Implant removal (explantation/exchange) was 8.5% and 16.5% for primary augmentation and primary reconstruction cohorts, respectively. Rates of local complications including infection and seroma were low with risk rates of 0.6% and 0.2% by subject.

CONCLUSIONS

Eurosilicone S.A.S. prospective study involving 1010 Eurosilicone silicone gel breast implants in both round and shaped profiles demonstrated a low rupture rate and an excellent safety profile through 5 years.

Evidence-based medicine: augmentation mammaplasty

LEARNING OBJECTIVES

After studying this article, the participant should be able to: 1. Recognize the role of biofilm in breast implant surgery and possible ways to reduce the incidence of capsular contracture. 2. Describe the advantages and disadvantages of various surgical approaches including the incision placement and implant location. 3. List the advantages and disadvantages of implant characteristics including implant fill, shell surface characteristics, and implant shape. 4. Take steps to avoid the phenomena of double capsule and late seroma.

SUMMARY

This article was prepared to accompany practice-based assessment with ongoing surgical education for the Maintenance of Certification for the American Board of Plastic Surgery. It is structured to outline the care of the patient presenting for cosmetic breast augmentation.

Transaxillary totally subfascial breast augmentation with anatomical breast implants: review of 27 cases

BACKGROUND

The transaxillary route is a popular method of breast augmentation because it is associated with inconspicuous scars. The subfascial plane carries the advantages and decreases the disadvantages of subglandular and submuscular planes. In the technique described, the authors placed the implant totally subfascially to strengthen the advantages of the traditional subfascial plane.

METHODS

Twenty-seven patients (50 breasts) were included in the study from 2009 to 2012. The mean patient age was 27.3 years (range, 19 to 32 years). An axillary incision was performed and the pectoralis major fascia was opened initially. With endoscopic assistance, the dissection continued craniocaudally underneath the fasciae of the pectoralis, serratus, and rectus abdominis muscles. Patients were followed up in terms of rippling, implant visibility, capsular contracture, and asymmetry.

RESULTS

Patients were followed up for an average of 21 months (range, 7 to 28 months). Anatomical, textured, and cohesive gel implants were used, with a mean implant size of 235 cc (range, 180 to 300 cc). In terms of the Baker classification, only 16 percent of the patients had grade II capsular contractures. There were no cases of malpositions, wrinkling, or rippling. Overall satisfaction was quite high (96 percent), and none of the patients required an implant removal or change.

CONCLUSIONS

A modification of the subfascial plane was demonstrated where the implants have been placed totally subfascially, in contrast to the traditional subfacial techniques. Satisfactory results have been obtained in terms of breast shape, nipple sensitivity, capsular contracture, and implant visibility. However, more long-term results are needed to evaluate the exact effect of total fascial coverage.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Therapeutic, IV.

Capsular contracture rate in a low-risk population after primary augmentation mammaplasty

BACKGROUND

The safety of augmentation mammaplasty has increased dramatically in the past 20 years. Capsular contracture (CC) is the most commonly reported complication of augmentation mammaplasty.

OBJECTIVES

The authors report the incidence of CC in a low-risk patient population after primary augmentation.

METHODS

The authors retrospectively reviewed the charts of 856 consecutive patients who underwent primary augmentation mammaplasty between 1999 and 2009. This series did not include patients who underwent breast augmentation-mastopexy, secondary augmentation, revision, and/or reconstruction. Data points included demographics, functional and aesthetic outcomes, complications, and revision rate/type.

RESULTS

The overall incidence of CC in 856 patients was 2.8%. Average follow-up time was 14.9 months. Antibiotic irrigation decreased CC rates from 3.9% to 0.4% (P = .004). Tobacco users had higher rates of contracture than nonsmokers (5.5% vs 1.9%; P = .036). Saline implants had a higher CC rate than silicone gel (4.3% vs 1.3%; P = .032). Using multivariate logistic regression, CC was 7.89 times more likely in saline implants than in silicone gel (P = .027, 95% confidence interval, 1.26-49.00).

CONCLUSIONS

Based on our findings, it is apparent that the early CC rate in primary augmentation can be less than 1%. To avoid CC, we advocate an inframmamary approach, submuscular implant placement, and antibiotic irrigation of the breast pocket.

LEVEL OF EVIDENCE

3.

A multi-institutional perspective of complication rates for elective nonreconstructive breast surgery: an analysis of NSQIP data from 2006 to 2010

BACKGROUND

As elective nonreconstructive breast surgery increases in popularity, there is greater demand for accurate multi-institutional data on minor and major postoperative complications.

OBJECTIVE

The authors utilized a multi-institutional database to compare 30-day morbidities and reoperation rates among the different types of elective nonreconstructive breast surgery.

METHODS

Patients in the National Surgical Quality Improvement Program (NSQIP) participant use file who underwent elective nonreconstructive breast surgery between 2006 and 2010 were identified. Twenty defined morbidities were compared among mastopexy, reduction mammaplasty, and augmentation mammaplasty patients using analysis of variance and χ(2) tests for continuous variables and categorical variables, respectively. Logistic regression modeling was employed to identify preoperative risk factors for complications.

RESULTS

Of the 3612 patients identified, 380 underwent mastopexy, 2507 underwent reduction mammaplasty, and 725 underwent augmentation mammaplasty. Complication rates were low in all cohorts, and patients undergoing augmentation mammaplasty had the lowest overall complication rate compared with mastopexy and reduction mammaplasty (1.24%, 2.37%, and 4.47%). Patients undergoing reduction mammaplasty had a modestly elevated incidence of overall morbidity, superficial surgical site infections, and wound disruptions (P < .05). Moreover, 30-day reoperation rates for mastopexy, reduction mammaplasty, and augmentation mammaplasty were low (1.58%, 2.07%, and 0.97%), as were the rates of life-threatening complications (0%, 0.16%, and 0%). One death was observed for all 3612 procedures (0.03%).

CONCLUSIONS

Elective breast surgery is a safe procedure with an extremely low incidence of life-threatening complications and mortality. Comprehensive data collated from the NSQIP initiative add to the literature, and the findings of this multi-institutional study may help further guide patient education and expectations on potentially deleterious outcomes.

Dual-plane breast augmentation for minimal ptosis pseudoptosis (the "in-between" patient)

BACKGROUND

Dual-plane breast augmentation (DPBA) can be an effective technique for treating patients with ptotic breasts who fall somewhere in between the traditional requirements for breast augmentation versus a more extensive augmentation-mastopexy.

OBJECTIVES

The author outlines indications for DPBA, describes the technique, and presents outcomes data from patients receiving gel or saline implants in an effort to clarify the advantages of DPBA compared with breast augmentation with or without mastopexy.

METHODS

This 8-year retrospective comparative study reviewed the results of saline implants placed with a DPBA technique in a single surgeon's practice during the final 4 years of the FDA moratorium (phase 1) compared with both gel and saline implants placed during the 4 years after the moratorium was lifted (phase 2). Patients were consecutive. The entire patient cohort (n = 1999 for primary BA; 3998 implants) was assessed for outcomes.

RESULTS

Of the entire cohort, 24.2% were followed for over 1 year; 23.5% of the 256 DPBA patients were followed for over 1 year. Mean (SD) age was 33.6 (8.7) years. The difference in revision rates between BA versus DPBA was 4.6% (95% confidence interval [CI], 0.7-8.5).

CONCLUSION

The DPBA approach is most likely suited for patients with minimal ptosis who fall into a "gray area" between normal anatomy (treated with a traditional BA) and frank ptosis (which would require mastopexy). Knowledge of this approach will allow surgeons to more effectively treat patients who present with unique "in-between" anatomy not addressed by ordinary BA and avoid more extensive mastopexy scars.

LEVEL OF EVIDENCE

3.