Aesthetic Breast Surgery Research Articles

Management of Granulomatous Mastitis Following Aesthetic Breast Surgery.

Granulomatous mastitis (GM) is not among the well-known diseases in the field of aesthetic breast surgery (ABS). The clinical presentation of GM resembles infectious diseases or malignancies, but the management of these diseases is quite different. In this study, we aimed to present the management of GM in patients who underwent ABS. In this study, patients with GM (n = 65) and patients who underwent ABS (n = 531) were evaluated. A total of six GM patients with a history of ABS were included in the study between January 1, 2010, and January 1, 2019. The data were collected retrospectively. The quantitative variables are shown as medians (minimum-maximum), and categorical variables are shown as numbers and percentages (%). Median duration of disease onset after the ABS was 16 (8-38) months. After the diagnosis of GM was obtained, all patients received steroid treatment. Median steroid treatment duration was 10 (8-20) weeks. Methotrexate was administered in two patients due to persistent breast mass and steroid side effect. Surgical excision was performed in three patients with wide excision. No patient needed further surgery such as mastectomy. Median follow-up period was 37.5 (18-70) months. This is the first study to declare GM in patients who underwent ABS. Atypical clinical presentation such as breast abscess, mass or fistula after ABS should alert the surgeon about GM. Unlike other mastitis, the primary treatment of this rare disease is steroid and immunosuppressive treatment. Insufficient knowledge about GM can lead to unnecessary surgeries or breast loss. 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 .

An Aesthetic Factor Priority List of the Female Breast in Scandinavian Subjects.

Background:There is little consensus about the relative determinative value of each individual factor in female breast aesthetics. When performing breast surgery with an aesthetic goal, certain factors will be more important than others. The purpose of this study was to make an aesthetic factor rank list to determine the relative contributions to overall breast aesthetics.Method:Volunteers were scanned using the 3-dimensional Vectra system. Ten Scandinavian plastic surgeons rated 37 subjects, using a validated scoring system with 49 scoring items. The correlation between specific aesthetic factors and overall breast aesthetic scores of the subjects were calculated using Pearson’s r, Spearman’s ρ, and Kendall’s τ.Results:A very strong correlation was found between overall breast aesthetic score and lower pole shape (0.876, P < 0.0001). This was also true for upper pole shape (0.826, P < 0.0001) and breast height (0.821, P < 0.0001). A strong correlation was found between overall breast aesthetic score and nipple position (0.733, P < 0.0001), breast size (0.644, P < 0.0001), and breast width (0.632, P < 0.0001). Factors that were only moderately correlated with aesthetic score were intermammary distance (0.496, P = 0.002), nipple size and projection (0.588, P < 0.0001), areolar diameter (0.484, P < 0.0001), and areolar shape (0.403, P < 0.0001). Perceived symmetry was a weak factor (0.363, P = 0.027).Conclusions:Aesthetic factors of the female breast can be ranked in a priority list. Shape of the lower pole and upper pole and breast height are primary factors of female breast aesthetics. These should be prioritized in any aesthetic breast surgery. Vertical dimensional factors seem to be more determinative than horizontal factors.

Cosmetic Breast Augmentation without Silicone Implants

Cosmetic Breast Augmentation without Silicone Implants Abstract. Cosmetic breast augmentation procedures without silicone implants are becoming increasingly popular. Mastopexy can be adapted to the needs of the patient and usually result in an at least optical augmentation. Lipofilling is a safe procedure in reconstructive and aesthetic breast surgery and can help to restore natural appearance, compensate volume deficiencies, and correct asymmetries, that may be congenital or a consequence of prior surgeries. Cosmetic breast augmentation of very small breasts or when aiming at higher breast volumes using lipofilling only are usually combined with procedures for tissue expansion in order to increase the take rate of the injected fat. Hyaluronic acid injections is no valid alternative and are not recommended for cosmetic breast augmentation.

146 Poster - A Randomised Controlled Trial (RCT) of 3-dimensional simulation of the aesthetic outcome of Breast Conserving Treatment (BCT)

Introduction: Almost two thirds of women with surgically-managed breast cancer in the UK undergo BCT. Standard practice is to describe likely aesthetic changes. Photographs are shown prior to reconstructive surgery or more complex oncoplastic procedures. Patients have expressed the desire for more information about likely appearance after surgery. Simulation of a patients’ individual aesthetic outcome has been used in aesthetic breast and facial surgery. We hypothesise that viewing a personalised 3D simulation improves patients’ preparedness for surgery.

Refining aesthetic approaches to tuberous breast using combined minimally invasive approaches to treat moderate asymmetric tuberous breast

Tuberous breast deformity refers to a deformity of the breast that is characterized by varying degree of herniation of the breast parenchyma, widened nipple areolar complex, constriction of the breast base and may involve some degree of hypoplasia. Tuberous breast deformity is most often seen in young women who commonly presents due to dissatisfaction with breast symmetry, as this can be a source of significant psychosocial distress. Principles of reconstruction are focused on recreating an aesthetically pleasing breast shape and achieving symmetrization. Traditionally, reconstruction commonly involved utilization of breast implants or local flap to achieve these goals. The introduction of fat transfer has led to a paradigm shift in aesthetic breast surgery. Fat grafting is safe and can reliably achieve satisfactory aesthetic results in selected cases and reduces the need for implants or local flaps. Concepts that reduce scar burden allows for even more satisfactory aesthetic outcomes.

Funnel usefulness in direct-to-implant breast reconstruction using periareolar incision with prepectoral implant placement and complete coverage with acellular dermal matrix

The funnel has been used in esthetic breast surgery that requires a small incision. Recent advances in minimally invasive surgical techniques have led to more cases of nipple-sparing mastectomy (NSM) through periareolar incision. However, prepectoral implant placement and complete coverage with acellular dermal matrix (ADM) is almost impossible with the periareolar approach. Funnels can also be useful for direct-to-implant breast reconstruction. NSM with periareolar incision and direct-to-implant breast reconstruction were performed with prepectoral implant placement between January 2017 and July 2019. The ADM full-wrapped anatomic textured implant was inserted using a funnel without additional incisions during surgery. A total of 21 patients were enrolled, including 2 who received bilateral breast reconstruction. All operations were successfully performed using funnels with minimal periareolar incisions. Anatomic textured implants (mean: 251.7 cc, range: 90-450 cc) wrapped in ADM can be effectively inserted in the prepectoral plane using a funnel. Two patients experienced delayed wound healing of the areola that was treated by conservative wound management. Patients also experienced less pain overall, and the cosmetic result was very good. Patient satisfaction scores were also very high. While the periareolar incision is esthetically pleasing, additional resection is often necessary. However, the use of funnels ensured that no additional incision was needed even in large implants. This subsequently led to better results in terms of pain and scarring. Prepectoral breast reconstruction involving complete implant coverage with ADM using a funnel through the periareolar approach represents a good alternative to the traditional dual plane subpectoral method. This method provides good patient satisfaction without adverse outcomes.

Visual Breast Asymmetry Assessment with Optical-Flow Algorithm.

Breast surgery is one of the most important procedures in cosmetic and reconstructive surgery. However, there is no ideal method to assess results. One of the greatest difficulties is the subjective aspect of evaluation. In recent years, several objective computer systems have been proposed and validated as assessment methods, such as BCCT®, OBCS®, GBAI©, etc. In this study, we propose a novel system named VIBA©, that uses an Optical Flow (OF) algorithm which objectively classifies results into symmetrical and asymmetrical categories, with a numerical score. Software was developed in MATLAB (MATLAB and Statistics Toolbox Release 2018b, The MathWorks, Inc., Natick, Massachusetts, USA) called VIBA-Calc© (VIBA stands for VIsual Breast Asymmetry). We compared our OF score with the well-established asymmetry scoring system called Objective Breast Cosmesis Scale (OBCS®). In order to do so, we studied 100 frontal photographs of patients who underwent aesthetic breast surgery between 2017 and 2018, from the senior author's private practice. VIBA-Calc© allows the user to load an image and then draw a rectangle containing both breasts. By simply clicking on a button, the program finds the midline of the rectangle and calculates the final score, as well as the color map of asymmetric regions. Classification into symmetric or asymmetric categories using OBCS and VIBA scores agreed in most cases. Concordance between both classification systems was almost perfect in the group of postoperative cases (k = 0.84; p < 0.001), and substantial in preoperative cases (k = 0.76; p < 0.001). Global Cohen's kappa coefficient was 0.80 (p < 0.001). VIBA© is a useful tool for pre- and post-operative evaluation of breasts, that could be used both in reconstructive and aesthetic surgery.

Simultaneous Augmentation Mammoplasty and Vacuum-Assisted Breast Biopsy for Enhanced Cosmesis and Efficacy.

In this era of expanding life expectancy and popularity of aesthetic breast surgeries, more women are likely to live more years with their augmented breasts. Thus, consistent attention to general breast health is crucial, and preoperative ultrasound is helpful to locate suspicious lesions. In this study, we present a combinative procedure of augmentation mammoplasty and vacuum-assisted breast biopsy (VABB). From January of 2018 to December of 2019, a total of 102 patients received simultaneous augmentation mammoplasty and VABB in our institute. Only patients of primary augmentation mammoplasty who received VABB on unilateral breasts were included. We sought to investigate the results of each breast and safety of adding VABB before performing augmentation within the same incision. Among 204 breasts and implants, 28.43% were done via endoscopic transaxillary approach and 71.57% via inframammary approach. The mean implant volume was 329.34 ± 44.79ml, and the mean follow-up period was 14.23 ± 4.64months. All of the complication rates exhibited no statistically significant differences between the two groups. Simultaneous augmentation mammoplasty and VABB prevented unnecessary scars and pain, and the complication rates did not statistically differ from those of augmentation only group. This co-operation is a safe and simple method potentially beneficial to many women interested in breast 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 .

Preliminary Outcomes of Hypochlorous Acid as an Adjunct for Pocket Irrigation in Revision Aesthetic Breast Surgery.

Capsular contracture is a challenging problem for plastic surgeons despite advances in surgical technique. Breast pocket irrigation decreases bacterial bioburden. Studies have shown that hypochlorous acid (HOCl; PhaseOne Health, Nashville, TN) effectively penetrates and disrupts biofilms; however, there are limited clinical data regarding this irrigation in breast augmentation. The aim of this study was to investigate the effects of HOCl pocket irrigation in revision breast augmentation by evaluating rates of capsular contracture recurrence, infection, and allergic reactions. We performed an institutional review board-approved retrospective chart review of revision breast augmentation cases for Baker grade III/IV capsular contractures in which pockets were irrigated with HOCl. Data were obtained from 3 board-certified plastic surgeons. The study included 135 breasts in 71 patients, who ranged in age from 27 to 77 years (mean, 53.7 years). Follow-up ranged from 12 to 41 months (mean, 20.2 months). Postoperatively, there were 2 unilateral Baker grade III/IV recurrences at 13 months and 1 bilateral Baker grade II recurrence at 3 months. There were no infections or allergic reactions. The overall Baker grade III/IV capsular contracture recurrence rate was 0% at 12 months and 1.5% at 15 months. Breast pocket irrigation decreases bioburden, which may influence capsular contracture recurrence. We evaluated 3 varied applications of HOCl in revision aesthetic breast surgery and found a low capsular contracture recurrence rate and no adverse reactions. We plan to report our findings with HOCl in primary breast augmentation in the future, and other studies are being conducted on the efficacy of HOCl in aesthetic surgery.

Determinants of surgeon choice in cases of suspected implant rupture following mastectomy or aesthetic breast surgery: Clinical implications.

Implant ruptures may be diagnosed by physical examination, ultrasound (US), and magnetic resonance imaging (MRI). The absence of standard guidelines to approach to implant ruptures may cause unnecessary surgical revisions in the absence of radiological confirmation of prosthetic damages.The purpose of this study was to analyze the diagnostic procedures applied to patients with suspected prosthetic rupture and surgeon choices to perform a revision or to plan a clinical and radiological follow-up.We conducted a retrospective study on 62 women submitted to revision surgery due to radiological diagnosis of suspected implant rupture, following mastectomy or aesthetic reconstruction, and admitted to a Plastic Surgery Department between 2008 and 2018.Seventy-three implants, believed to be ruptured, were explanted. One-third of these were intact and unnecessarily explanted. US associated with MRI evaluation resulted in the most helpful diagnostical method.A standardized clinical and radiological approach is essential to manage breast implant ruptures successfully. An innovative protocol is proposed in order to: ensure the appropriate management of implant ruptures and prevent unnecessary surgical revisions; reduce the risk of claims for medical malpractice in cases of unsatisfactory final aesthetic results or worse than before.

Use of Symmetry Assessment Methods in the Context of Breast Surgery.

Different procedures are available to help clinicians evaluate symmetry and cosmetic results in an objective manner after conservative breast cancer surgery. However, there are no similar methods in esthetic breast surgery, where the subjective assessment of the surgeon or the patient is usually considered the gold standard. The aim of this study is to evaluate the application of four software programs in the context of esthetic breast surgery and contrast their results with those of the subjective evaluation by a series of healthcare professionals. Sixty cosmetic breast surgery images were studied using four software programs considered appropriate for the objective evaluation (BCCT3.core®, Breast Analyzing Tool®, Objective Breast Cosmesis Scale® and GBAI-Global Breast Asymmetry Index®). The same cases were assessed by a group of 100 health professionals through an online survey as a subjective evaluation method. Concordance among participants was high (κ = 0.753) as well as between three of the objective methods (BSI, OBCS, GBAI), but not with the BCCT parameter. There was no association between objective and subjective methods studied by the survey, according to the logistic regression model. The "symmetry" and "asymmetry" categories were accurately distinguished by the objective methods. Objective evaluation in esthetic breast surgery has less variability than subjective assessment, and the estimation is possible through certain software previously restricted to conservative breast cancer 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 .

Application of Fat Grafting in Cosmetic Breast Surgery.

The role of fat grafting to the breasts has evolved in the recent past, gaining several new applications within both reconstructive and aesthetic surgery. Initially used for reconstructive purposes to fill lumpectomy defects or to correct residual contour deformities after breast reconstruction, it has since made its way into cosmetic breast surgery and has grown to encompass a wide variety of new indications. Fat grafting in aesthetic breast surgery may be performed as a form of primary autologous breast augmentation or as an adjunct to implant-based breast augmentation to disguise implant edges. It may also be used to provide added volume after explant surgery or to provide improvements in breast contour alongside mastopexy techniques. In this article, we will review the current applications of fat grafting in aesthetic breast surgery and provide an up-to-date summary of its reported outcomes, safety, and complications.

Siliconosis: an unknown entity in aesthetic breast surgery

Background: Siliconosis was first described in the late 1980s and it is still remaining as a rare condition and mainly as a diagnosis of exclusion after breast cancer investigation. There are only limited cases reported and published with even smaller amount related to the breast implants (31 studies and 8 related to breast implants found in PubMed search in December 2019). Case presentation: Authors present the case of siliconosis secondary to bilateral cosmetic breast augmentation performed back in 1989. The patient was troubled with a myriad of complications and underwent an exchange of implants with Trilucent™ implants in 1997 and their subsequent removal in 1998. Later, they underwent bilateral mastopexy and is currently free of implants. Ever-since the first operation patient complained of pain, localized tenderness, swelling, axillary fullness, paraesthesia and partial paralysis in her upper limbs amongst other symptoms. Objective investigations including plain radiographs, USS, CT, MRI, nerve conduction studies, rheumatological screen yielded essentially negative results. Thoroughly investigation for breast cancer was conducted, including several operations and biopsies of axillary swellings with confirming reactive lymphadenopathy. A working diagnosis of siliconosis has been made and the patient was treated expectantly. Conclusion: This case should remind our colleagues of the ethical and professional responsibilities we have toward our patients in explaining all the potential risks involved in breast augmentation and also to keep an open mind when meeting patients complaining of systemic symptoms post breast augmentation.

Recommendations for the Use of Antibiotics in Primary and Secondary Esthetic Breast Surgery.

Summary:The use of systemic prophylactic antibiotics to reduce surgical-site infection in esthetic breast surgery remains controversial, although the majority of surgeons prefer to utilize antibiotics to prevent infection. Nonetheless, postoperative acute and subclinical infection and capsular fibrosis are among the most common complications following implant-based breast reconstruction. After esthetic breast augmentation, up to 2.9% of women develop infection, with an incidence rate of 1.7% for acute infections and 0.8% for late infections. After postmastectomy reconstruction (secondary reconstruction), the rates are even higher. The microorganisms seen in acute infections are Gram-positive, whereas subclinical late infections involving microorganisms are typically Gram-negative and from normal skin flora with low virulence. In primary implantation, a weight-based dosing of cefazolin is adequate, an extra duration of antibiotic cover does not provide further reduction in superficial or periprosthetic infections. Clindamycin and vancomycin are recommended alternative for patients with β-lactam allergies. The spectrum of microorganism found in late infections varies (Gram-positive and Gram-negative), and the antibiotic prophylaxis (fluoroquinolones) should be extended by vancomycin and according to the antibiogram when replacing implants and in secondary breast reconstruction, to target microorganisms associated with capsular contracture. All preoperative antibiotics should be administered <60 minutes before incision to guarantee high serum levels during surgical procedure.

Valid BREAST-Q questionnaire for analysis of the outcomes in aesthetic breast surgery

Valid BREAST-Q questionnaire for analysis of the outcomes in aesthetic breast surgery

International Expert Panel Consensus on Fat Grafting of the Breast.

Autologous fat grafting has broad applications in reconstructive and aesthetic breast surgery as a natural filler and for its regenerative purposes. Despite the widespread use of fat grafting, there remains no shared consensus on what constitutes the optimal fat grafting technique and its oncological safety. For this reason, the authors of this study have organized a Survey and an International Consensus Conference that was held at the Aesthetic Breast Meeting in Milan (December 15, 2018). All studies on fat grafting, both for breast aesthetic and reconstructive purposes, were electronically screened. The literature review led to 17 "key questions" that were used for the Survey. The authors prepared a set of 10 "key statements" that have been discussed in a dedicated face-to-face session during the meeting. The 10 key statements addressed all the most debated topics on fat grafting of the breast. Levels of evidence for the key statements ranged from III to IV with 2 statements (20%) supported by a level of evidence III and 6 statements (60%) by level of evidence IV. Overall consensus was reached for 2 statements (20%) with >75% agreement reached for 7 statements. The survey demonstrated a diversity of opinion and attitude among the panelists with regard to technique. Clear recommendations for evidence-based clinical practice for fat grafting use both in aesthetic and reconstructive breast surgery could not be defined due to the scarcity of level 1 or 2 studies.

Aesthetic Breast Surgery: What Do the Measurements Reveal?

Do plastic surgeons really know what happens to the breast after surgery? We often think that we do, but we have very few measurements to show whether we are on the right track. Only when the surgeon can predict the changes can she or he achieve consistent outcomes. Measurements lead to understanding; understanding what the measurements show allows us to refine our approach. Consecutive patients in 4 categories were analyzed: breast reduction, mastopexy, augmentation, and mastopexy-augmentation. All procedures were performed by a single surgeon and all measurements were performed by the same surgeon. A standard measuring tape was utilized, and data were collected immediately preoperatively and at each follow-up visit. Only those patients with preoperative and complete 1-year postoperative measurements were included in this review. The parameters measured were clavicle to upper breast border (UBB), UBB to nipple, suprasternal notch (SSN) to nipple, SSN to inframammary fold (IMF), and chest midline to nipple. The changes were consistent. The borders of the breast footprint were expanded with the addition of an implant (UBB and IMF) and reduced with the removal of parenchyma (IMF). The existing SSN to nipple position was stretched when volume was added to the breast mound and it remained unchanged from the preoperatively marked position in a breast reduction. Although measurements are not necessary to achieve good aesthetic results in breast surgery, surgeons should understand what the measurements show and what happens to the different breast parameters.

Optimal assessment tools in assessing breast surgery: patient reported outcome measures (PROMs) vs. objective measures.

Improving the health-related quality of life (HRQoL) of patients is the fundamental aim of aesthetic breast surgery and its importance is increasingly recognised in breast cancer-related surgery. There has been growing acceptance of the value of assessing physical, psychological and social well-being through patient reported outcome measures (PROMs). It is important to consider the role of PROMs in relation to objective measures to ensure that the optimal assessment tools are selected when assessing outcomes in breast surgery. A narrative review was conducted of published articles identified on Ovid Medline by searching the terms: patient reported outcome measures, quality of life (QoL), functional outcomes, aesthetic outcomes, complications and breast surgery. Reference lists were also examined to find relevant articles not detected through the search. Survival and mortality are outcomes of immense importance in breast surgery that are not suitable for assessment through PROMs and should be measured objectively. Post-operative complication rates and markers of their severity are most appropriately assessed using objective measures, however, patients may provide valuable insights into the impact complications have on their QoL. All current assessment tools for assessing aesthetic outcome have inherent limitations, and thus it is likely that both subjective and objective measures are required to comprehensively assess aesthetic outcomes in breast surgery. Physical dysfunction can be assessed objectively, however, PROMs may better evaluate physical well-being, reflecting the real-life implications of a change in function. Psychological and social well-being is irrefutably personal in nature and best assessed through PROMs. There is no one optimal assessment tool for assessing breast surgery outcomes. Utilising a combination of PROMs and objective measures is necessary to accurately and comprehensively evaluate the impact and effectiveness of surgical breast interventions.

Maximizing Aesthetics and Patient Selection Utilizing Natrelle Inspira Line Implants in Aesthetic Breast Surgery

Aesthetic breast augmentation has recently experienced a significant boom in options available to achieve an ideal outcome. Evolving prosthetic device technology has now brought an array of implant gels, implant shells, and fill ratios to customize shape, composition/fill, and feel of the augmented breast. With the vast portfolio of currently available implants, surgeons now have a greater ability to produce tailored and desired outcomes. The Natrelle Inspira line of breast implants by Allergan Medical is a comprehensive portfolio of implants starting with the Responsive series with the softest gel, the SoftTouch series, and the fully Cohesive series. These options allow surgeons to help tailor and create the breast that patients desire.

Outcomes Utilizing Inspira Implants in Primary Aesthetic and Reconstructive Surgery

The evolution of silicone implants has included advances in both gel and shell technology to improve the clinical outcomes of the implants. The newest generation of implants includes implants with thick, strong shells and highly cohesive gel fill. These advancements allow for better maintenance of implant form and shape over time and improved implant safety. The Natrelle Inspira product line offers 3 different levels of gel cohesivity in a range of profiles to provide a wide variety of options for use in both breast augmentation and postmastectomy breast reconstruction. This article will review the use of Inspira implants in primary aesthetic and reconstructive breast surgery.