Commentary on: Transitioning From Conventional Textured to Nanotextured Breast Implants: Our Early Experience and Modifications for Optimal Breast Augmentation Outcomes

Alas, it seems the quest for the perfect breast implant, the holy grail of plastic surgery, continues. Since the modern era of alloplastic breast augmentation began in the 1960s, plastic surgeons have sought an implant that would improve breast aesthetics without a significant risk profile. After discovering that the first generation of silicone gel implants frequently developed capsular contracture, implants with softer shells and softer gels were created. We then found that these frequently ruptured, and implants with stronger shells and more cohesive gels were therefore developed. Polyurethane-coated implants showed promise by offering a reduced risk of capsular contracture compared with smooth-surface devices, so textured-surface implants were developed in an attempt to replicate these findings. Now we have determined that textured implants are associated with breast implant–associated anaplastic large cell lymphoma (BIA-ALCL) and other unique problems, forcing us to continue the search for the next great advance in breast implant technology. Enter nanotexturization: ‘a breast implant with a textured surface so fine that the implant looks, feels, and acts like it’s smooth.’ Of course, nanotexturization may prove to be the pinnacle of breast implant technology, but we could just as easily be talking about “picotexturization” in a decade, looking back on those old nanotextured implants with shells like sandpaper compared to the latest technology. Or maybe, just maybe, it is time plastic surgeons took a long, hard look in the mirror. Instead of internalizing praise for our successes and externalizing blame for our failures, we need acknowledge the fact that the techniques we utilize and the clinical decisions we make are imperfect because we are operating on living, breathing human beings. This does not imply that we are not constantly striving to improve our results and minimize complications. Instead, we must (1) realize how easy it can be to fall into patterns over time, and (2) recognize that accurate self-assessment is difficult to perform at the best of times, let alone within the confines of a busy plastic surgery practice that never pauses for a moment of reflection.1 Which brings us to this article,2 which highlights an issue that we see all too commonly in plastic surgery: a readiness (or even eagerness) to blame the device or patient instead of the technique. In this study, the authors sought to discuss their experience with the introduction of nanotextured implants in a single surgeon’s practice. They retrospectively compared the complication profile of nanotextured implants with that of conventional textured implants (which included both shaped and round implants from 3 different implant manufacturers). The authors report that in the early periods of their study, labeled periods 1 and 2 (though the actual duration of any of the 3 “periods” in the study is never defined), the incidence of implant malposition or “bottoming-out” at 1 year postoperatively was 14.0% and 6.0%, respectively, with nanotextured implants, compared with 0.7% and 0.0% in the time-matched conventional textured implant group. In response to these elevated complication rates, the authors restricted patient selection for nanotextured implants to include only individuals with “small and firm breasts” desiring implant volumes under 350 cc (although the original patient selection criteria for conventional textured vs nanotextured implant use is never clearly defined). By the end of the study, period 3, the majority of patients were receiving nanotextured implants, although the authors were now dissecting a “very tight pocket to minimize inferior and lateral migration” of the implant in addition to keeping patients in a supportive brassiere and restricting lifting and strenuous physical activities for 3 months. Although the complication rate for nanotextured implants dropped throughout the course of this retrospective study (likely as a result of the aforementioned technique and patient-selection modifications), the final complication rate for conventional textured implants (3.5%) was significantly lower than for nanotextured implants (8.7%). The authors do note that after the final study period was complete, the use of nanotextured implants dropped from 54.5% to just 19% (likely as a response to both the complication rate and the high degree of postoperative patient inconvenience). And just like that, the breast implant technology circle of life is complete. But was this all the fault of nanotextured implants? Can these implants only be used in patients with tight soft tissues seeking moderate size augmentation if they agree not to go to the gym and to wear a bra for 3 months after surgery? Or is there something else going on that we are overlooking, something that could explain the issues the authors have uncovered? Taking a closer look at Table 1, we see the average patient in this study was a primiparous female in their 30s (age range, 18-62 years) with a body mass index of around 20 kg/m2. The majority of patients (>95%) had an A or B cup bra size (although we know that this is not a standardized unit of measurement),3 and we see that 92.5% of patients in the conventional textured group and 91.9% of patients in the nanotextured group had their implants placed into a dual-plane 2 or 3 pocket. Therefore, it should come as no surprise that with a change from conventionally textured implants to nanotextured (read: functionally smooth) implants, the dynamics between the device and the soft tissues changed. This is a common complaint we hear from plastic surgeons who perform primarily subpectoral breast augmentation as they try to change (or are forced to change) from textured to smooth implants; smooth implants likely do not withstand the “down-and-out” contractile force from the pectoralis major muscle in the same way that textured implants do, which can result in inferolateral implant displacement (ie, “bottoming-out”). However, instead of seeing this as a failure of implant pocket selection, it is perceived to be an implant problem and the blame is placed squarely on the smooth (or in this case nanotextured) device. Nevertheless, plastic surgeons remain hesitant to embrace subglandular or subfascial breast implant placement, having been taught that implants placed under the muscle have a more natural appearance in the augmented superior pole. Many of these surgeons will cite Tebbetts’s landmark studies on this topic without recognizing that when the superior pole pinch thickness test was described, he was advocating for subpectoral or dual-plane implant placement for patients with a pinch thickness less than 2 cm, not in every single patient undergoing breast augmentation.4,5 Furthermore, since these studies were published there have been significant advancements in breast implant technology, particularly the development of cohesive silicone gel, which has reduced the risks of implant palpability, visibility, and rippling that historically plagued subglandular implants.6 Added to this are the advancements that have been made with fat grafting to the breast and the concept of composite breast augmentation, which have further alleviated some of these historical concerns.7 None of this is meant to imply that there are no patients who would benefit from dual-plane breast augmentation, only to try and break the “groupthink” notion that implants need to be placed under the muscle to appear natural. In our experience, we have not only been able to achieve good aesthetic outcomes with subglandular and subfascial implant placement in patients with less than 2 cm pinch thickness, but we have found that the placement of implants above the muscle actually allows for implant placement in patients with a greater variety of chest and breast morphologies, in particular for individuals with a low breast footprint, poorly defined breast borders, or patients with a wide sternum desiring improved medial cleavage.8,9 Subpectoral and dual-plane breast implant placement are not without their own inherent problems. We now have a much greater awareness of animation deformity and the impact that this chronic complaint of implant mobility with pectoralis major muscle activation can have on patients following breast augmentation.10-13 The double-bubble deformity also appears to be a problem exclusively related to subpectoral breast implant placement. Beyond aesthetics, we must also remember that the pectoralis major muscle serves as one of the primary stabilizers of the shoulder joint,14 and implant placement under the muscle has demonstrated a significant decrease in pectoralis major muscle volume,15,16 which could potentially alter shoulder stability and limit shoulder adduction strength.14,15,17 Nevertheless, in spite of all the aforementioned arguments, the primary reason why many plastic surgeons refuse to embrace (or even consider) subglandular or subfascial breast augmentation is the pervasive and dogmatic belief that smooth implants placed in the subglandular plane have a higher risk of capsular contracture. This belief persists despite the fact that many of the primary studies, meta-analyses, and systematic reviews that fueled this credence were performed prior to the introduction of the latest breast implant technology and the improved surgical techniques (eg, antibiotic irrigation, minimal-touch implant insertion, prospective hemostasis, nipple shields)18-22 that are now widely recognized as reducing the risk of capsular contracture.23-28 We recently published a study demonstrating that smooth-surface implants placed in the subglandular plane were not at a significantly increased risk of capsular contracture when compared to textured-surface implants.29 In fact, multiple recent studies have reported capsular contracture rates below 3%, suggesting that capsular contracture, the once insurmountable adversary that haunted plastic surgeons in their sleep, may actually be just another complication of breast augmentation and no different than hematoma or periprosthetic infection.18,30-35 So now that many plastic surgeons have been forced to reconsider the role of textured implants in their practice, it might finally be time for us all to step back and take that long, hard look in the mirror. Is a smooth (or nanotextured) implant to blame for inferolateral implant malposition, or is the implant pocket the real issue? Is it really worth it for us to continue implanting textured devices to possibly reduce the risk of capsular contracture from 3% down to 2%, knowing that we are exposing patients to the rare but potentially serious risk of BIA-ALCL, or more commonly occurring problems including malrotation, late seromas, and late hematomas?36 Does putting a modern, cohesive silicone gel implant under the muscle really make the superior pole so much more “natural” that it is worth the potential for animation deformity? We know how these questions have been answered in our practice, but take a moment to pause and reflect on some of these questions and you just may be surprised with what you find. Drs Austin, Ahmad, and Lista are key opinion leaders for InMode (Lake Forest, CA). Dr Ahmad is a consultant for Mentor Worldwide, LLC (Irvine, CA). The authors received no financial support for the research, authorship, and publication of this article.

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