Submuscular Augmentation Research Articles

Local Infiltration Anesthesia Versus Ultrasound-Guided Pectoralis (PEC1) + Serratus Anterior Plane (SAP) Blocks on Postanesthetic Care Unit Pain Control in Patients Undergoing Primary Submuscular Augmentation Mammoplasty

Background Ultrasound-guided regional field blocks are not widely used in outpatient plastic surgeries. The efficacy of truncal blocks (PEC1 + SAP) has not been established in plastic surgery. The purpose of this study was to analyze the outcomes of these newer anesthetic techniques compared with traditional blind local anesthetic infiltration in patients undergoing breast augmentation. Methods This retrospective institutional review board-approved cohort study compared the outcomes of the different practices of 2 plastic surgeons at the same accredited outpatient surgery center between 2018 and 2022. Group 1 received an intraoperative blind local infiltration anesthetic. Group 2 underwent surgeon-led, intraoperative, ultrasound-guided PEC1 (Pectoralis 1) + SAP (serratus anterior plane) blocks. Patients who underwent any procedure other than primary submuscular augmentation mammoplasty were excluded from the study. The outcomes measured included operative time, opioid utilization in morphine milligram equivalents (MME), pain level at discharge, and time spent in the post anesthetic care unit (PACU). Results Sixty patients met the inclusion criteria for each group for a total of 120 patients. The study groups were similar to each other. Patients receiving PEC1 + SAP blocks (group 2) had significantly lower average MME requirements in the PACU (3.04 MME vs 4.52 MME, P = 0.041) and required a shorter average PACU stay (70.13 minutes vs 80.38 minutes, P = 0.008). There were no significant differences in the pain level at discharge, operative time, or implant size between the 2 groups. Conclusions Surgeon-led, intraoperative, ultrasound-guided PEC1 + SAP blocks significantly decreased opioid utilization in the PACU by 33% and patient time in the PACU by 13%, while achieving similar patient pain scores and operating times.

Quantitative assessment of the breast implant malposition after augmentation mammaplasty

Slight displacement of breast implants from initial positioning is expected and inherent in submuscular augmentation mammoplasty (SAMP). However, due to various factors, displacement of implants can progress, causing discomfort, changes in the shape of the breast, and deterioration of aesthetics. The boundary between normality and pathology in the case of displacement of the mammary glands (MG) implants is currently unclear due to various reasons, including the lack of a quantitative measure of its assessment.
 Objective — to develop a quantitative assessment of breast implant malposition (BIM) and to determine its one‑year frequency within a year after SAMP.
 Materials and methods. The study included 112 women who underwent SAMP for hypomastia in the period from 2020 to 2022 at the Bogomolets National Medical University. The average age was 34.1±6.7 years, body mass index — 20.4±1.8 kg/m2; 78 (69.6%) women had a history of pregnancy and childbirth, and 75 (67.0%) were breastfeeding. Round prostheses with a smooth surface were implanted in all patients. The value of BIM was evaluated one year after SAMP according to the developed method as a percentage of the increase in the area of the non‑ossified area in relation to the area of the prosthesis.
 Results. In all women, there was a 7.94.5% (from 1.5% to 34.5%) displacement of the implants from their initial location in all MG. Among the vectors of BIM, lower‑lateral ones prevailed — 124 (55.4%) MG compared to 53 (28.6%) upper‑lateral ones, p=0.001. Lower 18 (8.0%) and upper‑lateral at 150° — 11 (4.9%) BIM were the least common. Symmetrical matching of prosthesis movement vectors in both MGs was observed in 75 (67.0%) women; in 37 (33.0%), they were different. The same values of BIM in both MGs were observed in 54 (48.2%) women. In other cases, the values of BIM were greater in the right MG — 40 (35.7%) or in the left MG — 18 (16.1%). Cluster analysis classified the displacement of implants into 4 degrees: the first — from 1.5% to 6.4%, the second — from 6.5% to 10.4%, the third — from 10.5% to 20.0%, and the fourth >20.0%.
 Conclusions. Using smooth‑surfaced, round implants, the displacement of all implants from their initial site was shown to be 7.9±4.5% one year following SAMP.

Breast implants malposition prevention after aesthetic augmentation mammoplasty

Prevention of breast implant malposition (BIM) after submuscular augmentation mammoplasty (SAMP) for hypomastia is an actual problem, as 4.7–5.2 % of women after primary SAMP and approximately 10 % after repeated SAMP require revision surgery due to this complication. The aim. To determine the effectiveness of prevention of BIM after SAMP by choosing the implant volume depending on the physique of women. Materials and methods. In 112 women, the choice of implant volume for SAMP was carried out in accordance with the High Five approach – the comparison group (Group C), in 46 women according to the developed algorithm – the main group (Group M). The algorithm took into account the risk of BIM in women of different physique depending on the implant volume. If a woman insisted on having a larger implant than was calculated, an additional internal bra was created. One year after SAMP, the amount of BIM was assessed according to the developed methodology, according to which BIM was characterised by the percentage increase in the area of the neo-osseous in relation to the area of the prosthesis. The following categories of BIM were distinguished: absent (insignificant) 1.5 % to 6.4 %, mild – 6.5 % to 10.4 %, moderate – 10.5 % to 20.0 %, significant – more than 20 %. Women's body type was assessed by the Pignet’s Index, which distinguished three categories: strong <16, medium 16–25, and weak 26–35. In group M, the maximum possible implant volume with a low risk of BIM was considered to be for women with a weak physique – 360 ml, medium – 430 ml, strong – 650 ml. Results The mean percentage of BIM was significantly lower in group M (7.2±1.8 %) compared to group C (9.1±6.1 %), p=0.036. At the same time, the incidence of significant BIM significantly decreased from 18 (16.1 %) in group C to 2 (4.3 %) in group M, p=0.044. Moreover, patients in group M had BIM that could be classified as moderate, while in group P, 9 (50 %) women had moderate and 9 significant BIM. In the case of additional creation of an internal bra, there was no significant BIM in any case, the average value of this indicator was 6.3±1.6 % (no or mild BIM). Conclusion. The developed personalised approach to the choice of implant volume, taking into account the physique of women, significantly improves the results of SAMP and prevents significant BIM

The Outcomes of Local Infiltration Anesthesia vs Ultrasound-guided Pectoralis (PEC1) + Serratus Anterior Plane (SAP) Blocks on Post Anesthetic Care Unit (PACU) Pain Control in Patients Undergoing Primary Submuscular Augmentation Mammoplasty

The Outcomes of Local Infiltration Anesthesia vs Ultrasound-guided Pectoralis (PEC1) + Serratus Anterior Plane (SAP) Blocks on Post Anesthetic Care Unit (PACU) Pain Control in Patients Undergoing Primary Submuscular Augmentation Mammoplasty

Breast Augmentation in Athletic Women: A Retrospective Survey Assessing Pectoral Muscle Function and Implant Aesthetics Post-Augmentation.

Breast augmentation is the most common cosmetic, surgical procedure (1). Implant insertion planes include subglandular or submuscular. Submuscular augmentation is often preferred in women with less soft tissue coverage; requiring pectoralis major dissection (2). However, loss of functional muscle fibres is undesirable in athletic women who actively train the pectoral region. 1. Assessment of pectoralis function and strength after breast augmentation in athletic women. 2. Augmentation aesthetical satisfaction at rest and whilst training. A retrospective survey was sent to female, fitness competitors with breast implants via social media over a six-month period. The survey assessed baseline demographics, pectoral strength (bench press, push-ups, pectoral fly), aesthetical satisfaction and issues during training including pain, rippling, firmness and implant movement. Eighty-one participants were surveyed. The mean age of augmentation was 29.7 (±8.41), and mean age of survey completion was 37.6 (±7.22) years. Submuscular augmentation was performed in 72.8% of participants. Recovery post-operative and time spent training was synonymous. The majority of participants' pectoral strength was unaffected or positively affected by breast augmentation. Assessment of post-operative performance and training issues of pain, rippling and firmness yielded no statistically significant difference between groups. Implant movement during pectoral exercises was 2.5 times more likely with submuscular augmentations, p= 0.038. Overall, the majority of the population were very satisfied or satisfied with their breast aesthetic at rest (92.6%) and during training (79.0%). Breast augmentation in athletic women has a high satisfaction rate with the majority maintaining or improving the strength of the pectoral region regardless of augmentation plane. 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 https://www.springer.com/journal/00266 .

Split Inferior Pedicle: The 1-Stage Augmentation Mastopexy for Grade 3 Ptosis.

In this article, the authors describe the 1-stage surgical technique that has been used by the senior author since 1990 for all his primary grade 2 and grade 3 augmentation-mastopexies. The article provides a safe, simple, and reproducible approach to a challenging procedure, one that tends to be the most litigious in aesthetic breast surgery. The key points of this technique are simple preoperative markings; the augmentation is performed with a true submuscular placement of smooth implants; and the mastopexy is performed with an inferior pedicle technique with unlimited skin flap undermining and no limitation of nipple elevation. Seventy-eight consecutive cases of augmentation mastopexy performed since 1999 by a single surgeon (V.S.) using the same technique were reviewed. The age range was 26-62 years old; the range of implant volume was 150-375 cc; and the follow-up time period was from 1 year to 22 years. After an extensive patient case review, the authors enforce true extended submuscular augmentation (TESMA) as a reliable augmentation technique that can be used as the first procedure in any grades 2 and 3 ptosis, 1-stage augmentation-mastopexies including bariatric cases. The authors believe that the split inferior pedicle for the mastopexy in combination with the TESMA is a breakthrough approach that eliminates the second stage for any augmentation mastopexy procedure. No major complications such as nipple necrosis, implant bottoming, malpositioning, or extrusions were observed. It is a safe, simple, and reproducible procedure. Level of Evidence: 4

Endoscopic transaxillary capsulectomy with immediate reimplantation performed as a single-operator outpatient procedure

Capsulectomy is a standard treatment for capsular contracture after breast augmentation. Incision via the endoscopic transaxillary approach is generally preferred by Asian women, but relevant literature addressing endoscopic transaxillary capsulectomy is limited. This study described the techniques of endoscopic transaxillary capsulectomy with reimplantation performed as a single-operator outpatient procedure. This retrospective study included patients with diagnosis of capsular contracture underwent endoscopic transaxillary capsulectomy with immediate reimplantation between January 1, 2013 and December 31, 2017. Data regarding history, implant type, operation time, duration of postoperative drainage, and complications were collected and analyzed. A total of 42 patients with a mean age of 36 years were included (11 unilateral and 31 bilateral capsulectomy). Total capsulectomy was performed on four (10%) patients for previous subglandular augmentation, and anterior capsulectomy was performed on 38 (91%) patients for previous submuscular augmentation. Mean sizes of previous and new (or reused) implants were 268 ml (median 283 ml, SD 57) and 317 ml (median 307 ml, SD 49), respectively. Mean operation time for unilateral and bilateral procedures were 4h 15min and 6h 28min, respectively. Postoperatively, mean duration of wound drainage was 10 (SD 3) days. Six (14%) patients experienced complications, including two (5%) patients with seroma, two (5%) with hematoma, one (2%) with infection, and four (10%) with recurrent capsular contracture. The four recurrent cases underwent repeat endoscopic transaxillary capsulectomy. All of the 42 patients had satisfactory clinical and esthetic outcomes. This study demonstrated the feasibility of endoscopic transaxillary capsulectomy with immediate reimplantation performed as an ambulatory surgery by a single surgeon who is in a stable and comfortable sitting position without the aid of a surgical assistant.

Augmentation mammoplasty for breast volume asymmetry

The aim — to evaluate the submuscular augmentation mammoplasty long‑term results in women with relative breast volume asymmetry with identical and different size implants.Materials and methods. The study included 102 women with breast volume asymmetry, in whom the submuscular augmentation mammoplasty was performed in the period from 2012 to 2017 in the Clinic of Plastic Cosmetic Surgery. In the comparison group (n = 49), breast implants of different volume were installed, in the main group (n = 53) — the same volume calculated with developed nomogram and formula. In all cases, anatomical implants were installed. Women in both groups were representative by age, pregnancy rate, breastfeeding, absolute volumetric asymmetry of the breast (in the comparison group — 133.8 ± 3.9 ml (from 78 to 244 ml), in the main group — 134.8 ± 4.2 ml (from 79 to 206 ml), p = 0.907) and relative volumetric asymmetry of the breast (relative breast volume asymmetry) (32.2 ± 0.6 % (from 21.0 to 47.7 %) and (31.9 ± 0.7 % (from 21.4 % to 44.1 %), respectively, p = 0.925). Evaluation of the relative breast volume asymmetry was carried out in 12 — 15 months. According to previously obtained data, the value of relative breast volume asymmetry from 1.1 to 25.4 % can be considered the population norm, from 19.3 to 25.4 % — the upper limit of the norm. In the same period, the presence of such complications as caudal prosthesis migration, breast fluid ptosis, in particular asymmetric ptosis, contouring of the prosthesis were determined. The analysis of the obtained data was performed using descriptive statistics, the comparison of the mean values of the variables was carried out with the Mann — Whitney U‑test, the comparison of the shares of the variables was performed with the χ2‑Pearson test.Results and discussion. The average values of absolute breast volume asymmetry and relative breast volume asymmetry in the comparison group decreased significantly compared with the preoperative values and amounted to 76.7 ± 2.5 ml and 10.9 ± 0.3 %, all p < 0.01 after the submuscular augmentation mammoplasty. The absolute breast volume asymmetry in the main group was not statistically significantly changed (130.8 ± 3.5 ml, p < 0.05), while the value of relative breast volume asymmetry has significantly decreased (15.5 ± 0.3 %, p < 0, 01) and was within the population norm. By mean values, the indices of absolute and relative breast volume asymmetry in the main group were statistically significantly higher compared with those in the comparison group (p < 0.05). Aesthetic complications occurred in 33 (32.4 %) women: in 17 (34.7 %) in the control group and in 16 (30.2 %) in the main group: one complication in 11 (22.4 %) women in the comparison group and 12 (22.6 %) in the main group, two complications respectively in 5 (10.2 %) and 4 (7.5 %), three complications in 1 (2, 0 %) women in the comparison group (p = 0.714) in 12 — 15 months after submuscular augmentation mammoplasty. The groups did not statistically significantly differ in the incidence of complications such as caudal implant migration (p = 0.453), contour implant contouring (p = 0.638) and breast ptosis (p = 0.330), but in women in the comparison group, asymmetrical ptosis occurred with a statistically significantly higher frequency (in 8 (16.3 %) versus 1 (1.9 %) in the main group, p = 0.019). These women, despite the elimination of the volumetric asymmetry of the breast, considered the result of the operation unsatisfactory.Results and discussion. The technique of breast volume asymmetry correction with submuscular augmentation mammoplasty using identical prostheses, the volume of which is calculated according to the developed method, makes it possible to reduce the relative breast volume asymmetry value to the limits of the norm and, unlike the use of prostheses of various sizes, is associated with a statistically significantly lower frequency of breast asymmetric ptosis 2 — 3rd degree in the postoperative period.Key words: breast volume asymmetry; submuscular augmentation mammoplasty; treatment.

Effects of Silicone Implants on the Mammary Gland: Ultrasonographic and 3D Study.

Breast implants may be responsible for secondary deformities produced by parenchymal atrophy. However, few studies in the literature have reported changes in breast tissue after augmentation surgery. In this study, the breast thickness of patients undergoing breast augmentation was monitored by ultrasound, and correlations with surface, volume and projection measurements were examined. We studied the parenchymal thickness at the lower pole of the breast with ultrasound in 36 women (72 breasts). In another group of 33 patients (66 breasts), we studied the thickness at the upper and lower poles along the meridian of each breast by ultrasound and measured the anthropometric metrics, volume and projection of the breast with a 3D camera. Midline measurements close to the areola showed reduced thickness at the lower pole, with 31.8% at the midpoint of the lower pole and 42% at the infra-areolar level (p < 0.0001). At the upper pole, there was a decrease of 14.6% (p < 0.001), but the thickness was increased by 6% and 38% at more cranial levels. No correlations with volume were found. Anatomical implants produced more atrophy at the lower pole, and round implants at the upper pole. More atrophy was found with subfascial than submuscular augmentation. Compared with the expected values, the final volume was very similar, but the projection was 29% less. Surface measurements changed significantly up to 4months postoperatively and remained stable thereafter. Implants affect significatively the thickness of the glandular tissue. All changes occur very soon postoperatively but stabilize after 4months. 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 .

Correction of small volume breast asymmetry using deep parenchymal resection and identical silicone implants: an early experience.

Virtually all patients presenting for augmentation mammaplasty will exhibit some degree of asymmetry. The use of asymmetric implants to address small- volume breast asymmetry introduces uncontrolled variables into the longevity of postoperative results. We described a novel method of addressing small-volume asymmetry using deep parenchymal resection (DPR) to achieve symmetry prior to insertion of identical implants. We also compared our results with this technique to a cohort of standard augmentation mammaplasty patients. All patients underwent 3-dimensional (3D) imaging during consultation. In patients with small-volume breast asymmetry, a uniform disk of deep parenchymal tissue was resected from the base of the larger breast cone through an inframammary incision. A standard submuscular augmentation was then completed. Five patients (DPR group) with appreciable small-volume asymmetry underwent DPR in the larger breast prior to insertion of identical implants. Fifty-six consecutive patients with no appreciable volume asymmetry (standard group) underwent standard submuscular breast augmentation. Using 3D imaging preoperatively, DPR-group patients had an estimated breast volume asymmetry of 86 ± 58 g and had 55 ± 27 g excised from the larger breast intraoperatively, allowing for insertion of identical implants in each patient. Complications in the standard group included 1 case of rippling and 2 cases of malposition. One case of malposition was noted in the DPR group. No other complications were recorded in either group over 6 months. Our novel method of addressing small-volume breast asymmetry allows for the use of identical implants and presents no increase in early complications.

Immediate Permanent Implant Reconstruction Following Mastectomy With Capsule Preservation in Patients With Prior Augmentation Mammoplasty

Prior breast augmentation in patients desiring post-mastectomy reconstruction provides a unique opportunity for capsular preservation and immediate, single-step implant reconstruction. We report a case series of a single-surgeon experience with immediate implant reconstruction after skin-sparing mastectomy in patients with prior subpectoral augmentation. Final implant volumes, complications, and outcomes were examined. Twenty patients (15 bilateral, total 35 breasts) were included. Eighteen (90%) patients were treated for cancer. Mean augmentation-to-reconstruction interval was 9 years (range, 3-19 years). Mean patient age was 45.1 years (range, 37-64 years). Eight patients (40%) received postoperative chemotherapy and two (10%) radiation. Mean mastectomy weight was 321 g. Mean weight of the implants removed was 346 g. Mean volume of new implants was 487 mL. All patients underwent capsulotomy (100% superior, 85% medial, 30% inferior, 5% lateral). Mean operative time was less than 1 hour for bilateral reconstruction. With average follow-up of 25.6 months, 2 patients were re-operated on for asymmetry (implant malposition, synmastia). Thirty-day complications included 1 implant loss due to infection, 1 drain placement with implant salvage, 1 hematoma requiring evacuation, and 1 cellulitis treated with antibiotics. There were no late complications and no capsular contractures. None have required further oncologic surgery. No cancer recurrences have been detected. In patients who desire prosthetic reconstruction similar to their original submuscular augmentation, capsule preservation and implant replacement with a larger prosthetic inserted within the old capsule is safe, fast, and aesthetically pleasing without compromising oncologic principles.

Breast Augmentation for Ptosis: Effective Upward Rotation of the Nipple

Background For the correction of small ptotic breasts, augmentation mastopexy provides a better shape than other techniques, but its periareolar or vertical scar is a limiting factor. Subglandular augmentation tends to increase ptosis. Submuscular augmentation may result in a "Waterfall" deformity (double contour deformity). This report uses examples of two patients to illustrate concepts for improving breast augmentation of ptotic breasts. Methods Two patients initially underwent insertion of breast implants for ptotic breasts, using full height type of implants inserted by the type III dual plane technique. Both patients had wanted breasts that were not excessively large, but which had an improved shape and minimal scars. At nearly the same time after the initial surgery (postoperative day 3 and 7), each patient exhibited a unilateral double contour breast deformity. The initial implants were changed to shorter height implants to shift volume to the lower pole. Results Changing the implants resulted in improved breast shape by enhancing the leverage effect. The double contour deformities observed after using the taller implants were improved by changing to shorter implants. Conclusions For rotating the nipple areolar complex upward during correction of small ptotic breasts with implants, the type III dual plane technique is an effective way to produce a larger volume pocket in the lower pole of the breast. More leverage effect can be obtained by using a shorter height and greater projection type of shaped implant instead of a full height implant. Keywords: Breast, Breast implantation, Mammaplasty, Postoperative complications

Muscle-Splitting, Subglandular, and Partial Submuscular Augmentation Mammoplasties: A 12-year Retrospective Analysis of 2026 Primary Cases

Augmentation mammoplasty is a commonly performed procedure with a very high satisfaction rate. Various techniques have been described since the report of the first augmentation mammoplasty in 1963. Muscle-splitting augmentation mammoplasty, a technique first published in 2007, has been used by the author for primary and secondary augmentation mammoplasties and for mastopexy with augmentation. A retrospective analysis of data prospectively collected using the Excel spreadsheet was performed. The patients were divided into three groups. The mammoplasty for group A used the subglandular pocket. In group B, the partial submuscular pocket was used for mammoplasties. Both of these groups had their mammoplasties performed between 1999 and 2005. Group C, the third group, included patients who had muscle-splitting mammoplasties between 2005 and 2011. Group A involved 793 patients who had their augmentation mammoplasties in the subglandular pocket. Of these 793 patients, 751 had the same size implants and were included in the analysis. The mean age of the patients in group A was 30.9±7.98 years (range 18-59 years), and their mean implant size was 317.5 cc±2.05 (range 200-555). In group A, 45.1% (n=339) of the patients were smokers, and 62.2% (n=467) had drains. The majority of the patients (78%) had an overnight stay in the clinic. Hematoma was seen in 2.7% (n=20) of the group A patients. Revision was performed for 6% (n=45). Periprosthetic infection was seen in 0.4% (n=3) and minor wound healing problems in 1.3% (n=10). Group B comprised 110 patients who had mammoplasties performed in partial submuscular pockets. All the patients had the same size implants. The mean age of the group B patients was 33±8.26 years (range 20-58 years), and their mean implant size was 300.6 cc±35.92 (range 205-395). Of these 110 patients, 51.8% (n=57) were smokers, and 94.5% (n=104) had drains. Hematoma was seen in 1.8% (n=2), and revision was performed for 7.3% (n=8) in the submuscular subgroup. Infection was seen in 3.6% (n=4) and minor wound healing problems in 4.5% (n=5). Group C consisted of 1,123 patients who had breast augmentation in the muscle-splitting biplane. Of these 1,123 patients, 914 had the same size implants. The mean age of the patients was 30.0±8.78 years (range 18-67 years), and their mean implant size was 338.2 cc±58.01 (range 170-655). In group C, 33.6% of the patients were smokers, and 8 % had drains. The majority of the patients (93.4%) were treated as day cases. Hematoma was seen in 0.7%, and 1.2% of the patients had revision surgery. Infection was seen in 1.6% (n=15) and minor wound healing in 4% (n=45). Muscle-splitting mammoplasty is a technique that can be performed as a day case without drains. The overall complications in the group were significantly lower than with the other two techniques performed by the author. This journal requires that authors assign a 41 level of evidence to each article. For a full description of 42 these Evidence-Based Medicine ratings, please refer to the 43 Table of Contents or the online Instructions to Authors 44 http://www.springer.com/00266 .

Evaluation, Comparison, and Analysis of Postoperative Injury between Submuscular and Retroglandular Augmentation Mammaplasty

Evaluation, Comparison, and Analysis of Postoperative Injury between Submuscular and Retroglandular Augmentation Mammaplasty

The Efficacy and Safety of DepoFoam Bupivacaine in Patients Undergoing Bilateral, Cosmetic, Submuscular Augmentation Mammaplasty: A Randomized, Double-Blind, Active-Control Study

Breast augmentation can result in significant postsurgical pain. The authors evaluate the extent and duration of analgesia achieved with extended-release DepoFoam bupivacaine (Pacira Pharmaceuticals, Inc., Parsippany, New Jersey) in patients undergoing bilateral, cosmetic, submuscular augmentation mammaplasty under general anesthesia. In this randomized, multicenter, double-blind study, patients received a single dose of DepoFoam bupivacaine 600 mg or bupivacaine HCl 200 mg divided into the implant pockets at the conclusion of surgery. The primary efficacy measure was cumulative pain score with activity through 72 hours postoperatively. Secondary efficacy measures included pain intensity with activity and at rest, postsurgical consumption of rescue opioids, and integrated rank analysis combining pain scores at rest with the amount of opioid used. One hundred thirty-six patients were randomized and treated (DepoFoam bupivacaine, n = 66; bupivacaine HCl, n = 70). Reflecting the underpowered nature of the study, the mean cumulative pain score (numeric rating scale with activity through 72 hours) was 441.5 with DepoFoam bupivacaine versus 468.2 with bupivacaine HCl (P = .3999). Total amounts of opioid consumed were significantly lower in the DepoFoam bupivacaine group through 24 hours (P = .0211) and through 48 hours (P = .0459). The prespecified integrated rank analysis showed statistically-significant differences at multiple time points up to and including 60 hours; results on most other efficacy measures trended in favor of DepoFoam bupivacaine. No serious adverse events were reported, and no patients discontinued the study due to adverse events. DepoFoam bupivacaine trended toward benefit versus bupivacaine HCl on most efficacy measures. Due to early termination, the study was underpowered to achieve statistical significance.

Dynamic Breasts: A Common Complication Following Partial Submuscular Augmentation and its Correction Using the Muscle-Splitting Biplane Technique

Dynamic Breasts: A Common Complication Following Partial Submuscular Augmentation and its Correction Using the Muscle-Splitting Biplane Technique

Gesteigertes Selbstvertrauen und vermindertes körperlich-sexuelles Missempfinden nach subpektoraler Mammaaugmentation

The study objectively discusses the causal relationship between submuscular breast augmentation mammaplasty and improved aspects of quality of life. The goal was to assess a possible increase in certain aspects after undergoing cosmetic breast enlargement surgery under consideration of 4 different aspects. Between 2005 and 2006, a total of 65 women were given a standardised patient questionnaire (body image assessment questionnaire) preoperatively as well as 6 months postoperatively after undergoing cosmetic submuscular augmentation mammaplasty: 58 of these questionnaires could be evaluated successfully. All of the patients had undergone augmentation mammaplasty for the first time. The following criteria were assessed and evaluated using a point value system (0-100 points): attractiveness/self-confidence, insecurity/anxiety, emphasis placed on physical appearance, and sexual discomfort. With regard to the questions dealing with attractiveness/self-confidence, a highly significant improvement in the patient's self-assessment of said criteria after undergoing cosmetic submuscular augmentation mammaplasty as compared to their own preoperative assessment was apparent. In addition, a significantly improved level of sexual satisfaction after the medical procedure was also demonstrated. In the same fashion, the answers to the series of questions dealing with emphasis placed on physical appearance also exhibited a positive change. The only topic that exhibited next to no change was the series of questions dealing with insecurity/anxiety. Cosmetic augmentation mammaplasty is an available therapy that can increase a patient's own self-assessment of attractiveness and self-confidence in a significant way. In addition, this operation leads to a significant increase in sexual satisfaction, and because of this and the aforementioned change of emphasis placed on physical appearance, an overall improvement in certain aspects of the quality of life can be achieved.

Multiplane technique for simultaneous submuscular breast augmentation and internal glandulopexy using inframammary crease incision in selected patients with early ptosis

Augmentation mammoplasty is a procedure with a high satisfaction rate. On the other hand, augmentation in a ptotic breast requires conventional mastopexy which has a high surgical morbidity. In selected cases, the multiplane technique, a simultaneous submuscular augmentation with internal glandulopexy, is a procedure which avoids the external scarring of mastopexy. Between June 2005 and October 2008, the author operated on 44 patients (12 unilateral for nipple level asymmetry not exceeding 1.5 cm and 32 bilateral procedures in patients with nipple-areolar complexes (NAC) below the inframammary crease (IMC) but not exceeding 1.5 cm). The procedure is performed under general anesthesia through an IMC incision. The average age of the patient was 33.5 years (range 19–50), and in all but one patient, a round, high-profile cohesive gel silicone implants with an average size of 354 cm3 (range 260–440) in bilateral and 350 cm3 (range 300–440) in unilateral procedures, were used. The average preoperative suprasternal notch to NAC measurement in unilateral (n = 12) and bilateral (n = 32) procedures was 22.2 cm (range19–24) and 23.2 cm (range 20–26) respectively. The preoperative average NAC distance to IMC distance in bilateral and unilateral cases was 8.03 cm (range 6–12) and 7.2 (range 4–9) cm respectively. The measured postoperative supra-sternal notch to NAC distance, 22.0 cm (range 19.5–23) in unilateral (n = 12) and 22.4 cm (range 20–26) in bilateral procedures (n = 32) respectively, shows the reduction in suprasternal notch to NAC distance. Postoperative NAC to IMC distance in bilateral and unilateral breasts was 9.3 cm (range 7–11) and 9.1 cm (range 7–10) respectively. When a unilateral procedure is performed, the contra lateral breast is used as a control to compare the results. One patient had an infection and of the 12 unilateral and 32 bilateral procedures, nipple sensation was present in 8 unilateral and 28 bilateral cases. Only one patient with bilateral procedure reported a bilateral loss of nipple sensation in the early part of her recovery. Two patients did have residual ptosis and one requested a bilateral vertical scar mastopexy. The multiplane procedure for submuscular augmentation with internal subglandular mastopexy is an option in selected patients with early ptosis or patients presenting with minor NAC asymmetry in the vertical axis. If necessary, conventional external mastopexy remains a possibility in patients with inadequate results.

Double Breast Contour in Primary Aesthetic Breast Augmentation

The goal of this study was to define the incidence of double breast contour in primary aesthetic breast augmentation and to analyze its risk factors. An independent plastic surgeon analyzed the data of 200 patients who had a primary aesthetic breast augmentation with silicone gel implant and with a minimum 12-month follow-up. All patients had pre and postoperative standardized photography. Mastopexy-augmentations, breast reconstructions, breast malformations (tuberous breasts and Poland syndrome), and patients with incomplete data were excluded from the study. Assessment was achieved using an original standardized evaluation form (preoperative breast morphology, surgical options, postoperative aesthetic results). Patients were also asked to complete an exhaustive satisfaction form. A double breast contour was assessed clinically using Massiha's classification. The mean follow-up was 36 months. The double breast contour incidence was 7%. All of them were type I (the so called waterfall deformity). There was no type II (double inframammary crease). They were minor for 6.5% and major for 0.5%. They were related to a preoperative breast ptosis, subpectoral placement, and implant upper malposition. The rate of the type I was 10.5% of submuscular augmentation and 15% of preoperative breast ptosis. A double breast contour was primitive for 6% and secondary for 1% (pregnancy and breast-feeding postaugmentation). It was bilateral for 4.5% (3 cases of upper malposition, 1 case of medial malposition, 2 cases of pregnancy with breast-feeding postaugmentation and 1 patient refused a mastopexy-augmentation). It was unilateral for 2.5% related to a preoperative breast asymmetry with ptosis asymmetry and skin quality asymmetry. The satisfaction rate in the group "double contour" (14 patients) was 85.7% (vs. 91.9%). One patient had revision surgery (upper malposition). These types of deformities are fundamentally different with consideration on their clinical aspects, physiopathogeny, prevention and treatment. Type I major risk factor is subpectoral augmentation of ptotic breasts (with medium to bad skin quality and loses muscle to gland attachments). The muscle at the inferior pole of the breast is a "brake" preventing implant to fill the envelope. This risk is increased with implant malposition, constitutional ptosis asymmetry with symmetrical implant placement and selection of an insufficient implant projection or dimensions. This deformity can be avoided with selection of a subglandular or dual plane (type II or III) placement, a sufficient implant volume or projection and anatomic prosthesis. Type II is related to a lowering of a well-defined submammary fold more commonly in constricted and dens glandular breasts. This deformity can be avoided with respecting the inframammary fold, radial incisions on the gland's posterior surface, and selection of anatomic implants.

Dynamic Breasts: A Common Complication Following Partial Submuscular Augmentation and its Correction Using the Muscle-Splitting Biplane Technique

Dynamic breast deformity following partial submuscular augmentation is not uncommon. The complication is due primarily to the release of the pectoralis and the true incidence of this complication is not known. The submuscular biplane pocket is a new pocket and is used to correct dynamic breasts following augmentation mammaplasty in the partial submuscular plane. After the first submuscular biplane muscle-splitting augmentation mammaplasty in October 2005, the author has performed 58 secondary augmentation mammaplasties for various reasons. Of these, nine patients showed marked dynamic breast deformity following partial submuscular augmentation and the submuscular muscle-splitting biplane was used to correct this complication. Good to excellent results were achieved in all patients with complete elimination of the dynamic breast deformity. The submuscular biplane is a new and versatile pocket and is used to correct dynamic breast deformity seen following partial submuscular augmentation mammaplasty.