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Preliminary report on the use of the Spectra™ implant for the correction of hypoplastic breasts with small-volume asymmetry
Journal of Plastic, Reconstructive & Aesthetic Surgery (2012) 65, 312e320
Preliminary report on the use of the Spectra implant for the correction of hypoplastic breasts with small-volume asymmetry Marco Mazzocchi a,*, Luca Andrea Dessy b, Davide Gagliardi b, ` Scuderi b Alessandra Martano b, Nicolo a b
Department of Plastic Surgery, University of Perugia, Perugia, Italy Department of Plastic Surgery, “La Sapienza” University of Rome, Rome, Italy
Received 25 April 2011; accepted 21 August 2011
KEYWORDS Hypoplastic breast; Small-volume asymmetry; Breast asymmetry; Breast implant
Summary Background: Small-volume breast asymmetry is a challenging problem. In 2008, an intra-operative volume-adjustable breast implant, consisting of a round textured implant with an outer chamber filled with cohesive silicone gel and inner chamber filled with varying amounts of saline solution was marketed in Europe. We describe our experience in the correction of hypoplastic breasts with small-volume asymmetry using this device. Methods: From May 2008 on, female patients presenting small-volume breast asymmetry were enrolled in the study. Standard pictures were taken before surgery and during follow-up visits over 1 year; standardised objective measurements of breast and chest were also taken. Statistical significance of value variation was assessed by Wilcoxon’s rank sum test. A Visual Analogue Scale (VAS) was used to evaluate patients’ and external physicians’ judgement of breast symmetry achievement at the end of follow-up. The development of capsular contracture was assessed by measuring mammary compliance. Results: A total of 38 females were treated. The implant pocket was subglandular in 14 cases, subpectoral in 14 and dual plane in 10. The adjustable implant was positioned in the smaller breast. A textured round implant, whose diameter was the same as the adjustable one, was positioned in the contralateral breast. Thirty-five patients were fully satisfied; three were partially satisfied. Good aesthetic and functional breast symmetry results were achieved in all patients, as demonstrated by the objective measurement statistical analysis. We observed one case of delayed wound healing, one of bleeding and one of seroma, with no major late complications. Baker’s classification grade III capsular contracture was detected in one patient. Both implants maintained their initial volume. Conclusions: The possibility of intra-operatively modifying implant volume according to breast volume differences provides a reliable corrective option for hypoplastic breasts with
* Corresponding author. Via Portuense 331, 00149 Rome, Italy. Tel./fax: þ39 065581815. E-mail address: [email protected] (M. Mazzocchi). 1748-6815/$ - see front matter ª 2011 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by Elsevier Ltd. All rights reserved. doi:10.1016/j.bjps.2011.08.047
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small-volume asymmetry. Although these results are encouraging, a longer follow-up is required to evaluate implant ageing and long-term outcome. ª 2011 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by Elsevier Ltd. All rights reserved.
Breast asymmetry is present in over two-thirds of females1e5; this problem, which is generally congenital and has no known aetiopathogenesis, represents one of the most difficult challenges in the field of cosmetic breast surgery. Several authors have proposed various surgical procedures for the management of breast asymmetry, even by using a different technique on each breast,1,6e10 although no definitive solution has yet been found, particularly in cases in which there is little difference in volume between the breasts. Early signs may be observed in prepubertal and pubertal ages, when hormonal factors stimulate the gland and the entire breast growth, resulting in the anterior projection of the nipple-areola complex (NAC) and peripheral expansion of breast base.6 This phase is critical in the genesis of all mammary malformations. According to Rees and Dupuis,3 the left breast is usually wider and more ptotic than the right breast, though with no difference in the areola or nipple; indeed, a certain degree of breast asymmetry is more common than the number of diagnosed cases suggests.2,10 Although breast asymmetry is very frequent, the degree of difference between the breasts rarely justifies or leads to surgical correction, as the high frequency of breast asymmetry in the normal population suggests.11 According to surgeons’ estimates, breast asymmetry is present in 80% of the female population, though this figure rises to 100% when appropriate measuring tools are used.3,11 The presence of any difference between breasts in volume and shape, even if minimal, may nevertheless create a psychological concern that results in the patient consulting a plastic surgeon. However, when the initial asymmetry is minimal, it is more difficult to achieve a satisfactory and stable correction.9,10 Although a wide range of classifications and related surgical strategies are available,12,13 minor breast asymmetry has as yet received little clinical interest due to the negligible entity of the defect, on the one hand, and the extreme difficulty that is encountered in achieving an aesthetic result that satisfies both the surgeon and the patient, on the other. An intra-operative volume-adjustable breast implant, named Spectra (Mentor Corporation, Santa Barbara, CA, USA), has recently been introduced in the European market. It can have a textured or a smooth surface as round implants. This implant has a low bleed, cohesive silicone gel-filled outer lumen and an adjustable saline-fillable inner lumen. The inner lumen can gradually be filled with saline intraoperatively through the fill tube by injecting saline into the injection dome. Once filled to the desired volume, the fill tube and the injection dome are removed, and the prosthesis remains in position as a fixed-volume breast implant. Alternatively, the fill tube and the injection dome are kept in place by bringing the injection port through the skin in the same way as a drain and the implant volume can be adjusted postoperatively. In this way, the patient can then be involved in deciding on minor volume adjustments.
The purpose of this implant is to provide volume flexibility and projection adjustability. We considered the possibility of treating small-volume breast asymmetry by means of this device in combination with a conventional non-adjustable round implant, with the same base size as the adjustable implant. We thus performed a prospective open-label study to assess the effectiveness of this new prosthesis in the correction of small-volume breast asymmetry.
Materials and methods From May 2008 to March 2009, patients affected by a hypoplastic breast with small-volume asymmetry were treated in our Institution. All the patients were informed about the indications for surgical correction and possible complications. Before enrolment, all the patients signed an informed consent form. All the patients underwent a mammary ultrasound assessment or mammography, or both, depending on age and the quality of mammary tissue. To correct the deformity, patients underwent a standard bilateral augmentation mammaplasty with a prosthesis; the most appropriate implant pocket (subglandular, subpectoral or dual plane) was selected after evaluating softtissue coverage and degree of breast ptosis.14,18 A textured fixed-volume round cohesive I implant (Mentor Corporation, Santa Barbara, CA, USA) was positioned in the larger breast, while a volume-adjustable Spectra implant with a textured surface was positioned in the smaller breast. Implant diameter was the same in both breasts. Before starting the intra-operative filling with saline solution, the patient was placed in the sitting-position. Once the adjustable implant was filled to the desired volume, breast symmetry achievement was assessed by performing intra-operative breast-specific objective measurements, and then the fill tube was removed. In those patients affected by tuberous breast deformity, Muti’s technique was used to correct it following a two-step procedure19: first, disepithelialisation of both periareolar and inferior poles was performed according to preoperative markings; subsequently, a glandular flap was overturned on the glandular lower pole as a finger flexes on its proximal interphalangeal join; normal dimension of the breast base was restored. With respect to volume adjustment, the second surgical step was characterised by a bilateral augmentation mammaplasty with two different implants, as in the other forms of small-volume breast asymmetry. All the surgical procedures were performed under general anaesthesia; intravenous cephalosporin was administered to all the patients and suction drains were used routinely. The cost in our country of the textured Spectra implant is V 700.00 plus 4% value-added tax (VAT), the cost of the intra-operative sizer is V170.00 plus 20% VAT and the cost of
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Figure 1 Above e preoperative frontal and oblique views. Below e one year postoperative frontal and oblique views of the same patient. Right: Siltex Round High Profile, Cohesive I e 350 cc, diameter 11.7 cm, projection 4.9 cm. Left: Siltex Round Spectra Adjustable Gel Breast Implant e 335 cc, diameter 11.7 cm, projection 4.9 cm. Volume of saline added: 50 cc (Total volume: 385 cc). Visual analogical scale (VAS) expressing judgments on breast symmetry e Patients’ judgment: 9 e Physicians’ judgment: 9.
the round-textured fixed-volume implant is V620.00 plus 4% VAT. Before surgery and during follow-up visits (scheduled at 1, 4 and 12 months after surgery), standard digital photograms (frontal, oblique and lateral views, with arms down and up) and standard objective measurements of the breast and of the chest were taken. Breast-specific objective measurements were based on the jugular-to-nipple, mid-clavicularto-nipple, sternum-to-nipple, mid-armpit-to-nipple and submammary fold-to-nipple distances on each breast. Value differences between breasts were calculated in each patient to evaluate the degree of symmetry achievement. Chestspecific circumferences were measured at the NAC and at the inframammary fold (IMF), with the lungs both full and empty. These measurements were used to detect any change in the size of the prostheses themselves over time. In fact, both circumferences can modify initially after surgery for postoperative oedema and subsequently for variation of softtissue thickness whilst the NAC circumference can modify also in case of change in the size of the prostheses themselves at any time. The stability of the IMF circumference assures the absence of soft-tissue thickness modifications. Differences of specific breast and chest measurements taken before surgery and during follow-up visits were statistically analysed by means of Wilcoxon’s matched pairs signed rank sum test; statistical significance was set at p < 0.05.
Breast appearance was subjectively evaluated by the patients 1 year after surgery. The subjects’ global impression of clinical improvement was recorded using a visual analogue scale (VAS), based on a score from 1 to 10 (1 Z no correction of breast asymmetry, 10 Z no residual difference between breasts). In addition, the degree of breast symmetry achievement was evaluated by an external panel of physicians 1 year after surgery based on a subjective impression, using the same VAS, by comparing preoperative and postoperative pictures. Capsular contracture was assessed at follow-up visits by means of the palpation method according to the Baker classification20,21 and by measuring the mammary compliance scores by means of the Anton Paar Mammacompliance system.22,23 Before surgery and at the 1-year follow-up visit, patients were asked to fill out a questionnaire designed to examine progress over time in their psychological state.
Results During the study period, 38 patients, whose age ranged from 18 to 36 years (mean 27 years and 3 months; median: 24 years), were treated. Twelve patients (31.5%) presented bilateral developmental hypoplasia with small-volume asymmetry, 10 patients (26.4%) presented small-volume
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Figure 2 Above e preoperative frontal and oblique views. Below e One year postoperative frontal and oblique views of the same patient. Right: Siltex Round Spectra Adjustable Gel Breast Implant e 240 cc, diameter 10.5 cm, projection 4.3 cm. Volume of saline added: 35 cc (Total volume: 275 cc) Left: Siltex Round High Profile, Cohesive I e 250 cc, diameter 10.5 cm, projection 4.5 cm. Visual analogical scale (VAS) expressing judgments on breast symmetry e Patients’ judgment: 10 e Physicians’ judgment: 10.
breast asymmetry with mild ptosis, eight patients (21%) presented unilateral iatrogenic hypoplasia as a result of previous surgical interventions (benign mass ablation), seven (18.5%) presented a tuberous breast deformity, while one patient (2.6%) was affected by a simple form of Poland’s disease, characterised by the presence of pectoral muscle, breast atrophy and a slight breast asymmetry with ‘pectus excavatum’. The implant pocket used was subglandular in 14 cases, subpectoral in 14 and dual plane in 10. The size of the textured round implants positioned in the larger breast ranged from 275 to 375 cc. The size of the adjustable volume implants ranged from 250 to 355 cc, while the saline load used to achieve symmetry ranged from 35 to 50 cc (mean: 47 cc). Good aesthetic and functional breast symmetry results were achieved in all the patients (Figures 1e4). Immediate complications comprised delayed wound healing in one case (2.63%), which occurred on the adjustable breast implant side, one case of haematoma (2.63%) and one case of seroma (2.63%), the last two occurring on the fixedvolume prosthesis side. None of the above complications had a negative effect on the ultimate achievement of breast symmetry. The mean length of hospital stay was 1.65 days (range: 1e3 days).
No major late complications occurred during the 1-year follow-up period. According to the Baker classification, the degree of capsular contracture at the 1-year follow-up on the adjustable implant side was grade I in 19 cases (50%), grade II in 18 cases (47.3%) and grade III in one case (2.63%). In the contralateral breast, it was grade I in 18 cases (47.3%), grade II in 19 cases (50%) and grade III in one case (2.63%). The mean value of mammary compliance obtained at the 1-year follow-up was 45.81 (range 35.6e54.4) in the adjustable breast implant side and 45.50 (range 34.7e52.6) in the contralateral side. No differences were found in relation to the type of implant pocket. Mean values and standard deviations of the differences of specific breast measurements and their statistical significance are summarised in Table 1, whereas those of specific chest circumferences are summarised in Table 2. According to the VAS, good-to-high patient satisfaction was observed (Table 3). In addition, the assessment of breast symmetry achievement conducted by the external panel of physicians yielded comparable results (Table 3). The patient questionnaire did not reveal any major changes in the patients’ psychological state, with all remaining stable.
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Figure 3 Above e preoperative frontal, oblique and lateral views. Below e One year postoperative frontal, oblique and lateral views of the same patient. Right: Siltex Round Spectra Adjustable Gel Breast Implant e 310 cc, diameter 11.4 cm, projection 4.6 cm. Volume of saline added: 50 cc (Total volume: 360 cc). Left: Siltex Round High Profile, Cohesive I e 325 cc, diameter 11.4 cm, projection 4.6 cm. Visual analogical scale (VAS) expressing judgments on breast symmetry e Patients’ judgment: 10 e Physicians’ judgment: 8.
Figure 4 Above e preoperative frontal, lateral and oblique views. Below e One year postoperative frontal, lateral and oblique views of the same patient. Right: Siltex Round High Profile, Cohesive I e 275 cc, diameter 10.8 cm, projection 4.4 cm. Left: Siltex Round Spectra Adjustable Gel Breast Implant e 260 cc, diameter 10.8 cm, projection 4.4 cm. Volume of saline added: 25 cc (Total volume: 285 cc). Visual analogical scale (VAS) expressing judgments on breast symmetry e Patients’ judgment: 9 e Physicians’ judgment: 10.
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Table 1 Mean values, standard deviations of differences of specific breast measurements (evaluated before surgery and during follow-up visits) and their statistical significance assessed by means of Wilcoxon’s matched pairs signed rank sum test. Nipple-jugular
Mid-clavicular to nipple
Sternum to nipple
Mid-armpit to nipple
Inframammary fold to nipple
M SD
M SD
M SD
M SD
M SD
T0 T1 T2 T3
0.574 0.2048 0.044 0.0714 0.053 0.0678 0.055 0.0676
0.650 0.2137 0.044 0.0593 0.052 0.0678 0.055 0.0676
0.539 0.2601 0.052 0.0595 0.058 0.0633 0.060 0.0629
0.374 0.2446 0.053 0.0716 0.055 0.0784 0.063 0.0840
0.760 0.6499 0.089 0.1187 0.092 0.1178 0.094 0.1218
T0eT1 T0eT2 T0eT3 T1eT2 T1eT3 T2eT3
p <0.0001 <0.0001 <0.0001 >0.05 >0.05 >0.05
p <0.0001 <0.0001 <0.0001 >0.05 >0.05 >0.05
p <0.0001 <0.0001 <0.0001 >0.05 >0.05 >0.05
p <0.0001 <0.0001 <0.0001 >0.05 >0.05 >0.05
p <0.0001 <0.0001 <0.0001 >0.05 >0.05 >0.05
M: mean; SD: standard deviation; p: probability; T0: preoperative; T1: 1 month after surgery; T2: 4 month after surgery; T3: 1 year after surgery.
Discussion Although breast asymmetry is present in over 80% of the female population,10,13 the number of cases that ultimately undergo surgery is relatively low, probably owing to the fact that this problem is of minor psychological concern to the majority of women; however, another reason may be that minor forms of breast asymmetry are extremely difficult to correct and the final aesthetic outcome is not always satisfactory.8 The technique we present in this study for the correction of small-volume breast asymmetries has indubitable advantages. In particular, the insertion of an implant in each breast means that both the mammary glands ‘grow old’ in the same manner while maintaining the same degree of ptosis over the years.
Volume-asymmetry correction was achieved in all the patients by means of implants of the same diameter with minimal differences in volume, with the fixed-volume prosthesis being positioned in the larger breast. The use of implants with the same base size contributed to the achievement of symmetry by allowing both breasts to be modelled according to a similar final base. The simultaneous use of two different breast implants in the same patient also allowed us, when we examined the overall follow-up data, to detect any difference in implant biocompatibility and duration. The volume difference was easily corrected during surgery by altering the volume of the expandable prosthesis. Indeed, the surgeon was able to increase the volume of saline both gently and safely, thereby adjusting the breast size during the intervention. When optimal symmetry was obtained, the surgeon simply extracted the
Table 2 Mean values, standard deviations of differences of specific chest measurements (evaluated before surgery and during follow-up visits) and their statistical significance assessed by means of Wilcoxon’s matched pairs signed rank sum test. Nipple-Areola complex
Inframammary fold
Maximum inspiration
Maximum expiration
Maximum inspiration
Maximum expiration
M SD
M SD
M SD
M SD
T0 T1 T2 T3
83.93 2.251 91.44 2.649 90.88 2.665 90.87 2.657
79.95 2.166 87.89 2.248 87.37 2.288 87.37 2.286
76.68 2.231 77.06 2.228 76.64 2.222 76.70 2.203
71.78 2.131 71.96 2.104 71.71 2.151 71.81 2.121
T0eT1 T0eT2 T0eT3 T1eT2 T1eT3 T2eT3
p <0.0001 <0.0001 <0.0001 <0.0001 <0.0001 >0.05
p <0.0001 <0.0001 <0.0001 <0.0001 <0.0001 >0.05
p <0.0001 >0.05 >0.05 <0.0001 <0.0001 >0.05
p <0.0001 >0.05 >0.05 <0.0001 <0.0001 >0.05
M: mean; SD: standard deviation; p: probability; T0: preoperative; T1: 1 month after surgery; T2: 4 month after surgery; T3: 1 year after surgery.
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Table 3 Visual analogical scale (VAS) of patients and physicians expressing their global judgments on breast symmetry (1: no improvement; 10 maximum improvement). VAS value Patients’ judgment Physicians’ judgment
1
2
3
4
5
6
7
8
9
10
1 1
1 1
1 2
14 15
16 13
5 6
fill tube and completed the wound/skin closure. In this way, we combined the benefits of breast gel implants with volume flexibility and the typical projection of an implant filled with saline. Furthermore, the implant pockets were created using the same technique on each side. The surgical techniques we used are fairly standardised owing to their widespread use in breast augmentation procedures.14e17 Either the periareolar or inframammary access was used, as appropriate; the pocket for the insertion of the prosthesis was submuscular, subglandular or dual plane, depending on the thickness and position of the soft tissue available to cover the implant.14,18 When bilateral tuberous breast correction was required, the technique described by Muti19 was executed on each side, and then the two different implants were positioned after pocket creation, following the previous described modalities. If we consider the potential pros and cons of inserting an adjustable implant in one breast, some concerns may be raised. An alternative method to correct hypoplastic breast with small-volume asymmetry would be to choose the same implant base dimension and use a different projection as the means of correcting for volume discrepancies, but this method allows only fixed-volume corrections and, depending on the dimension of the implant, these fixed volumes range from 25 to 165 cc. Thus, this method does not allow smaller volume corrections. In addition, although the volume of the Spectra implant can be adjusted either intra-operatively or postoperatively, we preferred to modify implant volume only intra-operatively for several reasons: first, postoperative tissue swelling can behave differently on each breast, thus altering the final result; second, we did not want to increase the probability of implant infection by keeping a direct communication between the implant and the external environment; third, we wanted to avoid an additional scar; and lastly, we did not want to negatively influence patient comfort for several days in the case of having an eternal tube and valve to manage with. Besides, the cost of the Spectra implant compared with an intra-operative sizer and then a fixedvolume implant is not significant. In fact, the cost of using the first time a fixed-volume reusable sizer plus a fixedvolume implant is higher; but considering that sizers can be re-sterilized for a maximum of 10 times, costs become comparable. Evaluation of capsular contracture did not reveal any difference between the fixed-volume and variable-volume implants. In our study, the correction of the asymmetry was confirmed by the reduction of the differences between left and right values for each specific breast measurement; they decreased after surgery and subsequently remained
stable over the 1-year follow-up, proving the maintenance of breast symmetry (Table 1). We did not observe any reduction in implant volume during follow-up. This finding was confirmed by the stability of both specific chest measurements (Table 2). These measurements were used to detect any change in the size of the prostheses themselves over time. In fact, both circumferences can modify initially after surgery for postoperative tissue swelling and subsequently for variation of the soft-tissue thickness related to body weight modifications, whilst the NAC circumference can modify also in case of change in the size of the prostheses themselves at any time. The stability of IMF circumferences proved the absence of relevant body weight modifications in the studied group, whilst the stability of postoperative NAC circumferences proved the maintenance of implant volumes. The objective data and statistical evidence of breast asymmetry correction were confirmed by the subjective evaluations. The VAS scores based on the patients’ and physicians’ judgements yielded almost total satisfaction as regards the aesthetic and functional outcomes. In our experience, the use of the adjustable implant has so far proved to be effective, to be free of any specific risks or complications and to yield good aesthetic results. Although the resistance of the housing and the efficiency of the valve for the adjustable implant remained unchanged in the 1-year follow-up period covered by our study, this volume-adjustable device warrants longer follow-up clinical trials designed to assess its durability over time.
Conclusions Recent statistics have shown that in the course of their professional activity, plastic surgeons deal with four to five cases of true breast asymmetry every year. This means that such surgeons need to be aware of new diagnostic methods and innovative surgical techniques, which go hand in hand with a surgeon’s technical skill and experience gained in the operating theatre. Therefore, the biggest challenge a surgeon faces in cases of mild asymmetry is finding the courage to recommend the most appropriate treatment even when the aesthetic results may not be satisfactory. The surgical strategy proposed in our study provides a comparative and temporal assessment of two different prostheses that are implanted in the same patient at the same time, thereby offering us the possibility to evaluate the durability of the adjustable implant. The results of this study highlight the efficacy, the reproducibility and the ease of the surgical strategy we propose to correct small-volume breast asymmetry. The main advantage of the Spectra implant is that it allows the surgeon to make very fine intra-operative adjustments to balance breast size, with all the benefits and product quality of gel implants. Using the satisfying results of this preliminary report as a starting point, we plan to continue our evaluation of the technique we have presented through a longer follow-up, focussing on the maintenance of the initial volume of these adjustable implants over time.
Invited commentary
Conflict of interest/funding None.
References 1. Grolleau JL, Lanfrey E, Lavigne B, Chavoin JP, Costagliola M. Breast base anomalies: treatment strategy for tuberous breasts, minor deformities, and asymmetry. Plast Reconstr Surg 1999;104:2040e8. 2. Godfrey PM. Breast asymmetry: varied problems, varied solutions. The clinic in operative plastic surgery. New York: Plastic Surgery Associates; 1996. 3. Rees TD, Dupuis CC. Unilateral mammary hypoplasia. Plast Reconstr Surg 1968;41:307e10. 4. Nassab RS, Hamnett N, Dhital S, Juma A. The relationship between hand dominance and breast size difference in congenital breast asymmetry. Plast Reconstr Surg 2010;125:211e. 5. Denoel C, Aguirre MF, Bianco G, et al. Idiopathic scoliosis and breast asymmetry. J Plast Reconstr Aesthet Surg 2009;62:1303e8. 6. Novakovi c M, Lukac M, Kozarski J, et al. Principles of surgical treatment of congenital, developmental and acquired female breast asymmetries. Vojnosanit Pregl 2010;67:313e20. 7. Cervelli V, Araco F, Araco A, Grimaldi M, Cervelli G. New view in the mammary asymmetry treatments. Minerva Chir 2005;60:91e8. 8. Me ´dard de Chardon V, Balaguer T, Chignon-Sicard B, Ihrai T, Lebreton E. Constitutional asymmetries in aesthetic breast augmentation: incidence, postoperative satisfaction and surgical options. Ann Chir Plast Esthet 2009;54:340e7. 9. Onesti MG, Mezzana P, Martano A, Scuderi N. Breast asymmetry: a new vision of this malformation. Acta Chir Plast 2004;46:8e11. 10. Malata CM, Boot JC, Bradbury ET, Ramli AR, Sharpe DT. Congenital breast asymmetry: subjective and objective assessment. Br J Plast Surg 1994;47:95e102.
319 11. Vandenbussche F. Asymmetries of the breast: a classification system. Aesth Plast Surg 1984;8:27e36. 12. Gliosci A, Presutti F. Asymmetry of the breast: some uncommon cases. Aesth Plast Surg 1994;18:399e403. 13. Smith Jr DJ, Palin Jr WE, Katch VL, Bennett JE. Breast volume and anthropomorphic measurements: normal values. Plast Reconstr Surg 1986;78:331e5. 14. Ramirez OM, Heller MDL, Tebbetts JB. Dual plane breast augmentation: avoiding pectoralis major displacement. Plast Reconstr Surg 2002;110:1198. 15. Tebbetts JB. A system for breast implant selection based on patient tissue characteristics and implant-soft tissue dynamics. Plast Reconstr Surg 2002;109:1396e409. 16. Tebbetts JB. Dual plane breast augmentation: optimizing implant-soft-tissue relationships in a wide range of breast types. Plast Reconstr Surg 2001;107:1255e72. 17. Tebbetts JB. What is adequate fill? Implications in breast implant surgery. Plast Reconstr Surg 1996;97:1451e4. 18. Hidalgo DA, Spector JA. Preoperative sizing in breast augmentation. Plast Reconstr Surg 2010;125:1781e7. 19. Muti E. Personal approach to surgical correction of the extremely hypoplastic tuberous breast. Aesth Plast Surg 1996;20:385e90. 20. Baker JL. Augmentation mammaplasty. In: Owsley JP, Peterson RA, editors. Symposium on aesthetic surgery of the breast. St. Louis: Mosby; 1978. p. 256e63. 21. Spear SL, Baker Jr JL. Classification of capsular contracture after prosthetic breast reconstruction. Plast Reconstr Surg 1995;96:1119e23. 22. Alfano C, Mazzocchi M, Scuderi N. Mammary compliance: an objective measurement of capsular contracture. Aesth Plast Surg 2004;28:75e9. 23. Mazzocchi M, Alfano C, Fioramonti P, Scuderi N. Changes over time in mammary compliance values following breast augmentation. Aesth Plast Surg 2006;30:198e205.
Invited commentary Marc D. Pacifico * Department of Plastic Surgery, Queen Victoria Hospital, Holtye Road, East Grinstead, West Sussex RH193DZ, UK Received 2 September 2011; accepted 17 September 2011
In this well-written paper, Mazzocchi and his co-authors present their initial impression of the use of Mentor’s Spectra implants. These are adjustable implants that are predominantly silicone, but with a small inner lumen to allow volume (mainly projection) adjustment of the implant. Breast asymmetry surgery, especially when mild, as in the theme of this paper, can be a considerable aesthetic challenge. The Spectra implants seem ideally designed for this situation. Although presenting some very good outcomes, my one reservation about Mazzocchi et al.’s
DOI of original article: 10.1016/j.bjps.2011.08.047.
approach is that they appear to have only capitalised on the adjustable nature of Spectra intra-operatively. Why not, then, just use a cheaper inflatable breast sizer, or a range of two or three fixed volume reusable sizers of fixed base dimensions (see Figure 1)? My rationale for using the Spectra is to allow the patient to gain ownership of the final fineetuning decision-making process postoperatively. This is possible in two ways e either the port can be exteriorised (in the same way as a surgical drain) and adjusted the day after surgery. Alternatively, it can be placed subcutaneously, to be adjusted in the
Preliminary report on the use of the Spectra implant for the correction of hypoplastic breasts with small-volume asymmetry Marco Mazzocchi a,*, Luca Andrea Dessy b, Davide Gagliardi b, ` Scuderi b Alessandra Martano b, Nicolo a b
Department of Plastic Surgery, University of Perugia, Perugia, Italy Department of Plastic Surgery, “La Sapienza” University of Rome, Rome, Italy
Received 25 April 2011; accepted 21 August 2011
KEYWORDS Hypoplastic breast; Small-volume asymmetry; Breast asymmetry; Breast implant
Summary Background: Small-volume breast asymmetry is a challenging problem. In 2008, an intra-operative volume-adjustable breast implant, consisting of a round textured implant with an outer chamber filled with cohesive silicone gel and inner chamber filled with varying amounts of saline solution was marketed in Europe. We describe our experience in the correction of hypoplastic breasts with small-volume asymmetry using this device. Methods: From May 2008 on, female patients presenting small-volume breast asymmetry were enrolled in the study. Standard pictures were taken before surgery and during follow-up visits over 1 year; standardised objective measurements of breast and chest were also taken. Statistical significance of value variation was assessed by Wilcoxon’s rank sum test. A Visual Analogue Scale (VAS) was used to evaluate patients’ and external physicians’ judgement of breast symmetry achievement at the end of follow-up. The development of capsular contracture was assessed by measuring mammary compliance. Results: A total of 38 females were treated. The implant pocket was subglandular in 14 cases, subpectoral in 14 and dual plane in 10. The adjustable implant was positioned in the smaller breast. A textured round implant, whose diameter was the same as the adjustable one, was positioned in the contralateral breast. Thirty-five patients were fully satisfied; three were partially satisfied. Good aesthetic and functional breast symmetry results were achieved in all patients, as demonstrated by the objective measurement statistical analysis. We observed one case of delayed wound healing, one of bleeding and one of seroma, with no major late complications. Baker’s classification grade III capsular contracture was detected in one patient. Both implants maintained their initial volume. Conclusions: The possibility of intra-operatively modifying implant volume according to breast volume differences provides a reliable corrective option for hypoplastic breasts with
* Corresponding author. Via Portuense 331, 00149 Rome, Italy. Tel./fax: þ39 065581815. E-mail address: [email protected] (M. Mazzocchi). 1748-6815/$ - see front matter ª 2011 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by Elsevier Ltd. All rights reserved. doi:10.1016/j.bjps.2011.08.047
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small-volume asymmetry. Although these results are encouraging, a longer follow-up is required to evaluate implant ageing and long-term outcome. ª 2011 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by Elsevier Ltd. All rights reserved.
Breast asymmetry is present in over two-thirds of females1e5; this problem, which is generally congenital and has no known aetiopathogenesis, represents one of the most difficult challenges in the field of cosmetic breast surgery. Several authors have proposed various surgical procedures for the management of breast asymmetry, even by using a different technique on each breast,1,6e10 although no definitive solution has yet been found, particularly in cases in which there is little difference in volume between the breasts. Early signs may be observed in prepubertal and pubertal ages, when hormonal factors stimulate the gland and the entire breast growth, resulting in the anterior projection of the nipple-areola complex (NAC) and peripheral expansion of breast base.6 This phase is critical in the genesis of all mammary malformations. According to Rees and Dupuis,3 the left breast is usually wider and more ptotic than the right breast, though with no difference in the areola or nipple; indeed, a certain degree of breast asymmetry is more common than the number of diagnosed cases suggests.2,10 Although breast asymmetry is very frequent, the degree of difference between the breasts rarely justifies or leads to surgical correction, as the high frequency of breast asymmetry in the normal population suggests.11 According to surgeons’ estimates, breast asymmetry is present in 80% of the female population, though this figure rises to 100% when appropriate measuring tools are used.3,11 The presence of any difference between breasts in volume and shape, even if minimal, may nevertheless create a psychological concern that results in the patient consulting a plastic surgeon. However, when the initial asymmetry is minimal, it is more difficult to achieve a satisfactory and stable correction.9,10 Although a wide range of classifications and related surgical strategies are available,12,13 minor breast asymmetry has as yet received little clinical interest due to the negligible entity of the defect, on the one hand, and the extreme difficulty that is encountered in achieving an aesthetic result that satisfies both the surgeon and the patient, on the other. An intra-operative volume-adjustable breast implant, named Spectra (Mentor Corporation, Santa Barbara, CA, USA), has recently been introduced in the European market. It can have a textured or a smooth surface as round implants. This implant has a low bleed, cohesive silicone gel-filled outer lumen and an adjustable saline-fillable inner lumen. The inner lumen can gradually be filled with saline intraoperatively through the fill tube by injecting saline into the injection dome. Once filled to the desired volume, the fill tube and the injection dome are removed, and the prosthesis remains in position as a fixed-volume breast implant. Alternatively, the fill tube and the injection dome are kept in place by bringing the injection port through the skin in the same way as a drain and the implant volume can be adjusted postoperatively. In this way, the patient can then be involved in deciding on minor volume adjustments.
The purpose of this implant is to provide volume flexibility and projection adjustability. We considered the possibility of treating small-volume breast asymmetry by means of this device in combination with a conventional non-adjustable round implant, with the same base size as the adjustable implant. We thus performed a prospective open-label study to assess the effectiveness of this new prosthesis in the correction of small-volume breast asymmetry.
Materials and methods From May 2008 to March 2009, patients affected by a hypoplastic breast with small-volume asymmetry were treated in our Institution. All the patients were informed about the indications for surgical correction and possible complications. Before enrolment, all the patients signed an informed consent form. All the patients underwent a mammary ultrasound assessment or mammography, or both, depending on age and the quality of mammary tissue. To correct the deformity, patients underwent a standard bilateral augmentation mammaplasty with a prosthesis; the most appropriate implant pocket (subglandular, subpectoral or dual plane) was selected after evaluating softtissue coverage and degree of breast ptosis.14,18 A textured fixed-volume round cohesive I implant (Mentor Corporation, Santa Barbara, CA, USA) was positioned in the larger breast, while a volume-adjustable Spectra implant with a textured surface was positioned in the smaller breast. Implant diameter was the same in both breasts. Before starting the intra-operative filling with saline solution, the patient was placed in the sitting-position. Once the adjustable implant was filled to the desired volume, breast symmetry achievement was assessed by performing intra-operative breast-specific objective measurements, and then the fill tube was removed. In those patients affected by tuberous breast deformity, Muti’s technique was used to correct it following a two-step procedure19: first, disepithelialisation of both periareolar and inferior poles was performed according to preoperative markings; subsequently, a glandular flap was overturned on the glandular lower pole as a finger flexes on its proximal interphalangeal join; normal dimension of the breast base was restored. With respect to volume adjustment, the second surgical step was characterised by a bilateral augmentation mammaplasty with two different implants, as in the other forms of small-volume breast asymmetry. All the surgical procedures were performed under general anaesthesia; intravenous cephalosporin was administered to all the patients and suction drains were used routinely. The cost in our country of the textured Spectra implant is V 700.00 plus 4% value-added tax (VAT), the cost of the intra-operative sizer is V170.00 plus 20% VAT and the cost of
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Figure 1 Above e preoperative frontal and oblique views. Below e one year postoperative frontal and oblique views of the same patient. Right: Siltex Round High Profile, Cohesive I e 350 cc, diameter 11.7 cm, projection 4.9 cm. Left: Siltex Round Spectra Adjustable Gel Breast Implant e 335 cc, diameter 11.7 cm, projection 4.9 cm. Volume of saline added: 50 cc (Total volume: 385 cc). Visual analogical scale (VAS) expressing judgments on breast symmetry e Patients’ judgment: 9 e Physicians’ judgment: 9.
the round-textured fixed-volume implant is V620.00 plus 4% VAT. Before surgery and during follow-up visits (scheduled at 1, 4 and 12 months after surgery), standard digital photograms (frontal, oblique and lateral views, with arms down and up) and standard objective measurements of the breast and of the chest were taken. Breast-specific objective measurements were based on the jugular-to-nipple, mid-clavicularto-nipple, sternum-to-nipple, mid-armpit-to-nipple and submammary fold-to-nipple distances on each breast. Value differences between breasts were calculated in each patient to evaluate the degree of symmetry achievement. Chestspecific circumferences were measured at the NAC and at the inframammary fold (IMF), with the lungs both full and empty. These measurements were used to detect any change in the size of the prostheses themselves over time. In fact, both circumferences can modify initially after surgery for postoperative oedema and subsequently for variation of softtissue thickness whilst the NAC circumference can modify also in case of change in the size of the prostheses themselves at any time. The stability of the IMF circumference assures the absence of soft-tissue thickness modifications. Differences of specific breast and chest measurements taken before surgery and during follow-up visits were statistically analysed by means of Wilcoxon’s matched pairs signed rank sum test; statistical significance was set at p < 0.05.
Breast appearance was subjectively evaluated by the patients 1 year after surgery. The subjects’ global impression of clinical improvement was recorded using a visual analogue scale (VAS), based on a score from 1 to 10 (1 Z no correction of breast asymmetry, 10 Z no residual difference between breasts). In addition, the degree of breast symmetry achievement was evaluated by an external panel of physicians 1 year after surgery based on a subjective impression, using the same VAS, by comparing preoperative and postoperative pictures. Capsular contracture was assessed at follow-up visits by means of the palpation method according to the Baker classification20,21 and by measuring the mammary compliance scores by means of the Anton Paar Mammacompliance system.22,23 Before surgery and at the 1-year follow-up visit, patients were asked to fill out a questionnaire designed to examine progress over time in their psychological state.
Results During the study period, 38 patients, whose age ranged from 18 to 36 years (mean 27 years and 3 months; median: 24 years), were treated. Twelve patients (31.5%) presented bilateral developmental hypoplasia with small-volume asymmetry, 10 patients (26.4%) presented small-volume
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Figure 2 Above e preoperative frontal and oblique views. Below e One year postoperative frontal and oblique views of the same patient. Right: Siltex Round Spectra Adjustable Gel Breast Implant e 240 cc, diameter 10.5 cm, projection 4.3 cm. Volume of saline added: 35 cc (Total volume: 275 cc) Left: Siltex Round High Profile, Cohesive I e 250 cc, diameter 10.5 cm, projection 4.5 cm. Visual analogical scale (VAS) expressing judgments on breast symmetry e Patients’ judgment: 10 e Physicians’ judgment: 10.
breast asymmetry with mild ptosis, eight patients (21%) presented unilateral iatrogenic hypoplasia as a result of previous surgical interventions (benign mass ablation), seven (18.5%) presented a tuberous breast deformity, while one patient (2.6%) was affected by a simple form of Poland’s disease, characterised by the presence of pectoral muscle, breast atrophy and a slight breast asymmetry with ‘pectus excavatum’. The implant pocket used was subglandular in 14 cases, subpectoral in 14 and dual plane in 10. The size of the textured round implants positioned in the larger breast ranged from 275 to 375 cc. The size of the adjustable volume implants ranged from 250 to 355 cc, while the saline load used to achieve symmetry ranged from 35 to 50 cc (mean: 47 cc). Good aesthetic and functional breast symmetry results were achieved in all the patients (Figures 1e4). Immediate complications comprised delayed wound healing in one case (2.63%), which occurred on the adjustable breast implant side, one case of haematoma (2.63%) and one case of seroma (2.63%), the last two occurring on the fixedvolume prosthesis side. None of the above complications had a negative effect on the ultimate achievement of breast symmetry. The mean length of hospital stay was 1.65 days (range: 1e3 days).
No major late complications occurred during the 1-year follow-up period. According to the Baker classification, the degree of capsular contracture at the 1-year follow-up on the adjustable implant side was grade I in 19 cases (50%), grade II in 18 cases (47.3%) and grade III in one case (2.63%). In the contralateral breast, it was grade I in 18 cases (47.3%), grade II in 19 cases (50%) and grade III in one case (2.63%). The mean value of mammary compliance obtained at the 1-year follow-up was 45.81 (range 35.6e54.4) in the adjustable breast implant side and 45.50 (range 34.7e52.6) in the contralateral side. No differences were found in relation to the type of implant pocket. Mean values and standard deviations of the differences of specific breast measurements and their statistical significance are summarised in Table 1, whereas those of specific chest circumferences are summarised in Table 2. According to the VAS, good-to-high patient satisfaction was observed (Table 3). In addition, the assessment of breast symmetry achievement conducted by the external panel of physicians yielded comparable results (Table 3). The patient questionnaire did not reveal any major changes in the patients’ psychological state, with all remaining stable.
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Figure 3 Above e preoperative frontal, oblique and lateral views. Below e One year postoperative frontal, oblique and lateral views of the same patient. Right: Siltex Round Spectra Adjustable Gel Breast Implant e 310 cc, diameter 11.4 cm, projection 4.6 cm. Volume of saline added: 50 cc (Total volume: 360 cc). Left: Siltex Round High Profile, Cohesive I e 325 cc, diameter 11.4 cm, projection 4.6 cm. Visual analogical scale (VAS) expressing judgments on breast symmetry e Patients’ judgment: 10 e Physicians’ judgment: 8.
Figure 4 Above e preoperative frontal, lateral and oblique views. Below e One year postoperative frontal, lateral and oblique views of the same patient. Right: Siltex Round High Profile, Cohesive I e 275 cc, diameter 10.8 cm, projection 4.4 cm. Left: Siltex Round Spectra Adjustable Gel Breast Implant e 260 cc, diameter 10.8 cm, projection 4.4 cm. Volume of saline added: 25 cc (Total volume: 285 cc). Visual analogical scale (VAS) expressing judgments on breast symmetry e Patients’ judgment: 9 e Physicians’ judgment: 10.
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Table 1 Mean values, standard deviations of differences of specific breast measurements (evaluated before surgery and during follow-up visits) and their statistical significance assessed by means of Wilcoxon’s matched pairs signed rank sum test. Nipple-jugular
Mid-clavicular to nipple
Sternum to nipple
Mid-armpit to nipple
Inframammary fold to nipple
M SD
M SD
M SD
M SD
M SD
T0 T1 T2 T3
0.574 0.2048 0.044 0.0714 0.053 0.0678 0.055 0.0676
0.650 0.2137 0.044 0.0593 0.052 0.0678 0.055 0.0676
0.539 0.2601 0.052 0.0595 0.058 0.0633 0.060 0.0629
0.374 0.2446 0.053 0.0716 0.055 0.0784 0.063 0.0840
0.760 0.6499 0.089 0.1187 0.092 0.1178 0.094 0.1218
T0eT1 T0eT2 T0eT3 T1eT2 T1eT3 T2eT3
p <0.0001 <0.0001 <0.0001 >0.05 >0.05 >0.05
p <0.0001 <0.0001 <0.0001 >0.05 >0.05 >0.05
p <0.0001 <0.0001 <0.0001 >0.05 >0.05 >0.05
p <0.0001 <0.0001 <0.0001 >0.05 >0.05 >0.05
p <0.0001 <0.0001 <0.0001 >0.05 >0.05 >0.05
M: mean; SD: standard deviation; p: probability; T0: preoperative; T1: 1 month after surgery; T2: 4 month after surgery; T3: 1 year after surgery.
Discussion Although breast asymmetry is present in over 80% of the female population,10,13 the number of cases that ultimately undergo surgery is relatively low, probably owing to the fact that this problem is of minor psychological concern to the majority of women; however, another reason may be that minor forms of breast asymmetry are extremely difficult to correct and the final aesthetic outcome is not always satisfactory.8 The technique we present in this study for the correction of small-volume breast asymmetries has indubitable advantages. In particular, the insertion of an implant in each breast means that both the mammary glands ‘grow old’ in the same manner while maintaining the same degree of ptosis over the years.
Volume-asymmetry correction was achieved in all the patients by means of implants of the same diameter with minimal differences in volume, with the fixed-volume prosthesis being positioned in the larger breast. The use of implants with the same base size contributed to the achievement of symmetry by allowing both breasts to be modelled according to a similar final base. The simultaneous use of two different breast implants in the same patient also allowed us, when we examined the overall follow-up data, to detect any difference in implant biocompatibility and duration. The volume difference was easily corrected during surgery by altering the volume of the expandable prosthesis. Indeed, the surgeon was able to increase the volume of saline both gently and safely, thereby adjusting the breast size during the intervention. When optimal symmetry was obtained, the surgeon simply extracted the
Table 2 Mean values, standard deviations of differences of specific chest measurements (evaluated before surgery and during follow-up visits) and their statistical significance assessed by means of Wilcoxon’s matched pairs signed rank sum test. Nipple-Areola complex
Inframammary fold
Maximum inspiration
Maximum expiration
Maximum inspiration
Maximum expiration
M SD
M SD
M SD
M SD
T0 T1 T2 T3
83.93 2.251 91.44 2.649 90.88 2.665 90.87 2.657
79.95 2.166 87.89 2.248 87.37 2.288 87.37 2.286
76.68 2.231 77.06 2.228 76.64 2.222 76.70 2.203
71.78 2.131 71.96 2.104 71.71 2.151 71.81 2.121
T0eT1 T0eT2 T0eT3 T1eT2 T1eT3 T2eT3
p <0.0001 <0.0001 <0.0001 <0.0001 <0.0001 >0.05
p <0.0001 <0.0001 <0.0001 <0.0001 <0.0001 >0.05
p <0.0001 >0.05 >0.05 <0.0001 <0.0001 >0.05
p <0.0001 >0.05 >0.05 <0.0001 <0.0001 >0.05
M: mean; SD: standard deviation; p: probability; T0: preoperative; T1: 1 month after surgery; T2: 4 month after surgery; T3: 1 year after surgery.
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Table 3 Visual analogical scale (VAS) of patients and physicians expressing their global judgments on breast symmetry (1: no improvement; 10 maximum improvement). VAS value Patients’ judgment Physicians’ judgment
1
2
3
4
5
6
7
8
9
10
1 1
1 1
1 2
14 15
16 13
5 6
fill tube and completed the wound/skin closure. In this way, we combined the benefits of breast gel implants with volume flexibility and the typical projection of an implant filled with saline. Furthermore, the implant pockets were created using the same technique on each side. The surgical techniques we used are fairly standardised owing to their widespread use in breast augmentation procedures.14e17 Either the periareolar or inframammary access was used, as appropriate; the pocket for the insertion of the prosthesis was submuscular, subglandular or dual plane, depending on the thickness and position of the soft tissue available to cover the implant.14,18 When bilateral tuberous breast correction was required, the technique described by Muti19 was executed on each side, and then the two different implants were positioned after pocket creation, following the previous described modalities. If we consider the potential pros and cons of inserting an adjustable implant in one breast, some concerns may be raised. An alternative method to correct hypoplastic breast with small-volume asymmetry would be to choose the same implant base dimension and use a different projection as the means of correcting for volume discrepancies, but this method allows only fixed-volume corrections and, depending on the dimension of the implant, these fixed volumes range from 25 to 165 cc. Thus, this method does not allow smaller volume corrections. In addition, although the volume of the Spectra implant can be adjusted either intra-operatively or postoperatively, we preferred to modify implant volume only intra-operatively for several reasons: first, postoperative tissue swelling can behave differently on each breast, thus altering the final result; second, we did not want to increase the probability of implant infection by keeping a direct communication between the implant and the external environment; third, we wanted to avoid an additional scar; and lastly, we did not want to negatively influence patient comfort for several days in the case of having an eternal tube and valve to manage with. Besides, the cost of the Spectra implant compared with an intra-operative sizer and then a fixedvolume implant is not significant. In fact, the cost of using the first time a fixed-volume reusable sizer plus a fixedvolume implant is higher; but considering that sizers can be re-sterilized for a maximum of 10 times, costs become comparable. Evaluation of capsular contracture did not reveal any difference between the fixed-volume and variable-volume implants. In our study, the correction of the asymmetry was confirmed by the reduction of the differences between left and right values for each specific breast measurement; they decreased after surgery and subsequently remained
stable over the 1-year follow-up, proving the maintenance of breast symmetry (Table 1). We did not observe any reduction in implant volume during follow-up. This finding was confirmed by the stability of both specific chest measurements (Table 2). These measurements were used to detect any change in the size of the prostheses themselves over time. In fact, both circumferences can modify initially after surgery for postoperative tissue swelling and subsequently for variation of the soft-tissue thickness related to body weight modifications, whilst the NAC circumference can modify also in case of change in the size of the prostheses themselves at any time. The stability of IMF circumferences proved the absence of relevant body weight modifications in the studied group, whilst the stability of postoperative NAC circumferences proved the maintenance of implant volumes. The objective data and statistical evidence of breast asymmetry correction were confirmed by the subjective evaluations. The VAS scores based on the patients’ and physicians’ judgements yielded almost total satisfaction as regards the aesthetic and functional outcomes. In our experience, the use of the adjustable implant has so far proved to be effective, to be free of any specific risks or complications and to yield good aesthetic results. Although the resistance of the housing and the efficiency of the valve for the adjustable implant remained unchanged in the 1-year follow-up period covered by our study, this volume-adjustable device warrants longer follow-up clinical trials designed to assess its durability over time.
Conclusions Recent statistics have shown that in the course of their professional activity, plastic surgeons deal with four to five cases of true breast asymmetry every year. This means that such surgeons need to be aware of new diagnostic methods and innovative surgical techniques, which go hand in hand with a surgeon’s technical skill and experience gained in the operating theatre. Therefore, the biggest challenge a surgeon faces in cases of mild asymmetry is finding the courage to recommend the most appropriate treatment even when the aesthetic results may not be satisfactory. The surgical strategy proposed in our study provides a comparative and temporal assessment of two different prostheses that are implanted in the same patient at the same time, thereby offering us the possibility to evaluate the durability of the adjustable implant. The results of this study highlight the efficacy, the reproducibility and the ease of the surgical strategy we propose to correct small-volume breast asymmetry. The main advantage of the Spectra implant is that it allows the surgeon to make very fine intra-operative adjustments to balance breast size, with all the benefits and product quality of gel implants. Using the satisfying results of this preliminary report as a starting point, we plan to continue our evaluation of the technique we have presented through a longer follow-up, focussing on the maintenance of the initial volume of these adjustable implants over time.
Invited commentary
Conflict of interest/funding None.
References 1. Grolleau JL, Lanfrey E, Lavigne B, Chavoin JP, Costagliola M. Breast base anomalies: treatment strategy for tuberous breasts, minor deformities, and asymmetry. Plast Reconstr Surg 1999;104:2040e8. 2. Godfrey PM. Breast asymmetry: varied problems, varied solutions. The clinic in operative plastic surgery. New York: Plastic Surgery Associates; 1996. 3. Rees TD, Dupuis CC. Unilateral mammary hypoplasia. Plast Reconstr Surg 1968;41:307e10. 4. Nassab RS, Hamnett N, Dhital S, Juma A. The relationship between hand dominance and breast size difference in congenital breast asymmetry. Plast Reconstr Surg 2010;125:211e. 5. Denoel C, Aguirre MF, Bianco G, et al. Idiopathic scoliosis and breast asymmetry. J Plast Reconstr Aesthet Surg 2009;62:1303e8. 6. Novakovi c M, Lukac M, Kozarski J, et al. Principles of surgical treatment of congenital, developmental and acquired female breast asymmetries. Vojnosanit Pregl 2010;67:313e20. 7. Cervelli V, Araco F, Araco A, Grimaldi M, Cervelli G. New view in the mammary asymmetry treatments. Minerva Chir 2005;60:91e8. 8. Me ´dard de Chardon V, Balaguer T, Chignon-Sicard B, Ihrai T, Lebreton E. Constitutional asymmetries in aesthetic breast augmentation: incidence, postoperative satisfaction and surgical options. Ann Chir Plast Esthet 2009;54:340e7. 9. Onesti MG, Mezzana P, Martano A, Scuderi N. Breast asymmetry: a new vision of this malformation. Acta Chir Plast 2004;46:8e11. 10. Malata CM, Boot JC, Bradbury ET, Ramli AR, Sharpe DT. Congenital breast asymmetry: subjective and objective assessment. Br J Plast Surg 1994;47:95e102.
319 11. Vandenbussche F. Asymmetries of the breast: a classification system. Aesth Plast Surg 1984;8:27e36. 12. Gliosci A, Presutti F. Asymmetry of the breast: some uncommon cases. Aesth Plast Surg 1994;18:399e403. 13. Smith Jr DJ, Palin Jr WE, Katch VL, Bennett JE. Breast volume and anthropomorphic measurements: normal values. Plast Reconstr Surg 1986;78:331e5. 14. Ramirez OM, Heller MDL, Tebbetts JB. Dual plane breast augmentation: avoiding pectoralis major displacement. Plast Reconstr Surg 2002;110:1198. 15. Tebbetts JB. A system for breast implant selection based on patient tissue characteristics and implant-soft tissue dynamics. Plast Reconstr Surg 2002;109:1396e409. 16. Tebbetts JB. Dual plane breast augmentation: optimizing implant-soft-tissue relationships in a wide range of breast types. Plast Reconstr Surg 2001;107:1255e72. 17. Tebbetts JB. What is adequate fill? Implications in breast implant surgery. Plast Reconstr Surg 1996;97:1451e4. 18. Hidalgo DA, Spector JA. Preoperative sizing in breast augmentation. Plast Reconstr Surg 2010;125:1781e7. 19. Muti E. Personal approach to surgical correction of the extremely hypoplastic tuberous breast. Aesth Plast Surg 1996;20:385e90. 20. Baker JL. Augmentation mammaplasty. In: Owsley JP, Peterson RA, editors. Symposium on aesthetic surgery of the breast. St. Louis: Mosby; 1978. p. 256e63. 21. Spear SL, Baker Jr JL. Classification of capsular contracture after prosthetic breast reconstruction. Plast Reconstr Surg 1995;96:1119e23. 22. Alfano C, Mazzocchi M, Scuderi N. Mammary compliance: an objective measurement of capsular contracture. Aesth Plast Surg 2004;28:75e9. 23. Mazzocchi M, Alfano C, Fioramonti P, Scuderi N. Changes over time in mammary compliance values following breast augmentation. Aesth Plast Surg 2006;30:198e205.
Invited commentary Marc D. Pacifico * Department of Plastic Surgery, Queen Victoria Hospital, Holtye Road, East Grinstead, West Sussex RH193DZ, UK Received 2 September 2011; accepted 17 September 2011
In this well-written paper, Mazzocchi and his co-authors present their initial impression of the use of Mentor’s Spectra implants. These are adjustable implants that are predominantly silicone, but with a small inner lumen to allow volume (mainly projection) adjustment of the implant. Breast asymmetry surgery, especially when mild, as in the theme of this paper, can be a considerable aesthetic challenge. The Spectra implants seem ideally designed for this situation. Although presenting some very good outcomes, my one reservation about Mazzocchi et al.’s
DOI of original article: 10.1016/j.bjps.2011.08.047.
approach is that they appear to have only capitalised on the adjustable nature of Spectra intra-operatively. Why not, then, just use a cheaper inflatable breast sizer, or a range of two or three fixed volume reusable sizers of fixed base dimensions (see Figure 1)? My rationale for using the Spectra is to allow the patient to gain ownership of the final fineetuning decision-making process postoperatively. This is possible in two ways e either the port can be exteriorised (in the same way as a surgical drain) and adjusted the day after surgery. Alternatively, it can be placed subcutaneously, to be adjusted in the