Effect of Incision Choice on Outcomes in Primary Breast Augmentation

Goals/Purpose:

The purpose of the study is to determine the effect of incision type on outcomes in primary breast augmentation. Capsular contracture is the most common complication following primary breast augmentation and one of the most common causes of reoperation. Various studies have suggested certain risk factors including radiation therapy, previous capsular contracture, infection (subclinical or clinical), hematoma, subglandular implant positioning, and choice of incision.  Our review was designed to investigate a possible association between the three most common breast augmentation incisions (periareolar, inframammary, and transaxillary) and the development of capsular contracture. 

Methods/Technique:

We conducted a retrospective chart review of 197 primary breast augmentation patients who underwent surgery between 2003 and 2009.  Significant capsular contracture was determined to have occurred if the patient required reoperation for a capsular contracture.

Demographic, procedural, and follow-up data were collected.  Patients were excluded if they underwent an augmentation/mastopexy, had previously undergone breast surgery, or had shaped silicone implants used, since these are currently investigational devices in the United States.  Patients with a history of breast cancer on the opposite side and who had not been exposed to radiation or a previous surgery on the noncancerous breast were included in the study. The primary endpoint of the study was the development of clinically significant capsular contracture, defined as reoperation or recommended reoperation for the contracture. Capsular contracture was graded using the Baker Classification, a commonly used scale in both practice and in studies due to its easy application.

Capsular contractures were analyzed on a per patient basis using Fisher’s Exact test and on a per breast basis using the Rao-Scott chi-squared test.

Results/Complications:

Three hundred thirty-six breasts were augmented in 183 patients who met inclusion criteria.  Average patient age was 36.5 years.  Mean follow-up was 392.6 days and median follow-up was 245.0 days.  Surgical complications included six breasts with capsular contractures (1.8%), three with hematomas (0.9%), and one with an infection (0.3%).   None of the patients with contractures were active smokers or had diabetes mellitus.

In the 336 augmented breasts in our study, transaxillary incisions produced the highest incidence of contracture with 6.4% (n  =  3, out of 47), periareolar incisions the next highest at 2.4% (n =  2, out of 84), and inframammary incisions the lowest incidence at 0.5% (n =  1, out of 205).  There was a statistically significant difference in the incidence of capsular contracture when compared among the three incision location sites (p = 0.03), with transaxillary, followed by periareolar incisions producing the most contractures.  The increased rate seen in transaxillary incisions compared with inframammary incisions was statistically significant whereas the increased rate seen in periareolar incisions compared with inframammary incisions did not reach statistical significance.  Of the six capsular contractures in our study, five were Baker II, and one was Baker III. No Baker IV capsular contractures were present in this study population.  

No significant association between implant fill material and contracture was found (p = 0.27). Due to the small number of capsular contractures, no p-values could be calculated for the association of capsular contracture with plane of implant placement, implant texture, or shape.

Three patients had hematomas (1.6%), and one developed an infection (0.6%). No patient with a hematoma or infection developed a capsular contracture.

Patients in the study were followed for a mean of 392.6 days.

Conclusion:

Consistent with the scant amount of published literature specific to this issue, this study demonstrates the lowest capsular contracture rate with an inframammary incision. The risk of clinically significant capsular contracture appears to be higher with the transaxillary incision as compared to the periareolar or the inframammary alternatives. This increase was statistically significant.  There is also the suggestion that there is an increased risk of capsular contracture after a periareolar incision as compared to an inframammary one, though this increase did not reach statistical significance.