Background: Implant placement can improve ptosis due to the position of the nipple, inframammary crease, and base of the breast acting together. The interrelationship between these was quantified via changes in morphometry following subfascial augmentation, and explains the circumstances under which dogma holds true.

Methods: One hundred seventy-five patients underwent a series of static measurements before and 3 months after subfascial breast augmentation. Ptosis in the nipple and base of the breast was calculated before and after surgery.

Results: All measurements except that of the the lateral sternal margin increased after surgery. All grades of ptosis reduced following surgery. There was lowering of the base in grade 1 patients, but not for other grades. Increased base ptosis correlated with reduced lateral sternal margin (1.9 cm compared with 2.9 cm; left, H5 = 24.7, p < 0.01; right, H5 = 24.5, p < 0.01). Implant volume did not correlate with change in ptosis at the nipple or base. Reduced ptosis was associated with implants that are a narrow match of implant to breast (0.52 to 0.95) (left, H5 = 28.3, p < 0.01; right, H5 = 24.9, p < 0.01). Decreasing ptosis correlated with lower lateral sternal margin compared to breasts that increased ptosis. Change in ptosis following surgery does not correlate with having children.

Conclusions: Subfascial placement has varying effects on ptosis. Non-ptotic or mildly ptotic breasts appear to improve due to a disproportionate descent of the inframammary crease relative to the nipple and base. Patients with little breast tissue are more susceptible to an increase in "bottoming out," particularly if broad implants are used. A ratio matching implant to the base width has predictive value on outcome.

Background: 

Outcome studies in breast augmentation do not assess how an implant has been matched to the soft tissue envelope. The study hypothesis is that there is a relationship between breast and implant dimensions and the subjective outcome of patient satisfaction.

Methods: 

In a study of patients undergoing subfascial breast augmentation (n = 341), morphometric measurements and a postsurgical survey of satisfaction with breast size were performed 3 months postoperatively. A ratio empirically derived from breast width, implant width, and projection (Rib) was calculated in patients who wished to have smaller, bigger, or no change in their implant size.

Results: 

76% were content with breast size, 16.7% wished to be larger, and 7.3% wished to be smaller. Rib differed between groups who did not want to change size (n = 259, mean = 5.8, SD = 0.9), those who wished to be bigger (n = 57, mean = 5.6, SD = 1.1), and those who wished to be smaller (n = 25, mean = 5.3, SD = 1.3, H(341) = 14.0, P < 0.01). Rib differed between groups whose result was as expected (mean = 5.6, SD = 0.9), compared with those who expected to be bigger (mean = 5.4, SD = 1.2) or who expected a smaller outcome (mean = 5.6 SD = 1.0, H(341) = 18.3, P < 0.01).

Conclusions: 

These data provide an objective measurement by which studies concerning breast augmentation can be reported and compared. The method may guide standardization of clinical research regarding breast implant surgery.

Background: The management of capsular contraction following breast augmentation has numerous, often conflicting potential treatment protocols, each designed to reduce the incidence of further recurrence. The use of the subfascial plane has not been investigated as an alternative to other treatment options.

Objectives: To examine the outcomes from patients presenting with recurrent capsular contraction after being treated for the first capsule by placement of an implant into the subfascial (SF) plane.

Methods: Retrospective analysis of 111 case notes of patients who presented with capsular contraction. 65 had undergone SF augmentation, 17 submuscular (SM) and 29 subglandular (SG) placement of implant at the primary procedure. At a secondary procedure, those with SF implants underwent open capsulotomy and those with SM and SG implants underwent a change in plane to SF.

Results: There is a significant difference in the proportion of patients that developed a capsule following the second surgery between the groups that had undergone capsulotomy (SF = 16.9%) or plane change (SM = 47% and SG = 37.9%, X² (2,111) = 8.6, P = 0.02). When recurrence at the same site was examined, there was also a significant difference between the groups (X² (2111) = 10.7, P < 0.01). A ruptured implant significantly increased the incidence of further capsular contraction when in the SG plane (X² (2,29) = 12.1, P < 0.01).

Conclusions: In the absence of implant rupture, changing the plane of an implant to a SF position at revision surgery does not reduce the incidence of subsequent capsular contracture compared with open capsulotomy. Open capsulotomy is a reasonable choice following recurrence of capsular contraction following initial SF placement.

Level of evidence iv: 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

The importance of measuring breast firmness reproducibly to monitor postsurgical progress has been appreciated for many years. This study ascertains whether a durometer can be used to quantify capsular contraction and to provide an objective, reproducible measure of fibrosis around an implant. Patients with clinically detected Baker 3 or 4 capsules following breast augmentation underwent firmness measurements using a durometer prior to corrective surgery. Durometry was undertaken on both breasts by an operator who was blinded to the clinical diagnosis. Firmness measurements were taken in each breast quadrant and directly over the nipple-areolar complex on each side. In the study, 16 patients were included. Capsules presented 16 to 714 weeks following surgery (mean 217, standard deviation (STD) 205.4 weeks). Differences in pressure were demonstrated in all quadrants of the breast and at the nipple-areolar complex except the lower inner quadrant. All significant differences demonstrated a higher pressure in the encapsulated breast. The mean pressure in an encapsulated breast was 0.66 kPa (STD 0.25) and 0.46 kPa (STD 0.16) in the normal breast. The durometer can reproducibly describe changes in pressure associated with capsular contraction compared with the contralateral breast. It provides a means of objectively describing capsular contraction following breast augmentation surgery for research and patient care.

Background: Subfascial placement of breast implants has the advantages of subglandular and submuscular placement without the adverse outcomes. There are few large series with longitudinal follow-up and outcome measures.

Methods: Seven hundred eighty-three patients underwent subfascial breast augmentation and were followed up for 10 years. Adverse outcomes, changes in breast morphometry, and patient satisfaction were outcome measures.

Results: All morphometry increased except soft-tissue thickness at the lateral sternal margin. The distance from the nipple-areola complex to the inframammary crease increased by 40 percent, with a concomitant 6.2 percent increase in the distance from the suprasternal notch to the nipple-areola complex. The capsular contracture rate was 6.48 percent, and correlates with a lateral sternal margin of less than 20 mm (r = 0.57, p < 0.001). Ripples occurred in patients with less than 10 mm of soft tissue at the lateral sternal margin; 11.6 percent of patients would choose a larger implant and 2.7 percent would choose a smaller implant.

Conclusions: Subfascial placement of breast implants provides a reliable technique. It can be used in patients with at least 20 mm of soft tissue at the lateral sternal margin. Those with 10 to 20 mm should be counseled that ripples may occur if they lose body fat. The technique is unsuitable for individuals with less than 10 mm measurable at the lateral sternal margin.

Clinical question/level of evidence: Therapeutic, IV.