Absence of capsular contracture in 319 consecutive augmentation mammaplasties: Dependent drains as a possible factor

Antiseptic Techniques in Breast Implant Surgery: Insights From Plastic Surgeons in Saudi Arabia

Background

Breast implant surgery is a popular procedure worldwide, and the same holds true for Saudi Arabia. Ensuring a sterile surgical environment is crucial to avert postoperative infections. This study explores the various antiseptic techniques adopted by Saudi plastic surgeons during breast implant procedures.

Objectives

This study aims to assess Saudi plastic surgeons' adherence to antiseptic measures in breast implant surgery, and determine what types of antiseptic measures are most commonly used among Saudi plastic surgeons.

Methods

The authors conducted a cross-sectional survey among board-certified plastic surgeons in Saudi Arabia, collecting data through a self-administered online questionnaire. This questionnaire, which covered their demographic information and their antiseptic practices during breast implant surgery, was disseminated via a WhatsApp (Menlo Park, CA) broadcast message from May 15 to June 27, 2023.

Results

Of the 52 Saudi plastic surgeons who completed the questionnaire, all reported employing preoperative antibiotics and skin disinfection. Other measures included pocket irrigation (86.5%), implant irrigation (92.3%), sleeve/funnel usage (65.4%), nipple shield usage (51.9%), and glove change during the procedure (96.2%). Nearly, all respondents used only a surgical cap for head cover (96.2%) and postoperative antibiotics as prophylaxis (98.1%). However, more than half of them did not minimize door movement during the procedure (51.9%).

Conclusions

This study offers a valuable insight into the antiseptic practices during breast implant surgery in Saudi Arabia. The findings underline the need for further research to establish evidence-based guidelines for antiseptic practices in this field.

Level of Evidence 5

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.

Preventing Infection in Implant-based Breast Reconstruction: Evaluating the Evidence for Common Practices and Standardized Protocols

Infection following implant-based breast reconstruction (IBBR) results in increased rates of hospital readmission, reoperation, patient and hospital expenses, and reconstructive failure. IBBR is a complex, multistep procedure, and there is a relative lack of high-quality plastic surgery evidence regarding "best practices" in the prevention of implant infections. In the absence of strong data, standardizing procedures based on available evidence can reduce error and improve efficacy and outcomes.

Methods

We performed a focused literature review of the available evidence supporting specific interventions for infection prevention in the preoperative, intraoperative, and postoperative phases of care that are applicable to IBBR. In addition, we examined previously published standardized perioperative protocols for implant reconstruction.

Results

Preoperative, intraoperative, and postoperative planning and organization is crucial in IBBR. Preoperative planning involves skin decolonization in advance of surgery with either chlorhexidine gluconate or mupirocin. Intraoperative methods that have shown potential benefit include double-gloving, breast pocket irrigation, separate closing instruments, and the utilization of "no-touch" techniques. In the postoperative period, the duration of drain removal and postoperative antibiotic administration play an important role in the prevention of surgical site infection.

Conclusions

There is a crucial need to establish an evidence-based set of "best practices" for IBBR, and there exists a paucity of evidence in the breast literature. These data can be utilized to develop a standardized protocol as part of a rigorous quality improvement methodology.

A Shakespearean Dilemma in Breast Augmentation: to Use Drains or not? a Systematic Review : Drains in Breast Augmentation

BACKGROUND

Breast augmentation is one of the most commonly requested and performed plastic surgery procedures. In order to prevent early postoperative complications such as seroma or hematoma, surgical drains could be useful. The aim is to perform a systematic review of the literature on the use of surgical drains in primary breast augmentation.

METHODS

This review was performed following the PRISMA guidelines. PubMed, SCOPUS, Web of Science and Cochrane Library databases were queried in search of clinical studies describing the use of surgical drains in women undergoing primary breast augmentation with implants and documenting seroma and/or hematoma formation rate and/or infection rate.

RESULTS

Initial search identified 2596 studies, and 162 were found relevant. Full-text review and application of our inclusion criteria to all retrieved papers produced 38 articles that met inclusion criteria. Among the included studies, 16 papers reported the use of surgical drains in breast augmentation, while in the remaining 22 articles drains were not used. Only 5 studies specifically investigated the role and effectiveness of surgical drains in augmentation mammaplasty and its possible relationship with complication rate such as seroma, hematoma or infection.

CONCLUSIONS

Despite similar complication rates emerged from the analyzed articles, because of the heterogeneity of the studies, we were not able to demonstrate specifically whether drain use affects the rate of early postoperative complications such as seroma, hematoma and infection. Additional randomized controlled trials are strongly advocated in order to provide the necessary scientific evidence.

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 .

Drainage on augmentation mammoplasty: Does it work?

BACKGROUND

Breast prostheses could be associated with complications, despite many studies on surgical materials and techniques. The role of surgical drainage in preventing complications on breast prostheses surgery is controversial.

OBJECTIVES

This study aimed to evaluate the role and effectiveness of vacuum drainage in the augmentation mammoplasty.

METHODS

A prospective multicentric randomized comparative clinical trial was conducted with 150 patients, who were the candidates for breast augmentation. The candidates were split into two groups to analyze the breast drain role. Group1: closed-suction drainage; measurements were taken every 24 h for 48 h. Group2: control (no drainage); all the patients were submitted to a clinical and postoperative ultrasonography evaluation (7th day and 3rd month). The late consultations (1st-, 2nd-, and 3rd-year postoperative time) were carried out to identify any complication, such as infection, seroma, hematoma, asymmetry, hypertrophic scarring, rippling, implant position, visible edges, and sensibility alteration.

RESULTS

A total of 150 female patients were operated with 300 breast implants placed into subglandular pocket. In the first 24 h postoperative (D1), the drainage volume ranged from 12 ml to 210 ml (mean= 74.90 ml; SD= 43.29 ml). After 24 h, on the second day (D2), the collected volume ranged from 10 ml to 120 ml (mean= 44.76 ml; SD= 24.80 ml). The total drainage volume in the 48 h ranged from 22 ml to 320 ml (mean= 119.7 ml; SD= 62.20 ml). The breast ultrasonography series (BUSGS) analysis was done on the 7th day and 3rd month in both groups. There was no significant difference between G1 and G2 groups (p = 0.05 and 0.25, respectively). In the follow-up, some patients (33-44%) declared sensitivity disturbing on the nipple-areola complex (NAC) and lower breast segment.

CONCLUSIONS

The closed-suction breast drainage in breast augmentation was associated with high cost and time-consuming and not demonstrated any benefit in a recent postoperative time.

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 .

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 10-Year Prospective Study of Implant-Based Breast Augmentation and Reconstruction

Objective: Observational studies are essential for ensuring patient safety, decreasing complications, and developing better surgical techniques and implants. The primary objective of this study is to demonstrate the safety and efficacy of Sebbin breast implants in both augmentation and reconstruction cohorts. Methods: This prospective, multicenter, observational 10-year study conducted in France included 205 patients (385 implants) who underwent breast augmentation (n = 166) or reconstruction (n = 39) with Sebbin round silicone gel implants. Data on patient demographics, surgical details, and complications were collected. Results: Median patient age was 39 years; 20.5% of patients were smokers. The augmentation cohort included 166 patients (81.0%); the reconstruction cohort, 39 patients (19.0%). Median implant volume was 280 ml; 91.2% of implants were textured, and 8.8% were smooth. Average patient follow-up was 63 months. The most frequent surgical approach in the Augmentation Cohort was periareolar (72.4%), with 45.5% submuscular and 51.5% subglandular placements. All patients received antibiotic prophylaxis, and postoperative antibiotic therapy was given to 39.5% of patients (average 4.8 days). Drainage was performed in 59.5% of patients (average 2.9 days). Of the reconstruction cohort, 64.1% had preoperative radiotherapy. Nine patients had Baker III/IV capsular contracture (3 bilateral; 4 had a history of radiotherapy) and 7 patients had implant rupture; 41 patients underwent explantation. No cases of double capsule, late seroma, or anaplastic large cell lymphoma occurred. Conclusions: This study found an excellent safety profile and very low capsular contracture rate with breast augmentation and reconstruction using Sebbin round silicone gel implants.

Low rate of capsular contracture in a series of 214 consecutive primary and revision breast augmentations using microtextured implants

Capsular contracture is the most common major complication after implant-based breast augmentation. The aetiology of capsular contracture is multifactorial. The author reports a retrospective personal series of patients managed over a seven-year period with a nearly unchanged surgical strategy implementing most of known measures for capsular contracture prevention. A microtextured silicone gel-filled implant from a single manufacturer was used in all cases.

There were 214 consecutive patients (126 primary augmentations and 88 revision augmentations) operated on over the study period. Mean age of the population was 40.0 years, and mean BMI was 22.0 kg/m². Of the patients in the revision cohort, 44.3% were reoperated on because of previous capsular contracture.

Average follow-up was 20.2 months. There was a 0% capsular contracture rate in the primary augmentation cohort and a 3.4% capsular contracture rate in the revision cohort. At last follow-up, 91.2% of breasts received a Baker I grading.

Although the follow-up was relatively short, this rate of capsular contracture would still be considered very low. Determining the reason for such a low rate of capsular contracture on Multivariate Analyses would be difficult due to the potential myriad of confounding variables. However, given the constancy of the technique and implant type employed by a single surgeon, the author is of the opinion that the microtexturing topography on the implant surfaceused in this series contributed to the low rate of capsular contracture formation. However, this would need to be tested in arandomized controlled trial comparing microtextured devices with implants that have macrotextured surfaces.

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.

Use of BioPatch® (Protective Disk with Chlorhexidine Gluconate) in Closed-Suction Drainage for Penile Implant Surgery

BACKGROUND

The use of closed-suction drains after penile implant surgery remains controversial. The use of BioPatch®, a protective disk with chlorhexidine gluconate, may reduce the incidence of drain-related infections, one of the feared complications of drains. The aim of this study is to describe a novel use of BioPatch® in penile implant surgery as well as additional techniques that may potentially minimize infection rates.

METHODS

A description of operative technique and a review of the literature will be presented. A novel approach to penile implant surgery that may reduce infection rates is described.

RESULTS

A simple technique is described for surgeons considering implementation of closed-suction drains after penile implant surgery.

CONCLUSION

Although randomized controlled studies looking at drain placement following penile implant surgery are lacking, the addition of BioPatch® and the implementation of surgical techniques as described are potentially helpful in preventing infection following this surgery.

Povidone-iodine combined with antibiotic topical irrigation to reduce capsular contracture in cosmetic breast augmentation: a comparative study

BACKGROUND

Antibacterial lavage with topical antibiotics may reduce the occurrence of capsular contracture (CC) in breast augmentation.

OBJECTIVES

The authors investigate the efficacy of povidone-iodine combined with antibiotic irrigation in reducing the CC rate.

METHODS

The charts of 330 consecutive women who underwent cosmetic breast augmentation during 2 different periods (group A: 2004-2009, n = 165; group B: 2009-2010, n = 165) were retrospectively reviewed. All patients in the series underwent augmentation with the same surgeon (A.S.) via the inframammary approach and dual-plane pocket. In group A, patients received a single perioperative dose of 1.5 g of intravenous cephalothin and 750 mg of oral cephalexin twice a day for 7 days after discharge. In group B, patients perioperatively received 750 mg of intravenous cefuroxime, and each implant and pocket were irrigated with 25 mL of a 10% povidone-iodine solution mixed with 750 mg of cefuroxime and 80 mg of gentamicin diluted in 15 mL of 0.9% sodium chloride solution. After discharge, patients received 500 mg of oral levofloxacin once a day for 5 days. Postoperative complications included occurrence of infection, hematoma, seroma, and CC.

RESULTS

Mean (SD) postoperative follow-up in groups A and B was 24 (+/- 13) months and 22 (+/- 3) months, respectively. The postoperative superficial wound infection rate was 1.8% and 1.2%, the seroma rate was 1.8% and 1.2%, and the hematoma rate was 0.6% and 1.2% in groups A and B, respectively. Ten CC cases (Baker grade 3 or 4) in group A and 1 in group B were reported (6% vs 0.6%; P = .006).

CONCLUSIONS

Povidone-iodine and antibiotic irrigation in cosmetic breast augmentation yielded a lower CC rate than standard perioperative antibiotics in this series of patients.

Minimal inframammary incision for breast augmentation

The inframammary approach in breast augmentation, still the most popular technique among plastic surgeons, has always been hampered by the undesirable appearance of its scar. The present paper describes a modified approach to inframammary augmentation with saline-filled prostheses. This approach uses a very short incision, thus resulting in a much less noticeable scar. The surgical technique is easy to learn, simple to execute, does not necessitate any special equipment and gives consistent results. Decreasing the scar length to an absolute minimum ensures higher patient and surgeon satisfaction.

Is a closed-suction drain advantageous for penile implant surgery? The debate continues

INTRODUCTION

The debate about leaving a closed-suction drain during penile implant surgery remains unsolved. What is the current thinking about the pros and cons of leaving a scrotal drain for inflatable penile implant (IPP) surgery?

AIMS

The aim of this study is to explore the fund of existing information, and formulate a point and counterpoint debate analyzing the drain issue for implant surgery.

METHODS

Two differing points of view are given to answer the question of benefit vs. risk drains in implant patients.

MAIN OUTCOME MEASURES

To facilitate the debate about a longstanding urologic question.

RESULTS

There are two conflicting points presented in this manuscript, one supporting drain placement, the other opposing it in light of the risks and benefits.

CONCLUSIONS

Without prospective randomized controlled trials specifically looking at drain placement following IPP, it is unclear whether or not this intervention is beneficial. Until a study of this type is performed, leaving a drain will largely remain a surgeon preference.

A comparison of outcomes involving highly cohesive, form-stable breast implants from two manufacturers in patients undergoing primary breast augmentation

BACKGROUND

Although there have been reports of single-surgeon outcomes with highly cohesive, form-stable silicone gel implants in women undergoing primary breast augmentation, there has been only one study published that compares the outcomes between the Allergan 410 and the Mentor CPG devices.

OBJECTIVES

The goal of the study is to compare outcomes in each cohort and to determine if quality systems and processes would have an impact on lowering the surgical revision rate, as compared to published reports for round gel implants and form-stable implants.

METHODS

Patients selected for the study were required to meet predefined inclusion criteria and general indications for breast augmentation. All subjects were treated uniformly with extensive informed consent prior to surgery. The entire process of breast augmentation (patient assessment, informed consent, the surgical procedure itself and postoperative instructions) was identical between the two groups. Patients were not randomized, as the studies did not start at the same time. The process for management of each patient was based on adaptation of the Toyota Production System and Lean Manufacturing, with emphasis on achieving operational excellence in the use of planning templates for surgery, including accurate management of patient expectations regarding size outcome.

RESULTS

Outcomes data included physical breast measurements, quality of life metrics, and patient/surgeon satisfaction assessment. Adverse events were compared against published data for breast implants. Follow-up ranged between 20-77 months (Allergan 410) and 16-77 months (Mentor CPG). The outcome data indicate that these devices produce natural-appearing breasts with extremely low aggregate reoperation rate (4.2%). Only 0.8% of the reoperations were attributable to surgeon-related factors. There were no reoperations to correct mismanaged size expectations during the course of each study. There were 13 pregnancies and no difficulties with lactation were reported. Rippling (lateral/medial, palpable and/or visible) was encountered in both cohorts. The Mentor CPG cohort had a fivefold greater incidence of rippling (37.3% versus 7.6% in Allergan 410 cohort). This was highly statistically significant (P < .001).

CONCLUSIONS

Provided that there is adherence to core principles and avoidance of errors in planning, patient expectations, and surgery, highly cohesive, form-stable breast implants can deliver excellent long term outcomes in primary breast augmentation in a diverse patient population. The impact of quality processes such as Toyota Production System and Lean Manufacturing was substantive in delivering operational excellence in primary breast augmentation.