In their recent article, Rubi et al. claim that a group of experts were unable to differentiate between round and anatomical implants.1 The group consisted of 15 plastic surgeons and 15 nurses. No information is given on the relative expertise of the plastic surgeons, nor is there any statement with regard to the knowledge of the nurses on this subject. Surgeons with no or minimal expertise in a specific type of implant might not be familiar with the postoperative appearance of that implant. Similarly, although experienced nurses can reliably assess breast aesthetics, without specific training on the expected appearance of round versus anatomical implants, their ability to differentiate cannot be assumed to be that of an expert. French philosopher Henri Bergson’s quote “The eye sees only what the mind is prepared to comprehend” is quite relevant. It is unwarranted to claim that “experts” are unable to differentiate between the two implants, if the expertise of half of the evaluators is unspecified and half of the evaluators are not experts.
The evaluators were not shown the profile view. In fact, this is the single most important view, if the goal is to assess the effect of an implant on the breast contour. On close observation of postoperative photographs of the patient shown in Figure 1, an expert can easily detect the slight concavity on the upper edge of the round implant in the profile view. This is not as obvious in the oblique view. The authors explain that plastic surgeons were statistically better in differentiating the implants, because of their assessment of the preoperative photograph. This would be true only if the operating surgeon had selected the implant type. However, in this study, the patient made the decision, and a patient best served with an anatomical implant might have well chosen a round implant and vice versa. The 5.2 and 14 percent rotation rates, presented as data that should deter use of anatomical implants, are not entirely applicable to this study. The two studies referred to involved subglandular placement and anatomically shaped saline implants, respectively.2,3 The rotation rates for submuscular anatomical implants can be as low as 0.42 to 1.1 percent.4,5 Finally, no information is provided on the breast and chest wall anatomy of the patients, or on the implant heights of the anatomical implants included in the study. In patients with good preoperative upper pole cover, the upper pole appearance may appear natural and anatomical even with round implants.4 Anatomical implants with low versus medium versus tall height vary considerably in their dissimilarity with round implants.
Thus, the study by Rubi et al. is a simplified way of looking at the difference between round and anatomical implants. Patient anatomy and implant variables not accounted for in the study can influence the appearance of the breast after augmentation and can obscure the difference between these implants. The only conclusion that could be drawn from the present study is that under certain and limited conditions the difference between round and anatomical implants is not apparent; this is knowledge that we had before the publication of this study.
Dr. Hedén is a consultant and speaker for Allergan, Inc. (Irvine, Calif.) and an unpaid consultant for Canfield Scientific (Fairfield, N.J.). Dr. Agko has no financial interests to disclose. No funding was received to assist in the creation of this communication.
Mouchammed Agko, M.D.Department of Plastic SurgeryChina Medical University HospitalTaichung, Taiwan
Per Hedén, M.D., Ph.D.AkademiklinikenStockholm, Sweden
1. Rubi CG, Lozano JA, Pérez-Espadero A, Leache ME. Comparing round and anatomically shaped implants in augmentation mammaplasty: The experts’ ability to differentiate the type of implant. Plast Reconstr Surg. 2017;139:6064.
2. Lista F, Tutino R, Khan A, Ahmad J. Subglandular breast augmentation with textured, anatomic, cohesive silicone implants: A review of 440 consecutive patients. Plast Reconstr Surg. 2013;132:295303.
3. Baeke JL. Breast deformity caused by anatomical or teardrop implant rotation. Plast Reconstr Surg. 2002;109:25552564; discussion 2568–2569.
4. Hedén P. Spear SL. Breast augmentation with anatomic, high-cohesiveness silicone gel implants (European experience). In: Surgery of the Breast: Principles and Art. 2011:3rd ed. Philadelphia: Wolters Kluwer/Lippincott Williams & Wilkins; 13221345.
5. Hammond DC, Migliori MM, Caplin DA, Garcia ME, Phillips CA. Mentor Contour Profile Gel implants: Clinical outcomes at 6 years. Plast Reconstr Surg. 2012;129:13811391.