Profile of breast augmentation surgery in Brazil
Perfil da cirurgia de aumento de mama no Brasil

INTRODUCTION

Brazil is one of the world leaders in the number of plastic surgery procedures performed annually. Considering its area and population (207 million inhabitants), Brazil is the fifth largest country in the world. In a recent survey, the International Society of Aesthetic Plastic Surgery (ISAPS) showed that in 2017, 2,524,115 plastic surgeries were performed in Brazil for aesthetic purposes¹.

Surgery for breast augmentation has been one of the most commonly-performed procedures, totaling more than 200,000 surgeries in 2016. Two major factors have contributed to this scenario: the large number of plastic surgeons in Brazil (6,200 active members of the Brazilian Society of Plastic Surgery - SBCP), and the availability of various implant brands, including domestic manufacturers such as Silimed^® and LifeSil^®, and different international brands, such as Allergan^®, Mentor^®, Polytech^® and Motiva^®, among others.

Many clinical studies have been conducted to understand the effects of silicone implants on breast tissue, along with approaches to resolve complications or other unexpected occurrences^2-9. Different criteria and methods can be applied in the selection of an ideal implant in terms of design, shape, and volume, including incisions, breast contour, and the anatomy of the nipple areola complex (NAP)^10-12.

A meticulous analysis of breast characteristics and patient cooperation during surgical planning is the key to achieving a pleasing outcome. Tebbetts & Adams¹³ have established an important protocol by adopting five anatomical measurements of the chest wall and breast to guide the planning of breast augmentation surgery. However, there is no consensus among plastic surgeons about breast augmentation, such as the best approach to rippling and capsular contracture, optimal implant design, and other controversial issues. In a recent study, Hidalgo & Sinno¹⁴ analyzed the profile of US plastic surgeons in relation to breast augmentation and showed some current tendencies in the US surgery.

Despite a great interest among surgeons and patients regarding breast enlargement, certain issues remain undefined, such as the “ideal” technique and the type of implant, including determination of the best brand, incisions, and use of the acellular dermal matrix (ADM), among others.

OBJECTIVE

The objective of this study is to evaluate current practices and trends in breast augmentation surgery in Brazil.

METHODS

A 31-item questionnaire was prepared and sent to all associate and full members of the SBCP. The research addressed current trends and controversial practices considering five areas: current controversies, new technologies, breast implants, technical considerations in secondary procedures, and demographic aspects.

The questionnaire was prepared to outline the knowledge of the plastic surgeon and their practices, procedures, and beliefs regarding the use of breast implants in Brazil. The questions were multiple choice, with variables extracted from the Hidalgo & Sinno questionnaire,14 for subsequent data comparison. The survey was sent via email, WhatsApp, and Facebook from May to June 2017. The survey was conducted using the site, www.junkmonkey.com (SurveyMonkey, Microsoft Corporation, USA).

RESULTS

A total of 505 questionnaires were collected (representing a response rate of approximately 8%). The results were distributed in five tables, by the major area of interest. Table 1, which expresses current controversies, shows that 50% of respondents do not use any protocol guidelines, basing their procedures simply on their own experience. In particular, they do not use anatomical implants. The reasons given for this were mainly the unproven aesthetic superiority of the anatomical prosthesis when compared to round implants, the possibility of rotation, and the higher cost.

Table 1 - Current Controversies.

Breast implants were used for primary increase (78.13%), mastopexy (18.29%), and in-breast reconstruction (3.58%).

Autologous fat grafting was mentioned by 29.08% of the surgeons interviewed, while 68.92% had never used it for this purpose. The fat grafting technique, as a complementary procedure, was employed by 54.9%. The main concerns regarding lipotransfer in the breasts as a primary augmentation procedure were (in order of importance): the possible need for multiple grafting sessions, the limited potential for augmentation, and interference with the breast cancer screening (imaging analysis).

Some surgeons reported cases of anaplastic large cell lymphoma (ALCL), but this represented an extremely low incidence among Brazilian plastic surgeons (0.08%).

The media technology, currently used surgical planning for educational and marketing purposes, does not consider breast imaging as a suitable method to achieve these goals (Table 2). The majority of surgeons do not use ADM; few use a plastic device in the funnel for implant placement. Adhesive plastic film, as a skin protector, is not routinely used. However, there have been reports of matrix indications for the treatment of capsular contracture, contour deformities, and undulations.

Table 2 - New Technologies.

The results obtained demonstrate that round silicone implants are prevalently used. Depending to the coverage area of the implant, more than half of the surgeons (52.51%) preferred micro-precision implants; 26.46% used polyurethane implants when the implants were placed in the subpectoral plane. On the other hand, when the plane was subglandular, microtextured implants were most commonly used (45.36%), followed by macrotexture (25.64%) and polyurethane (23.33%). The most prevalent volume ranges were between 275-325 mL (39.17%) and 250-300 mL (31.41%).

The most commonly used silicone implant brands were Silimed^® (54.69%), Mentor^® (44.71%), Allergan^® (31.74%), Polytech (23.95%), LifeSil^® (11.78%), and others (20.16%) (Table 3).

Table 3 - Implant Protocol.

Inframammary incisions were most preferred by the majority of surgeons (89;66), and the subglandular pocket (54.78%) was the most frequently used approach for implant placement. The irrigation of the pouch with a double antibiotic solution was used by 38.25% of surgeons and more than half used intravenous (94.22%) and oral (65.74%) antibiotic prophylaxis. Drains were used for 18.53%.

Considering the capsular contracture approach, more than half of the surgeons (52.89%) never used any pharmacological agent to prevent or treat this complication. In 33.93% of the cases, immunological modulators were used at the first sign of capsular contracture.

The most frequent motives for secondary surgery were included contracture (49.80%) and change in implant size (35.14%) (Table 4). Primary capsular contracture was more commonly treated with total capsulectomy (39.88%), capsulotomy (22.65%), and anterior capsulectomy (18.64%). Recurrent contractures in the subpectoral pocket were treated through pocket exchange (47.15%) and previous capsulectomy (15.86%).

Table 4 - Secondary mammoplasty.

Recurrent contractures in the subglandular pocket were treated with a surgical change from the implants to the subpectoral pocket (51.56%) and total capsulectomy (29.46%). The most common treatment for double-bubble deformity is the change of pocket (54.04%), the exchange of the implant using the same pouch (22.13%), pocket, the exchange of implant, and rescaling of the pocket with inframammary sutures to create a new groove (16.60%) (Table 4).

Three questions were drafted to analyze general demographic aspects. Regarding the surgeon’s experience, it was shown that 26.24% presented 0-5 years of practice in plastic surgery (Table 5), and most interviewees reported that they had experience in aesthetics. The mean number of mammoplasties performed annually ranged from 11-30 cases (34.26%) to 31-60 (31.27%) (Table 5).

Table 5 - General demographic aspects.

DISCUSSION

The scenario of breast augmentation mammoplasty presents great diversity in its practices and trends in different countries. It is extremely important to evaluate these differences and standardize those most accepted by these surgeons, thus increasing the level of safety of the surgery and the quality of the results. This present study aims to analyze the current practice of Brazilian plastic surgeons in relation to breast augmentation surgery, representing the practice of Brazilian plastic surgeons.

Almost half of these plastic surgeons (48%) follow their own experience as guidelines, ruling out any SBCP protocol. Most used breast implants for primary enlargement (78.13%) and mastopexy (18.29%), reflecting an international consensus.

Most surgeons do not use anatomical implants because they consider their esthetic result equivalent to the round implant, but with a higher rate of poor positioning and higher anatomical cost - which influenced the choice of the round implant. However, the choice was also based on personal expertise rather than clinical data.

In fact, no prospective study has yet been disseminated related to this subject. The consensus observed is that there is no ideal implant that meets the needs of all patients. Experienced surgeons suggest that both round and anatomical implants can bring successful results, regardless of implant shape¹⁵.

There is little difference in the final result between anatomical and round implants in some conditions, such as in patients with good coverage and tissue thickness. Considering the inclination and volume of the upper pole, round and anatomical implants may produce an overly full or empty upper pole if placed too high or too low, respectively.

Some conditions, such as tuberous breasts, in which there is a deficiency of glandular and cutaneous tissue in the lower pole, with a risk of contour deformities such as the “double-bubble” silhouette, are greater with round implants; in such cases, anatomical implants are an appropriate alternative¹⁶. An algorithm for selecting anatomical or round implants, based on clinical data applied by American plastic surgeons for many years, reports low rates of capsular contracture and other complications, as well as high rates of patient satisfaction^15-17.

Regarding the use of lipotransfer-primary breast augmentation, it was determined that most plastic surgeons have never used it (68.92%) because of the low potential for augmentation and the need for multiple sessions.

The incidence of ALCL associated with the implants among surgeons presented a low index (0.80%), probably due to the lack of adequate diagnostic protocol and the use of polyurethane coated implants in Brazil. This object seems to be a novelty of multifactorial causation, related to the texture of the implants; it is more frequent than what was previously been believed. If texturization proves to be a factor that contributes to, or specifically causes, ALCL, the continued use of textured implants would logically increase the number of patients at risk of developing this tumor^19-25.

Annually, new technologies have arisen, with new generation implants and new protocols. Regarding the use of the three-dimensional breast exam study, 96.41% of the interviewees did not use this tool because they felt that the high cost and time spent did not justify the investment (61.11%). Many attribute the use of this device as a marketing tool, with value added limited to preoperative evaluation. This latter belief is corroborated by recent studies showing that its use remains controversial²⁶.

Methods based on the assessment of local tissues provide critical information on the size restrictions imposed by individual anatomy¹³. The role of local tissue-based methods may be more suitable as a complement to sizing methods, whereby patient size preference is modified based on the anatomical limitations revealed through tissue-based analysis²⁷.

The characteristics of the breast implant are analyzed in this questionnaire. Most plastic surgeons preferred silicone gel implants (98.60%). As for the surface of the implant shell, microtexture implants represent a preference of more than 50%, followed by polyurethane- and macrotexture-coating in the case of subglandular implants. Smooth surfaces are often indicated in the subpectoral or submuscular technique.

Brazil has two factories that supply the domestic market, disseminating the use of polyurethane implants (Silimed®) and foam implants (LifeSil®). There are many brands of implants available, with good features for safe practice. Classification of the brand used showed the following in descending order: Silimed® (54.69%); Mentor® (44.71%); Allergan® (31.74%); Polytech® (23.95%); LifeSil® (11.78%), Motiva® (2.0%) and others (20.16%). The volume of implants most commonly used was in the range of 275-325 mL.

The use of microtextured or coated silicone round implants with polyurethane inserted in the submuscular plane (52.51% and 26.46%, respectively) (Table 3) represents the majority in this study²². However, microtexture coatings were preferred by 45.36%, followed by macrotexture (25.64%) and polyurethane (23.33%) in the subglandular plane.

Several comparative studies reveal the low rate of capsular contracture when polyurethane and textured implants are used, which would justify this practice, regardless of the benefits proclaimed by users of smooth implants^23,24. On the other hand, research by Hidalgo & Sinno¹⁴ suggests that it is currently possible to observe a US preference for smooth silicone implants inserted in the submuscular plane, probably due to the prevalence of ALCL among macrotextured prostheses.

Regarding the types of incision for the placement of implants, a vast majority opted for the inframammary incision (MFI) (89.66%), confirming a historical preference that is currently encouraged, based on the risk of infection when the periareolar technique is employed. In relation to the implant cavity, 54.78% of the surgeons declared their preference for the subglandular space, followed by the subfascial (26.49%) and partially submuscular (“dual plane”) spaces (14.14%). This profile has been observed in other studies^24-27. However, Singh et al.²² portrayed a different scenario, pointing to a significant preference (58.9%) for “dual plane” and subglandular (11.2%) pockets. Namnoum et al.²⁵ showed an incidence of 83% and 14% for the “dual plane” and subglandular planes, respectively²⁶.

The use of aspiratory drainage is still a controversial topic, and its benefit ratio remains undefined. In the sample analyzed, more than 80% do not use drains. Of those who used suction drains (18.53%), most did not maintain their use for more than 48 hours (61.66%). These surgeons justify the routine use of drains because of their low hematoma/seroma indices (lower inflammatory response, lower infection rates, and reduced skin fistulae, leading to implant exposure and, virtually, capsular contracture). A vast majority (94.22%) use intravenous prophylactic antibiotics for anesthetic induction and oral administration in the postoperative period (65.74%)²⁸.

In addition, 38.25% of the interviewees favor irrigation of the prosthesis pocket with saline added to the double antibiotic therapy scheme (aminoglycoside and cephalosporin). Liquid bacitracin is not available in Brazil, but it is widely used in the triple antibiotic therapy scheme in other countries. A recent survey by the American Society of Plastic Surgeons showed the same protocol, except for irrigation with triple antibiotic therapy in the implant pocket¹⁴.

The use of perioperative intravenous antibiotics and intraoperative antibiotic irrigation is predominantly prescribed, but the use of oral antibiotics in the postoperative period is defended by only half of the American surgeons^14,29. Implant pocket irrigation has been extensively studied and recommended for many years but has never been investigated in a randomized trial.

In addition, the specifications of this technique still need to be defined³¹. Many of the irrigation solutions used by surgeons have proved to be inadequate to significantly reduce capsular contracture. In vitro research on the efficacy of pocket irrigations, including with povidone-iodine, double antibiotic solution (polymyxin B and gentamicin), cefazolin, and bacitracin have shown that all these irrigations provide inadequate protection against bacteria, which are involved in the subclinical infectious process, producing a biofilm and capsular contracture^30,31.

Unfortunately, plastic surgeons tend to use prophylactic antibiotics inappropriately. Although there are evidence-based guidelines for selection of proper prophylaxis, and the time and duration of administration of antibiotic agents, many plastic surgeons ignore them^32,33.

Generally, the use of prophylactic antibiotics is frequent and prolonged. In recent decades, the use of prophylactic antibiotics in plastic surgery, especially for aesthetic procedures, has increased dramatically, despite the absence of clinical evidence demonstrating a drastic reduction in infection rates or antibiotic efficacy³⁴.

The rates of capsular contracture after breast implants range from 1.3-17%^35-38. Several studies have demonstrated that capsular contracture has a multifactorial cause and is not fully characterized³⁶. Studies have shown that capsular contracture is one of the main causes of breast implant replacement³⁷, showing several rates, with variables of 1.9%, 5.3%, 19.1%, 52.6% and 58%^38-42.

These rates are inconsistent, since the studies are extremely heterogeneous and follow-up is highly inconsistent. When these studies are compared, we notice a lack of standardization of surgical techniques involving various types of implants and incisions, favoring the heterogeneity of results. In a recent British study by Headon et al.³⁹, the authors analyzed several studies, covering 3716 patients, and demonstrated an average of 10% capsular contracture.

Factors associated with reduced rates of capsular contracture are related to the handling of implants during surgery⁴³, pocket irrigation with triple antibiotic therapy during surgery²⁹, the use of implants coated with polyurethane⁴⁴, steroid and vitamin E irrigation around the implant^3,45, systemic leukotriene antagonists^46,47, localization of locally active anti-inflammatory adhesives⁴⁸, topical application of 5-fluorouracil⁴⁹, and photochemical tissue treatment⁵⁰.

Pharmacological agents for the prevention of capsular contracture are not popular in Brazil, since 52.89% of respondents had never used them because of unclear evidence to prove their effectiveness⁵¹. Non-surgical methods for approaching capsular contracture were investigated, revealing that 35.94% did not use any clinical methods (e.g. massage, closed capsulotomy, use of leukotrienes, etc.).

Leukotriene antagonists (42.7%), massage (32.77%) and external ultrasound (11.42%) were used by the interviewees. Many plastic surgeons believe that pharmacological agents are more likely to work early in the contraction process and that leukotriene inhibitors are the best agents⁵².

The main causes of late replacement of breast implants in this study involved capsular contracture and the size change of the implant, representing indices of 49.80% and 35.14%, respectively. This high incidence of implant volume change surgeries observed in the study seems likely to improve with more adequate preoperative management. On the other hand, the atrophy of the breast tissue related to continuous pressure produced by the implant against glands should be considered⁵³.

Regarding the surgical approach of primary capsular contracture, the most-used method was total capsulectomy (39.88%), followed by capsulotomy (22.65%), anterior capsulectomy/site change (18.6%), and ADM (Table 4). There is no consensus that prior capsulectomy alone is an better treatment for primary capsular contracture over total capsulectomy.

A systematic review was conducted by Wan & Rohrich³⁷, attesting to limited clinical evidence regarding the surgical treatment of capsular contracture. Location change and implant replacement were associated with reduced rates of contracture recurrence, and probably played a beneficial role in the treatment of capsular contracture. The data on capsulectomy were less conclusive. The ADM was considered useful, but long-term data is still required⁵⁴.

Regarding the surgical approach of recurrent capsular contracture, in cases of subpectoral or subglandular implants, there was a preference for a change to implant pocket (47.15% and 51.56%) and total capsulectomy (17.1% and 29.46%), followed by anterior capsulectomy (15.86% and 8.48%), respectively (Table 4). Among US plastic surgeons, the use of ADMs alone or in combination with the techniques discussed above is gaining popularity^54-58.

As shown earlier in this study, most Brazilian plastic surgeons do not opt for the subpectoral pocket in primary surgery and capsulectomy plus site; and the exchange of implants is referred to by many as the gold standard treatment for clinically significant capsular contracture^59-61.

The demographic pattern found in this research provided a broad view of the surgeons’, experience, with a homogeneous distribution between 1 and 25 years of practice, lending balance and credibility to this survey. The profile found was distributed among different groups, and aesthetic procedures are the most frequent among plastic surgeons in Brazil.

CONCLUSIONS

The research pointed out that Brazilian plastic surgeons have notable preference for silicone implants with microtextures and polyurethane for use in primary procedures. The subglandular pocket and incision in the inframammary groove are also preferred by the majority of the surgeons. Sizing with round molds is also preferred as an important measure in the preoperative period. Intravenous antibiotics are recommended in the perioperative period and oral in the postoperative period.

During surgery, the irrigation of the pocket with a double antibiotic solution is routine. Implant sizes less than 325 mL are usually used. Drainage is not considered to be an effective tool by most of the surgeons. Finally, there is no consensus about lipotransfer in the breasts, management of capsular contracture, and double bubble deformity.