Evidence Based Breast Augmentation.
Article by Aldo Guerra, MD
Scottsdale Plastic Surgeon
Evidence based medicine is defined as the conscientious and judicious use of the current best evidence in making medical decisions about the care of our patients. In considering such evidence, the quality of the medical research is going to be very important in determining the value the study findings provide for patients and physicians. We should consider that higher quality studies create a higher value for its findings. In other words, when the research is better performed, the evidence supporting a certain medical decision is more powerful. While evidence-based has been practiced by other medical specialties more commonly and for a longer period of time, plastic surgeons have begun to implement this method of clinical practice.
Numerous studies performed using high quality methods allow physicians now to practice evidence-based breast augmentation. Questions which are most important to breast augmentation patients typically have to do with pain management and long-term results. The American Board of Plastic Surgery via the Maintenance of Certification program for surgeons has created a nice summary article on the best evidence with regards to breast augmentation and breast implants. Below, I discuss the points which I found to be most valuable in my clinical practice.
- Pain management general - Before breast implant surgery pain management starts with anesthesia. In a well-performed study, the use of intravenous (iv) steroid, called methylprednisolone, was found to reduce the amount of pain medications a patient uses while reducing nausea, vomiting, and fatigue after surgery. This one dose approach is simple and effective. In addition, a single dose of steroid does not lead to significant side effects. Reducing the number of pain pills a patient consumes is important because these medication can have significant side effects.
- Pain management local - Managing pain after breast implant surgery begins with interventions during the surgery. A gentle dissection by an experienced plastic surgeon, who specializes in breast augmentation, is most important. Local anesthetics studied for breast implant pocket irrigation with bupivacaine (a longer lasting local anesthetic) is another tool to reduce pain. Research into the subject, indicate that patients have less pain when compared to treatment groups not receiving the local anesthetic. This is another simple step that can speed up recovery and reduce the amount of pain medications used. The side effects of this technique are minimal to low in studies published.
- Additional pain management techniques - Adding medications like celecoxib (a.k.a. Celebrex) decreased the need for narcotics in a well performed study. This can be done as a one-time dose before surgery, but may also be continued for a few days after surgery. A second study, by the same team, which was performed later determined that adding gabapentin to celecoxib was superior to celecoxib alone in reducing the need for postoperative pain medication and a better experience. I have found that when using bupivacaine - I don't need to take this additional step with pain management.
- · Long-term result of breast implants - A study looking at Mentor devices (Mentor Core Memory Gel and Mentor Contour Profile Gel) demonstrated that devices are safe and effective. Another review involving 901 augmentation and 231 reconstruction patients showed high satisfaction. Another group of researchers demonstrated 90% percent of breast implants were intact after 10 years and a separate group looking at magnetic resonance imaging (MRI) studies on 163 patients found a 1.7 percent rupture rate over a median postoperative period of 8 years. All this evidence supports what I experience in my clinical practice, that breast implants make patients happy in the short and long-term.
- · Breast cancer risk - Evidence suggests that breast augmentation does not increase the risk of breast cancer. Two large cohorts of breast augmentation patients including 3486 patients followed for a period ranging of 9 to 37 years found that the breast cancer rate was lower than expected but the difference was not statistically significant. Importantly, the lymphatic drainage patterns is no different before and after surgery. Breast implants in the submuscular position interfere significantly less with mammography than implants in the subglandular position. In addition, Research conducted on the information available and concluded that silicone gel-filled implants do not affect the incidence of connective tissue disorders. With all this supportive evidence it is clear that breast implants are safe, effective and with good long-term results implants are not likely to increase the breast cancer incidence.
- Smooth versus textured breast implants - The smooth breast implant devices should be chosen in the vast majority of patients because there are no advantage to textured devices, for capsular contracture, when the devices are placed under the muscle. This is supported by the current evidence. In cases where a patient might have a better result with above-muscle placement textured breast implants do seem to reduce the risks of contracture. Texturing can increase the risk of ripples and possibly the risk of early leak. Going below the muscle has important advantages like resulting in a more natural shape, lowering the risk of capsule contracture, improving the results of mammography and many others which I routinely discuss with patients during consultations.
I believe this review of current evidence in breast augmentation will help many patients in making important decisions about their breast implant procedure. In my practice, which specializes on breast augmentation and breast implants, I use all the points discussed above during consultation. Because our clinic staff is also highly educated and experienced with breast augmentation, we are able to enhance the postoperative experience for patients. I have been told by many patients that our approach makes sense and helps to reduce the normal anxiety associated with the procedure. We also take away an additional anxiety by using the volume sizing systems, which helps to make sizing for the ideal cup easier for patients. We are also all about good pain control and really focus on the best ways to make patients comfortable after breast implants. In addition, good education helps all patients understand the procedure better and improves expectations and results, alike.