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Senior Publisher: Elizabeth Durzy
Editor-in-Chief: Rod J Rohrich, MD
Managing Editor: Aaron Weinstein
Production Director: Leslie Caruso
Managing Editor, Production: Erika Fedell
Senior Production Editor: Jeda Taylor
Production Manager: Jennifer Aronstein
Creative Director: Larry Pezzato
Copyright © 2014 by the American Society of Plastic Surgeons. Articles originally published in Plastic and Reconstructive
Surgery. Visit www.PRSJournal.com for journal information.
Published by Wolters Kluwer Health/Lippincott Williams & Wilkins
Two Commerce Square
2001 Market Street
Philadelphia, PA 19103
ISBN: 9781496304865
All rights reserved. This book is protected by copyright. No part of this book may be reproduced or
transmitted in any form or by any means, including as photocopies or scanned-in or other electronic copies,
or utilized by any information storage and retrieval system without written permission from the copyright
owner, except for brief quotations embodied in critical articles and reviews. Materials appearing in this book
prepared by individuals as part of their official duties as U.S. government employees are not covered by the
above mentioned copyright. To request permission, please contact Lippincott Williams & Wilkins at Two
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DISCLAIMER
Care has been taken to confirm the accuracy of the information present and to describe generally accepted
practices. However, the authors, editors, and publisher are not responsible for errors or omissions or for any
consequences from application of the information in this book and make no warranty, expressed or implied,
with respect to the currency, completeness, or accuracy of the contents of the publication. Application of this
information in a particular situation remains the professional responsibility of the practitioner.
Cover art © 2014 Alexandra B. Hernandez
Alexandra B. Hernandez of Gory Details Illustration
Plastic Surgery Complete
The Clinical
Masters
BREAST COLLECTION
CONTENTS
BREAST AUGMENTATION
Foreword
Foreword to the Breast Augmentation Collection
Maurice Y. Nahabedian, M.D.
MOC
Evidence-Based Medicine: Augmentation Mammaplasty
of PRS
denotesassociatedvideo
Frank Lista, M.D., and Jamil Ahmad, M.D.
CME
Breast Augmentation
William P. Adams Jr., M.D., and Patrick Mallucci, M.D.
SUPPLEMENTAL DIGITAL CONTENT IS AVAILABLE IN THE TEXT.
Breast Augmentation
David A. Hidalgo, M.D., and Jason A. Spector, M.D.
SUPPLEMENTAL DIGITAL CONTENT IS AVAILABLE IN THE TEXT.
Classic Articles
Dual Plane Breast Augmentation: Optimizing Implant–SoftTissue Relationships in a Wide Range of Breast Types
John B. Tebbetts, M.D.
On the Cover
Cover art by Alexandra B. Hernandez of Gory Details Illustration
The Process of Breast Augmentation: Four Sequential Steps for
Optimizing Outcomes for Patients
William P. Adams, Jr., M.D.
SUPPLEMENTAL DIGITAL CONTENT IS AVAILABLE IN THE TEXT.
Preoperative Sizing in Breast Augmentation
David A. Hidalgo, M.D., and Jason A. Spector, M.D.
Brava and Autologous Fat Transfer Is a Safe and Effective Breast
Augmentation Alternative: Results of a 6-Year, 81-Patient,
Prospective Multicenter Study
Roger K. Khouri, M.D., Marita Eisenmann-Klein, M.D., Eufemiano Cardoso, M.D.,
Brian C. Cooley, Ph.D., Daniel Kacher, M.S., Eva Gombos, M.D., and
Thomas J. Baker, M.D.
Understanding the Fascial Supporting Network of the Breast:
Key Ligamentous Structures in Breast Augmentation and a
Proposed System of Nomenclature
Simone A. Matousek, F.R.A.C.S., Russell J. Corlett, F.R.A.C.S., and
Mark W. Ashton, F.R.A.C.S.
Baker Gordon Symposium on Cosmetic Surgery
The Bilamellar Approach to Breast Augmentation:
Combining Implants with Autologous Fat Grafting
A lecture video by Daniel Del Vecchio, MD, from the 46th Annual Baker Gordon
Symposium on Cosmetic Surgery
In this video, fi lmed at the 2012 Baker Gordon meeting, Dr. Del Vecchio discusses
combining implants with autologous fat grafting: the bilamellar approach to
breast augmentation. Del Vecchio displays why the future of breast augmentation
may involve a combination of implant and fat, working together, to achieve an
optimal balance: the core projection of an implant and the natural look and feel
of fat. Used with permission from James Stuzin, MD.
Baker Gordon Symposium on Cosmetic Surgery
Acellular Dermal Matrices in Breast Augmentation
An interactive surgical video by G. Patrick Maxwell, MD, from the 45th Annual
Baker Gordon Symposium on Cosmetic Surgery
In this four-part video, fi lmed at the 2011 Baker Gordon meeting, Dr. Maxwell
demonstrates the use of acellular dermal matrix in reoperative breast surgery.
The technical details of combining breast implant replacement, capsulectomy,
and incorporating acellular dermal matrix to improve implant coverage as well
as a matrix for tissue ingrowth and regeneration are delineated. This treatment
algorithm allows for more control of postoperative breast contour and is a
method to diminish recurrent capsular contracture. Used with permission from
James Stuzin, MD.
Baker Gordon Symposium on Cosmetic Surgery
Autologous Fat Transfer Breast Augmentation
A surgical video by Roger Khouri, MD, from the 45th Annual Baker Gordon
Symposium on Cosmetic Surgery
In this four-part surgical video, presented at the 2011 Baker Gordon meeting,
Dr. Khouri and his team perform autoglogous fat transfer breast augmentation.
The team augments and corrects the tuberous breast deformity of a young woman
who had expanded her breast with Brava for 4 weeks prior to the procedure.
Used with permission from James Stuzin, MD.
Visit Plastic and Reconstructive Surgery Online for CME
articles and exams, supplemental material, and more.
PLASTIC AND RECONSTRUCTIVE SURGERY® (ISSN 0032-1052) is the offi cial journal of the American Society of Plastic Surgeons and is published
monthly by Lippincott Williams & Wilkins, 16522 Hunters Green Parkway, Hagerstown, MD 21740-2116. Business offi ces are located at Two Commerce
Square, 2001 Market Street, Philadelphia, PA 19103. Production offi ces are located at 351 West Camden Street, Baltimore, MD 21201-2436. Printed
in USA on acid-free paper. Subscription rates: $905 individual domestic, $905 individual international, $1395 institutional domestic, $1883 institutional
international, $448 resident/student domestic, $448 resident/student international, $158 single copy. The GST number for Canadian subscribers is
895524239RT. Canadian Publication Agreement 40052291. (Prices subject to change.) POSTMASTER: Send address changes to PLASTIC AND
RECONSTRUCTIVE SURGERY®, P.O. Box 1550, Hagerstown, MD 21740. Periodicals postage paid at Hagerstown, Maryland, and at additional
mailing offices. © 2014 by the American Society of Plastic Surgeons.
FOREWORD
Foreword to the Breast Augmentation Collection
Maurice Y. Nahabedian, MD
he Clinical Masters Series of Plastic and
Reconstructive Surgery is designed to provide
T
mative and instructive articles related to various
topics. Within the breast series is a comprehensive
section on augmentation mammaplasty. There are
numerous articles on this topic describing a variety
of techniques for augmentation mammaplasty. This
collection of high-quality articles should provide relevant and detailed information that will be useful to
experienced and novice surgeons with an interest in
breast augmentation.
Like all types of breast surgery, breast augmentation has been described with a variety of methods and
techniques, all of which have demonstrated success
under specifi c circumstances. As such, there has been
an emphasis on evidence-based articles that will guide
surgeons toward achieving predictable and reproduc-
plastic surgeons with a compilation of infor-
Also contributing to the evidence-based literature
is Frank Lista He provides evidence-based medicine
evaluating the role of biofi lm in the development of
capsular contracture and provides evidence to prevent
ible outcomes. Hidalgo and Spector in a CME article emphasize the importance and options regarding
incisions, pocket planes, and specifi c implant characteristics, all of which are paramount for surgical planning. They also discuss assessing patient expectations
and including them in the decision-making process
to improve overall patient satisfaction and reduce
requests for secondary surgery. Adams and Mallucci
in another CME article emphasize the importance
of patient education, tissue-based preoperative planning, refi ned surgical technique, and defi ned postoperative management. They espouse the concept that
the nonsurgical aspects of breast augmentation are
more important for optimizing outcomes and minimizing reoperation and complications. In the John
Tebbetts article, the dual-plane approach and how it
can be useful for optimizing the relationship between
and manage double capsules and late seromas.
Other breast augmentation topics covered in this
series include preoperative sizing, acellular dermal
matrices, the key ligamentous structures in the breast.,
optimizing outcomes, and the role of fat grafting. Fat
grafting for breast augmentation has become a hot
topic in plastic surgery. Roger Khouri is one of the
leaders and pioneers in this area and has evaluated outcomes using external expansion and autologous lipofi ll for primary breast augmentation in women with up
to 6-year follow-up. Watch a four-part video in which
Khouri and his team perform autologous fat transfer
breast augmentation in the Baker Gordon Symposium
video included at the end of this collection. In addition, watch a lecture video from Daniel Del Vecchio in
which he describes combining implants with autolo-
the soft tissues of the breast and the devices are nicely
described and illustrated.
!"#$%&'()*+,-+.(/012"-%-3(45-(/"&6&'#"(7#$%-+$(08(!9)(:(;+-#$%(<*,1-6%#%&06
gous fat grafting for the bilamellar approach to breast
augmentation.
For ew or d to the Br ea st Aug me ntation C ol lec ti on
This compilation of articles in the augmentation
mammaplasty section of the Clinical Masters Series
will serve as a valuable resource to all practicing plastic surgeons. It is accessible via the iPad or any ebook
reader.
FURTHER READING
Turn to PRSJournal.com for more breast augmentation topics, including the impact of anaplastic large cell
lymphoma (ALCL) associated with breast implants.
With the recent reports of ALCL associated with
breast implants, questions regarding safety have been
raised. Kim et al., in two separate articles, have completed a systematic review of this topic as well as published the results of a consensus panel. Information
related to clinical symptoms, implant characteristics,
Further Reading
1 Kim B, et al. Anaplastic large cell lymphoma
and breast implants: Results from a structured expert
consultation process. Plast Reconstr Surg 2011;128:629.
2 Kim B, et al. Anaplastic large cell lymphoma
and breast implants: A systematic review. Plast Reconstr
Surg. 2011;127:2141.
3 Thorne CH. An evidence-based approach
to augmentation mammaplasty. Plast Reconstr Surg.
2010;126:2184.
diagnosis, and treatment is provided.
For further evidence-based literature on this topic,
read Charles Thorne’s MOC article on breast augmentation. Contained within is level 1 and 2 evidence evaluating pain management as well as levels
1 through 3 evidence regarding the benefi t of device
texture, shape, and fi ll material. Also included is level 2
evidence evaluating cancer risk associated with breast
augmentation with devices as well as level 2 evidence
evaluating the risk of connective tissue disorders.
Maurice Y. Nahabedian, MD
Professor and Vice Chairman
Department of Plastic Surgery
Georgetown University Hospital
3800 Reservoir Rd NW
Washington, DC 20007
DrNahabedian@aol.com
202-444-6576
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MOCCME
Search Journal
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View Article
Evidence-Based Medicine: Augmentation
Mammaplasty
Frank Lista, M.D.
Jamil Ahmad, M.D.
Mississauga, Ontario, Canada
ind a Previous Iss
w Arti
Learning Objectives: After studying this article, the participant should
be able to: 1. Recognize the role of biofilm in breast implant surgery and
possible ways to reduce the incidence of capsular contracture. 2. Describe
the advantages and disadvantages of various surgical approaches including the incision placement and implant location. 3. List the advantages and
disadvantages of implant characteristics including implant fill, shell surface
characteristics, and implant shape. 4. Take steps to avoid the phenomena of
double capsule and late seroma.
Summary: This article was prepared to accompany practice-based assessment with ongoing surgical education for the Maintenance of Certification
for the American Board of Plastic Surgery. It is structured to outline the care
of the patient presenting for cosmetic breast augmentation. (Plast. Reconstr.
Surg. 132: 1684, 2013.)
reast augmentation continues to be one of the
most frequently performed aesthetic surgical pro-
B
formed in 2012.1 There are many surgical approaches
and dierent implants that are available. Substantial
clinical data exist regarding breast augmentation to
assist with evaluating the various options. The purpose
of this article is to provide a summary of the best available evidence on augmentation mammaplasty. When
combined with clinical expertise, this evidence will assist
the plastic surgeon in clinical decision making to provide the patient with a safer and better aesthetic result.
half a century, few describe the process of decision
making in breast augmentation. Tebbetts and Adams
cedures, with 286,724 breast augmentations per-
EVIDENCE ON PREOPERATIVE
ASSESSMENT
Despite the multitude of publications over the past
2,3
operative planning decisions by prioritizing five critical
decisions in breast augmentation: (1) optimal soft-tissue
coverage/pocket location for the implant; (2) implant
volume (weight); (3) implant type, size, and dimensions;
(4) optimal location for the inframammary fold; and (5)
incision location (Reference 3, Level of Evidence:
Therapeutic, III). This “high five” system was developed based on analyzing data from more than 2300
breast augmentations planned using the TEPID system.
Choudry and Kim5 surveyed current preferences
of plastic surgeons regarding preoperative assessment
and its eect on clinical outcomes in primary breast
augmentation. 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.
4
described a decision support process that enables surgeons to address all preoperative assessment and
From The Plastic Surgery Clinic.
Received for publication April 19, 2013; accepted May 14,
2013.
Copyright © 2013 by the American Society of Plastic Surgeons
DOI: 10.1097/PRS.0b013e3182a80880
11
EVIDENCE ON ANTIBIOTICS
Adams etal.6 performed a retrospective review of 335
patients that underwent aesthetic and reconstructive
Disclosure: The authors have no financial interest to
declare in relation to the content of this article.
!"#$%&'()*+,-+.(/012"-%-3(45-(/"&6&'#"(7#$%-+$(08(!9)(:(;+-#$%(<*,1-6%#%&06
Augmentation Mammaplasty
breast implant procedures using pocket irrigation with
triple antibiotic solution (including bacitracin, cephazolin, gentamicin), and reported a 1.8 percent capsular
contracture rate for patients undergoing breast augmentation, which was lower than previously reported rates.
They concluded that the use of triple antibiotic solution is associated with a low capsular contracture rate
and recommended use of this technique. Araco etal.
7
performed a retrospective review of 3002 patients that
underwent cosmetic breast augmentation with or without mastopexy. They found that implant brand (Mentor
compared with Poly Implant Prothèse or Eurosilicone)
and pocket irrigation with antibiotics were protective
against infection, whereas the use of drains significantly
increased the risk of infection. Pfeier et al.8 reviewed
414 patients that underwent pocket irrigation with or
without cephalothin added to the pocket irrigation fluid.
The frequency of infections and seromas was substan-
of capsular contracture. Over the past 15 years, with
increased recognition of this relationship and use of
interventions such as antibiotic pocket irrigation, there
has been a marked decrease in the reported rates of
capsular contracture after breast augmentation. Other
measures such as the use of funnels for insertion24 and
nipple shields25 have been proposed to prevent contamination of the implant.
EVIDENCE ON SURGICAL APPROACH
A multitude of surgical approaches for breast augmentation have been described. Surgeon preference
along with patient characteristics and wishes seem to
be largely the deciding factors in treatment planning.
Many published articles include data collected in a retrospective manner or opinions that are based on anecdotal experiences of the authors. Experiences with
inframammary,
26 – 28
transaxillary,
29 – 40
and periareolar41
tially higher in patients where the pocket irrigation fluid
did not contain antibiotics; there was no significant difference in the incidence of capsular contracture. Khan9
performed a retrospective review of 3256 breasts after
augmentation mammaplasty. Patients received prophylactic antibiotics as a single intravenous dose, a single
intravenous dose with an oral course for 24 hours, and
a single intravenous dose with an oral course for 5 days.
The incidence of infection was lowest with a single perioperative dose of intravenous antibiotics. Mirzabeigi
etal.10 performed a retrospective review of 605 implants
used in cosmetic breast augmentation. They compared
patients who received 3 days of postoperative antibiotics
and those who did not. They concluded that there was
no reduction in infection, capsular contracture, or total
complication rate with postoperative prophylactic antibiotics for either primary or secondary cosmetic breast
incision placement have been reported. With respect to
implant location, experiences with subglandular, subfascial,
42 – 47
submuscular,
48,49
dual plane,50 and musclesplitting biplane51 have been reported. Outcomes with
respect to safety and complication rates seem to be more
objectively measured than aesthetic results. A review of
comparative studies for incision placement and implant
location is presented.
Incision Placement
Momeni et al.52 compared 78 patients that underwent breast augmentation through either an endoscopic
transaxillary or inframammary approach. The complication rate was low for both groups, but patient satisfaction was higher in the transaxillary incision group, and
they felt that this approach was useful for patients that
preferred to have the incision at a distant site. Wiener53
augmentation. Hardwicke etal.11 published a systematic
review to examine the role of the prophylactic systematic
antibiotics on surgical-site infections in augmentation
mammaplasty. Two randomized controlled trials
two controlled trials
9,10
were included. A meta-analysis
12,13
and
of surgical-site infection incidence after augmentation
mammaplasty showed no eect on infection rates with
any antibiotic regimen (i.e., antibiotic versus none, single dose versus postoperative course). The overall infection rate with no prophylaxis was 0.3percent, and that
with any antibiotic regimen was 1.5percent. Data concerning incidence of capsular contracture or implant
removal did not allow for meta-analysis.
With regard to the eects of pocket irrigation with
antibiotics on capsular contracture rates, there is significant experimental
14 – 16
and clinical evidence
3,17 – 23
that biofilm is a significant cause in the development
retrospectively reviewed the incidence of capsular contracture for breast augmentations performed through a
periareolar incision versus an inframammary incision
and found that the capsular contracture rate was significantly higher using a periareolar incision. Jacobson
etal.54 conducted a retrospective review of 183 patients
that underwent breast augmentation and found that
transaxillary incision had the highest incidence of capsular contracture followed by periareolar and inframammary incisions. Stutman etal.55 retrospectively reviewed
619 patients who underwent breast augmentation to
examine the relationship of postoperative complications
to incision. Postoperative complications including capsular contracture were not associated with any particular incision. Reoperations were significantly higher with
inframammary incisions; however, these were for size/
style change, asymmetry, and ptosis.
2
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Augmentation Mammaplasty
Okwueze etal.56 studied 33 patients after breast augmentation through both subjective questionnaires and
objective sensory measurements to evaluate changes in
breast sensation between inframammary and periareolar incisions. They found that the inferior region of the
breast had significantly poorer sensitivity thresholds
than the periareolar incision at 6-month follow-up and
concluded that the periareolar incision may produce less
sensory loss in the lower pole of the breast. However,
Mofid etal.
57
evaluated 20 women that had breast augmentation through either inframammary or periareolar
incisions and found no dierence in sensory outcomes.
Araco etal.58 retrospectively evaluated 1222 patients for
risk factors associated with alterations of nipple-areola
complex sensitivity after breast augmentation. They
found that, compared with an inframammary incision,
a periareolar incision increased the risk of nipple-areola
subglandular and submuscular planes while minimizing the potential risks of each. Three variations of the
dual-plane approach were described to address the following: I, most routine breasts; II, breasts with mobile
parenchyma-muscle interface; and III, glandular ptotic
and constricted lower pole of breasts.
EVIDENCE ON IMPLANT SELECTION
From 1992 to 2006, the U.S. Food and Drug
Administration restricted the use of silicone implants for
breast augmentation, making saline implants the only
approved devices for breast augmentation.64 Between
2006 and 2012, the U.S. Food and Drug Administration
approved three premarket approval applications for silicone gel – filled implants produced by Allergan (Irvine,
Calif.), Mentor (Santa Barbara, Calif.), and Sientra
(Santa Barbara, Calif.). In 2013, Allergan also received
complex sensitivity alterations almost threefold and the
risk of areolar pain by more than threefold.
Implant Location
A meta-analysis by Barnsley et al.59 examining the
eect of texturization on capsular contracture noted the
benefit of texturization on reducing the capsular contracture rate in the subglandular location. Texturization
did appear to confer a protective eect in the submuscular location (Level of Evidence: Therapeutic,
II). However, this subgroup consisted of a single study,
which was dramatically underpowered. Data examined
in a systematic review by Schaub et al.60 loosely supported that implants in the submuscular location have a
lower capsular contracture rate.
Strasser61 retrospectively reviewed 100 patients with
subglandular implants and 100 with submuscular
approval for the Style 410 implant, which uses silicone
gel with higher cohesivity compared with their previously approved implants. There are several key considerations when choosing an appropriate breast implant
that warrant discussion. Several authors have published
systematic reviews60 and meta-analyses
59,65,66
examining
the eect of implant characteristics on outcomes after
breast augmentation.
67
Cunningham et al.
and Walker etal.68 published
outcomes data for saline-filled implants as part of the
premarket approval process. Allergan,
69 – 71
Mentor,
72 – 75
and Sientra76 have ongoing premarket approval studies
for silicone gel – filled implants with published follow-up
data between 5 and 6 years. In addition, there have been
several other large studies published reporting outcomes
for these implants.
77 – 89
These studies and key compli-
cation rates including capsular contracture, implant
implants. Submuscular location provided better concealment of upper pole rippling than subglandular
augmentation but had higher rates of muscle contraction – induced deformities and implant displacement;
capsular contracture occurred in both locations. Pereira
and Sterodimas62 performed a prospective study to
compare outcomes following transaxillary breast augmentation using round, textured, silicone implants in
the subglandular (18 patients), subfascial (18 patients),
and submuscular planes (17 patients). Other than three
patients with mild distortion of the implants during
pectoral contracture, patients had similar rates of satisfaction independent of the implant location. Brown63
retrospectively compared 200 subfascial implants with
83 subglandular implants and found no dierence in
complication rate or patient satisfaction. Tebbetts50
described a dual-plane approach in 468 patients
rupture/deflation, and reoperation are summarized in
Table1. Data reflecting primary breast augmentation
are summarized, but in some studies, these data are not
presented separately. Capsular contracture rates range
from 0 to over 20percent, with average follow-up as
long as 13 years, and appear independent of the type
of implant fill. Rupture/deflation rates are consistently
low for all implants. Reoperation rates range between
0 and 36percent and appear to increase with longer
follow-up. Many of these studies include heterogeneous
data sets representing results from multiple surgeons, a
variety of surgical approaches, and significant dierences in other variables such as the use of pocket irrigation, which can significantly aect certain outcomes. In
addition, the premarket approval studies from the various manufacturers cannot be compared on a valid scientific basis because comparative patient cohorts were
that attempts to make use of the benefits of both
3
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not established. Furthermore, many studies examining
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