Commentary on: Current Trends in Breast Augmentation: An International Analysis

Commentary on: Current Trends in Breast Augmentation: An International Analysis This study aimed to evaluate trends and current practices in breast augmentation surgery with a focus on international practice patterns.1 Specifically, the authors investigated a variety of areas including implant selection, implant size, pocket selection, specifics with regards to surgical technique, and management of complications. It was a survey based study that included questionnaires delivered to over 5000 breast surgeons in 44 countries. Surgeons were identified via access to member rosters of regional and national specialty societies. Response rate for the questionnaire was 18%. Countries were grouped into regions representing a total of 139 surgeons in Latin America, 341 surgeons in Europe, 90 surgeons from Asia, and 58 surgeons from Oceania. Data were then compared across regions and included a comparison to United States data that were collected in a separate study by Hidalgo and Sinno.2 There was a large amount of data collected, however key findings included a greater adoption of anatomic implants in Europe, Asia, and Oceania, as well as a higher percentage of composite breast augmentation with implants and fat in both Europe and Asia. It is not surprising that selection of implant shape differs worldwide. The decision to select an anatomic implant is related to multiple variables. These of course include surgeon and patient preference along with a desire or acceptance to use a textured surface device. The history of implant surface selection is interesting and instructive. Prior to the early 1990s, implant options and selection were similar worldwide. With the silicone gel implant moratorium in 1992, North America immediately became a saline only market. Parallel to this, the use of textured surface gel devices grew internationally and as a result, implant manufacturers developed textured surface saline implants for use in North America. Due to important differences in filler material and fill volume, the textured saline implants suffered from visible rippling and noticeable palpable edges around the periphery of the breast. This largely negative experience resulted in a generation of surgeons in North America that rejected textured devices and used primarily smooth saline implants. Following the reintroduction of silicone gel filled devices in the United States, the natural transition was to move from smooth saline to smooth gel. Manufacturer sales data have demonstrated a slow but continuous increase in adoption of textured surface gel devices as surgeons have accepted that there is a difference in the way textured devices perform when they are filled with a cohesive gel as opposed to saline. Of course, not all textures are the same, and with reports of late complications including seroma, double capsule, and a link between anaplastic large cell lymphoma (ALCL) and texture, surgeons worldwide, and particularly in North America, are evaluating their own “risk/benefit analysis” for implant surface selection. An interesting finding is that anywhere from 2% to 14% of respondents stated that they had encountered at least one case of ALCL in their practice. Given the current estimates of the incidence of ALCL, it is surprising that a survey of 628 surgeons worldwide would report such a high rate of practice exposure.3 This either reflects an underreporting of ALCL or more likely a selection bias of those surgeons participating and completing the study questionnaire. As mentioned by the authors, it is possible that surgeons completing this survey are more likely to have large breast focused practices and are perhaps more exposed to tertiary level breast cases. If this is true, then the reader must be cautioned about assessing the generalizability of the study findings to a general plastic surgery practice. Common themes existed across most regions including the use of an inframammary fold approach, placement of the implant in a dual plane pocket, and the use of perioperative IV antibiotics. It is not surprising that most surgeons worldwide select gel filled devices. The fact that the majority of US surgeons continue to offer and use saline devices in at least some of their patients is likely a result of persistent patterns from the 1990s and early 2000s. Other factors include patient desire for small incisions, reduced cost, and ongoing patient concerns about detection and consequences of implant rupture. In my own experience, saline implants are rarely used, however there is a population of patients who are just more comfortable with the use of a saline filled device.4 In the United States, the use of insertion devices or funnels have been available for well over a decade. The authors report that one in five American surgeons and almost one third of surgeons in Oceania use a funnel routinely. Adoption of funnel use elsewhere in the world has been minimal. With ongoing discussions regarding the role of biofilm in everything ranging from infection and contracture to the development of ALCL, it will be interesting to see if the use of insertion devices expands worldwide. My personal experience is that insertion funnels or sleeves simplify implant insertion, especially when used with textured devices. Potential benefits include minimizing contact between the implant and the skin, less stress to the implant shell on insertion, and allowing for implant placement through smaller incisions. A recent publication by Flugstad et al5 looked at two large groups of breast augmentation patients. One group had their implants inserted with a funnel and one without a funnel. The measured outcome was reoperation for Baker 3 or 4 contracture within twelve months of surgery. The authors demonstrated a 54% reduction in reoperation for capsular contracture when the funnel was used for insertion. Further work is necessary to demonstrate improved outcomes, especially in the long term. The authors conclude that geographical differences exist in breast augmentation practices throughout the world. This is not surprising given the wide array of cultural differences, surgeon experiences, regional medicolegal risks, patient body types, and product availability. The authors should be congratulated for trying to sample the opinions of a large number of surgeons in 44 countries. Unfortunately, the low response rate makes generalizability of these findings a problem for the individual surgeon. Disclosures The author declared no potential conflicts of interest with respect to the research, authorship, and publication of this article. Funding The author received no financial support for the research, authorship, and publication of this article. REFERENCES 1. Heidekrueger PI, Sinno S, Hidalgo DA, Colombo M, Broer PN. Current trends in breast augmentation: an international analysis. Aesthet Surg J . 2018; 38( 2): 133– 148. Google Scholar CrossRef Search ADS PubMed  2. Hidalgo DA, Sinno S. Current trends and controversies in breast augmentation. Plast Reconstr Surg . 2016; 137( 4): 1142- 1150. Google Scholar CrossRef Search ADS PubMed  3. Clemens MW, Miranda RN, Butler CE. Breast implant informed consent should include the risk of anaplastic large cell lymphoma. Plast Reconstr Surg . 2016; 137( 4): 1117- 1122. Google Scholar CrossRef Search ADS PubMed  4. Somogyi RB, Brown MH. Outcomes in primary breast augmentation: a single surgeon’s review of 1539 consecutive cases. Plast Reconstr Surg . 2015; 135( 1): 87- 97. Google Scholar CrossRef Search ADS PubMed  5. Flugstad NA, Pozner JN, Baxter RAet al.   Does implant insertion with a funnel decrease capsular contracture? a preliminary report. Aesthet Surg J . 2016; 36( 5): 550- 556. Google Scholar CrossRef Search ADS PubMed  © 2017 The American Society for Aesthetic Plastic Surgery, Inc. Reprints and permission: journals.permissions@oup.com http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png Aesthetic Surgery Journal Oxford University Press

Commentary on: Current Trends in Breast Augmentation: An International Analysis

Loading next page...
 
/lp/ou_press/commentary-on-current-trends-in-breast-augmentation-an-international-RcJDN5txEC
Publisher
Mosby Inc.
Copyright
© 2017 The American Society for Aesthetic Plastic Surgery, Inc. Reprints and permission: journals.permissions@oup.com
ISSN
1090-820X
eISSN
1527-330X
D.O.I.
10.1093/asj/sjx125
Publisher site
See Article on Publisher Site

Abstract

This study aimed to evaluate trends and current practices in breast augmentation surgery with a focus on international practice patterns.1 Specifically, the authors investigated a variety of areas including implant selection, implant size, pocket selection, specifics with regards to surgical technique, and management of complications. It was a survey based study that included questionnaires delivered to over 5000 breast surgeons in 44 countries. Surgeons were identified via access to member rosters of regional and national specialty societies. Response rate for the questionnaire was 18%. Countries were grouped into regions representing a total of 139 surgeons in Latin America, 341 surgeons in Europe, 90 surgeons from Asia, and 58 surgeons from Oceania. Data were then compared across regions and included a comparison to United States data that were collected in a separate study by Hidalgo and Sinno.2 There was a large amount of data collected, however key findings included a greater adoption of anatomic implants in Europe, Asia, and Oceania, as well as a higher percentage of composite breast augmentation with implants and fat in both Europe and Asia. It is not surprising that selection of implant shape differs worldwide. The decision to select an anatomic implant is related to multiple variables. These of course include surgeon and patient preference along with a desire or acceptance to use a textured surface device. The history of implant surface selection is interesting and instructive. Prior to the early 1990s, implant options and selection were similar worldwide. With the silicone gel implant moratorium in 1992, North America immediately became a saline only market. Parallel to this, the use of textured surface gel devices grew internationally and as a result, implant manufacturers developed textured surface saline implants for use in North America. Due to important differences in filler material and fill volume, the textured saline implants suffered from visible rippling and noticeable palpable edges around the periphery of the breast. This largely negative experience resulted in a generation of surgeons in North America that rejected textured devices and used primarily smooth saline implants. Following the reintroduction of silicone gel filled devices in the United States, the natural transition was to move from smooth saline to smooth gel. Manufacturer sales data have demonstrated a slow but continuous increase in adoption of textured surface gel devices as surgeons have accepted that there is a difference in the way textured devices perform when they are filled with a cohesive gel as opposed to saline. Of course, not all textures are the same, and with reports of late complications including seroma, double capsule, and a link between anaplastic large cell lymphoma (ALCL) and texture, surgeons worldwide, and particularly in North America, are evaluating their own “risk/benefit analysis” for implant surface selection. An interesting finding is that anywhere from 2% to 14% of respondents stated that they had encountered at least one case of ALCL in their practice. Given the current estimates of the incidence of ALCL, it is surprising that a survey of 628 surgeons worldwide would report such a high rate of practice exposure.3 This either reflects an underreporting of ALCL or more likely a selection bias of those surgeons participating and completing the study questionnaire. As mentioned by the authors, it is possible that surgeons completing this survey are more likely to have large breast focused practices and are perhaps more exposed to tertiary level breast cases. If this is true, then the reader must be cautioned about assessing the generalizability of the study findings to a general plastic surgery practice. Common themes existed across most regions including the use of an inframammary fold approach, placement of the implant in a dual plane pocket, and the use of perioperative IV antibiotics. It is not surprising that most surgeons worldwide select gel filled devices. The fact that the majority of US surgeons continue to offer and use saline devices in at least some of their patients is likely a result of persistent patterns from the 1990s and early 2000s. Other factors include patient desire for small incisions, reduced cost, and ongoing patient concerns about detection and consequences of implant rupture. In my own experience, saline implants are rarely used, however there is a population of patients who are just more comfortable with the use of a saline filled device.4 In the United States, the use of insertion devices or funnels have been available for well over a decade. The authors report that one in five American surgeons and almost one third of surgeons in Oceania use a funnel routinely. Adoption of funnel use elsewhere in the world has been minimal. With ongoing discussions regarding the role of biofilm in everything ranging from infection and contracture to the development of ALCL, it will be interesting to see if the use of insertion devices expands worldwide. My personal experience is that insertion funnels or sleeves simplify implant insertion, especially when used with textured devices. Potential benefits include minimizing contact between the implant and the skin, less stress to the implant shell on insertion, and allowing for implant placement through smaller incisions. A recent publication by Flugstad et al5 looked at two large groups of breast augmentation patients. One group had their implants inserted with a funnel and one without a funnel. The measured outcome was reoperation for Baker 3 or 4 contracture within twelve months of surgery. The authors demonstrated a 54% reduction in reoperation for capsular contracture when the funnel was used for insertion. Further work is necessary to demonstrate improved outcomes, especially in the long term. The authors conclude that geographical differences exist in breast augmentation practices throughout the world. This is not surprising given the wide array of cultural differences, surgeon experiences, regional medicolegal risks, patient body types, and product availability. The authors should be congratulated for trying to sample the opinions of a large number of surgeons in 44 countries. Unfortunately, the low response rate makes generalizability of these findings a problem for the individual surgeon. Disclosures The author declared no potential conflicts of interest with respect to the research, authorship, and publication of this article. Funding The author received no financial support for the research, authorship, and publication of this article. REFERENCES 1. Heidekrueger PI, Sinno S, Hidalgo DA, Colombo M, Broer PN. Current trends in breast augmentation: an international analysis. Aesthet Surg J . 2018; 38( 2): 133– 148. Google Scholar CrossRef Search ADS PubMed  2. Hidalgo DA, Sinno S. Current trends and controversies in breast augmentation. Plast Reconstr Surg . 2016; 137( 4): 1142- 1150. Google Scholar CrossRef Search ADS PubMed  3. Clemens MW, Miranda RN, Butler CE. Breast implant informed consent should include the risk of anaplastic large cell lymphoma. Plast Reconstr Surg . 2016; 137( 4): 1117- 1122. Google Scholar CrossRef Search ADS PubMed  4. Somogyi RB, Brown MH. Outcomes in primary breast augmentation: a single surgeon’s review of 1539 consecutive cases. Plast Reconstr Surg . 2015; 135( 1): 87- 97. Google Scholar CrossRef Search ADS PubMed  5. Flugstad NA, Pozner JN, Baxter RAet al.   Does implant insertion with a funnel decrease capsular contracture? a preliminary report. Aesthet Surg J . 2016; 36( 5): 550- 556. Google Scholar CrossRef Search ADS PubMed  © 2017 The American Society for Aesthetic Plastic Surgery, Inc. Reprints and permission: journals.permissions@oup.com

Journal

Aesthetic Surgery JournalOxford University Press

Published: Feb 1, 2018

There are no references for this article.

You’re reading a free preview. Subscribe to read the entire article.


DeepDyve is your
personal research library

It’s your single place to instantly
discover and read the research
that matters to you.

Enjoy affordable access to
over 18 million articles from more than
15,000 peer-reviewed journals.

All for just $49/month

Explore the DeepDyve Library

Search

Query the DeepDyve database, plus search all of PubMed and Google Scholar seamlessly

Organize

Save any article or search result from DeepDyve, PubMed, and Google Scholar... all in one place.

Access

Get unlimited, online access to over 18 million full-text articles from more than 15,000 scientific journals.

Your journals are on DeepDyve

Read from thousands of the leading scholarly journals from SpringerNature, Elsevier, Wiley-Blackwell, Oxford University Press and more.

All the latest content is available, no embargo periods.

See the journals in your area

DeepDyve

Freelancer

DeepDyve

Pro

Price

FREE

$49/month
$360/year

Save searches from
Google Scholar,
PubMed

Create lists to
organize your research

Export lists, citations

Read DeepDyve articles

Abstract access only

Unlimited access to over
18 million full-text articles

Print

20 pages / month

PDF Discount

20% off