March 2017 #PRSJournalClub: “Intraoperative Comparison of Anatomical versus Round Implants in Breast Augmentation”

by Francesco M. Egro, MD, MSc, MRCS (@FrancescoEgro)

The March edition of the #PRSJournalClub offered an exciting discussion of a great PRS article entitled “Intraoperative Comparison of Anatomical versus Round Implants in Breast Augmentation” by David A. Hidalgo (@DavidAHidalgoMD) and Andrew L. Weinstein (@AWeinstein_MD).

In the study, Hidalgo and Weinstein present a randomized controlled trial to determine whether anatomical implants are aesthetically superior to round implants in breast augmentation. A total of 75 patients undergoing primary breast augmentation had a round silicone implant placed in one breast and an anatomical silicone device of similar volume and optimal shape placed in the other breast. Before the anatomical device was replaced by a round implant, intraoperative photographs to be judged by 10 plastic surgeons and 10 lay reviewers. No observable difference in breast aesthetics between anatomical and round implants was reported by plastic surgeons in 43.6% or by lay individuals in 29.2% of cases. When a difference was perceived, neither plastic surgeons nor lay individuals preferred the anatomical side more often than the round side. Plastic surgeons judged the anatomical side superior in 51.1% of cases and the round side superior in 48.9% of cases (p = 0.496). Lay individuals judged the anatomical side superior in 46.7% of cases and the round side superior in 53.3% (p = 0.140). Plastic surgeons identified implant shape correctly in only 26.5% of cases. Thus, the authors concluded that no aesthetic superiority of anatomical over round implants exists, and argue against the continued use of anatomical implants in breast augmentation.

The article was first discussed by the current Resident Ambassadors to the PRS Editorial Board Jordan Frey (@JordanFreyMD), Shuja Shafqat (@shujashafqatmd), and Chad Purnell (@ChadPurnellMD), and the special guest moderator Dr. Nolan S. Karp.

Listen to the discussion now:

 

A vivid online discussion took place on twitter over a two-day period (March 26-27), where established plastic surgeons and residents were able to ask questions, and get answers from the authors of the article themselves! Don’t worry if you missed it! A summary of the exciting discussion is provided.

Enjoy it and see you all at the next PRS Journal Club!

Francesco

#PRSJOURNALCLUB DISCUSSION

@shujashafqatmd Mar 26: @DavidAHidalgoMD @AWeinstein_MD great paper! Are there any times you elect to use anatomic implants in #breastaugmentation#PRSJournalClub

@DavidAHidalgoMD Mar 26: Our study showed there is no advantage. I personally would never use them. #PRSJournalClub

@DrRodRohrichMar 26: I agree ! No reason at all in cosmetic #breast augmentation @DrRodRohrich @prsjournal 

@CaseyKraftMD Mar 26: Agree they don’t appear beneficial for #augmentation, but perhaps #breastreconstruction?

@carpcosmetic Mar 26: including constricted breast

@shujashafqatmd Mar 26: thank you! What about breast reconstruction or breast deformities ie tuberous breast? #PRSJournalClub

@DavidAHidalgoMD Mar 26: Not for tuberous breasts: smooth round + fat grafting later (if needed) is better.  #PRSJournalClub

 

@JordanFreyMD Mar 26: @DavidAHidalgoMD @AWeinstein_MD How do you counsel patients re: round v. anatomic implants in breast aug v. reconstruction?#PRSJournalClub

@DavidAHidalgoMD Mar 26: They may have a role in reconstruction but texturization/ALCL and no aesthetic advantage argues against aug use

@AraSalibianMD Mar 26: @DavidAHidalgoMD @AWeinstein_MD Amazing study! Any role for subglandular #breastaugmentation in your practice? #PRSJournalClub @prsjournal 

@DavidAHidalgoMD Mar 26: @AraSalibianMD @AWeinstein_MD @prsjournal Higher CC and imaging disadvantage – I never do #PRSJournalClub

‪@danielzliuMar 26: :Agree, in #BreastAugmentation anatomic implants cost more and carry additional potential complications

@DavidAHidalgoMD Mar 26: Yes! Malrotation as big a risk as CC #PRSJournalClub

@ChadPurnellMD Mar 26:: @DavidAHidalgoMD @AWeinstein_MD When surgeons thought they knew which type was which, they were often wrong. A surprise? #PRSJournalClub 

@DavidAHidalgoMD Mar 26: @ChadPurnellMD @AWeinstein_MD If you saw them on the table with one of each as we did it’s no surprise!#PRSJournalClub 

@ChadPurnellMD Mar 26: I found it pretty entertaining, as I mentioned in #PRSJournalClub #podcast @shujashafqatmd @JordanFreyMD

@IraSavetskyMD Mar 26: Do you cancel patients about ALCL when using smooth implants? @DavidAHidalgoMD @AWeinstein_MD @prsjournal #PRSJournalClub 

@DavidAHidalgoMD Mar 26: @IraSavetskyMD @AWeinstein_MD @prsjournal Good question. I do not. The overwhelming evidence implicates texturization. #PRSJournalClub

@shujashafqatmd Mar 26: Point brought up @ NESPS by @franklista in dual plane esp 2/3, majority of implant is subglandular. What are your thoughts? #PRSJournalClub 

@DavidAHidalgoMD Mar 26: Love Frank but disagree. Better contour, imaging subpec. High DP need rare #PRSJournalClub

@shujashafqatmd Mar 26: Off topic: if patients need concomitant pexy whats the go to technique or is it variable? #PRSJournalClub @DavidAHidalgoMD @AWeinstein_MD 

@DavidAHidalgoMD Mar 26: Vertical if a breast position problem, concentric if a NAC problem #PRSJournalClub 

@shujashafqatmd Mar 26: so no role for inverted T in primary aug/pexy? #PRSJournalClub 

@DavidAHidalgoMD Mar 26: Yes, for massive weight loss patients with huge skin excess #PRSJournalClub

@pallabc Mar 26: @DavidAHidalgoMD Logically augmentation is done beneath the gland, not muscle. Is sub glandular method to be condemned? also hold for sub glandular placements? #PRSJournalClub 

@DavidAHidalgoMD Mar 26: No data on SG.  Inherent aesthetic/CC/safety (imaging) disadvantages with SG. #PRSJounrnalClub

@pallabc Mar 26: @DavidAHidalgoMD Augmented patients r recommended MRI for evaluation, detection of path possible in SG also. Disadvantage? #PRSJournalClub 

@DavidAHidalgoMD Mar 26: @pallabc MRI not the gold standard yet for ca detection #PRSJournalClub 

@ChadPurnellMD Mar 26: realistically though MRI recommended isn’t always (usually) done after #breastaug #PRSJournalClub @prsjournal 

@pallabc Mar 26: @DavidAHidalgoMD Agree. Difficult to get appointments for MRI too. But best inv in augmented breasts. @DavidAHidalgoMD #PRSJournalClub

@pallabc@pallabc Mar 26: @DavidAHidalgoMD Long history of SG use all over the world. Tebetts accepts SG if tissue thickness enough. Disadvantage? #PRSJournalClub 

@DavidAHidalgoMD Mar 26: @pallabc Paradigm shift. Texturization safety issue now. Also, breast imaging not as good SG #PRSJournalClub 

@pallabc Mar 26: @DavidAHidalgoMD 2 mo back #PRSJournalClub with @PatMcguireMD discussed safety of Tex implants over 10y multi-C study. Confusing!? 

@DavidAHidalgoMD Mar 26: @pallabc Bottom line – texture/ALCL risk takes priority now. #PRSJournalClub 

@pallabc Mar 26: @DavidAHidalgoMD Respectfully disagree Sir! ALCL in informed consent, yes, but probably not priority. @PatMcGuireMD #PRSJournalClub 

@DavidAHidalgoMD Mar 26: @pallabc In US liability a strong driver. Texture ban will happen here first. #PRSJournalClub 

@pallabc Mar 26: @DavidAHidalgoMD Thank you! That helps. @PatMcGuireMD

@JordanFreyMD Mar 26: @DavidAHidalgoMD @AWeinstein_MD What tips do you have to minimize issues like double bubble? @prsjournal @Nolankarp #PRSJournalClub 

@DavidAHidalgoMD Mar 26: @JordanFreyMD @AWeinstein_MD Sharp crease/short areola-crease distance the issue Use small dia, higher profile.

@pallabc Mar 26: @DavidAHidalgoMD Was it ‘difficult’ to take down perfectly done closure after taking pics?! U would take SubQ sutures too? #PRSJournalClub 

@DavidAHidalgoMD Mar 26: @pallabc Inframammary incisions – stapled for photos

@pallabc Mar 26: @DavidAHidalgoMD Thanks. Taking down perfect SubQ closure cruel on a surgeon!! #PRSJournalClub

@pallabc Mar 26: @DavidAHidalgoMD How frequently did you encounter animation deformity in the long term with no gland-muscle release? #PRSJournalClub 

@DavidAHidalgoMD Mar 26: @pallabc Minor issue, typically minimal release. Rare complaints #PRSJournalClub 

@pallabc Mar 26: @DavidAHidalgoMD I thought strength in study was assessment by experienced plastic surgeons (>15y experience). Superb! #PRSJournalClub

@IraSavetskyMD Mar 26: Were you surprised how infrequent plastic surgeons were able identify the correct implant? @DavidAHidalgoMD @AWeinstein_MD #PRSJournalClub 

@AWeinstein_MD Mar 26: @IraSavetskyMD @DavidAHidalgoMD while counterintuitive, not surprising as finding c/w hypothesis of no aesthetic difference. #PRSJournalClub

@PatMcGuireMD Mar 26: @DavidAHidalgoMD Why use MM sizers which are close to round? Wouldn’t expect much difference. #PRSJournalClub 

@DavidAHidalgoMD Mar 26: @PatMcGuireMD Used all 5 FDA approved profiles. None made a difference. #PRSJournalClub 

@PatMcGuireMD Mar 26: @DavidAHidalgoMD The paper says MM, 23 for Allergan and 25 for Mentor.

3.2March_JC

@DavidAHidalgoMD Mar 26: @PatMcGuireMD MM only Mentor FDA approved profile. Other choices were tried and did not appear better.

@PatMcGuireMD Mar 26: @DrTeitelbaum But not shown to evaluators? Not mentioned in the paper. #PRSJournalClub

@shujashafqatmd Mar 26: But still should show shape and cohesivity which seem like the important properties of the shaped > smooth #PRSJournalClub

@PatMcGuireMD Mar 26: @shujashafqatmd Not when the “shape” is essentially round. Also form stable imparts shape with time, not immediately. Use round for most breasts: Consider shaped for constricted or asymmetry. Discuss risks/benefits. Sizers are also responsive gel, not form stable. #PRSJournalClub

@JuhaKii Mar 26: Excellent RCT @DavidAHidalgoMD! Do you have  any indication for anatomical implants in your practice any? #PRSJournalClub 

@DavidAHidalgoMD Mar 26: @JuhaKii None for augmentation. I no longer perform reconstruction. #PRSJournalClub

@DrTeitelbaum Mar 26: @DavidAHidalgoMD Did you study only pts who should benefit from shaped?  If all pts results would be diluted.
@DavidAHidalgoMD Mar 26: @DrTeitelbaum Hi Steve. We looked at all patients given no standardized selection criteria for shaped. #PRSJournalClub

@DrTeitelbaum Mar 26: @DavidAHidalgoMD that’s like having normotensive pts in anti-htn drug study; theyd have no benefit and dilute the results, right

@DavidAHidalgoMD Mar 26: @DrTeitelbaum Disagree in this case. Urge you to repeat study with your criteria. Predict same outcome #PRSJournalClub 

@shujashafqatmd Mar 26: Makes sense. Opinions on this article since says no aesthetic benefit but your article shows good safety? #PRSJournalClub @DavidAHidalgoMD 

@PatMcGuireMD Mar 26: @shujashafqatmd @DavidAHidalgoMD Higher risk of ALCL with texture. Risk vs benefits always. If no benefit use smooth round #PRSJournalClub 

@shujashafqatmd Mar 26: Does @DavidAHidalgoMD @AWeinstein_MD article make you more/less/similar likelihood to use anatomic for #breastaugmentation? #PRSJournalClub

3.3March_JC

For MORE from the March 2017 edition of Plastic and Reconstructive Surgery‘s PRS Journal Club live twitter discussion please visit @PRSJournal or search #PRSJournalClub on Twitter!

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