INTRODUCTION
Brazil was the country that performed the most cosmetic surgeries in 2018, with
1,498,327 procedures. Leading the table, augmentation mammoplasty appears
responsible for 18.4% of this total, which corresponds to 275,283
surgeries1. The need
for learning this area of plastic surgery during residency is evident. Teaching
this type of procedure is not limited only to the issue of insertion in the
labor market. Still, there is also training in the doctor-patient relationship,
evolving the ability of interpersonal communication, which is essential in the
practice of the specialty2.
Reparative treatment should still be the main pillar of resident training,
especially since it is normative to perform only 15% of cosmetic surgeries
during specialist training3.
The Unified Health System (SUS) offers several treatments involving plastic
surgery, such as oncology, microsurgery, trauma, surgery after massive weight
loss, treatment of lipodystrophy secondary to antiretroviral therapy. All these
subspecialties are part of the training of plastic surgeons, according to the
National Commission for Medical Residency guidelines in 20194.
Augmentation mammoplasty techniques are not limited exclusively to the use of
breast implants. Fat grafting has gained ground, with advanced studies regarding
its collection, preparation and application, in addition to being able to be
performed alone or in association with silicone implants5,6.
The correct indication of techniques and even the types of implants available
requires a detailed physical examination, aiming to adapt the prostheses to the
anatomical structure and profile of the patients7. It is worth highlighting the importance of
clinical evaluation, especially at the furcula-nipple distance between 17 and
21cm and the cutaneous envelope fold greater than 2cm, which may indicate the
need for a submuscular plane8.
The literature varies concerning what is considered an adequate increase in
breast size, changing between different cultures and times the ideal breast size
or shape. We found some attempts on the description of the breast with the best
shape and volume, but without a concrete formula7,9. The
same can be said about the technique, as different authors have preferences
regarding access routes - inframammary, periareolar and transaxillary -,
dissection planes - subfascial, “dual plane” (submuscular)
subglandular -, and types of silicone - macro and microtextured, among
others8,10.
Therefore, the correct indication and knowledge of available arsenals are
valuable tools for residents.
This article aims to present a survey of primary augmentation mammoplasty
performed by first- and second-year plastic surgery students at the Botucatu
Medical School Hospital das Clínicas in the last four years and discuss
teaching this type of surgery in the scope of medical residency.
OBJECTIVES
In this article, we aim to present a survey of primary augmentation mastoplasty
performed by first and second year plastic surgery students at the Hospital das
Clínicas of the Faculty of Medicine of Botucatu in the last four years
and discuss the teaching of this type of surgery in the scope of medical
residency
METHODS
We reviewed the medical records of patients who underwent primary augmentation
mammoplasty by residents of the first and second year of Plastic Surgery at the
Hospital das Clínicas, Faculty of Medicine of Botucatu UNESP (HC FMB
UNESP) in the last four years - the period from January 2017 to March 2020.
Outpatient routine and surgical schedule
Patients were selected who are followed up at the cosmetic plastic surgery
outpatient clinic, entered via Annex I of the Unified Health System with
complaints of hypomastia. All undergo screening, excluding cases of BMI
greater than 28 or less than 16, in addition to smokers and collagen
diseases or comorbidities that make it impossible to perform surgery under
general anesthesia. After this phase, patients undergo a consultation called
the “New Aesthetics Case,” where they undergo a complete
anamnesis and detailed physical examination, followed by surgical planning
with at least two different volumes of implants to be selected on the day of
the surgery, according to the size of the pocket created and joint decision
at the time of markings.
All patients are reassessed the day before or on the procedure when the
surgical planning is re-discussed, and the points of reference, breast
limits and incision site are marked with a dermographic pen.
After the surgeries, the patients were instructed to wear a surgical bra for
at least 30 days without interruption and at least 30 days at night.
Surgical technique
In this topic, there was little variation regarding materials, using lighted
retractors of different sizes, shapes and brands, and the suture threads
varied between mononylon, Monocryl and polydioxanone, as well as the
dressing methods, with micropore, rayon and tape adhesives. There was always
a change of gloves during implantation and cleaning of them with 0.9% saline
solution before handling the implant. In general, all patients were
positioned on tables with dorsiflexion capacity to assess symmetry after
implantation of the prostheses.
Inclusion criteria
All adult patients who underwent primary augmentation mammoplasty, strictly
for aesthetic indication, performed procedures by a first- or second-year
resident as the main surgeon.
Among the selected medical records, some patients underwent other procedures
at the same surgical time, such as liposuction, gluteal fat grafting,
rhinoplasty, abdominoplasty, papilla reduction and revision of other
scars.
Exclusion Criteria
As an exclusion criterion for medical records, we did not include patients
with congenital or acquired, post-bariatric thoracic deformities or the need
for pexia or any form of skin resection.
Data analysis
Descriptive statistical analysis was performed, with analysis of variance to
calculate the mean and standard deviation for the volume, according to the
position of the implant; chi-square test to assess complications; and
Goodman test to compare the profile of the implant and its position.
TCLE and CEP
Before the surgeries, all patients were submitted to sign an informed consent
form, including risks inherent to the anesthetic-surgical procedure and
specific to augmentation mammoplasty. The work follows the recommendations
of the Research Ethics Committee (CEP) of the HC FMB UNESP, being approved
under the opinion number 4,480,923.
RESULTS
Patients
One hundred twenty patients were identified in these four years (January 2017
to July 2020), with ages ranging from 19 to 47 years - a mean of 28.6
years.
The body mass index (BMI) ranged from 16.9 to 26.2 - an average of 21.73, and
in 26 patients, it was not possible to calculate BMI retrogradely at the
time of surgery.
Seven patients had hypothyroidism, one patient was hypertensive, and the
other had congenital adrenal hyperplasia. Still, all maintained adequate
clinical control during surgery and had a specialized and regular follow-up
of the individual comorbidities.
Implants
Table 1 - Mean and standard deviation for volume according to implant
position.
| Position x Volume of implant (ml) |
Subfascial |
“Dual
plane” (submuscular)
|
Subglandular |
p1 |
| Average |
333,3 |
308,1 |
325,2 |
0,08 |
| SD |
36,1 |
37,9 |
44,2 |
|
Table 1 - Mean and standard deviation for volume according to implant
position.
All surgeries performed were bilateral and had a round base as the implant of
choice and shared the same manufacturer - Silimed®. Only
one patient received the polyurethane type implant, and all the other
prostheses were textured.
The volume of implants ranged from 270 to 445ml, with an average of 327.25ml,
as shown in Table 1. The biggest
difference between the right and left sides was 85ml, and in 10 cases,
implants of different sizes were used.
There was a predominance of high-projection implants 75% (90/120), followed
by medium implants 14% (17/120) and extra-high 10.8% (13/120). No patients
received low-projection implants. Figure 1 shows the distribution of these data and their relationship
with the position of the implants using the Goodman test (p=0.03).
Surgical technique
The surgery time ranged from 45 to 330 minutes, with an average time of 116
minutes. Still, these values were affected by the performance of other
procedures in the same surgical time. It is not possible to quantify the
time spent with liposuction in some cases, for example.
The access route was invariably inframammary in the selected cases, with
irregular reports regarding the quality of the scar and the need to revise
it intraoperatively due to edge trauma caused by tissue manipulation during
implant inclusion.
As for the implant position, 67.5% (81/120) were placed in the subfascial
position, and 21.6% (26/120) were implanted in the subglandular position,
mainly due to difficulty identifying separating the fascia from the
pectoralis major muscle.
All patients who had implants placed with the “dual plane”
(submuscular) technique, which corresponded to 10.8% (13/120), left the
surgery with a portovac drain, with an average time of 2 to 7 days until
removal. Drain use was irregular in the other patients, with use being
reported in 15% (18/120) of cases, especially when intraoperative bleeding
that was difficult to control was noted. In these cases, the drain remained
for 2 to 7 days, respecting the same removal criteria: serous or serohematic
appearance and a flow rate of less than 30ml in 24 hours.
Comparisons between the profile and position of the implants are shown in
Figure 1.
Complications
Only one patient in the observed interval required surgical re-approach due
to unnoticed asymmetry during the intraoperative period, with symmetrization
being performed in a second time by the same surgeon nine months after the
first surgery, without approaching the capsule or changing implants. Another
patient complained of breast ptosis and underwent periareolar mastopexy one
year after primary mammoplasty. No other patient required surgical
re-approach until the time these results were released (January/2021).
Figure 1 - Relationship between position and profile of the implant.
Figure 1 - Relationship between position and profile of the implant.
During surgery, there was an external rupture during implantation, requiring
exhaustive washing of the skin and cavity, and replacement for an implant of
the same size, without other complications during the intra- and
postoperative period.
We did not identify major complications, such as cases of infection, seroma
or hematoma requiring surgical re-approach, as well as venous
thromboembolism or death. The only case of infection appeared on the 8th
postoperative day and was treated conservatively, with observation and
maintenance of the use of cephalexin for seven days.
Cases of hematoma and seroma, outflow of active secretion of blood or serous
fluid for more than seven days, without collections or bulging in the
breasts were considered. All spontaneously resolved with conservative
treatment.
The six cases of dehiscence were also clinically managed, without
re-approach, as they did not exceed a distance greater than 3mm.
The appearance of stretch marks in the breast in patients who underwent
subglandular implants was 11.5% (3/26), while in the subfascial plane, it
was 3.7% (3/81). This suggests a three times greater risk of streak
formation when opting for the subglandular plane than the subfascial plane
(p=0.22). Patients undergoing the “dual plane” (submuscular)
technique did not present this clinical change.
Hyperesthesia in the nipple-areola complex was a complaint in three patients
whose implants were in the subglandular plane, which was more superficial
(p<0.05).
75% of operated patients did not present any clinical changes, and five
patients were not followed up after the first consultation
(p<0.001).
Complications are grouped in Table 2,
divided between the different positions of the implants.
Hospital care and outpatient follow-up
The length of stay ranged from 2 to 3 days, and none of the patients required
admission to the intensive care unit.
It was impossible to estimate the time taken for the patients to return to
their usual activities due to irregular follow-up in the postoperative
period and incomplete data in this regard.
So far, the follow-up of patients has ranged from 4 to 41 full months, with
an average of 23.34 months.
All patients were questioned during their return to the clinic and considered
themselves satisfied with the esthetic result.
DISCUSSION
Residents’ assessment of their education is an important parameter to
analyze how their teaching and learning process is going. As reported by a
German study, most residents who graduated from plastic surgery services do not
feel confident about performing aesthetic procedures at the end of their
training11. Many wish
to have more cosmetic surgery performed during training. Augmentation
mammoplasty is among the most cited by residents, who suggest performing at
least 10 of these surgeries during their training. In our study, the average
number of procedures per resident was 15, which makes training considered
adequate from this perspective.
Table 2 - Complication rate and relationship with implant position.
| Complications |
Subglandular |
Subfascial |
“Dual
plane” (submuscular)
|
Total |
p1 |
| Seroma |
0 |
3 (3,7%) |
0 |
3 (2,5%) |
0,05 |
| Infection |
0 |
1 (1,2%) |
0 |
1 (0,8%) |
0,37 |
| Stretch
marks
|
3 (11,5%) |
3 (3,7%) |
0 |
6 (5%) |
0,22 |
| Bruise |
0 |
0 |
1 (4,3%) |
1 (0,8%) |
0,37 |
| Ptosis |
0 |
1 (1,2%) |
0 |
1 (0,8%) |
0,37 |
| Enlarged scar |
0 |
3 (3,7%) |
0 |
3 (2,5%) |
0,05 |
| Asymmetry |
0 |
1 (1,2%) |
1 (4,3%) |
2 (1,6%) |
0,61 |
| Hyperesthesia of CAP |
3 (11,5%) |
0 |
0 |
3 (2,5%) |
0,05 |
| Dehiscence |
1 (3,8%) |
5 (6,1%) |
0 |
6 (5%) |
0,03 |
| Breast tenderness |
1 (3,8%) |
1 (1,2%) |
1 (4,3%) |
3 (2,5%) |
1,00 |
| Without
changes
|
18 (69,2%) |
61 (75,3%) |
10 (43,4%) |
90 (75%) |
<0,001 |
| No follow-up |
1 (3,8%) |
3 (3,7%) |
1 (4,3%) |
5 (4,1%) |
0,45 |
Table 2 - Complication rate and relationship with implant position.
The importance of esthetic education during the years of medical residency also
involves the preservation of the labor market. The invasion of other medical and
non-medical specialties, in addition to legal actions in the legal environment,
has to be fought with the knowledge and training of plastic surgeons capable and
qualified to enter the labor market2.
The number of surgeries per resident in this article is within the 15% of
aesthetic procedures that the National Medical Residency Council matrix
recommends for specialist training.
In our sample, 77.5% (93/120) of augmentation mammoplasties occurred in the first
half of the second year of residency, and implant surgeries in “dual
plane” (submuscular) usually take place within four months of the
second-year residence, and after at least ten augmentation mammoplasties in
other plans. This can be explained by the need for muscle incision and more
careful dissection.
The first- and second-year surgeons are accompanied by at least one other
resident of the team as the first assistant, in addition to the presence of
staff, usually a teacher or preceptor, who assesses the execution of the steps
and guides in the main decision moments. Instrumentation was usually performed
by a general surgery resident, or a nursing technician hired for the position.
All anesthesia was performed by residents and/or preceptors of the HC FMB UNESP
anesthesiology service.
A work by Hidalgo and Sinno, in 201612, pointed out the profile of breast augmentation
surgeries in the United States performed by members of the American Society of
Plastic Surgeons (ASPS). It showed a preference for round, smooth implants, 42%
with 300 to 350cc and 42% above 350cc. Unlike our retrospective analysis, they
indicated the subfascial plane as used in only 2.4%, while the inframammary
route was also the most applied. Textured implants, which in our study were
unanimous, accounted for only 10% of the choices in that article.
An assessment like this one was presented in the Revista Brasileira de
Cirurgia Plástica by Charles-de-Sá et al. in
201913. In this study,
there was also a preference for round implants over anatomical ones, in addition
to a predominance of microtextured ones, followed by polyurethane implants. Skin
incision in the inframammary position was also the majority, and the implant
position in descending order of frequency was in the subfascial plane, followed
by the subglandular and, finally, submuscular (“dual plane”), in
proportions of 54, 26 and 14%, which is close to our experience.
In a retrospective study, Alves et al. (2018)14 evaluated as preferential the anatomical type implant
as more “natural,” also using the Silimed® brand
as a reference in this comparison.
The most frequent complications in our study were surgical wound dehiscence and
cutaneous streaks in the breasts, both found in 5% of cases. Although
complications can also be associated with the learning curve, some are also
found in services with long-term professionals. Basile et al. (2012)15 reported 19 cases of stretch
marks in 409 patients - 4.9% - evaluated in the postoperative period of
augmentation mammoplasty. The authors mentioned age as a risk factor for this
complication, as younger patients are more prone to fiber rupture during skin
distension. Tijerina et al. (2010)16 and Brown (2020)17 performed retrospective analyzes of 1,000 and 783 cases
of primary augmentation mammoplasty. The main complication found by both was
capsular contracture, 0.4% and 6.8%, respectively. In our analysis, this
complication was not evidenced; however, one must consider the fact that our
observation time, which is a key factor in this complication, was inferior.
When comparing the positions of the implants concerning complications, we noticed
that patients who underwent the subfascial technique were those who had fewer
postoperative complications. This differs from Brown et al. (2012)18, who reported no significant
difference when comparing the subglandular and subfascial positions. However,
when in the subfascial position, we present a higher rate of seroma, which
differs from the meta-analysis carried out by Li et al. (2019)19, who found no differences in
the seroma rate between implants placed in planes above or below the pectoralis
muscle.
As described in another large case series20, in which there are very low levels of complications
during and after augmentation mammoplasty, we did not obtain any major
complications, such as venous thromboembolism.
Another topic to be discussed is the increasing evidence and new research related
to anaplastic large cell lymphoma associated with a breast implant (BIA-ALCL).
This also interferes in this discussion and may affect shortly much of what is
considered about the use of prostheses21,22.
Despite satisfactory postoperative results and a substantial number of
procedures, more concrete teaching assessment tools need to be implemented to
create replicable training standards for new plastic surgeons. One of these
tools present in the current literature is the so-called “entrustable
professional activities” (EPA)23,24. In this
method, we try to translate the skills of each surgical procedure. In theory,
upon reaching pre-determined competencies, the surgeon in training would be
really qualified for unsupervised performance25. This mechanism can potentially make training
more objective and help organize inputs and resources spent on training the
plastic surgeon.
The EPA for augmentation mammaplasty can be later translated into Portuguese and
adapted to the reality of every service.
Among the limitations of this study, we must comment on its retrospective
character, which was carried out under the analysis of medical records. This
impairs the assessment of data such as the quality of healing and patient
satisfaction since the evaluators described them in a less objective
character.
Mammoplasty is the most common surgery performed by plastic surgeons in their
clinical practice, which makes it essential in the technical training of the
resident physician in the specialty. Maintaining a routine and a pattern in its
performance is important for the specialist’s evolution, both for the
refinement of one of his most sought-after surgeries and the development of the
skills needed to perform more complex surgeries.
Monitoring the evolution of the school service over time and following the
patients who received implants is essential to identify possible complications
early and offer patients satisfactory and long-lasting results.
CONCLUSION
Primary augmentation mammoplasty is one of the main procedures in most plastic
surgery offices. When performed in a medical residency service, by plastic
surgeons in training under adequate supervision can also bring satisfactory
results, with low complication rates.
REFERENCES
1. International Survey on Aesthetic/Cosmetic Procedures (ISAPS). ISAPS
International Survey on Aesthetic/Cosmetic Procedures [Internet]. West Lebanon:
ISAPS; 2018; 1-49. Available from: https://www.isaps.org/wp-content/uploads/2019/12/ISAPS-Global-Survey-Results-2018-new.pdf
2. Rohrich RJ. The importance of cosmetic plastic surgery education: an
evolution. Plast Reconstr Surg. 2000 Fev;105(2):741-2.
3. Sociedade Brasileira de Cirurgia Plástica (SBCP).
Serviços credenciados da SBCP. São Paulo: SBCP;
2017.
4. Ministério da Saúde (BR). Resolução
no 43, de 8 de abril de 2019. Estabelece novo prazo para entrada
em vigor da Resolução Normativa nº 39, de 20 de junho de
2018, do Conselho Nacional de Controle de Experimentação Animal,
que dispõe sobre restrições ao uso de animais em
procedimentos classificados com grau de invasividade 3 e 4. Diário
Oficial da União, Brasília (DF), 11 set 2019;
Edição: 70; Seção: 1:85.
5. Coleman SR, Saboeiro AP. Primary breast augmentation with fat
grafting. Clin Plast Surg. 2015 Jul;42(3):301-6.
6. Kerfant N, Marchac A, Auclair E. Fat grafting in composite breast
augmentation with round implants: a new concept for breast reshaping. Aesthet
Plast Surg. 2019;550-1.
7. Mallucci P, Branford OA. Concepts in aesthetic breast dimensions:
analysis of the ideal breast. J Plast Reconstr Aesthet Surgery. 2012
Jan;65(1):8-16.
8. Tebbetts JB. Dual plane breast augmentation: optimizing
implant-soft-tissue relationships in a wide range of breast types. Plast
Reconstr Surg. 2006 Dez;118(7
Suppl):81S-98S;discussion:99S-102S.
9. Wan D, Rohrich RJ. Modern primary breast augmentation: best
recommendations for best results. Plast Reconstr Surg. 2018
Dez;142(6):933e-46e.
10. Tebbetts JB, Adams WP. Five critical decisions in breast
augmentation using five measurements in 5 minutes: the high five decision
support process. Plast Reconstr Surg. 2005 Dez;116(7):2005-16.
11. Momeni A, Goerke SM, Bannasch H, Arkudas A, Stark GB. The quality of
aesthetic surgery training in plastic surgery residency: a survey among
residents in Germany. Ann Plast Surg. 2013 Jun;70(6):704-8.
12. Hidalgo DA, Sinno S. Current trends and controversies in breast
augmentation. Plast Reconstr Surg. 2016 Abr;137(4):1142-50.
13. Charles-De-Sá L, Gontijo-De-Amorim NF, Albelaez JP, Leal PR.
Profile of breast augmentation surgery in Brazil. Rev Bras Cir Plást
[Internet]. 2019; 34(2):174-86. Disponível em: http://www.gnresearch.org/doi/10.5935/2177-1235.2019RBCP0132
14. Alves DG, Santos Junior CAN, Vilca MMR, Arruda SCG, Medeiros MPC,
Decusati FL. Análise comparativa entre indicações de
implantes anatômicos ou redondos em mamoplastia de aumento. Rev Bras Cir
Plást [Internet]. 2018; 33:5-6. Disponível em: http://www.rbcp.org.br/details/2098/analise-comparativa-entre-indicacoes-de-implantes-anatomicos-ou-redondos-em-mamoplastia-de-aumento
15. Basile FV, Basile AV, Basile AR. Striae distensae after breast
augmentation. Aesthetic Plast Surg. 2012 Ago;36(4):894-900.
16. Tijerina VNE, Saenz RAE, Garcia-Guerrero J. Experience of 1000 cases
on subfascial breast augmentation. Aesthetic Plast Surg. 2010
Fev;34(1):16-22.
17. Brown T. A comprehensive outcome review of subfascial breast
augmentation over a 10-year period. Plast Reconstr Surg. 2020
Dez;146(6):1249-57.
18. Brown T. Subfascial breast augmentation: is there any advantage over
the submammary plane? Aesthetic Plast Surg. 2012
Jun;36(3):566-9.
19. Li S, Mu D, Liu C, Xin M, Fu S, Xu B, et al. Complications following
subpectoral versus prepectoral breast augmentation: a meta-analysis. Aesthetic
Plast Surg. 2019 Ago;43(4):890-8.
20. Alderman AK, Collins ED, Streu R, Grotting JC, Sulkin AL, Neligan P,
et al. Benchmarking outcomes in plastic surgery: national complication rates for
abdominoplasty and breast augmentation. Plast Reconstr Surg. 2009
Dez;124(6):2127-33.
21. Groth A, Graf R. Breast implant-associated anaplastic large cell
lymphoma (BIA-ALCL) and the textured breast implant crisis. Aesthetic Plast
Surg. 2020 Feb;44(1):1-12.
22. Clemens MW, Jacobsen ED, Horwitz SM. 2019 NCCN consensus guidelines
on the diagnosis and treatment of breast implant-associated anaplastic large
cell lymphoma (BIA-ALCL). Aesthet Surg J. 2019 Jan;39(Supl
1):S3-13.
23. Cate OT. Nuts and bolts of entrustable professional activities. J
Grad Med Educ. 2013 Mar;5(1):157-8.
24. Jones Junior MD, Rosenberg AA, Gilhooly JT, Carraccio CL.
Perspective: competencies, outcomes, and controversy--linking professional
activities to competencies to improve resident education and practice. Acad Med.
2011 Fev;86(2):161-5.
25. Courteau BC, Knox ADC, Vassiliou MC, Warren RJ, Gilardino MS. The
development of assessment tools for plastic surgery competencies. Aesthet Surg
J. 2015 Jul;35(5):611-7.
1. Hospital das Clínicas, Faculty of
Medicine of Botucatu, Botucatu, SP, Brazil.
Corresponding author: Balduino Ferreira de
Menezes Neto, Rua Hortênsia, 291, Apto 802, Jardim Bom Pastor,
Botucatu, SP, Brasil, Zip Code 18607-650, E-mail:
balduino.neto@unesp.br
Article received: October 18, 2020.
Article accepted: July 14, 2021.
Conflicts of interest: none.
Institution: Hospital das Clínicas da Faculdade de Medicina de
Botucatu, Botucatu, SP, Brasil.
