Reply: Do High-Projection Shaped Breast Implants Offer An Effective Alternative to Augmentation/Mastopexy?

Abstract

We appreciate Dr. Swanson’s letter regarding our article, “Breast Augmentation with Microtextured Anatomical Implants in 653 Women: Indications and Risk of Rotation.”1 We agree with Dr. Swanson that breast augmentation with high-projection anatomical implants cannot replace the mastopexy procedure. It would be wrong to offer a breast augmentation without a mastopexy to patients with severe ptosis who wish a substantial lift of the nipple-areola complex. However, we do believe that breast augmentation with anatomical implants is a valuable alternative to augmentation-mastopexy in a subgroup of women with glandular ptosis and a low position of the nipple-areola complex. These patients can benefit from smaller scars, less extensive surgery without the risk of nipple necrosis,2,3 and a lower cost but at the expense of lowering the inframammary fold.4 We attribute the benefit of anatomical implants in this selected group of patients with a low position of the nipple-areola complex to the shorter arch from the lower pole of the implant to the point of maximum projection compared with round implants, which limits the lowering of the inframammary fold.5 Our study is limited by the retrospective design with the lack of a standardized measurement tool, but it is strengthened by the large sample size, and it provides the readers with data on the reoperation rate due to malrotation of the implant. Dr. Swanson correctly states that our discussion of the beneficial properties of anatomical implants is based on first principles. We thank Dr. Swanson for adding the horizontal line to Figure 3 from the original article, as we think it illustrates the elevation of the nipple very well. On the left preoperative photograph, the line tangent is on the nipples’ superior border, whereas the line tangent is on the nipples’ inferior border on the right postoperative photograph. More importantly, there is less slack and more “breast” below the level of the nipple even though this comes at the expense of lowering the inframammary fold. We hypothesize that this type of patient is better treated with anatomical implants than with round implants if the augmentation is not accompanied by a mastopexy. However, this hypothesis needs to be tested against a control group before a firmer conclusion can be made. Regarding the implant rotation rate, we used the rate of reoperation, which was free of charge for the patients. We did not use diagnostic imaging to detect implant rotation because of the retrospective design of our study. We found an approximately 3 percent rotation rate requiring reoperation for microtextured implants, which is comparable to the incidence reported in the literature for macrotextured implants.1,6–8 As Dr. Swanson points out, this rate is almost certainly an underestimation as some patients might not detect a malrotation or may not want to go through revisional surgery even though this is free of charge. Sieber et al.9 reported a rotation rate of 42 percent when using high-resolution ultrasound but only 5 percent were clinically detectable. This vast difference between the imaging and the clinically observable malrotation makes it arguably more clinically relevant for both surgeons and patients to use the rate of clinically observable malrotation or the reoperation rate, when considering anatomical implants. We agree with Dr. Swanson that since the submission of our manuscript there have been more reported cases of breast implant–associated anaplastic large-cell lymphoma and the link to macrotextured implants is stronger.10 However, the current risk estimates are still very uncertain due to the low number of cases and the poorly reported medical history of each case.11 In our experience, patients are tolerant to the low risk of breast implant–associated anaplastic large-cell lymphoma associated with Siltex (Mentor, Irvine, Calif.) texturization, and most of the patients in our clinic prefer round Siltex implants over round smooth implants. In conclusion, we agree with Dr. Swanson that, as we mentioned in the Discussion section of our article, breast augmentation with high-profile anatomical implants cannot replace augmentation-mastopexy. We agree that women who emphasize lifting the nipple should be offered an augmentation-mastopexy. However, we suggest breast augmentation with high-projection anatomical implants is a valuable alternative to augmentation-mastopexy in a selected group of women with glandular ptosis who prefer a lowering of the inframammary fold over the scars that accompany a mastopexy. DISCLOSURE The authors have no financial interest in any of the products or devices mentioned in this communication. Tim K. Weltz, B.M.Sc.Andreas Larsen, M.D.Mathilde N. Hemmingsen, M.D.Mathias Ørholt, M.D.Louise E. Rasmussen, B.M.Sc.Department of Plastic Surgery and Burns TreatmentCopenhagen University HospitalRigshospitalet Peter S. Andersen, M.D.Faye Sarmady, M.D.Department of Plastic Surgery and Burns TreatmentCopenhagen University HospitalRigshospitaletAmalieklinikken Jens J. Elberg, M.D.Amalieklinikken Peter V. Vester-Glowinski, M.D., Ph.D.Department of Plastic Surgery and Burns TreatmentCopenhagen University HospitalRigshospitalet Mikkel Herly, M.D.Department of Plastic Surgery and Burns TreatmentCopenhagen University Hospital RigshospitaletDepartment of Immunology and MicrobiologyFaculty of Health SciencesUniversity of CopenhagenCopenhagen, Denmark