Commentary on: Secondary Composite Breast Augmentation: Concept and Outcomes, Introduction to a Layered Approach

The authors present a case series of a single-surgeon experience with secondary or revision composite breast augmentation.¹ Secondary breast implant surgery is an area of practice I am seeing more and more of, and indeed I now perform more secondary breast implant surgeries than primary breast augmentations. This is unsurprising because breast augmentation consistently ranks as the most performed cosmetic surgical procedure in annual surveys of plastic surgery aesthetic activity. Both the International Society of Aesthetic Plastic Surgery international survey and The Aesthetic Society annual survey of activities year on year rank breast augmentation as the number one surgical aesthetic procedure.^2,3 Secondary or revision breast augmentation is therefore an anticipated procedure in the future. Reported reoperation rates for primary breast augmentation range between 22.3% and 36.1% in 10-year studies such as the United States-based Core Clinical studies.^4-7

The layered approach advocated by the authors for preoperative analysis was interesting to read, and the methodical and systematic approach that it encourages is very appealing and logical to follow. I agree that thorough analysis of all the breast components preoperatively and recognition of where the tissue deformity and problem lies allow for better operative planning and help to predict the postoperative outcome. I would incorporate the layered approach into my clinical practice. This layered tissue analysis of the breast from nipple-areola complex to chest wall also allowed the authors to develop a treatment algorithm or preference for each layer deformity. Some excellent clinical results are shown in their series of patients, including in difficult and challenging cases, and I commend the senior author on achieving these results.

The most common causes for implant revision in this series was implant visibility and asymmetry. The preoperative implant plane was most commonly submuscular. This is somewhat different from the most common reasons for implant revision in my practice. Although I see many women who present because of implant visibility and asymmetry (the most common reason for reoperation in this paper), I perform secondary implant surgery most commonly for capsular contracture and breast ptosis. I also find many of the original implants in my patients have been placed in the subglandular plane, and therefore my pocket changes are frequently changing the implant from subglandular to dual plane after performing a capsulectomy. The variation and differences in prevalence of clinical presentations in secondary breast implant cases between plastic surgery practices are interesting to see.

In my experience, it has not always been necessary or mandatory, as the authors feel, to perform a composite breast augmentation in secondary cases. Women of a slim build and with small native breast tissue volumes resulting in little tissue coverage over their implants almost universally receive a beneficial effect on their breast aesthetics from the addition of lipoaugmentation at the time of their implant exchanges. However, in women who have a larger volume of native breast tissue, it is not always necessary to conduct a composite augmentation to achieve good breast shape and volume. I note that the authors excluded cases from their series who underwent implant exchange without lipoaugmentation. It would be interesting to know how many secondary or revision breast implant cases were excluded from the series over the same time period and why the excluded cases did not have composite breast augmentation. Did the layered approach have significantly different findings in this group, and did the findings steer the authors towards a different treatment approach or algorithm for this group?

For women who want smaller replacement implants and/or who have very thin soft tissue coverage over their implants and capsule, I find lipoaugmentation is a very useful adjunct. The transferred fat can improve implant coverage, improve cleavage lines, and augment breast fullness while keeping the replacement implant of a small to moderate size.

The authors mention acellular dermal matrices (ADMs) at the end of the paper, but ADMs did not play a role in this case series. The cost of ADMs is referred to as a reason for opting for lipoaugmentation or composite augmentation instead, but for many there is an additional cost for the lipoaugmentation component of composite breast augmentation compared with the same procedure without fat transfer; also, some women eventually receive a second lipotransfer procedure as well. Although I do not utilize ADMs in many cases in my clinical practice, in some secondary cases where additional coverage of the implant is desired and additional structural support (eg, to recreate or adjust an inframammary crease) is needed, ADMs may offer an alternative solution. They can be employed to provide implant coverage and also additional support of the implant.^8,9 ADMs do not have the same ability to add much volume or fullness to the breast as lipoaugmentation has, but they offer the advantage of helping confer additional structural support in some cases. The overall cost advantage of lipoaugmentation in composite breast augmentation compared with ADM would be interesting to consider, both for the initial surgery and over a long-term period also investigating additional surgeries needed after the first composite breast augmentation or implant and ADM procedure.

The article is very clearly written and provides a useful framework for breast analysis in secondary and revision cases. Some of the limitations include that it is a retrospective study and it publishes the selection and description of composite cases without clarifiying why this series had composite augmentation, whereas others (excluded from the surgery) did not. Nevertheless, I enjoyed reading the article. I think the layered approach will have many practical applications in the practice of an aesthetic plastic surgeon, and it is a valuable addition to the breast augmentation medical literature.

Disclosures

The author declared no potential conflicts of interest with respect to the research, authorship, and publication of this article.

Funding

The author received no financial support for the research, authorship, and publication of this article.

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