Contemporary Breast Augmentation Practice in the United States

Silicone Lymphadenopathy Following Augmentation Mammoplasty With Silicone Implants

BACKGROUND

Silicone implants are by far the most widely used implant globally for breast augmentation. Despite technological advancements, complications persist, with silicone lymphadenopathy (siliconoma) being a noteworthy concern. This phenomenon has been inadequately addressed in the existing literature.

OBJECTIVES

The aim of this study was to characterize axillary siliconomas and identify potential risk factors to help reduce their occurrence.

METHODS

The authors conducted a retrospective observational cross-sectional study spanning between 2011 and 2021 at the Shamir Assaf Harofeh Medical Center, Israel. Preoperative ultrasound examination was conducted, categorizing patients into those with siliconomas and those without.

RESULTS

A total of 614 women (1209 breasts) met the inclusion criteria. The incidence of siliconomas was 13.6% (165 breasts). In univariate analysis, older age (47 years vs 43 years, P < .001), older implant age (12.2 years vs 11 years, P = .026), ruptured implants (59.4% vs 17.7%, P < .001), subpectoral placement (P = .019), severe capsular contracture, and the use of Mentor implants (Irvine, CA; P = .007) and Poly Implant Prothèse implants (PIP; La Seyne-sur-Mer, France; P = .001) correlated significantly with the presence of siliconomas. In a multivariate analysis, implant rupture (odds ratio [OR] = 6.342), and implant manufacturer-Mentor (OR = 3.047) and PIP (OR = 3.475)-were identified as independent risk factors associated with a higher incidence of siliconomas. Severe capsular contracture was also associated with a higher incidence of siliconomas (OR = 1.65).

CONCLUSIONS

Surgeons should inform candidates about the potential risk of silicone migration. Patients with ruptured implants, significant capsular contracture, and Mentor and PIP implants face an increased risk for developing siliconomas. Closer monitoring for the detection of siliconomas in the axilla for these patients is advisable, and potential prophylactic replacement or removal of implants may be warranted to mitigate siliconoma risk.

LEVEL OF EVIDENCE: 3

The Reverse Dual Plane: A Novel Technique for Endoscopic Transaxillary Breast Augmentation

Background

Quite a few Asian patients prefer axillary incision for breast augmentation. However, this surgery needs improvement.

Objectives

To introduce a reverse dual-plane technique through a transaxillary approach and compare it with a transaxillary dual-plane approach.

Methods

Eighty-two patients were divided into Group A (n = 40) and Group B (n = 42). Axillary incision and endoscope were utilized in the 2 groups. Tebbetts' dual plane was performed in Group A patients. Patients in Group B underwent our reverse dual-plane technique, in which the upper 70% was subfascial and the lower 30% was subpectoral, with the fascia of the external oblique and anterior serratus being elevated together with the pectoral muscle. The Numeric Pain Rating Scale (NPRS) scores were recorded daily for 7 days. Breast shape and softness, in both sitting and supine positions, were assessed by the patients, and complications were compared.

Results

The NPRS scores of Group B patients were significantly lower than those of Group A patients (P < .01). The satisfaction rate of shape and softness in the seated position was not significantly different (P > .05). However, in the supine position, only 20 patients (50.0%) in Group A and 32 patients (76.2%) in Group B were satisfied with their breast softness (P < .01), and the breasts of the others became stiffer. Breast animation deformity (BAD) occurred in 2 patients in Group A and in no patient in Group B (P < .01). Other complications were not significantly different.

Conclusions

Compared with Tebbetts' dual plane, this procedure significantly reduced pain, improved breast softness, and eliminated BAD, without increasing complications.

Level of Evidence 4

Updated trends of breast implant surgeries: An Israeli analysis

INTRODUCTION

Breast augmentation remains one of the most prevalent procedures in plastic surgery. While most patients experience high satisfaction with the outcomes, a subset may encounter various complications or dissatisfaction with achieved results necessitating subsequent surgical intervention including implant removal or exchange.

MATERIALS AND METHODS

We collected information from three pivotal private medical centers in Israel where a considerable number of breast surgeries are performed. We examined the number of breast augmentations, implant exchange and implant removal surgeries with or without breast lift that were performed on a biannual basis for each center for the period 2018-2022. Trends in surgery types were analyzed and compared to registries in other countries.

RESULTS

Between the years 2018 and 2022, 20,075 surgeries were done in three main private medical centers in Israel. Data show a gradual increase in implant removal surgeries from 2018 (n = 80, 2.9%) to 2019 (n = 269, 9.9%), followed by a significant increase in 2020 (n = 1436, 27.3%), and a gradual decline between 2021 (n = 1019, 22.8%) and 2022 (n = 916, 18.5%). The overall number of breast implant insertion procedures (breast augmentation procedures and exchange procedures) was 2659 in 2018 (97%), 2424 in 2019 (90.0%), 3816 in 2020 (72.6%), 3437 in 2021 (77.1%), and 4019 in 2022 (81.4%).

SUMMARY

We present updated trends in breast implant surgeries in Israel. 2020 was a key year in which the rate of explantations was the highest, and the percentage rate of implantations was the lowest and a year in which the trend changed. These patterns partly align with trends seen in other countries worldwide.

The modified inframammary fold suture method and its clinical significance in primary augmentation mammoplasty

BACKGROUND

The inframammary approach is one of the most commonly used incisions in breast augmentation. There are many suture methods for inframammary incisions; however, no one method has proven optimal. We modified the traditional three-layer suture method according to the inframammary fold (IMF) cadaver dissection results. This study aims to investigate whether using a modified suture method can improve postoperative outcomes.

METHODS

Cadaver dissections were performed in order to clarify the anatomy of the IMF. From June 2013 to December 2017, a retrospective study of primary breast augmentation patients subjected to the inframammary approach was conducted. Patients were divided into two cohorts: the traditional suture method and the modified suture method. The patient's demographics, specifics of breast augmentation procedures, complications, and scar assessment were analyzed. Univariate and multivariable analyses were used to determine differences between the two cohorts.

RESULTS

One hundred eighty-four patients were included: 75 patients were subjected to the traditional suture method, and 109 patients were subjected to the modified suture method. Wound-related adverse events (p = 0.026) and IMF-indented scarring (p = 0.014) were significantly different between the two groups. Multivariable analysis showed that the suture method was the most influential factor related to IMF-indented scarring (OR = 16.9), followed by BMI (OR = 2.9).

CONCLUSIONS

We defined a new suture method for the inframammary incision in primary breast augmentation. This modified suture method reduces the occurrence of wound-related adverse events and IMF-indented scarring.

A Simple Preoperative Marking of Implant Augmentation Mammoplasty: The Semicircle Method

BACKGROUND

The location of the inframammary fold is the most critical step in the preoperative marking of implant augmentation mammoplasty. At present, most of the calculation formulas for new inframammary fold location determination are complicated.

OBJECTIVE

Based on the aesthetic standards of the breast, we proposed a simple and effective method, the Semicircle method, to determine the location of the new inframammary fold.

METHODS

In this prospective study, 21 patients were enrolled to record the distance from the nipple to the new inframammary fold calculated by the Semicircle method, Tebbetts method, Randquist method, Mallucci's ICE method and compare the Semicircle method to the other three methods by using the intraclass correlation coefficient.

RESULTS

According to the statistical results of the intraclass correlation coefficient, the Semicircle method had poor consistency with the Tebbetts and ICE methods, but good consistency with the Randquist method.

CONCLUSION

The Semicircle method is a simple and aesthetically acceptable design method for breast augmentation mammoplasty, which can quickly and efficiently determine the position of the new inframammary fold. At the same time, this method has good consistency with the Randquist method and can obtain satisfactory breast morphology.

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 .

Asiaticoside Combined With Carbon Ion Implantation to Improve the Biocompatibility of Silicone Rubber and to Reduce the Risk of Capsule Contracture

Capsular contracture caused by silicone rubber is a critical issue in plastic surgery that urgently needs to be solved. Studies have shown that carbon ion implant in silicone rubber (carbon silicone rubber, C-SR) can significantly improve the capsular structure, but the effect of this improvement only appear 2months or later. In this study, asiaticoside combined with carbon silicone rubber was used to explore the changes in the capsule to provide a reference for the treatment of capsule contracture. Human fibroblasts (HFF-1) were used for in vitro experiments. The combined effect of asiaticoside and carbon silicone rubber on cell proliferation was determined by the CCK8 method, cell migration changes were measured by Transwell assays, cell cycle changes were measured by flow cytometry, and the expression levels of fibroblast transformation markers (vimentin and α-SMA), collagen (Col-1A1) and TGF-β/Smad signaling pathway-related proteins (TGF-β1, TβRI, TβRII and Smad2/3) were detected by immunofluorescence. In vivo experiments were carried out by subcutaneous implantation of the material in SD rats, and asiaticoside was oral administered simultaneously. WB and ELISA were used to detect changes in the expression of TGF-β/Smad signaling pathway-related proteins. TGF-β/Smad signaling pathway proteins were then detected and confirmed by HE, Masson and immunohistochemical staining. The results shown that asiaticoside combined with carbon ion implantation inhibited the viability, proliferation and migration of fibroblasts on silicone rubber. In vitro immunofluorescence showed that the secretion levels of α-SMA and Col-1A1 were significantly decreased, the transformation of fibroblasts into myofibroblasts was weakened, and the TGF-β/Smad signaling pathway was inhibited. In vivo experimental results showed that asiaticoside combined with carbon silicone rubber inhibited TGF-β1 secretion and inhibited the TGF-β/Smad signaling pathway, reducing the thickness of the capsule and collagen deposition. These results imply that carbon silicone rubber combined with asiaticoside can regulate the viability, proliferation and migration of fibroblasts by inhibiting the TGF-β/Smad signaling pathway and reduce capsule thickness and collagen deposition, which greatly reduces the incidence of capsule contracture.

Validation of Ideal Breast Characteristics With Breast Augmentation Patients

Background

Breast augmentation procedures are one of the most commonly performed aesthetic procedures in the United States. Little work has focused on the general public's overall perception of the ideal breast or has validated them with patient photographs.

Objectives

To validate crowdsourced perceptions of breasts with their alignment to the aesthetics of breast augmentation patients.

Methods

A prospective cross-sectional study was performed using participants enrolled through the AmazonMechanical Turk crowdsourcing platform (Amazon Web Services, Amazon, Seattle, WA) to obtain participant opinions ofhow closely patient breasts aligned with previously obtained results of 4 ideal breast characteristics. Outcomes were reported based on the correlation between breast attractiveness and alignment to ideal breast characteristics, both before and after breast implant procedures.

Results

2306 responses from 737 participants reported patient photograph alignment with ideal breast projection proportion (1.0) as having the highest correlation to opinions of heightened aesthetic beauty (R = 0.98, P < 0.001), and ideal nipple direction (front) as having the lowest correlation to aesthetic beauty (R = 0.90, P < 0.001). Younger age groups (18-24) and participants with a high school diploma or less rated patients as less attractive, while married and wealthy individuals reported higher attraction levels.

Conclusions

Crowdsourcing can be a useful tool for aesthetic surgery preferences and has helped reveal key takeaways. The importance of the 4 breast characteristics has been validated, with alignment to all 4 characteristics tested having a high correlation to preferences. Differences in preference across demographic groups are a topic to further investigate.

Trends in Breast Augmentation Research: A Bibliometric Analysis

BACKGROUND

Breast augmentation is one of the most demanded procedures in plastic surgery and one of the most commonly performed by plastic surgeons. However, a bibliometric analysis of breast augmentation has not been published in recent years. The current study aimed to use a bibliometric analysis to conduct a qualitative and quantitative evaluation of breast augmentation research and provide the research trends and hotspots in this field.

METHODS

Publications on breast augmentation research were extracted from the Web of Science core collection database. VOSviewer 1.6.18 was used to assess co-authorship, co-occurrence, citation of countries, institutions, authors, and journals, as well as hotspot keywords.

RESULTS

On February 8, 2022, 4637 records of breast augmentation research published from 1985 to 2021 were collected. The bulk of the retrieved studies were original research articles (n = 2235, 48.20%). A total of 1053 (22.71%) papers were open access. The annual publication output increased annually. The USA was the driving force in this field and had a strong academic reputation. The top-contributing institution was the University of Texas MD Anderson Cancer Center (2.37%, with 110 publications). Plastic and reconstructive surgery (998 publications, 21.52%) published the most research in this field and was also the most frequently co-cited journal (22,351 citations, total link strength (TLS): 409,301). Clemens MW (68 publications, 1.47%) was the most prolific author, and Spear SL (1456 citations, TLS: 27,231) was the most frequently co-cited author. The research hotspots included the following four aspects: safety and effectiveness of breast implants, implant-based breast reconstruction, breast cancer incidence after breast implantation, and breast implant-associated anaplastic large-cell lymphoma (BIA-ALCL). The research trends were BIA-ALCL, implant-based breast reconstruction, BREAST-Q, acellular dermal matrix, capsular contracture, and autologous fat grafting.

CONCLUSION

The present study provides a panoramic view of breast augmentation research in plastic and reconstructive surgery. This novel comprehensive bibliometric analysis can help researchers and nonresearchers alike to rapidly identify the potential partners, research hotspots, and research trends within their areas of interest.

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 .

Implant-based multiplane breast augmentation—a personal surgical concept for dynamic implant–tissue interaction providing sustainable shape stability

Background

The aesthetic long-term stability in shape, symmetry, and natural appearance of an aesthetically augmented breast remains a constant challenge. It has become clear that the results depend strongly on the technique applied and the experience of the surgeon. An ongoing controversy concerns the positioning of the implants. Subglandular, submuscular, partial submuscular, and subfascial pockets have different tradeoffs and advantages. However, secondary deformity, unnatural feel, and appearance are not addressed uniformly. The aim of the following study was to establish a standard procedure allowing for the desired and reproducible results to provide long-term stability and aesthetic quality.

Methods

The authors have developed a standardized dissection of a dynamic implant pocket. In this approach, a submuscular dissection with lower and medial release of the pectoralis muscle is combined with a wide subfascial release of the breast gland and a scoring of the deep plane of the superficial glandular fascia. In the final step, the deep layer of the glandular fascia is sutured tightly and firmly to the deep layer of the abdomino-pectoral fascia. A total of 867 patients received a 4D pocket–based breast implant by the authors. A subset of 33 patients was further analyzed for long-term results. Retrospectively, all data were analyzed from the electronic patient information system and files of patients using GraphPad 8. For comparison of multiple experimental groups, one-way ANOVA was performed where indicated.

Results

The concept not only addresses the biplanar approach of submuscular implant placement (3D) but adds the 4th dimension (4D) of an aesthetically pleasing dynamic shape of the augmented breast providing long-term stability. Measurements—taken at 3 months, and 1, 2, 3, 5, and ≥ 7 years post augmentation—for SN-N, N-IMF, N-ML, and MC-N distances did not show any significant changes over time. In the patient cohort of 867 patients (1734 implants), the overall complication rate was < 5%. Revisions for bleeding were below 0.5%. Shape stability was observed over 7 years in more than 95% of the patients.

Conclusions

Our results indicate that our technique of multiplane breast augmentation provides long-term stability and aesthetic quality. It may solve some of the existing tradeoffs of the different methods by combining the benefits of each technique supported by an additional shaping through a controlled deep fasciotomy.

Level of evidence: Level IV, therapeutic study.