Research Article
Volume Change after Primary Breast Augmentation: Predicting and Defining a Significant Cause for Re-Operation
Hunter R Moyer* and Jessica Yeager
Department of Plastic Surgery, Emory University, USA
*Corresponding author: Hunter R Moyer, Department of Plastic Surgery, Emory University, 1400 Northside Forsyth Drive, Suite 390 Cumming, GA 30041, USA
Published: 27 Apr, 2017
Cite this article as: Moyer HR, Yeager J. Volume Change
after Primary Breast Augmentation:
Predicting and Defining a Significant
Cause for Re-Operation. Clin Surg.
2017; 2: 1445.
Abstract
Introduction: Accepted re-operation rates after primary breast augmentation range between 20%
to 30% with requests for volume change as a leading cause. This is the first report to characterize this
patient population and define actual volume changes.
Methods: We conducted a retrospective review of 812 patients that underwent primary augmentation
mammaplasty at the authors’ previous surgery center over a fifteen year period. On average, patients
were white females, 36 years old and with a BMI of 21.0 kg/m2. They were augmented primarily
with Mentor Moderate Profile implants (average 318 cc) in the sub-muscular plane (51.9%). Charts
were queried for patient demographics and implant characteristics. A Chi square test was used to
compare binary data and a Student’s t-test and correlation coefficients were used to compare ordinal
data.
Results: Our mean follow-up was 2.2 years (range 0 to 13 years) with a rate at six years of 31.5%.
The re-operation rate was 20.1% at three years and 5.7% of patients underwent volume change.
Women requesting a volume change were four times more likely to have saline implants (p=0.001),
thinner, and have larger implants placed at initial operation (p=0.012). Examining the 46 patients
revised for volume dissatisfaction, the average change was 10.2% larger (35.0 cc, range: -235 cc
to 170 cc). Women requesting larger implants had significantly more augmentations in the submuscular
plane and those requesting smaller implants had significantly more augmentations in the
sub-glandular plane (p=0.022). Time to re-operation, age, BMI, and type of fill material did not
significantly influence a woman’s desire to be larger or smaller.
Discussion: A majority of women re-operated on for volume discrepancy wished to be larger
(66.0%). Patients dissatisfied with their volume had significantly more saline devices and larger
implants at initial operation. Pocket location also significantly influences a patient’s perception of
breast size.
Keywords: Size; Volume; Change; Augmentation; Breast
Introduction
Over four million women worldwide have prosthetic breast implants for aesthetic and
reconstructive purposes. In 2015, roughly 279,000 women received breast implants in the United
States alone [1]. Although this is a decrease of 12% from the prior year, augmentation mammaplasty
remains the number one cosmetic surgical procedure. Patients and surgeons today have multiple
options of implant fill, surface texture, shape, projection and pocket location to tailor an implant
to both the patient’s body and her wishes. Despite this, patient dissatisfaction with size remains a
significant cause for revision surgery [2].
Implants are widely considered safe; however, they are not without local complications such
as hematoma, infection, and malposition and systemic complications of capsular contracture and
patient dissatisfaction. Most large series quote a re-operation rate at three years for augmentation
patients of approximately 20% to 30% [3,4]. Capsular contracture and volume dissatisfaction account
for a majority of these cases [5]. One positive from the FDA imposed moratorium on silicone breast
implants is the wealth of data from the pre-market approval studies (PMA) performed by Allergan
and Mentor Corporations. With a 61% six year follow-up, the Mentor study found a 19.4% reoperation
rate, a contracture rate of 9.8%, and a replacement rate for size discrepancy of 3.9% [3].
The Allergan study had an 81% follow-up at six years and a revision
rate of 28.0% [4]. Almost 15% noted significant capsular contracture
and 10% of patients were revised for volume dissatisfaction. Of these,
two thirds requested larger implants although the actual volume
changes are not published.
Patient expectation and ultimate satisfaction with the volume,
feel, and look of their breasts is subjective. The ultimate decision on
implant volume is made in the operating room based on patient input
and surgeon experience. Complicating the design is the fact that well
over 80% of women do not wear the correct bra size; thus, quoting
cup size is an inexact science [6,7]. Previous reports have focused
on anatomic measurements, pre-operative bra fillers and computer
simulations to improve patient satisfaction [8-14]; however, volume
dissatisfaction remains a significant cause for re-operation.
The purpose of this study is to review our experience with revision
breast augmentation surgery and to both define the volume changes
and describe the patient population. Our fundamental questions
were: (i) what percentage of patients that we see in follow-up request
an implant size change, (ii) can we predict those patients that will be
unhappy with their implant volume, and (iii) whom are the patients
wanting to be smaller or larger?
Methods
A medical record search was conducted at Paces Plastic Surgery
in Atlanta, Georgia to review patients that underwent primary breast
augmentation. Data was taken from pre-operative consultations,
operative reports, implant identification cards, and follow-up notes.
When applicable, pre-operative and post-operative photographs were
taken. Between 1994 and 2005, women received only saline filled
breast implants due to the FDA imposed moratorium on silicone gel
devices. Thereafter, both silicone and saline devices were implanted.
Pre-operative assessment was performed via the high-five
measurement technique, and taking account of the patient’s subjective
desires. The authors used the axiom that a skin pinch of less than 2 cm
obligated placing the implant in the sub-muscular plane. Nipple to
notch, nipple to inframammary fold, and base width measurements
were also variably used to guide implant volume.
All patients were given pre-operative antibiotics, most often
cefazolin, and drains were not used. Incisions were made in the axilla,
inframammary fold or around the areola. Both sub-muscular and
sub-glandular pockets were created based on the patient’s overlying
tissue envelope and the surgeon’s preference. Strict hemostasis was
ensured in all cases and pockets were universally irrigated with either
saline or a triple antibiotic irrigant. Post-operative care included
wearing a supportive bra for two weeks, avoiding excessive lifting or
exercise for three weeks, and breast massage starting two weeks after
surgery. Patients were offered free revision surgery up to one year
after the original operation and a discounted rate thereafter.
Statistics and graphs were analyzed using StatPlus (AnalystSoft,
Vancouver, BC). Two-sample T-tests and chi-square tests of
association were conducted to determine significance of the
continuous and categorical covariates, respectively. In addition,
simple logistic regression was used, with dichotomous outcome
direction of desired change, to assess the significance of each covariate
individually. Unadjusted odds ratios and corresponding 95 percent
Wald confidence intervals were calculated for each covariate.
Table 1
Table 2
Results
Eight hundred and twelve patients (1,624 implants) had sufficient
data to be included in this study. The patients were all female,
predominantly Caucasian, 36 years of age (range 16-72), and with a
body mass index (BMI) of 21.0 (range 15.3-40.7). Mentor implants
(Mentor Corporation, Santa Barbara, CA) were exclusively used in
this cohort. Patients were augmented predominantly with a Moderate
Profile implant averaging 318 cubic centimeters (range 125 cc to 650
cc). Saline-filled implants were used in 59.4% of patients. There was
an even distribution between sub-muscular placement (51.9%) and
sub-glandular placement (Table 1). The mean follow-up time was 2.2
years (range 0 to 14.5 years) with a six year follow up of 31.5%. The
mean follow-up time for silicone implants was shorter than saline due
to the moratorium on silicone implants by the FDA (1.3 years vs. 2.8
years).
Forty-six patients (5.7%) were later revised for volume
dissatisfaction at a mean of 22 months post-augmentation (range 0 to
119 months). These women were on average 34.5 years old (range 19
to 58) and with a BMI of 20.5 (range 17.7-23.9). The revised patients
had larger implants placed originally (340.2 cc), but with a similar
percentage of implants in the sub-muscular plane (57%). Considerably
more patients revised for volume dissatisfaction had saline devices
place on initial operation (80.4%). No statistical difference existed
between the revised and non-revised patients in regard to age, BMI,
and pocket location (Table 1).
In total, women undergoing revision were up-sized on average
10.2% (34.9 cc) with a range of -235 cc to 170 cc. One-third of patients
requested and received smaller implants at an average of a 92 cc
decrease while two-thirds of patients received larger implants at an
average of a 103 cc increase. Sixty-five percent of women with saline
implants received saline implants at re-operation while thirty-five
percent switched to silicone. A majority of those switched from saline
to silicone after the FDA moratorium was lifted in 2005. No patients
were converted from a sub-glandular to a sub-muscular pocket, but
21.5% of sub-muscular implants were changed to sub-glandular
(Figure 1A and 1B).
The average time to re-operation for the 46 women was 26
months. Those women requesting smaller implants were re-operated
on at 32 months and those requesting larger implants at 23 months
(p=0.29). There was no difference in BMI for patients receiving
larger versus smaller implants (average BMI=20.5 for both groups,
p=0.86). The original implants in the population down-sized were
smaller when compared to the patients up-sized (329 cc and 346 cc,
respectively), however, this was not statistically significant (p=0.30).
Patients augmented with saline implants were re-augmented with
a 40 cc increase compared to a 14 cc increase for silicone implants
(p=0.38). The average age of women requesting smaller implants was
37.4 years vs. 32.9 years for women wanting larger devices, a trend
that was close to significance (p=0.095).
Sub-muscular placements were significantly associated with
patients requesting larger implants both on uni-variate and mulitvariate
analysis. Women augmented in the sub-muscular plane
received larger implants initially (342 cc vs. 331 cc for sub-glandular);
however, they requested and were augmented with significantly
larger implants at re-operation (15.8% increase vs. a 1.0% increase,
p=0.022). Significant results are displayed in Table 1 and 2.
Figure 1A
Figure 1B
Discussion
Roughly one in four women will undergo re-operation after breast
augmentation due to local and systemic complications [15]. Volume
dissatisfaction ranks as one of the leading causes; however, there is a
dearth of information in the literature defining volume discrepancies.
Previous reports have focused on pre-operative bra fillers and
anatomical measurements to improve patient satisfaction. These
methods are a great adjunct as they focus on prevention; unfortunately
they cannot simulate the feel, weight and look of breast implants.
To date, only pre-operative ptosis and concomittant mastopexy are
shown to predict the need for re-operation in augmentation patients
[16]. Therefore, we wanted to review our experience to determine if
patient and surgical factors could predict those patients likely to be
unhappy with their augmented breast volume.
Women that return to clinic dissatisfied with their augmented
breast volume may be a unique population. A large majority of these
patients requested and received larger implants at re-operation.
Originally, we speculated that women requesting larger implants
would be younger, heavier, have smaller implants placed initially,
and implants in the sub-muscular plane. This was not evident in this
series nor our previous experience [17], and it is likely attributable to
several factors.
BMI
Our population of primary breast augmentation patients
represents a regional sample of young, thin, healthy women. As a
result, the standard deviation of BMI in the overall cohort was only
2.45 points, and thus the difference between a “heavy” and “thin”
patient is minimal. The population of women, we re-operated on
for volume discrepancy had a statistically significant lower BMI;
however, the difference was less than a point and we feel is not
clinically relevant despite previous anecdotal reports [18]. To support
this, no BMI differences were seen between women wanting larger
versus smaller implants.
Age
Women seen in follow-up requesting a volume change were
relatively the same age at primary surgery as the cohort. A trend
was evident that younger women were more likely to request larger
implants; however, the numbers were not large enough to reach
statistical significance. This is partially due to the relative homogeneity
of our patients. The ideals, perceptions and body image of a 33-yearold
female are not likely to be vastly different from that of a 37-yearold
woman.
Implant fill
We did see more women with saline devices return unhappy with
their volume; however, both the FDA moratorium and the longer
follow-up with our saline devices are confounders. Most women reoperated
on after the moratorium was lifted changed from a saline
device to a silicone implant. We cannot fully determine if these
patients were solely unhappy with their volume or if they had extra
motivation to seek consultation due to a desire to switch implant
fill. Furthermore, the overall follow-up for our saline cohort is twice
that of the silicone population; therefore, we may expect to see more
silicone patients requesting size change as time goes on.
Initial volume
Women returning for volume revision had significantly, both
statistically and clinically, larger implants placed at initial operation.
More profound, those that desired volume had even larger implants in
place. One explanation is larger and potentially firmer breast implants
are more explicit and by nature subject to more scrutiny. Another
possibility is that the patients we see for revisional surgery requesting
larger implants are those women that desire the “augmented” look of
larger, pronounced devices. In support of this are four women whom
returned for tertiary volume change, three of which requested and
received even larger implants.
Pocket location
Overall, the returning patients had a similar percentage of submuscular
and sub-glandular devices as the overall cohort; however,
pocket location appears to influence volume perception when directly
comparing the smaller cohort of women requesting smaller implants
versus those requesting larger implants. The odd is that a woman will
request larger implants with sub-muscular devices are 4.4 times that
of a woman with implants in the sub-glandular plane. It is clinically
evident that sub-muscular implants have less upper pole fullness and
less projection while sub-glandular have a more pronounced upper
pole shoulder and medial fullness. It appears that women are seeking
a compromise between the flat but more natural upper pole of a
sub-muscular implant and the medial cleavage and show of a subglandular
implant. These two competing elements, the augmented
cleavage and the natural upper pole slope, appear to significantly
motivate a woman to seek volume change. Of note, no patients
underwent a pocket change from sub-glandular to sub-muscular, but
21% changed from sub-muscular to sub-glandular. Unlike Lesavoy
et al. [19] description of their experience with site change from submuscular
to sub-glandular formal-position and hyper-animation,
all our patients presented to clinic with a primary complaint of
size dissatisfaction. They describe an average decrease of 27 cc in
36 patients when changing pocket which partially accounts for the
increased prominence expected with sub-glandular augmentation.
A woman’s perception and overall happiness with her breast
augmentation is dynamic and multi-factorial. The final breast is
a combination of width, height, projection, and feel coupled with
pre-operative expectations and sense of self. Both implant location
and initial volume play integral roles in the feel of the breast as well
as the inner and upper pole fullness. Most women desiring to have
larger implants after augmentation are larger to begin with and have
sub-muscular implants. Thus, it is possible that surgeons are underestimating
the influence of cleavage and upper pole show in this
patient population.
The greatest limitations of this study are its retrospective nature
and the low rate of follow-up. An initial strength of our review
was the rather large patient sample, however, because our followup
rate was only 31% and the volume revision rate only 5.7% we
have a small cohort of women returning for volume discontent.
This is compounded when comparing the populations requesting
larger versus smaller implants. Thus, differences may exist that we
cannot detect from this study. We are sure that some patients may
be unhappy with their implant volume but not to the degree that
warrants a follow-up consultation. Furthermore, other patients likely
seek another surgeon for potential revision surgery. Therefore, we feel
that our revision rate and dissatisfaction rate are underestimations.
Conclusion
In our experience, 20% of patients undergoing breast augmentation returned for additional surgery. If a patient returns to clinic complaining of volume disatissfaction, she most often wishes to be larger. These women are more likely to have larger than average implants and implants placed in the sub-muscular plane.
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