In the February 2021 Aesthetic Surgery Journal, there was an article about transitioning from conventional textured implants to nanotextured implants. What I love about medicine is that science is about questioning and discourse. In reading the commentary, I thought the author brought up a bunch of good points.
The authors stated they did not use nanotextured implants in patients with poor tissue and those who went over 350cc. They had 24/7 bra wearing for 3 months, and they restricted active gym use for 3 months after surgery. They used these implants as they did traditional textured implants, where they placed it partially under the pectoral muscle.
The commentator reviewed the information – the average patient in the study was a female in their thirties, with one child, and a BMI of 20. The majority of these patients had a A or B cup bra, and had their implants placed in a dual plane pocket.
The commentator cites that with new implant more cohesive technologies, perhaps we should not be putting the implants behind the muscle. He states a primary reason we put breast implants behind the muscle was because of issues of rippling in the upper cleavage area of the breast, and thinks we must still do subpectoral placement in really thin tissue patients.
But he questions our basic thinking, and he is clearly a fan of putting breast implants in front of the pector muscle. He states with using all the new techniques we do for implant placement (antibiotic irrigation, keller funnel, no touch technique, etc), the traditional thinking that implants under the breast gland have a higher capsular contracture rate may not longer be true.
My thoughts?
We always need to evolve. I think there are good points in his critique. Without the truly textured implants, thin tissue, large implants, or poor rib cage shape patients have an issue. So what are our current options?
- We can put the implant in and hope it doesn’t stretch. You wear good support 24/7.
- We can use mesh (like galaflex) to try to support the weight of the implant. This adds cost and a layer of complexity, but may be effective.
- We can put the implants in front of the muscle. I agree with many of the author’s points, as he is clearly a fan of putting the implants in front of the muscle, but I do think there are issues with that placement. When you use a higher cohesive implant, they do not ripple or wrinkle as much, but they can look more fake, they are firmer in their feel, and they may have a more brusque transition. They can still ripple and wrinkle. Traditional teaching is that they have a higher rate of capsular contracture when placed under the breast gland. I would like to see current studies showing that issue has changed. And there was a huge study which showed delayed breast cancer detection in women with implants, and when doing a deep dive, it appeared that the delay it was in part because it is harder to image the breast when implants are in front of the pectoral muscle.
So I don’t know the right answer. I appreciate these studies and insights.