Subfascial breast augmentation: is there any advantage over the submammary plane?

Complications following Breast Augmentation in Transfeminine Individuals: A Systematic Review and Meta-Analysis

BACKGROUND

Breast augmentation is the most commonly performed procedure for gender affirmation in transfeminine individuals. Although adverse events among breast augmentation in cisgender women are well described, their relative incidence in transfeminine patients is less elucidated. This study aims to compare complication rates after breast augmentation between cisgender women and transfeminine patients and to evaluate the safety and efficacy of breast augmentation in transfeminine individuals.

METHODS

PubMed, the Cochrane Library, and other resources were queried for studies published up to January of 2022. A total of 1864 transfeminine patients from 14 studies were included in this project. Primary outcomes including complications (capsular contracture, hematoma or seroma, infection, implant asymmetry/malposition, hemorrhage, skin or systemic complications), patient satisfaction, and reoperation rates were pooled. A direct comparison of these rates was performed against historical rates in cisgender women.

RESULTS

Within the transfeminine group, the pooled rate of capsular contracture was 3.62% (95% CI, 0.0038 to 0.0908); the hematoma/seroma rate was 0.63% (95% CI, 0.0014 to 0.0134); the infection incidence was 0.08% (95% CI, 0.0000 to 0.0054); and implant asymmetry rate was 3.89% (95% CI, 0.0149 to 0.0714). There was no statistical difference between rates of capsular contracture ( P = 0.41) and infection ( P = 0.71) between the transfeminine versus cisgender groups, whereas there were higher rates of hematoma/seroma ( P = 0.0095) and implant asymmetry/malposition ( P < 0.00001) in the transfeminine group.

CONCLUSION

Breast augmentation is an important procedure for gender affirmation and, in transfeminine individuals, carries relatively higher rates of postoperative hematoma and implant malposition relative to cisgender women.

Practice Patterns in Primary Breast Augmentation: A 16-Year Review of Continuous Certification Tracer Data from the American Board of Plastic Surgery

BACKGROUND

As part of the continuous certification process, the American Board of Plastic Surgery collects case data for specific tracer procedures in aesthetic surgery to assess practice improvement by the diplomates. These case-based data provide valuable information on national trends in clinical practice. The current study was performed to analyze practice patterns in aesthetic primary breast augmentation.

METHODS

Breast augmentation tracer data were reviewed from 2005 to 2021 and grouped into an early cohort (EC), from 2005 through 2014, and a recent cohort (RC), from 2015 through 2021. Fisher exact tests and two-sample t tests compared demographic characteristics of the patients, surgical techniques, and complication rates.

RESULTS

Patients in the RC were slightly older (34 versus 35 years; P < 0.001), more likely to have ptosis greater than 22 cm (20% versus 23%; P < 0.0001), less likely to smoke (12% versus 8%; P < 0.0001), and less likely to undergo a preoperative mammogram (29% versus 24%; P < 0.0001). From a technical standpoint, inframammary incisions have become more common (68% versus 80%; P < 0.0001), whereas periareolar incision use has decreased (24% versus 14%; P < 0.0001). Submuscular plane placement has increased (22% versus 56%; P < 0.0001), while subglandular placement has decreased (19% versus 7%; P < 0.0001). Silicone implants are most popular (58% versus 82%; P < 0.0001). Textured implant use increased from 2011 (2%) to 2016 (16%), followed by a sharp decline to 0% by 2021. Trends follow U.S. Food and Drug Administration approvals and warnings.

CONCLUSIONS

This study highlights evolving trends in aesthetic breast augmentation over the past 16 years. The most common technique remains a smooth silicone prosthesis placed in the subpectoral plane through an inframammary incision.

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.

The Application of Anatomy Combined With Ultrasound Knife in Transaxillary Endoscopic Biplane Breast Augmentation

Objective

We aim to clarify the vascular and nerve anatomy of the breast and combine it with an ultrasound knife to use in transaxillary endoscopic biplane breast augmentation.

Methods

This study is a retrospective review of patients undergoing transaxillary endoscopic biplane breast augmentation between October and October 2021. Related variables were collected using a standardized data collection template. The detailed process of the transaxillary endoscopic biplane breast augmentation under anatomy instruction is carefully described in this study, and the postoperative effect was closely observed.

Results

Sixty-three female patients underwent transaxillary endoscopic biplane breast augmentation. The average implants volume counted 242.46 ± 31.34 cc, and the average operation time was 155.92 ± 22.34 min. Patients were followed up for a mean of 13.67 months (range, 3-27 months), and most of the patients achieved good postoperative results and no severe complications and were satisfied with both appearance and function.

Conclusions

The application of anatomy combined with an ultrasound knife in transaxillary endoscopic biplane breast augmentation is a promising way to achieve good breast shapes with high patient satisfaction and is worthy of clinical promotion and application.

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

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.

Subfascial versus Subglandular Breast Augmentation: A Randomized Prospective Evaluation Considering a 5-Year Follow-Up

BACKGROUND

Subfascial breast augmentation is becoming popular because of a better understanding of breast anatomy. However, because the subglandular approach is also another popular method, it is critical to assess the influence of the superficial fascia of the pectoralis major muscle on the subfascial and subglandular pockets to determine if one method is superior to another. This study investigated whether there are clinical/radiological differences between subfascial and subglandular pockets following primary breast augmentation.

METHODS

Twenty patients were recruited, and each was randomly sorted to the subfascial and/or subglandular pocket per breast. Both patients and surgeons were blinded. Differences were evaluated through five independent surgeons and by magnetic resonance imaging scans. Subsequently, 1-year and 5-year follow-ups were conducted.

RESULTS

The results of the 5-year follow-up considering the aesthetics of the breast contour were significantly different between groups, with more good and excellent evaluations in the subfascial group. Regarding breast shape, there were also statistical differences, also with more good and excellent evaluations in the subfascial group. For breast consistency, subglandular had 84.20 percent of patients classified into Baker I and II, whereas subfascial had 100 percent. Magnetic resonance imaging scans showed a smaller implant base in the subglandular pockets, which was a significant result. There were no significant differences in implant projection. Comparison of the number of folds revealed significant differences between groups, with more folds in the subglandular group.

CONCLUSION

Statistical differences between methods were found regarding breast shape and contour, capsular contracture, implant base, and the number of folds, showing that subfascial breast augmentation is superior to subglandular breast augmentation.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Therapeutic, II.

Plane Change Vs Capsulotomy: A Comparison of Treatments for Capsular Contraction in Breast Augmentation Using the Subfascial Plane

BACKGROUND

The management of capsular contraction following breast augmentation has numerous, often conflicting potential treatment protocols, each designed to reduce the incidence of further recurrence. The use of the subfascial plane has not been investigated as an alternative to other treatment options.

OBJECTIVES

To examine the outcomes from patients presenting with recurrent capsular contraction after being treated for the first capsule by placement of an implant into the subfascial (SF) plane.

METHODS

Retrospective analysis of 111 case notes of patients who presented with capsular contraction. 65 had undergone SF augmentation, 17 submuscular (SM) and 29 subglandular (SG) placement of implant at the primary procedure. At a secondary procedure, those with SF implants underwent open capsulotomy and those with SM and SG implants underwent a change in plane to SF.

RESULTS

There is a significant difference in the proportion of patients that developed a capsule following the second surgery between the groups that had undergone capsulotomy (SF = 16.9%) or plane change (SM = 47% and SG = 37.9%, X² (2,111) = 8.6, P =  0.02). When recurrence at the same site was examined, there was also a significant difference between the groups (X² (2111) = 10.7, P < 0.01). A ruptured implant significantly increased the incidence of further capsular contraction when in the SG plane (X² (2,29) = 12.1, P < 0.01).

CONCLUSIONS

In the absence of implant rupture, changing the plane of an implant to a SF position at revision surgery does not reduce the incidence of subsequent capsular contracture compared with open capsulotomy. Open capsulotomy is a reasonable choice following recurrence of capsular contraction following initial SF placement.

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 .

Revisionary Surgery Following Primary Augmentation Mammoplasty in Muscle Splitting Biplane Pocket: An Appraisal of 93 Revisionary Surgeries

BACKGROUND

Muscle splitting augmentation mammoplasty is the creation of a submuscular pocket which is gaining attention and acceptance by plastic surgeons worldwide. First introduced in 2007, muscle splitting augmentation mammoplasty has since been used for primary and secondary augmentation mammoplasty and augmentation mastopexy procedures. A personal experience of revision surgeries following muscle splitting augmentation mammoplasty is presented.

METHODS

A retrospective data analysis for revision surgeries, following muscle splitting primary augmentation mammoplasties, performed between October 2005 and October 2018 was carried out.

RESULTS

A total of 1511 primary augmentation mammoplasties were performed. Of these 1511 patients, 93 (6.1%) patients had revisionary or secondary surgery. The mean age of the patients was 33.8 + 9 years (range 20-60). Of the 93 patients, 78 patients had same size implants, mean 337 cc + 53.5 (range 230-495), and 14 had different size implants. Of these 14 patients, mean implant size on right and left was 331 cc + 59.4 (range 225-425) and 351 cc + 61.7 (range 260-450), respectively. Of the recorded texturing in 1495 patients, only 3.1% had smooth implants. Leading causes for revision were implant exchange for various reasons, in 33 (35.4%); 25 (26.8%) wanted larger implants, revisionary surgery for capsular contracture in 18 (19.3%), implant rupture was seen in 9 (9.6%), 4 (4.3%) patients had surgery for recurrent back-to-front flipping, 2 (2.1%) patients wanted a smaller size, 1 (1.07%) patient had fold flaw failure, and in 1 (1.07%) the cause was not recorded. There were no haematoma and breast implant-associated anaplastic large cell lymphoma (BIA ALCL) recorded in the series.

CONCLUSION

The incidence of revisionary surgery following muscle splitting primary augmentation mammoplasty is acceptable and can be corrected using the described 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 .

Observations Concerning the Match between Breast Implant Dimensions, Breast Morphometry, and a Patient-reported Outcome

Background:

Outcome studies in breast augmentation do not assess how an implant has been matched to the soft tissue envelope. The study hypothesis is that there is a relationship between breast and implant dimensions and the subjective outcome of patient satisfaction.

Methods:

In a study of patients undergoing subfascial breast augmentation (n = 341), morphometric measurements and a postsurgical survey of satisfaction with breast size were performed 3 months postoperatively. A ratio empirically derived from breast width, implant width, and projection (Rib) was calculated in patients who wished to have smaller, bigger, or no change in their implant size.

Results:

76% were content with breast size, 16.7% wished to be larger, and 7.3% wished to be smaller. Rib differed between groups who did not want to change size (n = 259, mean = 5.8, SD = 0.9), those who wished to be bigger (n = 57, mean = 5.6, SD = 1.1), and those who wished to be smaller (n = 25, mean = 5.3, SD = 1.3, H(341) = 14.0, P < 0.01). Rib differed between groups whose result was as expected (mean = 5.6, SD = 0.9), compared with those who expected to be bigger (mean = 5.4, SD = 1.2) or who expected a smaller outcome (mean = 5.6 SD = 1.0, H(341) = 18.3, P < 0.01).

Conclusions:

These data provide an objective measurement by which studies concerning breast augmentation can be reported and compared. The method may guide standardization of clinical research regarding breast implant surgery.

Hot Topics in Breast Surgery

Since the first implant-based breast surgeries were performed nearly 70 years ago, breast augmentation it has changed drastically. As understanding of breast augmentation has advanced, so too have the technologies and techniques used to improve results and minimize the risk of complications in breast implant surgery. This article reviews some of the novel techniques and technologies used today in breast augmentation surgery. How these tools and techniques will withstand the test of time remains to be seen, but they no doubt will add to the fascinating and ever-evolving history of breast augmentation.

Subfascial Breast Augmentation with Crossed Fascial Sling, Under Tumescent Anaesthesia With or Without Sedation and Lower Periareolar Access

The tumescent technique is very effective for subfascial breast implant surgery. A total amount volume of 330 cc (120/160 cc for each breast) ensures a clean and bloodless field, leading to less postoperative bruising and prolonged local anaesthesia effects. The surgical procedure can be performed with or without associated sedation. Lower periareolar anaesthesia allows for good and painless infiltration of the surgical field, up to the prepectoralis plane. A smooth, vertical dissection reached the pectoralis fascia, which was smoothly opened, leaving the gland adhesions in place. Subfascial pocket dissection was performed, and the implant was then inserted. The fascial sling, consisting of 2 strips of approximately 4/5 cm × 2 cm each, was prepared superiorly and crossed for inferior fixation. One hundred patients were included over 18 months, and all surgeries were performed under tumescent anaesthesia with general sedation. Overall, we did not need to convert from local anaesthesia in general. No complications were observed, and good cosmetic results were achieved. The follow-up periods lasted for 6 months or, in a few cases, for 1 year.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 .

The New Method of Pocket Forming for Breast Implant Placement in Augmentation Mammaplasty: Dual Plane Subfascial

Introduction:

Breast augmentation is one of the most frequently performed aesthetic surgical procedures in the world. The most important preoperative decisions which influence the final appearance of the augmented breast are the breast implant pocket choice and selection of the most appropriate implant. Described pocket locations are subglandular, subfascial, partially retropectoral, totally submuscular and dual plane.

Aim:

We have introduced a new method of pocket forming for implant placement, which is combination of Tebbett’s dual-plane 2 or 3 and Graf’s subfascial. We named it as dual plane subfascial.

Methods:

Between January 2016 and April 2018, total of 27 patients were operated using dual plane subfascial breast augmentation. The pinch test in the medial pole less than 2,0 cm and in upper pole less than 2,5 cm are indications for this technique. In our modification, in primary cases a dissected flap in front of muscle is fasciocutaneous (not cutaneous as in Tebbett’s technique). It will be finally located caudally of pectoral muscle and in front of the lower pole of implant. Fasciocutaneous flap in primary cases and two independent levels of soft tissue coverage (fascial and cutaneous) in secondary cases (subglandular to dual plane subfascial conversion) in front of the lower pole of implants provide better coverage than cutaneous flap alone.

Results:

Hematoma and infection did not occur in any patient in our study. A capsular contracture grade I/II without the need for reoperation occurred in two patients. In one patient with secondary augmentation minimal bottoming out was noticed (before reoperation patient had significant bottoming out deformity). Minimal palpability of implants is recorded in three patients.

Conclusion:

Dual plane subfascial is a good option in primary breast augmentation with a well set indication especially in the breasts with the upper pinch test less than 25 mm and medial pinch test less than 20 mm. The idea can be followed even in secondary breast augmentation (subglandular to dual plane subfascial conversion). There is additional soft tissue in front of the implant which led to a less implant palpability, especially in thin patient with smaller amount of subcutaneous fat.

Subfascial Breast Augmentation: A Systematic Review and Meta-Analysis of Capsular Contracture

BACKGROUND

Subfascial breast augmentation is a technique originally developed to reduce the risks of capsular contracture while decreasing the postoperative pain associated with subpectoral augmentation. It was pioneered in Brazil by Dr. Graf and others, and recently this technique has gained interest in the aesthetic world.

OBJECTIVES

The goal of this study was to provide a systematic analysis of subfascial breast augmentation to assess the combined reported rates of capsular contracture, animation deformity and complications.

METHODS

The PubMed, Embase, and Web of Science databases were searched for the use of the subfascial plane for breast augmentation. We included studies that reported on capsular contracture and other outcomes following subfascial breast augmentation.

RESULTS

Through the initial search, 26 articles were identified. Of which, 22 were included in the final study. A total of 3743 patients were identified across these studies with a total number of 38 cases of capsular contracture representing a rate of 1.01% of capsular contracture. Several articles reported on demographics, perioperative and long-term complications, and outcomes with regards to the aesthetic outcome from the surgeon's perspective. Several infections were reported representing a rate of 0.1%. Animation deformity was not reported, although rippling was occasionally reported as was malrotation, axillary banding, sensory deficit, and asymmetry. Subfascial breast augmentation appears to have a low complication rate and an extremely low rate of capsular contracture at approximately 1%.

CONCLUSIONS

Subfascial breast augmentation may provide the benefits of low rates of capsular contracture while avoiding the discomfort and future animation deformity of subpectoral augmentation.

LEVEL OF EVIDENCE 4

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.

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.

The Use of a Retromammary Adipofascial Flap in Breast Augmentation for Patients with Thin Soft Tissue

BACKGROUND

In patients with a thin soft tissue breast envelope, lower pole implant palpability is a postoperative sequela that concerns patients. Anatomically, the lower aspect of the breast near the inframammary fold lacks sufficient soft tissue to cover the breast implant after augmentation.

METHODS

A transareolar incision was made, and subcutaneous dissection was performed. The dissection first proceeded caudally to the lower aspect to the breast parenchyma. The dissection then changed direction and moved cephalad to the mid breast or nipple region. The fatty tissue and pectoralis muscle fascia were cut transversely at this level, and the dissection was reversed caudally in a subfascial plane to the new inframammary fold region. This maneuver created a retromammary adipofascial flap.

RESULTS

A total of 368 breast augmentations were performed in 184 patients. Breast implants were inserted in the subfascial plane in 40 patients (21.7%) and in the subpectoral-subfascial plane in 144 patients (78.3%). A total of 368 breast implants were inserted, including 140 smooth cohesive silicone implants (38.0%), 2 textured round implants (0.5%), and 226 anatomic-type implants (61.5%). A cadaveric dissection revealed that a retromammary adipofascial flap measuring 3-4 mm in thickness can be acquired. Capsular contracture occurred in six breasts (1.7%).

CONCLUSIONS

During breast augmentation, an inferiorly based retromammary adipofascial flap can be created to help cover the lower pole of the breast from implant palpability. This is helpful especially in patients with thin skin, hypoplastic breasts, or constricted 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 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.

Breast Durometer (Mammometer): A Novel Device for Measuring Soft-Tissue Firmness and Its Application in Cosmetic Breast Surgery

The measurement of soft-tissue firmness has many potential applications in medical practice. This study reports a user-friendly, novel device that is capable of measuring changes in soft-tissue firmness in a reproducible manner. The study reports the development of the equipment and how it has been applied to breast implant surgery. The device was tested for both intra- and inter-observer variability on an in vitro model, using a breast implant. Once reproducibility was confirmed, breast firmness was measured on a series of patients who underwent sub-fascial breast augmentation (n = 50) to examine how it varied post-operatively. Firmness in the upper half of the breast increased to a maximum level two weeks post-surgery (0.44-0.61 Pa), reducing to pre-operative levels by 6 weeks (0.37-0.54 Pa). There was no further significant change at 12 weeks. Firmness in the nipple areolar complex (NAC) and at the lower outer quadrant (LOQ) followed a similar pattern, but remained firmer at 12 weeks. We interpret these patterns as implying that measurements taken at the upper half of the breast are indicative of post-operative oedema, whereas those at the NAC and LOQ represent changes in firmness produced by the breast implant composite. We consider the potential for this novel device in the measurement of soft-tissue firmness in aesthetic breast surgery and would encourage other researchers to explore novel applications. 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 .

Objective Sensory Changes Following Subfascial Breast Augmentation

BACKGROUND

Sensory changes occur following breast augmentation, and describing the incidence, pattern, and course of deficit is important for informed consent.

OBJECTIVES

To examine sensory changes following subfascial breast augmentation, and the influence of change in breast volume caused by an implant.

METHODS

One hundred and sixty-two consecutive patients undergoing subfascial breast augmentation were assessed for sensory changes using a Semmes Weinstein monofilament test before surgery, 2, 6, and 12 weeks postoperatively. Morphometric measurements allowed a breast volume to be calculated and the percentage change in volume produced by the implant.

RESULTS

Most women (92.5%) regained preoperative levels of sensation in all areas of the breast, excepting the lower-outer quadrants (16.15%) by 12 weeks following surgery. Four percent of nipple-areolar complexes (NAC) failed return to preoperative levels of sensitivity by 12 weeks after surgery. Younger patients or those who have a high BMI and a measurably thicker soft tissue envelope were more likely to experience sensory deficits. Breast augmentation in this series produced calculated volume changes by an implant of between 12.1% and 102.7%. Within these limits there is no association between percentage increase in breast volume and sensory deficits.

CONCLUSIONS

The study demonstrates that for calculated volume increases of up to 102% of the initial breast volume, sensory loss at 12 weeks after surgery is 4% at the NAC. The commonest area of diminished sensitivity is the lower-outer quadrant (16.15%), relating to the use of the inframammary crease incision. It provides a useful adjunct in monitoring patient recovery following subfascial breast augmentation. LEVEL OF EVIDENCE 4: Therapeutic.

[Should we drain after pre-pectoral breast implants? Analysis of a cohort of 400 patients operated for breast augmentation with pre-pectoral silicone implants]

AIM OF THE STUDY

During breast augmentation, surgical drainage remains a source of debate. The objective of the study was to determine the interest of the drainage after pre-pectoral breast implants pre, analyzing the risk of hematoma and capsular contracture.

PATIENTS AND METHODS

We retrospectively analyzed a cohort of 400 patients who underwent a first aesthetic breast augmentation by pre-pectoral silicone gel implants. Patients were followed with a maximum of nine years and a minimum of one year.

RESULTS

The mean age of patients was 37 years (18-64). Ninety-two percent (368 cases) had no drainage (patients "low risk of bleeding") and 8% (32 cases) underwent a bilateral drainage (patients "high risk of bleeding"). We recorded 1.75% hematoma (7 cases) and 2% of capsular contracture (8 cases).

CONCLUSION

We believe that the drainage should not be systematic for pre-pectoral breast implants. In patients at high risk of bleeding that we drained, it does not prevent the occurrence of a possible hematoma. In patients at low risk of bleeding that we have not drained, we do not observed more hematoma or capsular contracture than data published for drained patients.

[Optimization of primary aesthetic breast augmentation using implants: an evidence-based level approach]

The primary aesthetic breast augmentation has been the most performed cosmetic surgery procedure in the world for over 40 years. The current literature focuses on the new concept of "process of breast augmentation" and the importance of non-surgical part (patient selection, preoperative planning and personalized management of postoperative care) in potentiating the cosmetic results and reducing the rate of complications and reoperations. This review of literature discusses, through an analysis of scientific evidence levels, every step of the whole process of breast augmentation in order to determine the current best practices tailored to each patient to optimize satisfactory and durable cosmetic outcomes.

Patient expectations after breast augmentation: the imperative to audit your sizing system

Patient dissatisfaction with breast size after breast implant surgery can lead to early secondary procedures in a minority of cases. Different systems of sizing a patient preoperatively have been proposed, including detailed measurements and computer-assisted assessment. Whatever system is used, a surgeon needs to obtain feedback to ascertain that the system is effective at producing a satisfactory outcome. In this study, 137 patients who underwent breast augmentation by a single surgeon were prospectively assessed for a 12-week period after surgery to determine their satisfaction with their breast size. Both expectations and desire to change implant size were assessed. Early (week 1) expectations of the patients were a good predictor of their long-term assessment 12 weeks after surgery and their desire to change their implant size. The patients with a greater body mass index (BMI) and larger implant volume were more likely to express a desire for a change in implant size early in the postoperative course. The findings showed that 19.4 % (26/134) of the patients wished to have larger implants by 12 weeks after surgery and that 3.7 % (5/134) felt smaller implants would be preferable. The information produced by this audit is important to the provision of future informed consent for this surgeon. Without similar data from their individual practices, surgeons cannot provide patients with an accurate assessment of their satisfaction after breast augmentation surgery. A similar undertaking is strongly recommended for surgeons performing breast implant surgery.

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 .

Breast implant procedures under conscious sedation: a 6-year experience in 461 consecutive patients

BACKGROUND

Breast implant procedures are commonly performed using general anesthesia; however, patient apprehension, the potential for improved safety, lower costs, and faster recovery times have increased interest in the use of conscious sedation in plastic surgery. The authors examined the safety and efficacy of breast implant procedures performed under conscious sedation over a 6-year period using their standardized institutional protocol.

METHODS

Between 2002 and 2008, 461 consecutive patients underwent breast implant procedures under conscious sedation using a protocol of preoperative intravenous diazepam along with intraoperative midazolam, fentanyl, and local anesthetic. All operative and follow-up data were recorded. Augmentation mammaplasty patients were further analyzed for conscious sedation medication dosing.

RESULTS

The study population was divided into two groups (years 1 to 3 and years 4 to 6 of the study period) to analyze changes to the authors' regimen over time. In years 4 to 6, higher preoperative doses of diazepam (p = 0.01) allowed more effective local anesthesia administration, thereby reducing intraoperative fentanyl requirements (p < 0.0001). Midazolam doses and operating times did not differ significantly between groups. No patient required conversion to a deeper method of anesthesia. The overall complication rate was 4.34 percent.

CONCLUSIONS

The authors' study demonstrates the safety and efficacy of conscious sedation in breast implant procedures. Higher preoperative doses of diazepam have significantly reduced fentanyl requirements, resulting in shorter recovery times, decreased postoperative nausea/vomiting, and elimination of unintended admissions. These benefits are obtained without increasing operative times or complications. The authors conclude that conscious sedation is the preferred method of anesthesia for most patients undergoing breast implant procedures.