Breast Augmentation/Breast Implant Efficacy and Safety - Board Review

Question 1

What are the findings on mammogram after fat transfer breast augmentation? Are these findings more or less common than breast reduction patients?

Answer 1

Lipid cysts, diffusely scattered calcifications, sometimes can appear more like malignant findings (clustered branching calcifications and spiculated masses) - less common than found on breast reduction patients

Question 2

What complication is more likely to occur with aug/masto in tuberous breast patient?

Answer 2

Double bubble if the native IMF is not properly released. May improve spontaneously.

Question 3

What factors are linked to higher rate of reoperation in patients undergoing augmentation?

Answer 3

Pre-existing breast ptosis and simultaneous mastopexy (increasing grades of ptosis associated with higher reoperation rates)

Question 4

What are the correlations with incision placement and rate of capsular contracture?

Answer 4

IMF incisions have the lowest rate, periareolar and transaxillary have 5-10x higher complications

Question 5

What is the main factor that can contribute to adverse outcomes with simultaneous aug/mastopexy?

Answer 5

large prosthesis (>350ml) leads to greater adverse effects and soft-tissue attenuation

Question 6

What is double capsule phenomenon and with what type of implants does it more commonly occur?

Answer 6

Late onset seroma without signs of infection. Capsule layer is seen lining the pocket and often contains serosang seroma fluid, a second tight pocket is found around the implant. Usually textured implants.

Question 7

What is the most important factor in determining the maximum acceptable prosthesis size for a patient?

Answer 7

Breast base width

Question 8

What is the main arterial supply to the breast gland and nipple during submuscular augmentation?

Answer 8

Thoracoacromial travels just deep to the pec major muscle. Subglandular dissection disrupts this blood supply.

Question 9

What is the appropriate intervention for implants appearing “too high” soon after augmentation?

Answer 9

Breast massage and breast band application.

Question 10

What is the most common complication after cohesive gel breast prosthesis?

Answer 10

Grade III/IV Capsular contracture (9.8% for aesthetics, 13.7% for recon at 6 years). Rupture 1.1%/3.8% and infection 1.6%/6.1%

Question 11

What factors are associated with increased risk of rippling implants?

Answer 11

Textured implants, saline implants, subglandular placement, thin native breast tissue, ptosis

Question 12

What are the disadvantages and disadvantages of an augmentation performed in the subglandular plane as compared with subpectoral?

Answer 12

Advantages: increased control of IMF, shape and no animation deformity
Disadvantages: higher rate of capsular contracture, less satisfactory for mammography, higher risk of visibility, palpability, sharp transition in upper pole

Question 13

Which patients should subpectoral implantation be used with caution and why?

Answer 13

Patient with significant postpartum atrophy, glandular ptosis, significant native volume loss; higher risk of double bubble deformity

Question 14

What is the significance of the “pinch test”?

Answer 14

Minimum 2cm pinch in superior pole for adequate soft-tissue thickness to cover subglandular implant

Question 15

What is dual plane augmentation?

Answer 15

Subpectoral dissection combined with subglandular dissection that extends a variable distance above the inferior border of the pectoralis major muscle. Used to reduce the risk of double bubble

Question 16

What is the most common complication with breast augmentation?

Answer 16

Capsule contracture, 0.5%-30%

Question 17

What should the implant pocket be irrigated with to decrease infection and contracture?

Answer 17

50,000 U bacitracin, 1g ancef, 80mg gentamicin, 500ml saline

Question 18

What is the rate of capsular contracture with primary breast augmentation and revision augmentation?

Answer 18

20-28% for primary

34-40% with revision

Question 19

Compare contracture, leakage, wrinkling rates between saline and silicone implants. What is the advantage of saline implants?

Answer 19

Same. Leaks/ruptures are easier to detect with saline.

Question 20

What factors should be evaluated prior to performing an augmentation?

Answer 20

Base width (BW), nipple to IMF distance, soft tissue pinch, anterior skin pull stretch

Question 21

In which patients should peri-areolar incisions be used with caution?

Answer 21

Small areolas <3cm, light colored areolae with indistinct borders

Question 22

In which patients should inframammary incisions be used with caution?

Answer 22

Poorly defined IMF, constricted breasts, or IMF too close to the areola

Question 23

What are the disadvantages of transaxillary approach?

Answer 23

Less control and accuracy, Difficult/impossible with silicone implants, Can injury intercostobrachial or medial brachial cutaneous nerves

Question 24

In which patients should transaxillary approach NOT be used?

Answer 24

Patients with tuberous breasts, patients who require parenchymal rearrangement, anatomic or large implants

Question 25

What are the long term changes seen in the breast tissue and chest wall in an augmented patient?

Answer 25

Breast parenchymal atrophy, costal cartilage remodeling

Question 26

What is the reported infection rate with augmentation?.

Answer 26

1-2.2%

Question 27

What is the most common aerobic pathogen? Anaerobic?

Answer 27

Staph epidermidis; Propionibacterium acnes

Question 28

What is the treatment of infection after implant placement?

Answer 28

Superficial: oral or IV antibiotics without drainage
Severe (involving pocket): implant removal, irrigation, capsule debridement, antibiotics, reinsertion of the implant several months later

Question 29

On average, what is the reported rate of decreased nipple sensation?

Answer 29

15% regardless of incision

Question 30

What is the rupture rate for saline implants per year?

Answer 30

1%

Question 31

What is the reoperation rate for silicone implant-related complications during the first 6 years after primary and revision augmentation?

Answer 31

Primary: 20-25%
Revision: 35%

Question 32

What factor increases the risk of rupture for saline implants?

Answer 32

Underfilling leading to implant fold abnormality

Question 33

What is the most accurate imaging modality for evaluating implant integrity?

Answer 33

MRI (Liguini sign indicates intracapsular silicone implant rupture)

Question 34

According to the US FDA what is the recommended schedule of MRI screening to detect silicone prosthesis rupture?

Answer 34

3 years after surgery and every 2 years

Question 35

What are the key characteristics of tuberous breast deformity?

Answer 35

Herniation of the breast tissue into the NAC, cylindrical projection with relatively large areolae, deficiency of lower pole breast tissue in both horizontal and vertical axis, hypoplasia, constricted and high IMF

Question 36

What is the primary treatment and augmentation incision type for tuberous breasts?

Answer 36

Periareolar mastopexy with augmentation, radial-releasing incisions to allow expansion of the base of the breast, areolar reduction and lowering iMF

Question 37

What is symmastia and what are the risk factors for developing it during breast augmentation?

Answer 37

When the breast implant crosses the midline, even if only on one side. Risk factors include large implants with large bases, multiple successive enlargement procedures, pre-existing chest wall deformities, subpectoral implant positioning