Anatomical Variations of the Pectoralis Muscle and Its Importance for Breast Implant Surgery.

In breast augmentation, during submuscular or dual plane dissection, anatomical variations of the inferior and costal origin of the pectoralis major muscle (PMM) play a key role to ensure optimal implant coverage. Especially, a short and narrow muscle or surgical release along the sternum increases the risk of irregularities and animation deformities of the implant. Methods: In 84 consecutive aesthetic breast augmentations intraoperatively, measurement of PMM dimensions was performed bilaterally. These PMM measurements were then correlated with the preoperative breast width, the inframammary fold, and the placement of the implant's lower pole. Results: One hundred sixty-eight PMMs of 84 patients were dissected with a dual plane II or III technique for primary aesthetic breast augmentation. In 88% of breasts, the calculated implants' lower pole was below the inferiomedial origin of the pectoralis muscle. In 10% of patients, a separation (more than 1 cm wide and 2 cm wide) in the inferior-medial origin of the PMM was noted. An asymmetry more than 0.5 cm in length between the left and right pectoralis major was noted in 36% of patients. Conclusions: In this series, the anatomy of the PMM demonstrates a substantial variability in width and length and a considerable asymmetry in its dimensions. These findings emphasize the importance of good access and visualization of the origin of the PMM fibers before its division.

Patient and Clinician Reported Outcomes of the Inframammary Incision "Short Scar Technique" in Primary Breast Augmentation.

Background: Breast augmentation is a common aesthetic surgery procedure and surgeons are constantly trying to develop techniques that help improve patients' outcome. One of the most important aspects is achieving a favorable scar. The "traditional" breast augmentation scar is in the inframammary fold (IMF), whereas trans-axillary and trans-umbilical approaches have been described as an attempt to move the "location" of the scar and make it less noticeable. Nonetheless, relatively little attention has been paid to improving the IMF scar, which remains the most commonly used scar for silicone implants. Objectives: The authors have previously described a technique that uses an insertion sleeve and custom-made retractors to allow implant insertion through a shorter IMF scar. However, at the time, the authors did not evaluate the quality of the scar and patient satisfaction. In this manuscript, the authors describe patient and clinician-reported outcomes for this short scar technique. Methods: All consecutive female patients, undergoing primary aesthetic breast augmentation with symmetric implants were included in this review. Results: Three different scar-assessment scales demonstrated good results at 1-year postop, as well as the good correlation between patient-reported and clinician-observed scores. BREAST-Q subscale for overall satisfaction also demonstrated good overall patient satisfaction. Conclusions: Besides providing an added aesthetic value to the result of breast augmentation, a shorter scar may also appeal to patients who are concerned about the size and quality of postoperative scars and like to search for "before and after" pictures prior to scheduling consultations.

Modified Delphi Technique to Identify Management of Aesthetic Breast Augmentation: Will We Reach a Consensus?

BACKGROUND: Breast augmentation is a common operation. Evidence has grown with experience and long-term studies, but variation in practice exists. The authors detail the existing practices of a group of surgeons for primary and secondary aesthetic breast augmentation. METHODS: Seventy-two plastic surgeons with a specialist interest in aesthetic breast surgery were asked to participate in the survey about aesthetic breast augmentation. A 54-point online survey was given, covering demographics about the surgeon and practice, implant choice and perioperative technique, use of emerging evidence and surgical techniques, preferences about secondary surgery, and opinions about topics of controversy. RESULTS: All 72 surgeons completed the survey. Their mean age was 57.6 years, 56.9% had been in surgical practice for over 20 years, and 88.9% were performing more than 50 primary breast augmentations per year. The most commonly used measurement for implant selection was breast width, the most common implant type was silicone (81.9%), and volume range was 250 to 350 cc (86.1%). A total of 36.1% of surgeons use anatomic implants in more than half of their cases. Opinions were divided about postoperative return to work, use of insertion funnel, and acellular dermal matrix. CONCLUSIONS: Multiple factors affect clinical outcome in primary and secondary aesthetic breast surgery. A few well-established techniques have gained common acceptance, but opinions are more diverse for difficult, complicated, or challenging scenarios. This survey helps clarify the decision-making process of expert surgeons with an interest in aesthetic breast surgery.

In search for the 'perfect' breast implant: are textured implants still indicated in today's breast augmentation practice?

The popularity of breast augmentation procedure has driven research and debate as to whether any given implant characteristic offers a functional advantage. One such debate exists about the role of surface texturing. In the aftermath of the recent withdrawal of aggressively textured surfaces we would like to summarize the first author's experience of nearly 1500 primary aesthetic breast augmentations with different surfaces and offer our thoughts on this topic. All consecutive primary breast augmentations operated by the first author from January 2010 to June 2019 were included. All patients had silicone implants inserted via inframammary incision. Of all the operated cases, 1029 consecutive female patients had at least 6 months' follow-up (mean 15.1 months). Their mean age was 31.2 years, mean BMI 20.8 kg/m2 and mean implant volume was 311 cc. 997(96.9%) patients had dual plane and 32(3.1%) had sub-glandular implant placement. In total 113 patients (11.0%) developed a complication. This represented 15.1% of those with round and 10.0% of anatomical shape (or 10.6% of textured and 14.5% of smooth surface implants). As clinicians, we like patients to receive all the advantages of an implant but not be exposed to any risks. However, in reality, such a 'perfect implant' still does not exist. New literature continues to shed light on this trade-off between an implant's perceived utility and its complications profile. We hope that the search for an alternative technology, with more beneficial surface characteristics and less drawbacks, continues.

The Dual Vascular Pedicle: A Novel Method to Approach Challenging Cases in Single-Stage Mastopexy/Augmentation.

BACKGROUND: Age, pregnancy and weight change can affect the shape of the female breast. Various mastopexy/augmentation techniques have been described to address these changes which work well in primary and uncomplicated cases. However, there is a distinctive category of high-risk patients which includes post-bariatric, active smokers, those with poor skin quality, wanting larger implants or undergoing secondary surgery. The complications reported in this group of patients are as high as 32%. MATERIALS AND METHODS: We describe a new technique of one-stage mastopexy/augmentation, using a wide dermo-glandular pedicle, and our early results with 51 consecutive patients. RESULTS: Fifty-one patients were operated between January 2016 and September 2018, with a mean age of 40.0 years. Ten patients were smokers, eight were post-massive weight loss, six had previous mastopexy. At a mean follow-up of 22 months, only two patients had a unilateral bottoming out. There were no incidents of hematoma, seroma, capsular contracture or major tissue-related complications. CONCLUSION: Plastic surgery has been described as a struggle between beauty and blood supply. We have performed a one-stage mastopexy/augmentation using a wide and thick dermo-glandular glandular pedicle to maximize the blood supply in a range of challenging patients with promising results. 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 .

Two-person screening of mental well-being before primary breast augmentation: Can we do more?

Patients choosing aesthetic surgery are asymptomatic individuals opting for surgery. Psychologists and surgeons have been interested in identifying characteristics of these individuals' preoperative as well as postoperative psychological changes. It was identified that a small number of patients have a primary issue with self-body image, which resulted in altered perceptions and attitudes such that the preoccupation with perceived deficiencies continued even after surgery. The recommended course is to attempt to screen for the patients' mental well-being, as surgery alone does not improve the patients' symptoms. In the first author's practice, each prospective patient is reviewed by two individuals on separate occasions in order to discuss surgery and assure their mental and physical suitability. However, we encountered four patients who exhibited a strong negative reaction to their new shape, to the point that it necessitated explanation in the immediate postoperative phase in two of them. To our knowledge, this situation has not been described in the literature. We discuss the available literature as well as our consent process for breast augmentation. The first author has since introduced BREAST-Q to assess general patient well-being in the pre- and post-operative phases as a result of this experience. We also discuss the results for each of its domains and offer our thoughts about the management of such a situation.

Benchmarking the Outcomes of Single-Stage Augmentation Mastopexy against Primary Breast Augmentation: A Single Surgeon's Experience of 905 Consecutive Cases.

BACKGROUND: Augmentation mastopexy may be a one- or two-stage procedure. Because of the opposing force vectors in augmentation and in mastopexy, some surgeons advocate a two-stage procedure. The literature appears divided on which operation has a more favorable complication profile. The purpose of this review was to benchmark the outcomes of single-stage augmentation mastopexy against those of a commonly performed aesthetic breast operation (primary breast augmentation). METHODS: THE AUTHORS: reviewed electronic patient records of all consecutive female patients who underwent single-stage augmentation mastopexy and primary breast augmentation performed by the first author at our clinic between April of 2009 and May of 2017 with at least a 6-month follow-up. Data from single-stage augmentation mastopexy were benchmarked against the outcomes of primary breast augmentations performed by the same surgeon, for the same period, and at the same clinic. RESULTS: ONE HUNDRED FOUR: single-stage augmentation mastopexies and 801 primary breast augmentations were performed during this period, with mean follow-up of 15.4 months and 14.0 months, respectively. Augmentation mastopexy patients were significantly more likely to be older, have a higher body mass index, have more children, and were significantly less likely to use oral contraceptives. There was no statistically significant difference in overall complication rate between the two groups. CONCLUSIONS: THE AUTHORS': experience suggests that single-stage augmentation mastopexy has outcomes comparable to those of primary breast augmentation. Smokers were more likely to undergo reoperation because of postoperative complication (seroma), but the rate of implant exchange was not different. CLINICAL QUESTION/LEVEL OF EVIDENCE: THERAPEUTIC, III.

Online and Social Media Footprint of All Swedish Aesthetic Plastic Surgeons.

BACKGROUND: The visual nature of the Internet and its newer technologies makes it naturally aligned to plastic and aesthetic surgery. While many studies have looked at the use of social media ('SoMe'), they have been limited by either low response rate or limited scope. Our aim was to analyse a whole community of aesthetic plastic surgeons and their use of the Internet and social media platforms over a period of many years. METHODS: All active members of the Swedish national aesthetic plastic surgery society were identified. Webpages, professional (LinkedIn), social media (Facebook, Twitter, Instagram) and video-sharing (YouTube) accounts as well as online patient forum (Plastikoperationsforum) mentions of the surgeons and their clinics were identified, and corresponding platform-specific metrics were analysed. RESULTS: Of the 85 active members, 67 (78.9%) had a webpage on one of the 34 different clinic websites. The websites of older established clinics had a significantly better Alexa ranking than newer ones. Surgeons with a profile on Facebook or Instagram were significantly younger than those without an account. Twitter was the least preferred social media platform. Each surgeon had a mean 12.8 threads per year as compared to a mean 34.3 threads per clinic per year. CONCLUSION: Most of the new practices established by Swedish aesthetic plastic surgeons in the last 10 years are single-surgeon ones. Instagram and Facebook accounts of their clinics seem to be the most popular SoMe platforms. Younger surgeons were more likely to have a Facebook or Instagram account and to be using two or more social media platforms. These data provide information about all aesthetic plastic surgeons registered with the Swedish national body and their increasing use of SoMe. LEVEL OF EVIDENCE V: 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 .

Design of a combined cartilage graft crusher, morselizer and holder for use in rhinoplasty.

A combined cartilage holder and crusher is described that allows the surgeon to hold, crush, morselize, and suture a single piece or stack of cartilage graft without letting it slip. The customized slit-shaped jaws allow adequate room for the suture needle, while the serrated surfaces hold the cartilage firmly. The use of this instrument is advocated primarily in rhinoplasty for manipulating and suturing a small cartilage graft or a stack of grafts. The use of this instrument may be extended to aesthetic or reconstructive cases where cartilage grafts need to be sutured or shaped, as in eyelid, ear, and nipple reconstruction.

Patients' and Surgeons' Perceptions of Social Media's Role in the Decision Making for Primary Aesthetic Breast Augmentation.

BACKGROUND: Social media (SoMe) has evolved to be a platform that patients use to seek information prior to an operation, share perioperative and postoperative journey, provide feedback, offer and receive support. While there have been studies looking at the evolution and usage of SoMe either by patients or by surgeons, there is no information that compares its usefulness for both the groups. OBJECTIVES: The aim of this study was to compare the views held by patients and surgeons, towards social media and other internet resources, in relation to one commonly performed operation. METHODS: A questionnaire was presented to 648 consecutive patients who attended our clinic for consultation for primary breast augmentation from September 2016 to March 2017. A separate "surgeons' questionnaire" was answered by a group of 138 plastic surgeons who were either practicing in branches of our clinic, had previously done fellowship with us, or were visiting the clinic. RESULTS: All 138 surgeons and 648 patients responded to the questionnaire. A total of 91.4% of patients said that they had searched online and 61.4% had searched in specific online groups for information on breast augmentation. A total of 88.9% of patients had specifically looked for clinical photographs and 73.4% had specifically searched for unfavorable reviews of the surgeon. In comparison, 72.5% of surgeons thought that over three quarters of patients gather information on the internet while only 20.3% thought that over three quarters of patients use social media for their information. A total of 52.5% of surgeons have noticed that social media affected their consultations. CONCLUSIONS: With the evolution of the internet and related technologies, the role of social media continues to increase. While patients use social media to help make their decisions, it is not the only deciding factor. Surgeons appear to underestimate the patients' use of these technologies. There is concern in each group about the amount of inaccurate information on the social media. This underlines the importance of providing factual, evidence-based information to the patients.

Do Not Fear an Implant's Shape: A Single Surgeon's Experience of Over 1200 Round and Shaped Textured Implants in Primary Breast Augmentation.

BACKGROUND: Breast implants can be characterized by their fill material, surface texture, or shape. Whereas long-term good quality studies have provided evidence for the fill material and texture, there is still little consensus for choosing the shape of an implant. Surveys indicate that many surgeons choose only one implant shape, for reasons that may not always agree with outcomes from long-term studies. OBJECTIVES: We reviewed the first author's experience over the last six years with both round and anatomical implants, compared the rate of complications with either implant shape, and discussed the importance of keeping an open mind about using both implant shapes for primary breast augmentation. METHODS: A review of all consecutive primary breast augmentation patients by the first author over a six-year time period who had a minimum follow up of 6 months after surgery. RESULTS: Six-hundred and forty-eight female patients had 1296 silicone breast implants inserted over the six-year period. Mean age at surgery was 30.5 years and mean BMI was 20.6 kg/m2. All implants were textured, 134 (in 67 patients, 10.3%) were round in shape with mean volume of 338 cc (range, 220-560 cc), while 1162 implants (in 581 patients, 89.7%) were anatomical shaped with a mean volume of 309 cc (range, 140-615 cc). Among these patients, 11.9% (n = 8) with round implants and 9.0% (n = 52) of those with anatomical implants developed complications postoperatively. CONCLUSIONS: A single, ideal implant that is suitable for every primary breast augmentation does not exist. The optimum choice of implant shape in any given situation should take into account the patient's physical characteristics, available implant types, patient's desires, and the surgeon's experience. Together with round implants, anatomical devices ought to be considered as one of the tools in the surgeon's toolbox. By choosing to ignore them a priori means that the surgeon will only have access to half of his armamentarium and will therefore be able to offer a limited set of options to his patients.

Autologous Collagen Matrix (ACM): Lower Pole Support With a Supero-Anterior Capsular Flap in Secondary Subpectoral Breast Augmentation.

Background: Secondary aesthetic breast surgery is a complex and challenging scenario. It requires the surgeon to identify contributing factors, provide patient education, make a further management plan, and optimize the conditions for a favorable result. Various techniques have been described in literature but the rate of reoperation is still high. The first author has been using a supero-anterior capsular flap with a neopectoral subcapsular pocket and an implant change in these cases. Objectives: To review the patient characteristics, indications, and early results of using part of the existing implant capsule for secondary subpectoral breast augmentations. Methods: All patients who underwent secondary breast augmentation, over a period of 2 years by the first author (P.M.), using the supero-anterior capsular flap technique were included. The technique involves dissection of a new subpectoral pocket and uses the existing implant capsule as an internal brassiere. Results: A total of 36 patients were operated by this technique. Of these, 17 patients had developed a complication while 19 patients wanted a change in size only. At a mean follow up of 10.2 months, there was no bottoming out, double bubble, or capsular contracture. Conclusions: This reliable technique provides stable results as shown by low rate of complications with the existing follow up.

Role of Macrotextured Shaped Extra Full Projection Cohesive Gel Implants in Primary Aesthetic Breast Augmentation.

Background: Extra full projection implants are used in a select group of aesthetic breast surgery patients. Their use is selective enough that they have not been included in long term manufacturer studies and the indications for their use have attracted much debate. Only a handful of studies have reported the outcomes from implantation of these devices. Objectives: We review our experience of using extra full projection anatomically shaped macrotextured silicone gel implants discussing our rationale, indications, and results. Methods: All patients undergoing primary aesthetic breast surgery with extra full projection anatomical implants by the first author (P.M.) over a seven-year period (January 2009 to December 2015) were included. Results: Three hundred and ten female patients had 620 macrotextured extra full projection anatomically shaped cohesive silicone gel breast implants of mean volume 338 cc (range, 195-615 cc) placed over the seven-year period. All of them had at least a 6-months follow up. There were 39 complications (12.6%) at an average follow up of 12.3 months, including implant malposition/rotation (5.4%), capsular contracture (2.6%), and bottoming out (1.6%). A total of 41 patients (13.2%) were reoperated, of which 30 (9.7%) were due to a complication and 11 (3.5%) because of patient choice. Most of the complications were in the initial part of the case series. Conclusions: The outcomes following the use of extra full projection implants in a carefully selected group of patients are comparable in the short term to those reported for other shaped implants and complications appear to decrease with experience. Level of Evidence: 4.

Using LinkedIn for Continuing Community of Practice Among Hand Surgeons Worldwide.

BACKGROUND: Hand surgeons need continuing professional development due to rapid advancement in the field. Traditional approaches have proven to be challenging due to the nature of surgical practice and other demands. Social media sites have shown the potential to build an online community of practice. METHODS: One of the authors (VR) started Hand Surgery International on LinkedIn in February 2011. RESULTS: The number of members increased from 38 in the beginning to 4106 members by August 13, 2015, with members from all over the world. Half of them are from plastic surgery, with 16.8% hand and 17.8% orthopedic surgery; 63.8% of them are consultants. There were 151 discussion topics, which generated 1238 comments at an average of 8.2 comments per discussion thread. The topics focused on management of difficult patients, seeking consensus, and searching information. The features participants found most useful included case-based discussion, polls/surveys, and network opportunity. Members perceived the LinkedIn community as user-friendly and easy to use. It does not require significant technical knowledge. For the question "How would you rate the overall ease of using this platform?" 42% answered "strongly agree" and 37% "agree". CONCLUSION: The LinkedIn group serves as an effective means for continuing professional development for hand surgeons.

A prospective randomized trial of the efficacy of marginal quilting sutures and fibrin sealant in reducing the incidence of seromas in the extended latissimus dorsi donor site.

BACKGROUND: The extended latissimus dorsi is a workhorse flap and plays an important role in breast reconstruction. Unfortunately, seromas at the flap donor site are a frustrating problem complicating many procedures. The purpose of this study was to evaluate the efficacy of a combination of fibrin sealant (Quixil; Johnson & Johnson, Langhorne, Pa.) and limited quilting sutures at reducing seroma formation. METHODS: This was a prospective, double-blinded, clinical trial under a single surgeon. Twenty-six patients were enrolled in the study, and all were followed up for a period of 6 months. The patients were randomized to receive either quilting sutures only (group 1) or a combination of Quixil sealant and marginal quilting sutures (group 2). RESULTS: The incidence of seroma was 23.1 percent in group 1 and 7.7 percent in group 2 (odds ratio, 0.28; relative risk, 0.33). The mean total volume aspirated was significantly higher in group 1 (196.7 ml compared with 30 ml, p = 0.01). The average number of aspirations was 2.7 in group 1 compared with one in group 2. There was a significant reduction in inpatient stay for group 2 by 2 days (p = 0.01). Operative time was shortened by an average of 25 minutes. CONCLUSIONS: The combination of fibrin sealant and marginal quilting sutures significantly reduces total drainage, hospital stay, and seroma formation. In the authors' opinion, the benefits of seroma prevention outweigh the extra costs associated with this product. The potential, albeit small, risk of virus transmission and allergic reaction, however, needs to be taken into consideration, as with any blood transfusion product.

Investigation of safety and efficacy of a pneumatic finger tourniquet.

Finger tourniquets are widely used in hand surgery. However, they do not provide an estimate of the amount of pressure exerted and can potentially be left in situ with grave consequences. We assessed the pneumatic finger tourniquet in 57 adult patients in operations under local anaesthesia distal to the proximal interphalangeal joint. The average tourniquet time was 12 minutes. The tourniquet maintained its pressure for the length of the operation in 96.5% of cases. This airtight flat tubing is made of synthetic polymer, designed and manufactured by Barloworld Scientific Ltd (Staffordshire, UK). The tourniquet was easy to use and easily located after the operation. No complications were reported. This study supports the use of a pneumatic tourniquet in finger injuries requiring use of a finger tourniquet.