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. The author declared no potential conflicts of interest with respect to the research, authorship, and publication of this article. The author received no financial support for the research, authorship, and publication of this article.

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