Effect of incision choice on capsular contracture after breast augmentation

Most patients tend to think that the type of incision used for breast augmentation doesn't make a difference, and that they all work equally.  Turns out, that isn't the case at all.  The incision placement actually makes quite a difference on the frequency of complications.

In this month's issue of ASJ (the Aesthetic Surgery Journal) is a nice little study by Dr. Scott Spear and colleagues, comparing the rates of capsular contracture (breast hardness after implant placement) in 183 breast augmentation patients.  Dr. Spear is a respected plastic surgeon, and an expert on breast augmentation, having been very much involved with the FDA review panels on the topic.

The patients were divided into three groups, based on whether they had an inframammary crease incision, a nipple incision, or the transaxillary (armpit) incision, and were followed for an average of 13 months after surgery.

The researchers found that the incision placement did make a significant difference.  Capsular contracture and hardening of the breast happened most often with the transaxillary incision (6.4%) and the periareolar incision (2.4%).  The infra-mammary incision had the lowest rate of complications, at only 0.5%

This report supports a previous publication which found the same kind of results - inframammary incisions have the lowest capsule rate.  And since CC is the most frequently encountered complication after breast augmentation, it really makes sense to do everything possible to reduce the chance of this problem happening.

In this study, there was no difference in capsule rates between saline and silicone gel implants, which is the same trend as the data in the Mentor - FDA follow-up study.

Bottom line:  If patients want to have a periareolar incision, they are putting themselves at risk for a five-fold increase in capsular contracture rates, and the subsequent surgery to fix it.  That's a pretty major difference, and a big trade-off.  I typically recommend the infra-mammary incision to my Orlando breast augmentation patients, based on this data.

Proven: liposuction and tummy tuck improve Quality of Life

In the "Seems Like an Obvious Result" Category, here is a study from this month's issue of PRS, showing good outcomes and improved quality of life and self-esteem with tummy tucks and abdominal liposuction, either separately or in combination. Here's the summary, courtesy of PS News.


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Dr. Eric Swanson, a plastic surgeon in Kansas, formally evaluated quality of life and other outcomes in 360 patients undergoing liposuction and/or abdominoplasty to remove excess abdominal fat. About 60 percent of patients underwent liposuction alone, while 35 percent underwent a combination of liposuction and abdominoplasty. The rest underwent abdominoplasty alone.

The patients' average age was 42 years; 85 percent were women. Thirty percent of patients underwent other cosmetic plastic surgery procedures (such as face lift or breast augmentation) at the same time. Outcomes were assessed an average of four months after surgery.

Patients undergoing liposuction alone had shorter recovery times: average time off work was about six days, compared to 16 days with abdominoplasty (with or without liposuction). The liposuction-only patients also had less discomfort: average pain score 6 out of 10, compared to 7.5 for those undergoing abdominoplasty.

Combined Procedure Yields Best Results

Patients undergoing abdominoplasty rated their cosmetic outcomes higher than others: average score 9 out of 10, compared to 8 out of 10 with liposuction only. Liposuction plus abdominoplasty produced the highest patient satisfaction rate-over 99 percent-with no increase in pain compared to abdominoplasty alone.

Ninety-eight percent of patients undergoing liposuction plus abdominoplasty said they would undergo the procedure again and 99 percent that they would recommend it to others.

Overall, 86 percent of patients reported an improved sense of self-esteem after surgery. About 70 percent reported improved quality of life, more commonly after liposuction plus abdominoplasty.

Quality of life is an increasingly important focus measure of effectiveness for all types of medical and surgical treatments. Even though liposuction and abdominoplasty are among the most frequently performed cosmetic surgery procedures, few studies have formally evaluated their impact on quality of life and other patient-reported outcomes.

"Liposuction and abdominoplasty, individually and in combination, produce high rates of patient satisfaction and reliably improve self-esteem," Dr. Swanson writes. By formally assessing these important outcomes in a large number of patients, he hopes his study will provide a clearer picture of the expected results and recovery times associated with these widely performed cosmetic surgery procedures.


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Editor's note: We find similar results in our Orlando practice. Tummy tuck, with or without liposuction, makes a dramatic improvement in self-esteem and quality of life, according to our patients.  Kudos to Dr. Swanson for formally documenting this finding.

The Miss Plastic Surgery award goes to.....

Guess which country has the most plastic surgery per capita...I'll give you a hint - it's not the United States or even Brazil, that hotbed of South American cosmetic surgery, although in total numbers, the U.S. is #1.

I was surprised to learn that, according to research firm Trend Monitor, South Korea has more procedures per capita than anywhere else. Nearly one out of five women there have had "something done" - whether it's a non-invasive procedure or actual surgery. Here's the graph, reproduced from The Economist.com

Headline from ASLMS: cosmetic laser surgery not always best

An article in the Orlando Sentinel covering the recent laser meeting in Orlando (American Society for Laser Medicine & Surgery, also known as "ASLMS") came out with this headline.  I thought it would be educational to look at the article in more detail, and comment on it.

Article:  "...of all the procedures, hair removal seemed to deliver best on its promise.  The before and after photos presenters showed of vascular lesions - particularly the small broken blood vessels on the side of the nose and red birthmarks - also showed clear improvement"

Comment: I agree.  These are mature laser technologies, and do work effectively.

Article:  "Least impressive were results from laser-assisted body contouring and face and neck lifting.  One practitioner on the body contour panel said that in only 20% of cases where a patient had the non-invasive Cool Sculpting procedure were both the doctor and the patient satisfied..."

Comment:  I agree here too.  It's hard to beat a well-performed liposuction with either PAL or standard tumescent techniques, or a traditional surgical facelift.  The laser-assisted liposuction devices are still evolving and changing every year.  Manufacturers and surgeons can't seem to agree on which wavelength, power and other parameters are the best for these fat-busting lasers - which tells you that they really don't yet know.  I'm surprised that the satisfaction number is only 20%.  That's really dismally low for laser liposuction.

Article:  Discussing laser treatments of the face & neck, the report quotes Dr, Zelickson, a renowned laser researcher and developer of the Zeltiq, "In many cases, results are very modest; tightening is hard to measure."

Comment:  Truthful words from Dr. Z.  That's one reason why I don't use Ulthera - the results are too darn subtle. I think patients want to see obvious visible improvements without having to scrutinize their before and after photos for minor improvements.

Article:  "Patients need to do their homework and not go off a billboard", said Dr. Geronemus.

Comment:  Truer words were never spoken!

So even though a procedure with the word "laser" attached to it sounds all high-tech and cool, it's not always the best choice.  Be sure to check out the alternatives.

No more "boob-jab" - Macrolane withdrawn from breast augmentation in UK

For the past 5 years, there was an injectable filler called Macrolane that was being used in the UK for all sorts of body contouring operations - including breast augmentation.  As you might imagine, the idea of a "lunchtime" breast augmentation by injection - in 45 minutes without the need for implants - became quite popular in the U.K.

However, there were significant problems with breast hardness and lumpiness after the treatment. Rather than behaving like a typical soft tissue filler like we might use in the lips or in a facial wrinkle, large deposits of Macrolane seemed to behave more like an actual implant, with potential for capsular contracture formation, and potential for hardness or tissue distortion.

According to the Daily Mail newspaper, the manufacturers of the product (Q-Med of Sweden) have now decided to withdraw it from use in the breast, due to concerns that it would make mammograms more difficult to read or make a cancer more difficult to detect.

A spokesman for the British equivalent of the FDA, known as the Medicines and Healthcare products Regulatory Agency (MHRA) said: "This is not because of safety concerns with the product itself but because the product may interfere with the reading of mammograms and could make diagnosis more difficult. The product can still be used in its other indications, such as augmenting body contour and correcting soft tissue defects."

The British Association of Aesthetic Plastic Surgeons (BAAPS) said that in a survey of its members, 25% of surgeons reported patient complications after the use of Macrolane.

Macrolane, a thicker cousin of Restylane, is not yet available in the U.S. for any application.

ASAPS 2012 annual meeting

Once again, it's nearly time for the super-specialists of aesthetic plastic surgery to get together for the annual ASAPS meeting.  This year, the meeting is in my hometown of Vancouver, Canada, May 3- 8.  It's the best meeting I know of in our field.  I always hear neat new ideas there from the thought leaders in our field, and see surgical results that make me aspire to match them!

I'll be attending some specialized courses taught by world-leading plastic surgeons, and for the first time, I've been invited to be involved with teaching part of a course (on lasers & cosmetic medicine).  It will be exciting, and I'm looking forward to seeing colleagues from throughout the US and Canada.

I'll also be blogging from the meeting, with updates on what's hot & what's not, and new technology that might be relevant to our mission of providing scientifically proven techniques that work safely, and avoiding hype and marketing spin!

Stay tuned....