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Matching the Implant to the Breast: A Systematic Review of Implant Size Selection Systems for Breast Augmentation

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Matching the Implant to the Breast: A Systematic Review of Implant Size Selection Systems for Breast Augmentation

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Abstract

Background: For primary breast augmentation, several implant selection systems have been described to guide the surgeon with choosing from a variety of manufactured implant dimensions and properties. Controversy exists regarding the most efficacious method of selecting an appropriate implant size that best matches the patient's breast. Methods: The goal of this systematic review was to provide a comprehensive list of documented implant size selection systems, and to critically evaluate them. Implant size selection systems were grouped into categories based on selection principles. Articles were evaluated based on reported outcome measures and methodologic quality. Results: Thirty-three implant size selection systems were included in the final analysis. Only 12 percent of articles (four of 33) reported clinical outcomes that could be compared to accepted literature values or industry standards. Articles that described tissue-based planning systems, which use clinical guidelines to determine the optimal patient-specific implant dimensions, were of highest methodologic quality using the Methodological Index for Non-Randomised Studies scale, when compared to systems that used breast "dimensional" analyses that stress tissues to the desire of the patient and/or surgeon, and compared to systems that did not use breast measurement (means ± SD, 6.0 ± 1.4, 1.4 ± 2.3, and 0.0 ± 0.0, respectively). Conclusions: There is some evidence to support tissue-based planning as a superior approach to implant size selection planning; studies that used tissue-based planning reported lower reoperation rates compared with industry standards and accepted literature values. The authors offer several suggestions on how to improve the methodologic quality of future studies describing new implant selection systems.

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... 7,8 Selecting the appropriate implant, however, is important to optimize surgical outcomes, and a general principle has gained acceptance in the surgical community to guide this process-matching the implant to the needs and characteristics of the patient. 5,7,[9][10][11][12] Although breast augmentation preoperative methodologies and surgical techniques have been described in detail, 2,9,10,13 there is opportunity for additional refinement and direction with respect to matching the implant to the patient. 9 For example, considerable geographical differences in surgical approach may influence implant selection decisions. ...
... 7,8 Selecting the appropriate implant, however, is important to optimize surgical outcomes, and a general principle has gained acceptance in the surgical community to guide this process-matching the implant to the needs and characteristics of the patient. 5,7,[9][10][11][12] Although breast augmentation preoperative methodologies and surgical techniques have been described in detail, 2,9,10,13 there is opportunity for additional refinement and direction with respect to matching the implant to the patient. 9 For example, considerable geographical differences in surgical approach may influence implant selection decisions. ...
... 5,7,[9][10][11][12] Although breast augmentation preoperative methodologies and surgical techniques have been described in detail, 2,9,10,13 there is opportunity for additional refinement and direction with respect to matching the implant to the patient. 9 For example, considerable geographical differences in surgical approach may influence implant selection decisions. 14,15 Surgeons in Australia and New Zealand (ANZ), in particular, have distinct practice patterns, including a tendency to use larger implants than surgeons in Europe or Asia and less pocket irrigation with triple-antibiotic solution than other regions of the world. ...
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Background:. Geographical differences in breast implant selection approaches exist, and clinical data to guide the process are limited. Developing knowledge of implant-related risk factors further complicates the process. This analysis aimed to establish expert consensus on considerations for breast implant selection in Australia and New Zealand based on practice patterns in those countries. Methods:. A modified Delphi method was used to gain consensus from experts in breast augmentation surgery in Australia and New Zealand. Panelists anonymously completed an initial questionnaire on current considerations in implant selection, discussed a summary of their responses in a live meeting, and completed a final consensus survey based on their live recommendations. Results:. Seven panelists completed the final consensus survey. Consensus recommendations included ensuring consideration of proper surgical technique (pocket formation, positioning of implant) and patient tissue and anatomical characteristics, weighing relative expected results of various surface textures, sizes, and degrees of cohesivity, and careful contemplation of the migration risk. Conclusions:. This modified Delphi exercise provided consensus recommendations on the key factors involved in implant selection from the perspective of plastic surgeons with practices in Australia and New Zealand. A primary recommendation was that the choice of implant for each patient should be individualized to patient tissue and anatomical characteristics.
... 4. Breast hypoplasia with asymmetry Eight patients. In the cases of bilateral breast augmentation alone, usually a difference of no more than 80 cc between both sides is considered, so as the wider base of the 15,16,17,18,19). In this case, with a significant asymmetry of 256 g (case #6), two different alternatives were considered: performing the surgery with or without breast gland resection. ...
... Recently, Adams, Jr. and MacKee [17] published that breast implant size selection systems based on breast tissue measurements may provide better outcomes than reliable approaches according to the patient's or surgeon's preference. The study data suggest that an ideal implant size selection system for breast augmentation should be comprehensive, versatile, simple to use and teach, easily reproducible through objective measurements and structured execution, and supported by the available evidence regarding patient outcomes. ...
Article
The surgical approach to breast asymmetry depends on several factors, including the surgeon’s experience, the anatomy of the patient, and several methods that may help to choose a technique and define the size of the implant or the amount of breast tissue to be excised. The aim of this study is to assist in evaluation of breast volumes with the Quantra™ software application, intended for use with Hologic™ digital mammography systems. Twenty-eight women were studied with full-field digital mammography (FFDM) with the Quantra™ software application, for use with Hologic™ digital mammography systems preoperatively. The case diagnoses were as follows: breast hypertrophy, ptosis, hypoplasia, and reconstruction, and the surgeries included breast reduction, mastopexy, mastopexy and breast reduction, mastoplasty and breast augmentation, breast augmentation, and immediate or delayed breast reconstruction. Patients were evaluated from 6 to 18 months after surgery. Volumetric mammogram studies help to decide the amount of tissue to be excised, the size of the implants, and the combination of both. The results of this study were evaluated by surgeons and patients and found to be highly satisfactory. The use of full-field digital mammography with adequate software should be considered as another tool to assist in making decisions regarding the correction of breast asymmetries.
... In clinical practice, adequate preoperative evaluation usually depends on the experience, skill, and ability of the surgeon. A number of methods have been described in the literature for the assessment of breast volume to enhance clinical evaluation [1][2][3]. However, there is no consensus on the best approach. ...
... Bouman suggested a water displacement method; however, this may underestimate the volume as it may not adequately measure the tissue lateral to the pectoral fold [14]. All these methods are impractical in the clinical setting as they require special instruments and can be inconvenient to both the patient and the surgeon [1,2]. Many different formulas have also been described in the literature based on anthropometric measurements such as Westreich's formula for the 'ideal' breast volume based on manubrium-to-nipple and the nipple-to-nipple distance [15], and by Otiefy, based on the measurements of breast circumference [16]. ...
Article
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Background: Estimating the size and volume of the breast preoperatively is an important step in surgical planning for many breast procedures such as immediate implant-based breast reconstructions and reduction mammoplasties. Breast volume estimation helps in appropriate implant selection preoperatively. Objectives: The aim of this study was to objectively evaluate the estimation of breast weight by automatic volumetric breast assessment in digital breast tomosynthesis (DBT) using Quantra™ 2.2 Breast Density Assessment Software (Hologic Inc., Marlborough, Massachusetts, United States). Methods: Breast specimen weight after mastectomy and volume estimated by Quantra software were recorded. Results: Volume assessment obtained from Quantra software showed a high correlation with actual mastectomy specimen weight, with Pearson's correlation coefficients of 0.952. Conclusions: The automated DBT-derived breast volume using the Quantra software is a simple and practical method to assess breast size and weight preoperatively.
... Implant size selection is a critical component of preoperative planning for immediate breast reconstruction. An ideal implant size selection system should be comprehensive, versatile, simple to use and teach, easily reproducible through objective measurements and structured execution, and supported by evidence based on patient outcomes [1]. Although various methods have been developed in recent years, there is minimal evidence in the literature and no universal consensus supporting a particular approach [1,2]. ...
... An ideal implant size selection system should be comprehensive, versatile, simple to use and teach, easily reproducible through objective measurements and structured execution, and supported by evidence based on patient outcomes [1]. Although various methods have been developed in recent years, there is minimal evidence in the literature and no universal consensus supporting a particular approach [1,2]. There are virtual assessment systems like CRISALIX 3D® and VECTRA 3D®, which are known to be accurate in predicting implant size [3,4]. ...
Article
Full-text available
Background Implant size selection is a critical component of preoperative planning for immediate breast reconstruction. This paper introduces a novel formula, based on preoperative mammograms, for estimating implant volume in patients undergoing immediate breast reconstruction. Methods A retrospective analysis of 115 consecutive patients with immediate breast reconstruction following skin or nipple sparing mastectomy was performed. A calculated implant size was obtained using the formula, calculated implant size (ml) = π × height (cm) × [base width (cm) − 3]. The calculations were performed independently by two surgeons and based on the ipsilateral preoperative mammogram. The calculated implant size was compared with the actual implant size used during the surgery and results were analysed. Results The mean calculated and actual implant sizes were 376.03 ml and 324.49 ml, respectively. There was no difference found between calculated and actual implant sizes (t = − 1.704, p = 0.090), and there was a strong positive correlation between calculated and actual implant sizes (r = 0.7748, p < 0.00001). Further analysis revealed greater accuracy of the formula in patients with an estimated implant size of less than 350 ml, and a tendency to overestimate implant size in breasts with an estimated volume of more than 350 ml. Conclusions The mammography-based formula is a simple and practical method to estimate implant size preoperatively. Ultimately, implant selection for the best possible cosmetic outcome is a multifactorial process, of which breast volume is one consideration. This formula can serve as a useful adjunct for preoperative assessment. Level of Evidence: Level III, diagnostic study.
... They continue to descend naturally with the overlying breast tissue, safeguarding against the Snoopy deformity where the breast tissue descends over and under the implant. 9,19,21 The horizontal excess was addressed using a tailortacking technique to access the horizontal skin excess and the amount of breast tissue resection in the inverted T-scar. With proper implant and pocket selection, we had a comparatively low revision rate of 4% at the 1-year follow-up. ...
Article
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Planning a combined procedure requires ensuring an optimal fill of the reduced breast skin envelope, which in turn requires a system to quantify skin excess to ensure that the selected implant achieves that optimal fill. This has led us to develop a five-step approach that a surgical team can use to assess patients scheduled to undergo an augmentation mastopexy and arrive at an optimal surgical strategy. Methods: This retrospective study included 50 consecutive cases where layered mastopexies combined with augmentation mammaplasties were performed. Step 1 entailed a preoperative examination and evaluation of the breasts. In step 2, the breast volume was assessed. The pocket plane was determined in step 3. The choice of which surgical technique to use was done in step 4, and in step 5, the horizontal skin excess was assessed. Results: The average implant size was 300 cm3 (range: 170-350 cm3). The overall revision rate was 4%: on average, revision surgeries were performed 24 months after the first surgery. The average implant size was 300 cm3 (range: 170-350 cm3). Conclusions: Early results of single-stage augmentation with mastopexy have shown that the design of this systematic five-step approach demonstrates a great potential for producing reliable results with minimal risk. Using this five-step approach will improve patient and surgeon satisfaction and help to replace the old concept of "fill and re-drape" with a new one of "plan, reduce, fill, and re-drape."
... 3 Attempts to develop soft-tissue-based planning systems to rigorously define implant choice can result in patient dissatisfaction (the "engineers" approach), whereas pure patient preference can give rise to long-term complications (the "artists" approach). 4,5 When comparing studies that have "patient satisfaction" or other outcome measures, there has been no objective quantification of how a particular implant is chosen to fit an individual's unique morphometry. Consequently, results are difficult to compare across studies. ...
Article
Full-text available
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.
... The nuance in this scenario is that implant profile or projection is the variable that should be preferentially altered while keeping other implant variables relatively constant when choosing between different implants. Regardless of whether one prescribes to "tissue-based" or "dimensional analyses" planning systems 8 in selecting breast implants, implants chosen should ideally have base diameter and height measurements that approximate the native breast footprint to achieve the most natural and aesthetic results. The implants chosen for the LAM patients were upsized (average, 490 g) compared to the MAM patients (average, 450 g) and the RAM patients (average, 430 g) − perhaps this suggests that more of a lift was attempted by using a larger sized implant in the LAM group. ...
... Adams and Mckee [7] concluded that there is some evidence to support tissue-based planning as a superior approach to implant size selection planning; studies that used tissue based planning reported lower re operation rates compared with industry standards and accepted literature values. ...
Article
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Introduction: Breast augmentation is one of the most common aesthetic surgical procedures. Physical characters of the patients markedly affect choice of size and projection of the implant. Aim: Analyze the effect of skin laxity on the size and projection of breast implant. Patients and Methods: Retrospective analysis of the effect of degree of skin laxity of patients had breast augmentation on the size and projection of the implant. Patients decided into groups each group have almost similar cheat wall diameter, age and marital stat. the study included 20 patients received breast augmentation between January 2014 to January 2016 at Mawada privet hospital, Menou a. All implants were inserted through inframammary approach and were place in sub glandular pocket. Results: Relation between degree of skin laxity and size of breast implant show (Correlation coefcient) (r) (0.73) close to +1 which means that the two variables are closely related with each other with signifcant p value <(0.001). Also signifcant relation between the degree of skin laxity and implant projection also with deferent intraoperative steps during the procedure. Conclusion: Degree of skin laxity directly affects the size and projection of the breast implant.
... The majority of decision-making methods for preoperative planning do not come from the results of multivariable logistic regression models or, more generally, clinical studies. A recent systematic review of implant size selection systems for breast augmentation reports that only 12% of articles included outcomes that could be compared to accepted literature values or industry standards [20]. The present study has critically addressed this problem for breast reconstruction and searched for mathematical intervals of confidence. ...
Article
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Background Preoperative implant planning for breast reconstruction is often at risk of being changed perioperatively. This study examined which factors are associated with a change of implant selection. Methods Women who had unilateral two-stage breast reconstruction between 2002 and 2007 were studied. Inclusion criteria were photographic evidence of preoperative skin markings indicating breast dimensions and a selected implant model. Multivariable logistic regression was used to identify variables associated with a changed selection. Results Among the 496 women studied, 308 preoperative implant choices (62.1%) were changed during surgery. A change in plan was significantly associated with symmetrization surgery involving contralateral reduction mammaplasty (OR = 1.92; 95% CI, 1.12 to 3.29) and contralateral mastopexy (OR = 2.26; 95% CI, 1.29 to 3.96), but not with BMI. The required implant width changed more than 0.5 cm in 70 cases (14.1%) while height changed more than 0.5 cm in 215 cases (43.2%). The likelihood of a change was high for large preoperative widths (OR = 9.66 for 15.5 cm) and small preoperative heights (OR = 2.97 for 10.5 cm). At a mean follow-up of 16.6 months, patient satisfaction was good or average in 92.1% of cases and 5.9% of implants had been replaced with another model, indicating that the perioperative implant selection was usually appropriate. Conclusions This study documents the frequency with which implant choices, despite accurate preoperative planning, are changed perioperatively as a result of relatively small differences in anthropomorphic measurements. Perioperative recalculation of breast dimensions may have an advantage in terms of patient reoperation rates. Changes in width were less frequent than changes in height and projection. Contralateral surgery, large width, and small height were the most influential factors. Level of Evidence: Level IV, risk / prognostic study.
... [23][24][25] All of these considerations define the final implant-soft tissue relationship at the completion of surgery and are addressed in the multiple tissue-based planning systems utilized to minimize reoperative surgery. 26,27 The introduction of Tebbet's dual-plane techniques suggested a means of customizing the muscle coverage (and therefore compliance) of the lower pole of breasts to meet the aforementioned anatomic variables of this area while maintaining the benefits of upper pole muscle coverage. 9 In this way, muscle coverage of the upper pole of the implant would still minimize upper-pole rippling, palpability, and capsular contracture rates. ...
Article
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Breast augmentation surgical planning based on soft-tissue characteristics including the type of lower-pole pocket direction has been described. Objective outcome measures of the effects of some of these choices on postoperative lower-pole settling, including dual-plane dissection type, have been lacking. Objective: The aim of this study was to determine whether the type/extent of dual-plane dissection, patient age, or variables in breast implant characteristics affected implant-soft tissue dynamics of the lower pole of the breast enough to cause difference in implant settling during the postoperative period. Methods: Measurements of nipple-to-inframammary fold distance in primary breast augmentation patients were collected prospectively for 227 female primary breast augmentation patients during postoperative visits over an 8-year period. Changes in this distance during the postoperative period were evaluated for correlation with dual-plane dissection type, patient age, implant fill material, implant size, and implant profile. Results: Increasing dual-plane dissection type did demonstrate a trend toward greater postoperative lower-pole stretch. Only implant profile affected lower-pole stretch, with statistical significance shown in the ultrahigh-profile group. Age, implant fill material, and size of implant did not show any notable effect. Conclusions: Ultrahigh-profile implants cause significantly more lower-pole stretch postoperatively, whereas increasing dual-plane dissection type appears to have some effect as well. Age, implant material, and size of implant are of less importance over a 6-month period.
... 2,3 As a result, the most common cause for elective reoperation among breast patients is unsatisfactory implant size. 4,5 This has amplified plastic surgeons' responsibility to help patients set realistic surgical goals in the preoperative settinga longstanding communication challenge in the field. ...
Article
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Background Managing patient expectations is important to ensuring patient satisfaction in aesthetic medicine. To this end, computer technology developed to photograph, digitize, and manipulate three-dimensional (3D) objects has been applied to the female breast. However, the systems remain complex, physically cumbersome, and extremely expensive. Objectives The authors of the current study wish to introduce the plastic surgery community to BreastGAN, a portable, artificial intelligence-equipped tool trained on real clinical images to simulate breast augmentation outcomes. Methods Charts of all patients who underwent bilateral breast augmentation performed by the senior author were retrieved and analyzed. Frontal before and after images were collected from each patient’s chart, cropped in a standardized fashion, and used to train a neural network designed to manipulate before images to simulate a surgical result. AI-generated frontal after images were then compared to the real surgical results. Results Standardizing the evaluation of surgical results is a timeless challenge which persists in the context of AI-synthesized after images. In this study, AI-generated images were comparable to real surgical results. Conclusions This study features a portable, cost-effective neural network trained on real clinical images and designed to simulate surgical results following bilateral breast augmentation. Tools trained on a larger dataset of standardized surgical image pairs will be the subject of future studies.
Chapter
Three-dimensional imaging is a powerful new modality to help patients and surgeons with surgical planning and managing expectations with aesthetic breast surgery. The systems can help assess asymmetries and can provide anatomic simulations for varying implants. Further modifications can help assess breast outcomes with mastopexies. As with all computer-based imaging systems, limitations exist, and these are meant to bolster traditional clinical evaluation and decision-making without wholly replacing them. The authors present case presentations that illustrate the specific utility of 3D imaging in planning complex breast cases.
Chapter
Breast augmentation is one of the most popular aesthetic surgeries performed worldwide. Yet, it has high complication and revision rate due to in part improper patient selection, incorrect implant selection, and poor surgical technique. The operation can and must become predictable, reliable, and highly satisfying with less risk of reoperation. This requires understanding certain principles in breast anatomy, patient selection, biodimensional planning, and meticulous surgical techniques.
Article
Background: A growing number of transgender women present to plastic surgeons seeking breast augmentation. Despite some advocating their technical similarity, the authors have found substantially different planning and techniques are needed to obtain aesthetic results in transgender patients versus cosmetic breast augmentation. The authors sought to develop an approach for operative planning and technique to elucidate these differences and obtain consistent results. Methods: All patients who underwent breast augmentation at the Johns Hopkins Center for Transgender Health were included in this study. Anthropometric assessments were obtained and comparative statistics between operative and nonoperative cohorts were calculated. Outcomes were analyzed and a patient-reported survey was performed to evaluate patient satisfaction. Results: Fifty-nine consecutive transfemale patients presented for evaluation. Anthropometric measurements included base width (median, 15.0 ± 2.1 cm), notch-to-nipple distance (median, 22.0 cm), nipple-to-midline distance (median, 12.0 cm), areolar diameter (median, 3.5 ± 1.5 cm), and upper pole pinch (mean, 1.8 ± 1.1 cm). Thirty-six patients underwent augmentation mammaplasty. Postoperative complications (8.3 percent) included a minor hematoma and grade III capsular contracture in two patients. Patients were asked to complete a brief outcomes survey and reported an improvement in psychosocial well-being and high satisfaction rate (100 percent) with the overall cosmetic result. Conclusions: Transgender female patients represent a unique patient population requiring special consideration of anatomical differences in key planning decisions. The authors delineate the first systematic algorithm that addresses these differences, emphasizing maneuvers such as routine inframammary fold lowering. This can allow experienced augmentation surgeons to obtain excellent aesthetic and patient-reported outcomes in this population. As with cosmetic breast augmentation, patient satisfaction rates are high. Clinical question/level of evidence: Therapeutic, IV.
Article
Background: In breast augmentation, breast base diameter has been recognized as an important variable in implant selection. However, breast implant volume also has a tremendous impact on the final result. Previous methods of preoperative volume determination have been limited to external devices in a bra. Computer-based three-dimensional simulation technology now allows the physician to effectively communicate with the patient preoperatively regarding volume. Methods: A cohort of 40 consecutive patients underwent routine breast augmentation with either anatomically shaped or round implants. Five methods of preoperative volume determination including the Crisalix three-dimensional computer imaging system (Crisalix Virtual Aesthetics, Lausanne, Switzerland), along with an associated virtual reality tool, were used to assess the preoperative desires of the patients. A postoperative questionnaire was used to assess patient satisfaction with each volume determination method. Results: Of the 40 patients, 100 percent were satisfied with their result; however, given the opportunity, 12 percent would have chosen a larger implant. The virtual reality tool and external sizers were shown to be the most effective in choosing an implant. The virtual reality tool was judged to be very helpful (62 percent), very accurate (78 percent), and important (88 percent) in helping patients choose their desired implant size. Conclusion: Prioritizing volume as an implant selection variable in breast augmentation results in a very high rate of patient satisfaction. Clinical question/level of evidence: Therapeutic, IV.
Article
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Background Breast augmentation is one of the most commonly performed cosmetic surgeries worldwide. Therefore, it is imperative to have evidence with high methodological quality to guide clinical decision making. Objectives To evaluate the methodological quality of the systematic reviews (SRs) focused on breast augmentation. Methods: A comprehensive search of MEDLINE, Embase and the Cochrane Library of Systematic Reviews was performed. SRs that have a particular focus on breast augmentation and were published in the top 15 plastic and reconstructive surgery journals were included. Quality assessment was performed using A Measurement Tool to Assess Systematic Reviews (AMSTAR). Study characteristics were extracted including journal and impact factor, year of publication, country affiliation of corresponding author, reporting adherence to Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines, number of citations, and number of studies included. Results Among the 22 studies included for analysis, the mean AMSTAR score was moderate (5.55), with no SR achieving good quality (AMSTAR score ≥9). There were no significant associations between AMSTAR score and journal impact factor, number of citations, year of publication, or number of included studies. Studies that reported adherence to PRISMA guidelines on average scored higher on the AMSTAR tool (p=0.03). Conclusions The methodological quality of reviews about breast augmentation was found to be moderate, with no significant increase in studies or quality over time. Adherence to PRISMA guidelines and increased appraisal of SRs about breast augmentation using methodological assessment tools would further strengthen methodological quality and confidence in study findings.
Article
Learning objectives: After reading this article, the participant should be able to: 1. Develop a practical method for preoperative implant size selection. 2. List characteristics and examples of fourth- and fifth-generation silicone implants. 3. Recognize the differences in "profile" designations across implant manufacturers. 4. Recall updated statistics on breast implant-associated anaplastic large cell lymphoma and describe current guidelines on disease diagnosis and treatment. 5. Apply atraumatic and aseptic surgical techniques in primary breast augmentation. Summary: Modern primary breast augmentation requires an intimate knowledge of the expanding breast implant market, including characteristics of current generation silicone implants and "profile" types. Optimal implant size selection requires balancing patient desires with tissue qualities. Evidence and awareness of breast implant-associated anaplastic large cell lymphoma continue to grow, and patients and surgeons alike should be informed on the most updated facts of the disease entity. Atraumatic surgical technique and aseptic adjuncts are critical in reducing periprosthetic inflammation and contamination, both of which are known instigators of capsular contracture and potentially breast implant-associated anaplastic large cell lymphoma.
Article
Background: Previous aesthetic breast surgery algorithms have not addressed the importance of evaluating the native inframammary fold before primary breast augmentation. In the authors' experience, assessment of native inframammary fold anatomy significantly impacts surgical planning and technique. Failure to adequately evaluate and manage the inframammary fold leads to many of the common problems of the lower pole, including double-bubble deformity. Methods: The authors assessed the inframammary fold preoperatively in 2192 consecutive patients undergoing primary breast augmentation between June of 2014 and December of 2018. A novel classification of inframammary fold morphology was devised based on review of standardized preoperative photographs. Outcome assessment was performed postoperatively at 3-month intervals. Results: The authors identified four clear inframammary fold subtypes based on their clinical appearance, ranging from the nonexistent type F0 to the well-formed and fixed type F3. The key outcome measure examined was the presence of double-bubble deformity postoperatively. There were three total cases of double-bubble deformity identified in our cohort (<1 percent of patients). All cases of double-bubble deformity occurred in patients with a type 3 fold. Conclusions: The inframammary fold defines the inferior boundary of the lower pole of the breast and is a critical landmark to the aesthetic breast surgeon. The authors describe a unique and simple inframammary fold classification system that assists in selection of the appropriate approach to the inframammary fold in addition to implant dimensional planning. The authors have found that this system-in particular, the identification of the type F3 inframammary fold-has minimized the risk of inframammary fold-associated complications in over 2000 cases. Clinical question/level of evidence: Therapeutic, IV.
Article
BACKGROUND: Outcomes in primary breast augmentation depend on careful preoperative planning and clear communication between patient and surgeon. Three-dimensional imaging with computer simulation is an evolving technology with the potential to enhance the preoperative consultation for patients considering primary breast augmentation. The purpose of this study was to prospectively evaluate the impact of three-dimensional imaging with computer simulation on patient-reported and objective, mammometric outcomes in women undergoing primary breast augmentation. METHODS: One hundred patients were enrolled in a prospective trial with randomized and nonrandomized arms. The randomized arm was composed of a control group consisting of patients who underwent tissue-based planning without simulation (n = 13) and an intervention group consisting of patients who were simulated (n = 10). The remainder constituted the nonrandomized group who specifically sought preoperative simulation. Patient-reported outcomes (BREAST-Q) and mammometric data were recorded and compared preoperatively and 6 months postoperatively. RESULTS: Over time, significantly more patients refused randomization and chose simulation (p = 0.03). Breast augmentation led to substantial improvements in satisfaction with breasts, sexual well-being, and outcome. Simulation, however, did not significantly impact patient-reported outcomes or mammometric parameters. No strong correlations were identified between patient-reported outcomes and mammometrics. CONCLUSIONS: Patients are likely to use novel technology such as three-dimensional photography with computer simulation if they perceive it to enhance their understanding of their final outcome. These patients may seek out practices specifically offering such technology. Incorporation of simulation into the preoperative consultation, however, did not lead to clinically meaningful changes in patient-reported outcomes. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, II.
Article
There are numerous measuring systems that practitioners employ as part of their presurgical assessment for breast implant surgery. These range from direct measurements of patients using a tape measure, to assessment of standardized photographs and 3-dimensional scanning technologies. This personal view describes the authors system, developed over 20 years. The data yielded have assisted in assessing breast symmetry, ptosis, and match of implant to patient, with proven benefits for managing patient outcomes and expectations. It is simple, rapid to undertake, and requires inexpensive measuring equipment to provide useful data.
Chapter
Cosmetic breast surgery is popularly perceived as artistic. Unfortunately, this notion has allowed nonscientific concepts to persist, without proper scrutiny to establish validity. Without measurements, there is no means to test the effectiveness of surgical methods. Existing level of evidence scales benefit from modification to include important methodological considerations. Randomization is impractical for elective surgery. However, well-done observational studies can be just as useful. Consecutive patients are needed to avoid selection bias. Prospective studies are initiated before the data are collected, not after. A prospective study among consecutive patients meeting eligibility criteria, with a reported inclusion rate, the use of contemporaneous controls when indicated, and consideration of confounders, is a realistic goal. Such measures are likely to improve study quality. Commercial bias is an endemic problem in medicine. A plastic surgeon may function as a highly paid consultant or as an impartial investigator, but not both. Patient-reported outcomes are essential in plastic surgery because patient satisfaction is the most important determinant of surgical success. Unfortunately, plastic surgeons are not in the habit of soliciting their patients’ opinion regarding the result. A proprietary psychometric test, known as the BREAST-Q, has limited clinical usefulness. Ad hoc surveys provide useful clinical information that can be used to compare operations. There is no better education than performing outcome studies on one’s patients.
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A supra-inframammary fold (supra-IMF) dissection preserves the inframammary fascial condensations. This safe dissection plane minimizes the risk of bottoming out or the dreaded double-bubble deformity. A trans-areola incision may be used to simultaneously correct inverted or protruding nipples. Finger dissection preserves the lateral intercostal nerve branches to the nipples. Subpectoral implant placement is preferred for optimal upper pole appearance. The lower sternal origin is released cautiously to avoid symmastia. “Dual plane” is a misnomer. Three-dimensional simulations are not yet capable of predicting postoperative appearance. The patient’s size preference is most relevant in determining implant size, not tissue-based calculations. There is no evidence that large implant sizes (i.e., >350 cc) are especially risky. An average implant size of 390 cc is typical. The mean overall pain rating is 5.9 on a scale of 1 (worst) to 10 (best). A 24-h recovery is unrealistic. Patients report being “back to normal” approximately 25 days after surgery and being able to sleep comfortably 18 days after surgery. Although shaped “form-stable” implants have been heavily promoted, there is no evidence for their superiority over round implants. Their disadvantages include cost, firmness, and the possibility of malrotation. Anaplastic large cell lymphoma is linked to textured implants. Wrinkling can occur with both silicone gel and saline implants. As expected, breast implants reliably increase breast projection, upper pole projection, and breast area. The nipple level is unchanged. The IMF normally descends after a breast augmentation. Breast self-consciousness drops from 86% before surgery to 13% after surgery. Breast augmentation reliably improves self-esteem (91%) and quality of life (64%). Nipple numbness is common after breast augmentation (39%), but persistent numbness is unusual (2.3%). Almost all women (98.7%) would repeat the surgery.
Chapter
Augmentation mastopexy is still regarded with trepidation by some surgeons. The conventional view is that the operations are at cross-purposes: the implant stretches the skin envelope while the mastopexy tightens it. The limitations of nonvertical methods are exposed when an implant is introduced, such as added pressure on a long inferiorly based pedicle. Clinical experience and laser perfusion data demonstrate that, when a vertical technique with a medial pedicle is used, the combined procedure is safe. A medial pedicle is well-perfused and preserves superficial nipple innervation from the 3rd, 4th, and 5th anterior cutaneous branches. A deep parenchymal attachment maintains deep innervation. The medial pedicle is preferred over a superior pedicle, which sacrifices deep nipple innervation. The combined operation offers many synergies. Breast asymmetry, for example, is much easier to treat. Almost all cosmetic breast patients may be treated with either a breast augmentation or a vertical mammaplasty performed individually or in combination. Staging is unnecessary. A woman who lifts her breasts up with the cups of her hands to demonstrate what she wants is best served with an augmentation mastopexy. Complications include persistent ptosis (8.7%), scar deformities (7.9%), delayed wound healing (7.1%), and asymmetry (6.0%). In secondary cases, the nipple/areola may require little or no elevation. The original surgical pattern does not need to be followed. Patients report being “back to normal” 1 month after surgery. The mean pain rating is 5.3 on a scale of 1 (least pain) to 10 (worst pain). According to patient surveys, 84% of women are satisfied with their result, 94% would repeat the surgery, and 96% would recommend it to others. Almost all women (97%) are pleased with their decision to have implants. Self-esteem is improved in 86% of patients and 70% of women report an improved quality of life.
Article
Full-text available
The inframammary incision is the most versatile and popular approach in breast augmentation. For an optimal aesthetic result, the incision site should be chosen in such a way that the scar is carefully hidden in the (new) inframammary fold. Based on an assumption of the senior author (B.v.d.L.) that the Pythagorean theorem (α + β = γ) is suited to describe the ratios of implant and incision location variables, the authors developed an almost perfect roadmap for accurate determination of the right incision location in augmentation mammaplasty with round implants through the inframammary incision. The authors plenary judged the photographs of 263 augmented breasts whether the scar of the augmentation mammaplasty was located in the neo-inframammary fold. In all cases, the Pythagorean theorem was used to determine the exact location of the site of incision. In only four of the 263 augmented breasts (1.5 percent), the position of the scar was a little below the neo-inframammary fold and thereby visible with the patient in the upright position. A scar correction to reposition the scar into the inframammary fold was performed in one patient on one breast by means of additional skin excision above the scar; in the two other cases, the scar was accepted by the patients as being not too bothersome. The Pythagorean theorem is an effective method for determining the right incision site in augmentation mammaplasty with round implants through an inframammary approach.
Article
Full-text available
When using the inframammary access incision for breast augmentation, careful planning is critical to allow the surgeon to set the inframammary fold (IMF) at the most optimal position, minimize scar visibility, and mitigate the main disadvantage of this approach. Current popular evaluation systems for breast augmentation include the High Five and Randquist systems and they base their calculations on inconsistent variables like skin stretch measurements. We propose a simple method that is not dependent on skin stretch measurements to properly determine implant size, profile, and position of the inframammary fold. Excluding digital scans and computer-based systems that are not universally available, the proposed simplified assessment tool was compared to the two most popular manual measuring tools (High Five and Randquist). Twenty-five female volunteers were included in the study. The projected IMF positions over the midsternal line for each measuring tool were recorded on each patient and the sternal notch (SN) to projected IMF distance SN–IMF1 (simplified evaluation system), SN–IMF2 (High Five System), and SN–IMF3 (Randquist system) were compared. The anticipated new IMF position is determined based on the vertical implant dimension and not on breast base width. For most subjects, the differences between the three evaluation systems were minimal. The proposed breast measurement tool constitutes a new, much simpler, and practical method that proved to be successful in our hands. Level of Evidence V 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.
Article
Full-text available
The authors describe a modified method for determining the size of implants in augmentation mammaplasty. Preoperatively, 35 women filled their brassieres with rice bags and expressed their opinion and wishes. Postoperatively, all of them were satisfied with their new breasts.
Article
Full-text available
Choosing the right implant size for a specific patient is a challenging aspect of breast augmentation. Bust circumference is obtained by measuring the chest circumference at the level of the nipple-areola complex. Pre- and postoperative bust circumference measurements obtained from 147 patients who underwent primary bilateral breast augmentation using round, textured, gel-filled implants were evaluated, and a practical reference list for future operations was developed. According to the results, each additional 100 ml in implant size yielded an approximate 2-cm increase in bust circumference. The authors believe these results gathered from systematic measurements may serve as a useful guide for choosing the right size implant for a satisfactory augmentation procedure.
Article
The concept of breast augmentation surgery has traditionally been focused on implant volume; however, with the advent of anatomic breast implants in the 1990s, a new era in breast augmentation surgery started, focusing on dimensions and proportions. In 823 patients, 1676 anatomic cohesive silicone gel implants have been used in this series. To date this is the world’s largest experience from one center. The concept of using these types of implants is very different from other augmentation techniques and many considerations in the preoperative assessment have to be respected for optimal results. A “decision tree” has been constructed to aid the surgeon to choose the right type of implant. In this article, advantages and disadvantages, indications, contraindications, preoperative measurements and considerations, surgical technique, postoperative management, and results are presented.
Article
The use of implants in aesthetic breast surgery may lead to complications resulting in the need for reoperation. This study examines outcomes following breast augmentation in a single surgeon's practice and investigates the effect of implant selection and surgical technique on complications and reoperations. A retrospective review of a single surgeon's prospectively maintained database over 15 years was performed. All primary bilateral breast augmentation patients were included. Implant characteristics-including implant type, fill, shape, surface, and projection; incision type; and pocket location-were collected. Complications and reasons for reoperation were analyzed using survival analysis. One thousand five hundred thirty-nine patients with 3078 implants were included. Implant types included 596 shaped textured gel, 515 round smooth saline, 192 round textured gel, and 236 round smooth gel implants. Follow-up ranged from 0 to 155 months (average, 18 months). Total complication and reoperation rates were 6.8 and 7.7 percent, respectively. Inframammary incisions and the use of shaped textured gel implants were associated with lower rates of complications. The use of a dual-plane II or III pocket, and implant volumes over 400 cc, were associated with higher rates of complications. Full-projection round implants had rates of complications and reoperations equivalent to those of moderate-projection devices. Both textured shaped gel implants and a subpectoral pocket location were associated with the lowest rates of capsular contracture. This large series of breast implant patients demonstrates that both implant- and technique-related factors may influence complications and reoperations in breast implant surgery. Therapeutic, IV.
Article
Breast implants have been used in aesthetic and reconstructive breast surgery since the early 1960s. One facet regarding the use of these devices that has not changed over these past 50 years relates to the fact that the thinner the soft-tissue envelope is, the more visible the implant will become. Therefore, the design features of the device become more important in these types of patients. With the evolution of implant design, several different design variables have been re-engineered including the use of different fill materials, the alteration of the surface features of the shell, and changes in the overall shape of the implant. Although various advantages and disadvantages have been postulated regarding each of these variables, the incorporation of an anatomic shape into the implant is perhaps the most intriguing design feature yet developed. It seems a short intellectual leap to postulate that the normal, slightly ptotic, or teardrop look of the youthful breast would be best achieved using an implant that had a similar shape. However, despite what might on the surface appear to be a straightforward conclusion, the development, approval, and acceptance of the anatomically shaped implant has been a slow, arduous process. The purpose of this article is to describe the proper technique required to safely and effectively use these devices in aesthetic and reconstructive breast surgery cases and provide representative case examples demonstrating the outstanding results that can be obtained.
Article
With the 2006 Food and Drug Administration approval of round silicone gel breast implants in the United States, there still remained a lack of versatility in implant options. The approval of Sientra's shaped cohesive implants in 2012 brought with it the innovations needed to address varying patient needs. Because access to shaped devices is still fairly recent in the United States, some surgeons remain uncomfortable with implementing shaped cohesive gel implants into their practice. The author outlines surgical techniques and algorithms from experience with the Sientra shaped device, covering the preoperative stage, measurements (base diameter, sternal notch to nipple, tissue pinch, and nipple to inframammary fold), ideal first candidates, operative techniques, and complication avoidance, as well as important factors for shaped-implant selection, including chest base diameter, implant height, implant volume, and implant projection for the patient's desired outcome. With experience, surgeons will find new utility with shaped implants for a variety of patients in their practices.
Article
Background: For patients considering breast augmentation, 3-dimensional (3D) imaging provides a preoperative simulation of the postoperative result. However, the clinical accuracy of these simulations has not been assessed. Objective: The authors compared preoperative simulations with postoperative results of breast augmentation to permit more informed decisions about breast augmentation. Methods: To determine differences between simulations and actual results, volumetric and contour analyses were performed for patients who underwent 3D imaging both preoperatively and 3 months after breast augmentation. All patients received round smooth silicone implants or anatomically shaped cohesive silicone gel implants; the mean volume was 295 cc. Results: Twenty patients (40 breasts) underwent 3D imaging both pre- and postoperatively. There were no procedural complications or revisions. The mean difference between preoperative simulation and postoperative breast volume was 27.2 cc (range, 1.4-99.5 cc), representing a 9.2% mean difference in volume and an accuracy of 90.8%. The mean absolute difference (root mean square) of all surface points along the breast in aggregate was 4.0 mm (range, 1.8-8.3 mm). No specific location along the surface contour of the breast could be identified as having the greatest differences. Conclusions: The preoperative simulation provided by 3D imaging is >90% accurate in predicting postoperative breast volume. The mean absolute differential for surface contour in this study was 4 mm, representing 98.4% accuracy based on average surface area. Level of evidence: 3.
Article
The aim of this study was to prospectively evaluate patient satisfaction and quality of life with elective breast augmentation. Patients with bilateral submuscular breast augmentations prospectively completed the BREAST-Q preoperatively and 6 weeks and 6 months postoperatively; t tests compared preoperative and postoperative scores at 6 weeks and 6 months, and standard indicators of effect sizes were calculated. Logistic regression was used to evaluate the association between patient and surgical factors on satisfaction outcomes. The study sample included 611 female patients with the following characteristics: (1) mean age of 33.5 years; (2) mean body mass index of 21.7; (3) and mean implant volume of 360; with (4) 73 percent having received a silicone implant. Significant improvements were found in patient satisfaction with breasts (p < 0.001), psychosocial well-being (p < 0.001), and sexual well-being (p < 0.001) at 6 weeks and 6 months postoperatively, and all were associated with a very large Kazis effect size of 3.66, 2.39, and 2.56 at 6 months, respectively. However, at both 6 weeks and 6 months postoperatively, physical well-being remained significantly below preoperative baseline scores. In addition, satisfaction with breasts and with the overall surgical experience was significantly lower among older patients (p = 0.01 and 0.02, respectively). Breast augmentation is associated with high patient satisfaction and significant improvements in quality of life. However, physicians should inform patients that submuscular augmentations are associated with a delay in recovery of physical functioning and be aware that older patients may experience diminished satisfaction and should counsel accordingly. Therapeutic, IV.
Article
In augmentation mammaplasty cases it has been impossible for the patient to relate to the doctor preoperatively exactly how large they want their new breasts to be. Many of these patients are uncomfortable because they are not given a realistic impression of how large they will be postaugmentation. We have devised a mammary sizer which gives the patient a better idea of how large she will be postaugmentation. It gives the doctor a better impression of what size implant to use to achieve the desired size.
Article
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. 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 .
Article
Currently, aesthetic and reconstructive surgery of the breast should be considered in terms of contouring, and hence in terms of dimensions. Based on experience performing more than 5,000 breast augmentations with highly cohesive anatomic implants, the authors explore the aesthetic anatomy of the (augmented) breast and explain the importance of the breast implantation base (BIB), the aesthetic proportions of the lower breast pole, and the patient's somatotype in the implant selection for a natural-appearing breast augmentation. A method is described for transferring all these concepts and proportions to the preoperative marking of the individual patient. 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 .
Article
Background: Selecting the appropriate implant is one of the most important and demanding decisions in breast augmentation with anatomical implants, because different widths, heights, and projections can be found for a given volume. Most of the related literature and surgeons' concern have focused on width and projection. Implant height selection, however, has remained deeply overlooked, and it has been assumed that it depended on the suprasternal notch-to-nipple distance and, to a large extent, on the patient's height. Methods: With more than 5123 breast augmentations performed over the past 15 years, the authors performed an analysis of the breast and implant height with consequences in aesthetic augmentation of the breast. Two concepts--breast implantation base (or breast footprint) and somatotype--were explored. Their influence in the selection of the appropriate anatomical implant height is investigated. Results: Selection of implant height should follow the patient's breast implantation base, which is highly influenced by her somatotype. With this assumption, a "number Y" is proposed that correlates the suprasternal notch-to-nipple distance with the thoracic perimeter and unveils the shape of the breast implantation base in the particular patient. Conclusions: Adjusting the implant shape/footprint to the breast implantation base/breast footprint gives the surgeon control over the upper pole of the breast and allows a predictable postoperative result. The number Y rationalizes the selection of the implant height in breast augmentation. Clinical question/level of evidence: Therapeutic, IV.
Article
Background: Improvements in satisfaction and quality of life following breast augmentation have been shown in the literature. However, few studies have used validated survey instruments. The BREAST-Q is a strong and validated questionnaire for breast augmentation. Objective: The authors implement the BREAST-Q to analyze patient-reported satisfaction and quality of life following breast augmentation. Methods: In this prospective study, all patients who underwent breast augmentation with a single surgeon (AT) between January 2008 and May 2009 were asked to fill out BREAST-Q surveys anonymously during the preoperative and 6-week postoperative periods. Statistical analysis was performed and a P value of <.05 was considered significant. Results: Of the 155 patients who underwent breast augmentation during the study time period, 59 (38%) completed the preoperative survey and 70 (45%) completed the postoperative survey. Significant improvements were seen for satisfaction with breast appearance (P < .001), psychosocial well-being (P < .001), and sexual well-being (P < .01) between pre- and postoperative surveys. Conversely, a significant decrease was seen in the physical well-being category (P < .001). Satisfaction with overall outcomes most strongly correlated to satisfaction with appearance of breasts (r = 0.8) and less strongly with psychosocial well-being and sexual well-being (r = 0.6). No correlation was found between satisfaction with overall outcomes and physical well-being (r = 0.0). Conclusions: As the implementation of evidence-based medicine continues to grow in everyday practice, there is increasing pressure to use validated survey instruments to demonstrate patient-reported outcomes. In this study, the authors have shown that breast augmentation significantly improves satisfaction with breast appearance, psychosocial well-being, and sexual well-being and that overall satisfaction is most strongly correlated with breast appearance satisfaction.
Article
: The purpose of this study was to determine the current preferences of plastic surgeons regarding preoperative assessment and their effect on clinical outcome in primary breast augmentation. : An eight-question online survey was sent to members of the American Society of Plastic Surgeons. Data collected online were analyzed using Student's t test or Pearson's chi-square test. A value of p < 0.05 was considered statistically significant. : The response rate was 20.1 percent (604 respondents). Breast base diameter [n = 286 (47.4 percent)] was ranked the most important consideration vital in choosing implants. Most surgeons chose to reeducate their patients to resolve a conflict between their patient's implant size request and the surgeon's clinical judgment [n = 385 (63.7 percent)], whereas 151 (25 percent) would proceed anyway. Those surgeons who chose reeducation ranked breast base diameter as a vital consideration significantly higher than those who would accommodate their patients (2.03 ± 1.41 versus 2.31 ± 1.41; p = 0.041). Similarly, surgeons who reeducated their patients ranked implant volume as the vital consideration significantly lower than those who accommodated their patients (2.90 ± 1.67 versus 2.44 ± 1.47; p = 0.002). Regarding size change, 332 surgeons (55 percent) reported their rate was 5 percent or less, whereas 272 (45 percent) reported it was greater than 5 percent. Surgeons who reported a 5 percent or less rate ranked implant volume significantly lower than those with reoperation rates greater than 5 percent (2.93 ± 1.71 versus 2.55 ± 1.53; p = 0.004). : Breast base diameter and implant volume were the two most important considerations in choosing an implant for breast augmentation. Reported reoperation rates for size change were significantly lower for surgeons who regarded breast base diameter as more vital than those who valued implant volume more.
Article
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Article
Learning objectives: After reading this article, the participant should be able to: 1. Cite the key concepts in the process of breast augmentation that optimize outcomes; 2. Cite key components of tissue-based planning for implant selection; 3. Discuss complications and risks of breast augmentation. Summary: Breast augmentation remains one of the top surgical procedures performed by plastic surgeons. Current literature supports the concept that breast augmentation outcomes are optimized using a concept of "the process of breast augmentation." Breast augmentation is often thought of as a surgical procedure; however, the nonsurgical aspects of the procedure are more important for optimizing outcomes and minimizing reoperation and complications. The process of breast augmentation includes patient education, tissue-based preoperative planning, refined surgical technique, and defined postoperative management. This CME article reviews and discusses the current relevant topics and issues surrounding breast implants. There are also supporting videos to enhance the reader's experience. CME questions are present at the end for a self-assessment.
Article
No publications exist describing the impact of three-dimensional imaging on the consultation process for breast augmentation, nor have existing software products claiming simulation features been validated. The authors describe the application of four-dimensional technology during patient consultation to assist in planning implant size and type. Forty-six primary breast augmentation patients underwent preoperative consultation with 4D simulation software; 35 out of 46 also received follow-up imaging. At six months postoperatively, simulated measurements were compared to actual measurements and questionnaires were mailed to patients asking them to assess the imaging experience. A follow-up phone survey 18 months postoperatively examined the persistence of patient attitudes about implant size and imaging. Practice productivity was evaluated by comparing specific parameters (such as scheduling rates) between three separate time periods for the same clinic. Across all parameters, breast augmentation simulations correlated highly with positive surgical outcomes (R-value = 0.68). The majority (95%) of patients believed the simulations were accurate; 89% also expressed that it enhanced trust in the surgeon and 74% reporting that it helped in choosing an implant size. Despite 48% also indicating that they would select a larger implant if they were to undergo surgery again, no patients have undergone reoperations of any kind. Compared to historical controls, scheduling rates in the practice increased from 40% to 77% after addition of simulation software. 4D breast imaging appears to be an accurate system for analysis, planning, simulation, and patient education for women considering primary breast augmentation, and application of this technology during the consultation process was correlated with a high degree of patient satisfaction and practice productivity.
Article
This study evaluated patients who underwent primary breast surgery within a single group practice from 1994 to 2009. Reoperations were divided by reoperation reason into total reoperations and implant-specific reoperations. The authors hypothesized that the implant-specific reoperation rate will provide the most accurate measurement of complications caused by the breast implant device. A total of 812 patients received the same brand of breast implant for primary breast augmentation or augmentation/mastopexy. Safety and efficacy data were recorded and complication rates were calculated. Statistics were applied using Kaplan-Meier estimated cumulative incidence calculations. This study included 482 patients with saline and 330 patients with silicone implants. The most common complications included capsular contracture, rippling, rupture, infection, and hematoma. A total of 8.2 percent of patients developed Baker grade III/IV capsular contracture by 6 years. The raw incidence of rippling was 7.1 percent, and the rate was significantly increased in underweight patients with subglandular saline implants (p = 0.045). The rate of total reoperation at 1 year was 14.2 percent. While a significantly increased rate of total reoperation was seen for silicone compared with saline implants (p < 0.01), no difference was seen in the rate of implant-specific reoperation for saline compared to silicone implants (p = 0.582). The use of total reoperation rates as an indication of complications of breast implants can lead to both an overestimation of implant-related complications and the inaccurate conclusion that silicone implants result in higher complication rates than saline implants. The implant-specific reoperation rate may provide a more accurate incidence of implant complications than the total reoperation rate, which includes reoperations for factors unrelated to the implant.
Article
In recent years there has been a considerable increase in understanding of changes in mortality in Russia and some other former Soviet republics. However, the situation in the republics of the Caucasus remains poorly understood. Information on Georgia is especially fragmentary as a fifth of the country remains outside government control, there has been large scale migration since 1991, and the introduction of fees for vital registration has compromised the quality of official statistics.The aim of the study is to produce plausible estimates for life expectancy in Georgia for the period 1990–1998 and thus to assess whether Georgia has undergone changes similar to other former Soviet republics in the post-independence period.Four models were used to construct life tables. Model 1 used officially published statistics on deaths and population. Model 2 applied new estimates of population derived from household surveys to the observed deaths. Model 3 adjusted model 2 for under-registration at extremes of life, with parameter estimates derived from a survey of infant mortality and comparison of observed rates with Coale-Demeny standard life tables. Model 4 arose following inspection of death rates by cause that revealed implausible discontinuities in cancer mortality rates and involved applying the estimates of under-registration that this finding implied to model 3.The four models produce quite different estimates of life expectancy, differing by 7.8 y for men and 6.8 y for women by 1998. In any of the models, however, Georgia does not appear to have experienced the marked deterioration in life expectancy seen in Russia following the transition to independence. Importantly, Georgia had also not experienced a marked improvement in life expectancy during the 1985 Soviet anti-alcohol campaign, again unlike other Soviet republics.Official statistics substantially over-estimate life expectancy at birth in Georgia. Despite undergoing a civil war, life expectancy in Georgia has been less affected by the transition than has Russia and the overall trends in mortality since the mid 1980s suggest that this may be because alcohol has played a smaller role in these changes than it did in Russia. Public Health (2001) 115, 394–400.
Article
The aesthetic results of augmentation mammaplasty are essentially determined by the size and the shape of the implant as well as its position on the chest. To achieve successful aesthetic results, customized surgery planning based on a reliable visual concept of the prospective surgery outcome and quantitative methods for assessment of three-dimensional (3D) breast shape could be of considerable additional value. This report evaluates a novel method for customized planning and quantitative optimization of breast augmentation based on 3D optical body scanning of the patient's breast and computational modeling of soft tissue mechanics. This method allows a 3D photo-realistic appearance of postsurgery breasts to be simulated for different surgical scenarios. It also allows the result of a virtual simulation to be implemented using measurements derived from a computationally predicted breast model. A series of clinical studies are presented that demonstrate the feasibility and accuracy of the proposed approach for customized 3D planning of breast augmentation, including direct comparison between simulated and postsurgery results. Our experimental results show that for 89% of the breast surface, the average difference between the simulated and postsurgery breast models amounts to less than 1 mm. The presented method for customized planning of augmentation mammaplasty enables realistic prediction and quantitative optimization of postsurgery breast appearance. Based on individual 3D data and physical modeling, the described approach enables more accurate and reliable predictions of surgery outcomes than conventionally used photos of prior patients, drawings, or ad hoc data manipulation. Moreover, it provides precise quantitative data for bridging the gap between virtual simulation and real surgery.
Article
All breast implants can potentially have deleterious effects on patients' tissues. Limiting negative tissue consequences and potential uncorrectable deformities requires that surgeons be aware and educate patients regarding potential consequences of various implant designs. High-profile implants have been available for decades, and during the current decade, extra-high-profile implants have become available, but no valid peer-reviewed and published studies have compared the potential tissue consequences of these designs to those of other breast implant designs. Valid comparative studies are exceedingly difficult to perform because of the number of variables that must be addressed to establish valid comparative cohorts. Nevertheless, the potential occurrence of negative tissue consequences from high- and extra-high-profile implants in primary breast augmentation and breast augmentation reoperation cases is well known to experienced aesthetic breast surgeons. This article addresses potential negative effects on patients' tissues of high- and extra-high-profile breast implants used for breast augmentation. This Special Topic article is not structured or intended as a scientific article. It is written as a Special Topic and not an Editorial at the editor's request. The cases presented are selected examples to illustrate potential clinical eventualities. The rate of occurrence of uncorrectable tissue deformities relates directly to surgeon and patient awareness of the potential consequences of implant selection decisions and requests. To minimize risks of negative tissue consequences for patients, surgeon awareness, patient education, and optimal implant selection decision processes are essential.
Article
Implant size selection in breast augmentation patients is one of many variables to be determined before surgery. Few methods exist today that allow the patient to participate in this process and accurately determine optimal size. The authors describe a simple method of preoperative sizing using silicone implant samples. A total of 567 patients underwent breast augmentation: 297 had surgery before implementation of preoperative sizing and 270 patients were sized preoperatively. Sizing consisted of fitting the patients with various size silicone implants in a larger bra at least twice before surgery to determine desired size. Surveys were sent to both groups to inquire about overall satisfaction, how many preferred a different size postoperatively, and how many ultimately underwent size change surgery. One hundred two responses (34.3 percent) were obtained from the control group and 142 (52.6 percent) were obtained from the sized group. Sized patients received smaller implants (average, 276.6 cc nonsized versus 246.4 cc sized; p < 0.001). Four patients (1.4 percent) in the control group underwent a size change procedure compared with none in the sized group. In the sized cohort, 69 percent believe they are the size that the process predicted, 21 percent are smaller, 9 percent are larger, and 1 percent did not answer the question. Sized patients were more satisfied than controls and fewer were interested in having a different size implant postoperatively. Sized patients indicated that preoperative sizing was both helpful and reasonably accurate in predicting final breast size.
Article
“Surgical Strategies” focuses on refinements in aesthetic surgical techniques. Contributors are Aesthetic Society members or other recognized experts.
Article
Breast augmentation has been an integral part of plastic surgeons' practices for over 40 years. Although devices have evolved, patient outcomes are still not ideal, as documented in multiple premarket approval clinical trials. Unlike many other areas of surgery, the practice of breast augmentation has suffered from the lack of a defined process for patient management. The purpose of this study was to clinically define and evaluate the process of breast augmentation and analyze patient outcomes using these practices compared with existing premarket approval trial data. Three hundred consecutive primary breast augmentations from 2001 to 2005 were followed prospectively. Each patient underwent a defined process of breast augmentation including structured patient education and informed consent; tissue-based preoperative planning consultation; refined surgical technique; and structured postoperative instructions, management, and follow-up. The mean follow-up was 2.1 years. The most common complications were rippling and palpability, soft-tissue stretch, and hypersensitivity. The overall reoperation rate was 3.7 percent for the entire group and 4.7 percent and 2.9 percent for saline and form-stable cohesive gel implants, respectively. Optimizing patient outcomes in breast augmentation requires defining the overall process to allow for enhanced patient outcomes. This is the first report that defines and integrates the entire process comprehensively that is validated by outcomes data. This process is transferable to other surgeons and, using this algorithm, patient outcomes in this study were superior to premarket approval clinical trial data. In summary, approaching this procedure with a global process produces superior patient outcomes in breast augmentation.
Article
A simple method of determining the size of prosthesis in augmentation mammaplasty is described. It depends on the insertion of sufficient prepacked 25-ml sachets to fill a brassiere the patient selected as being the cup size she would like.
Article
The authors describe in detail a test to determine lumbrical function.
Article
The described technique is of value in correcting an erroneous clinical assessment of the probable size of the prosthesis required. With this simple and quick test, using an inflatable balloon, the effects of different sizes of prostheses can be observed before the actual size is selected.
Article
A simple and accurate method of measuring differences in breast volume based on Archimedes' principle is described. In this method, a plastic container is placed on the breast of the patient who is lying in supine position. While the breast occupies part of the container, the remaining part is filled with water and the volume is measured. This method allows the measurement of the volume differences of asymmetric breasts and also helps the surgeon to estimate the size of the prosthesis to be used in augmentation mammaplasty.
Article
A retrospective study of 220 patients was performed to review surgical design in breast augmentation. Three specific issues were studied: incision site, implant variables, and pocket plane selection. The influence of these three factors on aesthetic results in both primary and secondary cases was the focus of the analysis. No attempt was made to address long-term issues such as capsular contracture or saline implant deflation rates. In 77 primary augmentation patients and 80 unilateral augmentations for symmetry in breast reconstruction, there were the following untoward results: 11 revisions for unilateral malposition, change to a different implant shape, or change to a larger implant size; four deflations of saline implants requiring replacement; and four conversions of saline to silicone gel implants. In 63 secondary cases, there were two hematomas and two infections requiring implant removal and subsequent replacement. Operative technique in breast augmentation is described, as are recommendations for each of the options associated with the three variables studied.
Article
The concept of breast augmentation surgery has traditionally been focused on implant volume; however, with the advent of anatomic breast implants in the 1990s, a new era in breast augmentation surgery started, focusing on dimensions and proportions. In 823 patients, 1676 anatomic cohesive silicone gel implants have been used in this series. To date this is the world's largest experience from one center. The concept of using these types of implants is very different from other augmentation techniques and many considerations in the preoperative assessment have to be respected for optimal results. A "decision tree" has been constructed to aid the surgeon to choose the right type of implant. In this article, advantages and disadvantages, indications, contraindications, preoperative measurements and considerations, surgical technique, postoperative management, and results are presented.
Article
Primary breast augmentation patients have widely varying characteristics of their breast envelope, parenchyma, and adjacent tissues. When preoperative breast implant selection does not specifically address critical soft-tissue parameters individual to each patient, risks of complications increase. Complications that occur from failure to reconcile a patient's wishes for breast size with her individual tissue characteristics include skin stretch and thinning, ptosis, atrophy of parenchyma, implant edge or shell visibility, implant edge or shell palpability, visible traction rippling, "bottoming" deformities, and lateral implant displacement with widening of the intermammary distance. Previous dimensional systems address implant parenchyma base width relative to implant base width, but no published system adequately addresses or attempts to quantitate the third dimension, tissue stretch, that is critical to estimate amount of fill necessary in a wide range of breast and tissue types. This system addresses the tissue characteristics (T) of the envelope (E), the parenchyma (P), and the implant (I), and the dynamics (D) of implant and filler distribution that affect soft tissues. The acronym TEPID summarizes the key factors that determine aesthetic results and occurrence of problems and reoperations following breast augmentation. This simple, efficient, and clinically practical system focuses on only three tissue measurements to estimate implant volume required to fill each patient's existing breast envelope, on the basis of her individual tissue characteristics: base width of the parenchyma, anterior pull skin stretch, and areola- and/or nipple-to-inframammary-fold distance measured under maximal stretch. The surgeon then adjusts initial volume to address differences in degree of skin stretch (anterior pull skin stretch) and contribution of the patient's existing parenchyma to stretched envelope fill, and to address differences in implant dimensions and filler distribution dynamics. To base decisions of implant pocket location on quantifiable soft-tissue coverage thickness, the system measures soft-tissue pinch thickness of the upper pole and at the inframammary fold. Surgeon time required to measure, estimate, and make preoperative implant selection decisions is less than 5 minutes. This system evolved from compiling and reviewing measurements and results from 330 primary breast augmentations from 1996 to 1999, including round and anatomic implant types with smooth shells and two different textured shells. The TEPID system was then used concurrently with the previous dimensional system for patient tissue evaluation and preoperative implant selection in 627 consecutive primary augmentation cases over a 3-year period from January of 1998 to January of 2001. Implant selection that did not comply with the parameters of the system was necessary in only eight cases. The TEPID system is a simple, efficient, and clinically practical method that allows surgeons to base implant selection on clinically quantifiable, individual patient tissue characteristics.
Article
Because of specific methodological difficulties in conducting randomized trials, surgical research remains dependent predominantly on observational or non-randomized studies. Few validated instruments are available to determine the methodological quality of such studies either from the reader's perspective or for the purpose of meta-analysis. The aim of the present study was to develop and validate such an instrument. After an initial conceptualization phase of a methodological index for non-randomized studies (MINORS), a list of 12 potential items was sent to 100 experts from different surgical specialties for evaluation and was also assessed by 10 clinical methodologists. Subsequent testing involved the assessment of inter-reviewer agreement, test-retest reliability at 2 months, internal consistency reliability and external validity. The final version of MINORS contained 12 items, the first eight being specifically for non-comparative studies. Reliability was established on the basis of good inter-reviewer agreement, high test-retest reliability by the kappa-coefficient and good internal consistency by a high Cronbach's alpha-coefficient. External validity was established in terms of the ability of MINORS to identify excellent trials. MINORS is a valid instrument designed to assess the methodological quality of non-randomized surgical studies, whether comparative or non-comparative. The next step will be to determine its external validity when used in a large number of studies and to compare it with other existing instruments.
Article
In planning a breast augmentation, the choice of an appropriate breast implant volume is sometimes a problem, particularly for unskilled surgeons. The authors have used a little trick to make the choice easier for both the surgeon and the patient.
Article
Breast implants have been used worldwide for more than 40 years. Despite extensive clinical experience, there is continued concern about the safety of these devices. The purpose of this study was to compare the efficacy, complication rates, frequency of reoperation, and degree of patient satisfaction with different types of implants. This is a consecutive, population-based study consisting of all patients receiving implants at a multidisciplinary breast center between 1979 and 2004 (25 years). A prospective implant database was constructed and maintained in Excel, and statistical analysis was performed using SAS 8.2. Various outcomes, including infections, hematomas, undesirable waviness, capsular contracture, deflation, rupture, reoperation, and patient satisfaction, were monitored. Data were collected on 3495 implants in 1529 women. The longer implants were in place, the greater the cumulative risk of developing contracture; hematoma significantly increased the risk of contracture; smooth and textured implants had similar contracture rates; polyurethane foam-covered implants had a reduced risk of contracture persisting for at least 10 years after implantation. There was a relatively high rate of reoperation and a relatively short interval between primary surgery and reoperation; the most common indication for reoperation was capsular contracture. Implant recipients expressed a high overall level of satisfaction. Breast implants are associated with a significant rate of local complications and reoperation. There are marked differences in outcomes as a function of implant surface type and surgical indication. Despite relatively frequent complications and reoperations, implant recipients are largely satisfied.
Article
Capsular contracture remains one of the most common complications involving aesthetic and reconstructive breast surgery; however, its cause, prevention, and treatment remain to be fully elucidated. Presently, there is no accurate and reproducible pathologic in vitro or in vivo model examining capsular contracture. The purpose of this study was to establish an effective pathologic capsular contracture animal model that mimics the formation of capsular contracture response in humans. New Zealand White rabbits (n = 32) were subdivided into experimental (n = 16) and control groups (n = 16). Each subgroup underwent placement of smooth saline mini implants (30 cc) beneath the panniculus carnosus in the dorsal region of the back. In addition, the experimental group underwent instillation of fibrin glue into the implant pocket as a capsular contracture-inducing agent. Rabbits were euthanized from 2 to 8 weeks after the procedure. Before the animals were euthanized, each implant was serially inflated with saline and a pressure-volume curve was developed using a Stryker device to assess the degree of contracture. Representative capsule samples were collected and histologically examined. Normal and contracted human capsular tissue samples were also collected from patients undergoing breast implant revision and replacement procedures. Tissue samples were assessed histologically. Pressure-volume curves demonstrated a statistically significantly increased intracapsular pressure in the experimental group compared with the control group. The experimental subgroup had thicker, less transparent capsules than the control group. Histologic evaluation of the rabbit capsule was similar to that of the human capsule for the control and experimental subgroups. The authors conclude that pathologic capsular contracture can be reliably induced in the rabbit. This animal model provides the framework for future investigations testing the effects of various systemic or local agents on reduction of capsular contracture.
Article
The estimation of breast implant size in both aesthetic and reconstructive surgery often is a matter of clinical and intraoperative trial and error, with subsequent differences in the resulting postoperative outcomes. Numerous techniques for preoperative estimation of implant size are in current use. However, although such techniques are inexpensive, they often are inaccurate and prone to error on the part of both the surgeon and the patient. Techniques for intraoperative estimation of breast implant size involve either the use of trial sizers or the surgeon's own guesswork based on the preoperative consultation. A novel technique is presented that uses commonly available surgical gauze swabs. The senior author has applied this technique in both aesthetic and reconstructive breast surgery for many years. This easily reproducible method is inexpensive and produces reliable and highly satisfactory results.
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