Inservice Exam - 2005
Breast Augmentation

In implantation of saline breast prostheses, which of the following fill levels is most likely to result in rupture due to fold flaw?

(A) Above the manufacturer’s recommended maximum
(B) Below the manufacturer’s recommended minimum
(C) Between the manufacturer’s recommended minimum and maximum
(D) Manufacturer’s recommended maximum
(E) Manufacturer’s recommended minimum

The correct response is Option B.

Based on engineering principles, studies have shown that implant longevity requires an adequate fill level to decrease fold-flaw failures and premature failures that result from underfilling (filling at or below the manufacturer’s recommended minimum level). They have also shown that filling the implants to their least-wrinkled fill level increases implant longevity and decreases premature failure. This generally requires overfilling exceeding the manufacturer’s recommended maximum level.


At lower fill levels, implants are softer and more sloping in contour but tend to wrinkle more and have a demonstrably shorter life span because of stress caused by wrinkling. As implant volume increases, palpable and visible wrinkling decreases and longevity increases.

References:
1. Dowden RV. Saline breast implant fill issues. Clin Plast Surg. 2001;28:445-450.
2. Dowden RV, Reisman NR. Breast implant overfill, optimal fill, and the standard of care. Plast Reconstr Surg. 1999;104:1185-1186.


A healthy 24-year-old woman undergoes bilateral cosmetic breast augmentation with subglandular saline implants. Which of the following percentages best represents this patient’s 10-year risk for reoperation because of an implant-related indication?

(A) 5%
(B) 25%
(C) 50%
(D) 75%
(E) 95%
The correct response is Option B.

After breast augmentation with saline implants, the 10-year risk for reoperation for any implant-related indication is about 25%. Implant-related indications include deflation of the implant, capsular contracture, hematoma, wound infection, and seroma.

In one multicenter retrospective study of 450 patients with a mean follow-up period of 13 years, the reoperation rate for implant-related indications was 25.8%. In another multicenter retrospective study of 504 patients with a mean follow-up period of 6 years, the rate was 21%. In a third retrospective study of 749 women with a mean follow-up period of 5 years, the rate was 12% for cosmetic breast augmentations and 34% for breast reconstructions.


References:
1. Cunningham BL, Lokeh A, Gutowski KA. Saline-filled breast implant safety and efficacy: a multicenter retrospective review. Plast Reconstr Surg. 2000;105:2143-2151.
2. Gutowski KA, Mesna GT, Cunningham BL. Saline-filled breast implants: a Plastic Surgery Educational Foundation multicenter outcomes study. Plast Reconstr Surg. 1997;100:1019-1027.
3. Gabriel SE, Woods JE, O’Fallon WM, et al. Complications leading to surgery after breast implantation. N Engl J Med. 1997;336:677-682.



A woman comes to the office for consultation regarding explantation of breast prostheses without replacement. In this patient, which of the following quantifications best determines whether mastopexy will be needed in addition to removal of the prostheses?

(A) Amount of breast tissue overlying the prostheses
(B) Degree of preoperative ptosis
(C) Position of the prostheses
(D) Size of the areolae
(E) Type of implants


The correct response is Option B.

The degree of preoperative breast ptosis is the most important factor in determining whether a patient will need mastopexy after explantation of breast protheses. Because breast ptosis remains relatively unchanged or worsens postoperatively, patients with grade II or III ptosis are excellent candidates for breast contouring procedures.

The amount of breast tissue overlying the prostheses determines the safety of a breast contouring procedure done simultaneously with explantation. In general, at least 4 cm of breast tissue should be present to allow for adequate vascularity of the skin and separated glandular-nipple flap used for breast contouring, as assessed by the superior and inferior “breast pinch” test.

Important factors in determining the type of mastopexy after explantation include the position of the prostheses, the size of the areolae, and the type of implants. For example, if the areolae exceed 50 mm, circumareolar mastopexy is an option.


References:
1. Rohrich RJ, Beran SJ, Restifo RJ. Aesthetic management of the breast following explantation: evaluation and mastopexy options. Plast Reconstr Surg. 1998;101:827-837.
2. Spear SL, Giese SY, Ducic I. Concentric mastopexy revisited. Plast Reconstr Surg. 2001;107:1294-1299.



A 32-year-old woman is undergoing breast augmentation. Which of the following antibiotic solutions is most appropriate for irrigation of the breast pocket?

(A) Bacitracin, cefazolin, gentamicin
(B) Polymyxin B, gentamicin, cefazolin
(C) 10% Povidone-iodine, gentamicin, cefazolin
(D) 50% Povidone-iodine


The correct response is Option A.


Breast pocket irrigation has been advocated for many years to decrease the incidence of capsular contracture and periprosthetic breast implant infection. Multiple organisms have been cultured around breast implants, and in vitro studies have demonstrated that a combination triple antibiotic (10% povidone-iodine, gentamicin, cefazolin) combination provided improved broad-spectrum activity against the bacteria commonly cultured around breast implants compared with other antibiotic combinations, including polymyxin B, gentamicin, and cephazolin.


In 2000, the U.S. Food and Drug Administration approved the premarket application for saline implants; however, contact of the implant with povidone-iodine was stated as a contraindication. Subsequent in-vitro studies examined alternative nonBpovidone-iodine-containing breast pocket irrigation solutions and similar broad-spectrum antibiotic activity was found with the triple combination of bacitracin, cefazolin, and gentamicin.
Povidone-iodine (50%) does not provide optimal broad-spectrum activity, and contact of the implant with povidone-iodine is contraindicated. The triple combination of 10% povidone-iodine, gentamicin, and cefazolin is a viable alternative. However, if this combination is to be used, pockets would need to be irrigated clear after its instillation; therefore, this is not the optimal choice.

The combination of polymyxin B, gentamicin, and cefazolin has been shown in in-vitro studies to have inferior activity against the common bacteria cultured around breast implants.

References:
1. Adams WP Jr, Conner WC, Barton FE Jr, et al. Optimizing breast pocket irrigation: the post betadine era. Plast Reconstr Surg. 2001;107:1596.
2. Adams WP Jr, Conner WC, Barton FE Jr, et al. Optimizing breast pocket irrigation: an in vitro study and clinical implications. Plast Reconstr Surg. 2000;105:334.