We read with great interest the article by Rubi et al.1 They compared aesthetic outcome in 30 patients after primary breast augmentation. The outcome was rated, using frontal and oblique views, 12 weeks apart by the same set of observers who were blinded to the choice of breast implants. Patients whose nipple-to–inframammary fold distance was less than 4 cm were excluded from the study. The authors do not comment on patients’ chest dimensions, the information provided to the patients about the implants, or what prompted patients to choose an implant shape (e.g., online information, friends, or previous consultations). There is only one set of clinical photographs provided.
In our experience,2,3 the final aesthetic outcome depends not only on the implant shape but also on the tissue distribution. In a patient with very thin tissue cover, the implant shape will determine the final breast shape. However, in a patient with good soft-tissue cover, the final shape is less dependant on the shape of the implant. This means that a certain subgroup of patients have a pleasing result with either implant shape. However, the converse is not true (i.e., every patient will not achieve an aesthetic result with an arbitrary choice of implant). This is especially true of patients with short nipple-to–inframammary fold distance, which were excluded in the study by Rubi et al. In our practice, this particular subgroup benefits the most from anatomical implants.
It also must be remembered that aesthetic outcome is not the only guiding principle for choosing an implant, as the authors comment on the rotation rate of anatomical implants. The long-term studies have shown4 that the 10-year risk of complications is between two and three times higher with round implants, even from the same manufacturers. Most of these complications are attributable to an increased risk of capsular contracture and implant malposition. Some of the increased risk of capsular contracture may be explained by the presence of smooth implants in that cohort (the manufacturers did not specify complications of round implants based on their surface). However, that still does not account for the higher risk of malposition.
We are not suggesting that one implant shape is always superior. We do indeed use round implants for primary (and secondary) aesthetic breast augmentation in the presence of certain indications.5 However, we feel that appearance alone cannot be the sole factor in choosing an implant. Instead, we recommend customizing the choice of implant to each individual patient’s body habitus and soft-tissue distribution. We urge caution in blanket interpretation of the results of this study.
Dr. Cheema has no disclosures. Dr. Montemurro is a consultant and speaker for Allergan, Inc. (Irvine, Calif.). Dr. Hedén is a consultant and speaker for Allergan, Inc., and an unpaid consultant for Canfield Scientific (Fairfield, N.J.).
Mubashir Cheema, F.R.C.S.(Plast.)Paolo Montemurro, M.D.Per Hedén, M.D., Ph.D.AkademiklinikenStockholm, Sweden
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2. Hedén P, Jernbeck J, Hober M. Breast augmentation with anatomical cohesive gel implants: The world’s largest current experience. Clin Plast Surg. 2001;28:531552.
3. Montemurro P, Cheema M, Hedén P, Ferri M, Quattrini Li A, Avvedimento S. Role of macrotextured shaped extra full projection cohesive gel implants in primary aesthetic breast augmentation. Aesthet Surg J. 2017;37:408418.
4. Derby BM, Codner MA. Textured silicone breast implant use in primary augmentation: Core data update and review. Plast Reconstr Surg. 2015;135:113124.
5. Hedén P, Montemurro P, Adams WP Jr, Germann G, Scheflan M, Maxwell GP. Anatomical and round breast implants: How to select and indications for use. Plast Reconstr Surg. 2015;136:263272.