Breast implants may be introduced through several different incisions. According to a 2016 survey,1 the most common approach is inframammary (83.9%), followed by periareolar (12.6%), transaxillary (3.3%), and periumbilical (0.2%). When combined with a vertical mastopexy, the implant is usually inserted through an incision contained within the area of the lower pole marked for resection (Fig. 1).2
Capsular contracture remains the most frequent complication after breast augmentation and the most common indication for reoperation.1,3 However, its etiology remains unknown.4 A link has been proposed to an infected biofilm,5 leading plastic surgeons to efforts to reduce possible implant contamination.5 A 14-point plan was introduced to reduce the risk of both capsular contracture and breast implant–associated anaeplastic large-cell lymphoma, including a recommendation to avoid a periareolar5,6 or axillary incision.6 This recommendation was made in a 2018 Continuing Medical Education article.7 The scientific basis for the 14-point plan has been challenged.8–10
This review was undertaken to explore the scientific basis for the incision location as a factor related to the incidence of capsular contracture.
A PubMed electronic literature search was conducted to identify clinical publications in English that compared capsular contracture rates with the incision used for implant placement.
Ten publications were identified that compared capsular contracture rates by the incision.11–20 Most were retrospective chart reviews.12–17 Three were prospective core studies.18–20 A 2005 Danish study found an advantage for an inframammary incision over other approaches, but the sample sizes were small.11 Wiener12 reported a significantly increased risk of a capsular contracture using a periareolar incision versus an inframammary incision at the time of breast augmentation.
Jacobson et al13 reported an increased rate of capsular contracture after transaxillary breast augmentation compared with an inframammary or periareolar approach, but the authors recognized that their sample size was modest (197 breast augmentations). The difference in capsular contracture rates comparing an inframammary versus periareolar incision was not significant.13
By contrast, Stutman et al14 found no correlation between incision location and 5 complications (capsular contracture, hematoma, rippling, infection, and rupture). Benito-Ruiz et al15 compared reoperation rates in breast augmentation patients. The most common reason for reoperation was capsular contracture. The authors reported no difference in reoperation rates comparing an axillary incision (81% of patients) with a periareolar incision (19% of patients).
A 2014 core study evaluating 455 breast augmentation patients with a 10-year follow-up found no significant difference in capsular contracture rates comparing inframammary (17.4%) and periareolar incisions (18.6%).19 Two other core studies, with shorter follow-up, found risk differences in favor of the inframammary approach.18,20
Bresnick17 recently concluded that adding a separate inframammary incision for breast implant placement at the time of a vertical augmentation/mastopexy reduced the capsular contracture rate. Valente et al16 reviewed the TOPS (Tracking Outcomes and Operations for Plastic Surgeons) database. These authors found an increased risk of complications using a periareolar incision, but not specifically for capsular contracture.
The hypothetical basis for an increased risk of capsular contracture using a periareolar approach is that the tissue contains more milk ducts, located close to the nipple, which are transected and may cause more bacterial contamination than a more distant site.12,21
The most recent publication, by Bresnick,17 is the only study to compare capsular contracture rates by incision for augmentation/mastopexy, as opposed to breast augmentation alone. Comment is needed regarding the statistical comparisons. If the data are compared in a 3 × 2 χ2 contingency table (appropriate for 3 groups and 2 categories), the P value for the comparison is 0.058, indicating no significant difference in capsular contracture rates.22
Lista et al23 use the same concept, inserting the implant through an inframammary incision and placing it above the muscle, before proceeding with a periareolar mastopexy. When using a vertical mastopexy, these authors insert the implant through a vertical incision contained in the resection pattern of the lower pole.23 Weiner12 also uses a separate inframammary incision for subpectoral implant insertion when performing a periareolar augmentation/mastopexy. The authors' assumption is that using a separate inframammary incision for placement of an implant reduces the risk of a capsular contracture.12,23 Hubbard24 inserts the implant through a vertical incision on the lower pole, dissecting down to the pectoralis and inserting the implant through a sleeve, followed by muscle closure to minimize (“isolate” might be an overstatement) contact with the breast parenchyma. Interestingly, Hubbard makes the periareolar skin incision first. Hubbard recognizes the influence of Mladick,25 who first proposed a “no touch” technique to minimize breast implant handling.
A peculiarity of Bresnick's study is the distinction between a periareolar and vertical access for the implant.17 The author reports that surgeons commonly use periareolar, vertical, or inframammary “access incisions” for implant placement, supported by 2 references26,27 that do not in fact include discussion of an inframammary approach or periareolar placement of implants during vertical augmentation/mastopexy (these incisions are used for inverted-T and periareolar augmentation/mastopexies, respectively). The first reference did not include any vertical augmentation/mastopexies.26 It is not clear that the author's periareolar access group is really a vertical augmentation/mastopexy, as opposed to a periareolar augmentation/mastopexy. Photographs would be helpful, illustrating the 3 approaches and details of the pedicle used for nipple/areola repositioning.
In a vertical augmentation/mammaplasty, the access wound is on the lower pole, within the vertical elliptical resection pattern. The vertical mastopexy wound connects with the periareolar incision (Fig. 1). There is no tissue barrier. Therefore, the periareolar and vertical access groups should be considered 1 group. Comparison of capsular contracture rates for vertical augmentation/mastopexy with or without a separate inframammary incision for implant placement yields a nonsignificant P value (Table 1).22
TABLE 1 -
Rates in Vertical Augmentation/Mastopexy
Patients Treated With and Without an Inframammary
||No. Capsular Contractures by Breast (%)
||No. Capsular Contractures by Patient (%)
|Vertical plus inframammary incision
*A χ2 test was performed.
Bresnick17 does not report the mean follow-up time or the inclusion rate. Cosmetic breast patients are notorious for not keeping long-term appointments.3 Not all patients will return at 1 year, which was the time point chosen for assessment for capsular contracture. Moreover, a 1-year follow-up time is short for a study on capsular contracture.4
The author reports capsular contracture rates per breast,17 which effectively reduces the rates by half. There appears to be an error in the rate calculated for the vertical group (4/172 breasts = 2.33%, not 3.48%). Other publications report capsular contracture rates per patient,11–20,23–30 including the author's previous study.28 Obviously, the same denominator is needed when comparing results with other published studies. The authors do not report any bilateral contractures. If the contractures were all unilateral, the capsular contracture rate for the vertical access group is 4/86 (4.7%). The risk for the inframammary approach is 5/152 women (3.3%). By comparison, the author reports that the series of vertical augmentation/mastopexy patients reported by Swanson29 had a “high capsular contracture rate of 6.2%.” The actual rate from the referenced 2017 publication was 12/252 (4.8%).29 This incidence is similar to the rates reported by the author for either a vertical (4.7%, P = 0.96) or inframammary access incision (3.3%, P = 0.48), calculated per patient using the χ2 test.22
The author references his previous study,28 among others, supporting an increased risk of capsular contracture with a periareolar incision compared with an inframammary incision. However, a χ2 test finds the difference nonsignificant (21/554 vs 5/233, P = 0.24).22 Core studies are regarded as most robust. Although a meta-analysis has been published,30 finding a higher rate of capsular contracture associated with a periareolar incision, the authors recognize a high degree of data heterogeneity, with multiple variables affecting comparisons and a limited follow-up time of most studies.
The conceptual basis for a difference in capsular contracture rates depending on the access incision is open to question. It is not clear that the difference in centimeters of the incision from the areolar border is relevant. A 2016 microbiological study of cultures obtained from breast skin and parenchyma at surgery found that the cultured organisms are not distinct from ordinary skin flora, and that the periareolar approach is microbiologically safe.31 A specific microbiome or organism has not been linked to capsular contracture. Bacterial profiles are patient-specific rather than disease-specific.32
The term “no touch” technique is not entirely accurate. Bresnick33 clarifies that “no touch” (particularly when using an introduction sleeve) is a misnomer and really a marketing term because it is impossible to insert implants properly without at least some manual contact.
Confirmation bias must be considered. The inframammary approach is Bresnick's preferred method for inserting the implant.17 If the conclusion was that there is no benefit, hundreds of patients have been given an unnecessary extra scar. Cognitive dissonance might prevent acceptance of such a negative finding. However, an unbiased perspective suggests that the supporting evidence is tenuous.
A review of the evidence is not persuasive in favoring one incision over another to reduce capsular contracture risk. There is no need to make a separate incision to insert the implant at the time of augmentation/mastopexy, or to isolate the implant from contact with breast parenchyma. Little evidence supports the “no touch” technique. The etiology of capsular contracture remains unknown.
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