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    Rethinking breast augmentation

    In the world of breast augmentation, some “truths” may seem self-evident.

    Like this criticism of tissue-based planning: It’s for plastic surgeons who ignore the needs of their patients. Or this assumption about surgical strategy: You don’t need to learn how to perform transaxillary incisions. Or this belief about the placement of breast implants: They go under the muscle.

    It’s time to think again. That’s the word from a trio of plastic surgeons who challenged each of these beliefs during a session this week at The Aesthetic Meeting, the annual meeting of the American Society for Aesthetic Plastic Surgery and Aesthetic Surgery Education and Research Foundation.

    William Adams, Jr., M.D., clinical associate professor at University of Texas Southwestern Medical Center and chief of Plastic Surgery at Parkland Health and Hospital Systems in Dallas, says tissue-based planning doesn’t deserve a bad rap. It’s not a technique that summarily rejects the wishes of patients, he says, nor is it reserved for small patients.

    Instead, the approach relies on the breast tissue itself, since that’s “what really matters,” Dr. Adams says. “It optimizes patient outcomes; it provides infrastructure, control and efficiency; and it enhances patient and surgeon experience.”

    He uses the analogy of trying to decide between an artistic approach and an engineering approach. “The truth is that neither of these is ideal. Engineering provides boundaries for the artist to work in,” he says. Instead, “think of it as being a craftsman. That’s how you master control with tissue-based planning.”

    David Hidalgo, M.D., a plastic surgeon based in New York City who’s well-known for his intricate pencil drawings of faces, turned to another hot topic: the various incision approaches used in breast implant procedures.

    The inframammary incision remains the most popular by far among plastic surgeons, he says. It works well for silicone implants in women with small areolas, as a treatment for atrophy after pregnancy and in cases when no breast lifting is planned. However, he says, high and sharp creases are a challenge, the incision location must be accurate and hypertrophic scars are possible.

    Periareolar incisions can be appropriate in cases of difficult breast shapes and when breast lifting is planned, he says. But their efficacy is limited in women with small areolas, and they’re hazardous in women who’ve had multiple pregnancies. In addition, “sometimes you’ll get a dent, and they’re hard to fix.”

    The rare transaxillary incision, meanwhile, is “the best route” for saline implants, he says, and it can work well for patients who are young and haven’t been pregnant. As for side effects, “hematomas are extremely rare,” he says. “I’ve never had to do a second incision.”

    However, the procedure is not taught much anymore, he says, and inexperience can lead to malpositionining.

    Frank Lista, M.D., a plastic surgeon who practices near Toronto, offers his own challenge to tradition. He urges his colleagues to consider not always embracing the submuscular implant placement that’s common in North America.

    This placement contributes to problems like “bottoming out, double bubble, waterfall deformity, lateralization and animation deformities,” he says. But what about the reported lower risk of capsular contracture in submuscular implant procedures? He says research suggesting a lower risk is flawed.

    Here’s what you should know, he says: “There are patients who’d look better with the implant under the gland. Generally, it’s the heavy patient with poorly defined breast borders. They need better breast definition, and you want to see some edges. It’s the opposite of what we think about the thin patients.”


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