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Expandable implants should be used in special cases only
Expandable Implants Should Be Used in Special Cases Only n my opinion, soft tissue expandable implants should not be used routinely, but only in special cases. For example, I would consider using expandable implants for patients undergoing surgery to correct breast asymmetry, because in these cases the implant size chosen is often not exactly right and some degree of adjustment may be indicated postoperatively. I would also consider using expandable prostheses to treat tubular breast deformities and when ptosis is desired to match the opposite breast.
I
I have been using round, saline-filled implants since 1991. I place the implants beneath the muscle, preferably through an inferior circumareolar incision. I dissect around the breast tissues, then through the muscle to the subpectoral plane, dissecting the pocket digitally down to below the preoperatively marked inframammary fold. I have been using circumareolar incisions almost exclusively since I switched to using saline implants. The inferior circumareolar incision allows a direct approach to the submuscular pocket, dissection around--not through~breast tissue, easy access to the medial pectoral fibers, and easier inspection of the central pocket for bleeding. The loss of sensitivity of the nipple with the circumareolar incision is no greater than that with either the transaxillary or inframammary incision. The cosmetic result is excellent in that the incision falls along the line of demarcation between the pigmented skin and normal skin, and therefore generally becomes virtually invisible in a few weeks. Although some saline implants are expandable, I prefer not to adjust them after an agreed upon volume has been achieved. My guiding principle in breast augmentation procedures is not to create too large a breast. When I discuss breast size with a patient undergoing augmentation, I tell her that she may at some point--whether it is 1 year or 10 years later--have different feelings about the breast
size that she desires; I can predict that this will happen with reasonable certainty. My patient and I consider this fact carefully when deciding on a permanent size. I believe that suggesting to the patient that her breast size may be easily changed L Franklyn EIIiott, MD, Atlanta, GA, is a board-certified at a later date creates a conplastic surgeon and an A S A P S fusing array of options for member. her. In fact, I believe that given those options, a patient's desire to change her breast size might be based more on the knowledge that it can be done rather than on a genuine desire for the change. Knowing that she has the option of increasing .... or decreasing her breast size at any given point opens a Pandora's box. In my mind, the claimed advantages of using expandable implants are not particularly compelling. I do not believe that overfilling implants resolves rippling. I also do not see how refilling a prosthesis is a permanent solution to leaking. I believe that when an implant leaks, it should be replaced. In addition, I am not aware of any data that show that expansion is a permanent cure for capsular contracture, so I would hesitate to use it for that purpose. Finally, if an injection port is placed permanently, it seems likely that over time it will incur increasing morbidity. Because of the lack of evidence to show that expandable implants provide permanent solutions for breast rippling, leaking, or contracture, I would strongly recommend that these prostheses be used only in special cases such as those involving asymmetry, ptosis, and tubular deformities. 9 Reprint orders: Mosby-Year Book, ~nc., 11830 West~ine industrial Drive, St. Louis, MO 63146-3318; phone (314) 453-4350; reprint no. 70/1/81889.
AESTHETIC
SURGERY
JOURNAL
~
MARCH/APRIL
1997
131
MY V I E W
Subperiosteal Face Lift: A Mid Face Degloving Technique Through an Intraoral Approach continued from page 125
Expandable Implants Offer Breast Augmentation Patients More Options continued from page 130
tions, and the aesthetic results have been very good (Figure). The site of the imbrication sutures can be constructed to produce some malar prominence. Of course, the long-term results of this technique are not yet known. 9
result is not maintained permanently, the technique can be repeated. In addition to the potential technical advantages, expandable implants offer an important psychological benefit. They enable the patient to participate in the decision making; she can feel as if she has an active part in her procedure as opposed to being a passive object of it. All patients, and especially young persons, are good candidates for the procedure. In my opinion the downside of using these prostheses is their cost. In addition, problems with filling port malposition or overturn are not uncommon. However, when I explain all of the potential advantages of having expandable prostheses to patients, they usually choose them instead of nonexpandable implants. 9
Suggested Reading Ramirez O. Classification of facial rejuvenation techniques based on the subperiosteal approach and ancillary procedures. Plast Reconstr Surg 1996;97(1):45-55. Reprint orders: Mosby-Year Book, Inc., 11830 Westline Industrial Drive, St. Louis, MO 63146-3318; phone (314) 453-4350; reprint no. 70/1/81521,
Reprint requests: Mosby-Year Book, Inc., 11830 Westline Industrial Drive, St. Louis, MO 63146-3318; phone (314) 453-4350; reprint no.
70/1/81888.
*132
AESTHETIC
SURGERY
JOURNAL
-
IMARCH/APRtL
1997
Volumel7, Number2
I
I have been using round, saline-filled implants since 1991. I place the implants beneath the muscle, preferably through an inferior circumareolar incision. I dissect around the breast tissues, then through the muscle to the subpectoral plane, dissecting the pocket digitally down to below the preoperatively marked inframammary fold. I have been using circumareolar incisions almost exclusively since I switched to using saline implants. The inferior circumareolar incision allows a direct approach to the submuscular pocket, dissection around--not through~breast tissue, easy access to the medial pectoral fibers, and easier inspection of the central pocket for bleeding. The loss of sensitivity of the nipple with the circumareolar incision is no greater than that with either the transaxillary or inframammary incision. The cosmetic result is excellent in that the incision falls along the line of demarcation between the pigmented skin and normal skin, and therefore generally becomes virtually invisible in a few weeks. Although some saline implants are expandable, I prefer not to adjust them after an agreed upon volume has been achieved. My guiding principle in breast augmentation procedures is not to create too large a breast. When I discuss breast size with a patient undergoing augmentation, I tell her that she may at some point--whether it is 1 year or 10 years later--have different feelings about the breast
size that she desires; I can predict that this will happen with reasonable certainty. My patient and I consider this fact carefully when deciding on a permanent size. I believe that suggesting to the patient that her breast size may be easily changed L Franklyn EIIiott, MD, Atlanta, GA, is a board-certified at a later date creates a conplastic surgeon and an A S A P S fusing array of options for member. her. In fact, I believe that given those options, a patient's desire to change her breast size might be based more on the knowledge that it can be done rather than on a genuine desire for the change. Knowing that she has the option of increasing .... or decreasing her breast size at any given point opens a Pandora's box. In my mind, the claimed advantages of using expandable implants are not particularly compelling. I do not believe that overfilling implants resolves rippling. I also do not see how refilling a prosthesis is a permanent solution to leaking. I believe that when an implant leaks, it should be replaced. In addition, I am not aware of any data that show that expansion is a permanent cure for capsular contracture, so I would hesitate to use it for that purpose. Finally, if an injection port is placed permanently, it seems likely that over time it will incur increasing morbidity. Because of the lack of evidence to show that expandable implants provide permanent solutions for breast rippling, leaking, or contracture, I would strongly recommend that these prostheses be used only in special cases such as those involving asymmetry, ptosis, and tubular deformities. 9 Reprint orders: Mosby-Year Book, ~nc., 11830 West~ine industrial Drive, St. Louis, MO 63146-3318; phone (314) 453-4350; reprint no. 70/1/81889.
AESTHETIC
SURGERY
JOURNAL
~
MARCH/APRIL
1997
131
MY V I E W
Subperiosteal Face Lift: A Mid Face Degloving Technique Through an Intraoral Approach continued from page 125
Expandable Implants Offer Breast Augmentation Patients More Options continued from page 130
tions, and the aesthetic results have been very good (Figure). The site of the imbrication sutures can be constructed to produce some malar prominence. Of course, the long-term results of this technique are not yet known. 9
result is not maintained permanently, the technique can be repeated. In addition to the potential technical advantages, expandable implants offer an important psychological benefit. They enable the patient to participate in the decision making; she can feel as if she has an active part in her procedure as opposed to being a passive object of it. All patients, and especially young persons, are good candidates for the procedure. In my opinion the downside of using these prostheses is their cost. In addition, problems with filling port malposition or overturn are not uncommon. However, when I explain all of the potential advantages of having expandable prostheses to patients, they usually choose them instead of nonexpandable implants. 9
Suggested Reading Ramirez O. Classification of facial rejuvenation techniques based on the subperiosteal approach and ancillary procedures. Plast Reconstr Surg 1996;97(1):45-55. Reprint orders: Mosby-Year Book, Inc., 11830 Westline Industrial Drive, St. Louis, MO 63146-3318; phone (314) 453-4350; reprint no. 70/1/81521,
Reprint requests: Mosby-Year Book, Inc., 11830 Westline Industrial Drive, St. Louis, MO 63146-3318; phone (314) 453-4350; reprint no.
70/1/81888.
*132
AESTHETIC
SURGERY
JOURNAL
-
IMARCH/APRtL
1997
Volumel7, Number2