Diagnosis and management of galactorrhea after breast augmentation.

BACKGROUND: A known but not fully understood complication of breast augmentation is galactorrhea. To date, all publications on this subject have been case reports. The purpose of this retrospective study was to examine a large group of consecutive patients who had undergone breast augmentation and identify the incidence of galactorrhea and galactocele, and the associated preoperative and intraoperative risk factors. The authors also evaluated the treatment algorithm used. METHODS: A retrospective chart review was performed on patients who underwent primary breast augmentation using silicone implants in a single group practice from 2008 to 2013. Logistic regression for rare events data was applied to evaluate the risk of galactorrhea according to the variables. RESULTS: The study included 832 patients (1664 implants) who had undergone breast augmentation. The follow-up period ranged from 12 to 52 months (mean, 15 months). Eight patients (0.96 percent; 95 percent CI, 0.42 to 1.89) experienced galactorrhea after breast augmentation during the follow-up period. All eight patients had bilateral involvement, and three (0.36 percent of the total and 38 percent of the galactorrhea cases) presented with a galactocele. Use of a periareolar incision, however, statistically significantly increased the incidence of galactorrhea among these patients. The authors' management algorithm proved to be an effective clinical course of action. CONCLUSIONS: Although galactorrhea is rare after breast augmentation, it can be disfiguring and devastating for the patient. This is the first longitudinal retrospective study on the subject. Adequate treatment and patient information are essential. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, III.

Use of selective serotonin reuptake inhibitors antidepressants and bleeding risk in breast cosmetic surgery.

BACKGROUND: Selective serotonin reuptake inhibitors (SSRIs) are the most common antidepressant prescribed currently. Data regarding SSRI use among plastic surgery patients may differ between different populations, but the incidence could be as high as 10 %. It is known that SSRIs decrease platelet serotonin storage and platelet function, and their association with postsurgical bleeding in mastectomy patients and orthopedic surgery patients is well established. An increased risk of postsurgical bleeding among plastic surgery patients may have important clinical implications, but this has not been evaluated to date. The authors therefore conducted a hospital-based study with prospectively collected data to examine the association between the use of SSRIs and postsurgical bleeding. To the authors' knowledge, this is the first study to evaluate the effects of SSRIs on bleeding risk in the breast cosmetic surgery population. METHODS: All patients who underwent breast cosmetic plastic surgery procedures (breast augmentation, breast reduction, or mastopexy) at our institution between January of 2001 and December of 2011 were reviewed. The patients were divided into two groups by SSRI use history: a no-use group and an active-use group. The primary end point for a bleeding event was the need for intervention. Patients were further subcategorized by type of breast surgery performed, body mass index, and age. Descriptive statistics tabulated the frequency of a bleeding event within the groups. Logistic regression was applied to evaluate the risk of a bleeding event according to the use of SSRIs. The odds ratios (ORs) with their 95 % confidence intervals (CIs) associating SSRI use with postoperative bleeding were computed. RESULTS: During the study period, 2,285 patients had breast cosmetic surgery, and 33 of these patients (1.44 %) experienced a bleeding event (hematoma requiring surgical draining). Of the 196 patients (8.58 %) in the active-use group, 9 (4.59 %) experienced a bleeding event. Of the 2,089 patients in the no-use group, 24 (1.15 %) presented with bleeding. The patients using SSRIs had a 4.14-fold greater risk of breast hematoma needing intervention than the patients who were not users (OR, 4; 95 % CI, 1.90-9.04). Logistic regression also showed that bleeding events were more common among the SSRI users regardless of the type of procedure performed, the body mass index, or the age group. CONCLUSIONS: Use of SSRIs is associated with a fourfold increased risk of bleeding after breast cosmetic surgery (from 1.44 to 4.59 %). The decision of psychologically vulnerable patients to stop SSRIs before surgery should not be made without a complete discussion of the risks and benefits. LEVEL OF EVIDENCE III: This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Striae distensae after breast augmentation.

BACKGROUND: One known but not fully understood complication after breast augmentation is the new onset of stretch marks (striae distensae) on the surgically treated breast. To date, all publications on this subject have been case reports. No report has fully described the actual incidence, risk factors, or management of striae distensae after breast surgery. METHODS: This study prospectively followed patients who underwent primary breast augmentation using silicone implants in a single group practice from 2007 to 2011. New-onset striae distensae were actively investigated. Time from surgery to the moment of striae onset, patient age, nulliparity, use of oral contraceptives, overweight, personal history of stretch marks, and other variables were evaluated. RESULTS: A total of 409 patients were included in the study. In 19 cases (4.6%), new-onset striae distensae after breast augmentation were observed. The population with striae distensae was significantly younger than the total population (29.56 vs 20.91 years; p=0.012). Striae distensae also were more common in nulliparous than in multiparous women (8.29 vs 0.52%; p=0.006), overweight women (17.77 vs 3.02%; p=0.016), women using oral contraceptives (7.89 vs 0.55%; p=0.008), and women with a personal history of stretch marks (8.97 vs 3.36%; p=0.031). No relation was shown regarding implant pocket type, size, or profile. CONCLUSION: Striae distensae may be a common but underreported complication after breast augmentation. In this series, striae distensae developed in 4.6% of the patients within 1 year after breast augmentation. Severity may vary from inconspicuous small marks (classifications 1 and 2) to wide red and active striae rubra (classifications 3 and 4). Nulliparity, use of oral contraceptives, overweight, personal history of stretch marks, and younger age were related to a higher incidence of striae distensae. The increased rates in these groups may be associated with their exposure to higher estrogen levels and the important role of this hormone in facilitating the formation of striae distensae. Further studies are needed to show whether changes in these risk factors (i.e., weight loss, contraceptive withdrawal) may help to decrease striae distensae rates is these populations. LEVEL OF EVIDENCE IV: This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors at www.springer.com/00266.

Triple-anchoring sub-SMAS face-lift.

BACKGROUND: This article presents the senior author's (ARB) 10-year experience with a rhytidectomy technique that incorporates concepts of modern facial shaping and contour using a sub-SMAS repositioning of volumetric units with partial sub-SMAS elevation (tunnel dissection), periosteal anchoring of SMAS and volumetric units, and limited skin undermining. METHODS: The cases of triple-anchoring sub-SMAS face-lift performed from January 2000 to January 2010 were analyzed retrospectively. Primary and secondary cases were included. All case data and photography were analyzed. Data regarding patient age, sex, and operative time were gathered. Complication rates were also calculated. RESULTS: A total of 626 patients had a face-lift using the author's technique in this period. A total of 484 patients had a primary face-lift and 142 had secondary surgery. Experience with 626 rhytidectomies performed over a 10-year period indicates that this operation can be completed safely with satisfactory results and a low incidence of complications. To alter effectively the facial contour, a system that reliably elevates the facial volumetric units is needed. After adequate release of the retaining ligaments, the thick SMAS is used as a load-bearing layer. All the tension is transferred from the SMAS to a fixed periosteal anchor point. Each volumetric unit of the face (mala, lateral, and cervical) should be independently mobilized and fixed. CONCLUSION: The author's technique was shown to be effective in repositioning facial volumes. It was a predictable and reliable technique with few complications over the years. LEVEL OF EVIDENCE IV: This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors at http://www.springer.com/00266.

Reoperative transaxillary breast surgery: using the axillary incision to treat augmentation-related complications.

BACKGROUND: The axillary incision for breast augmentation has been an option for patients and surgeons for more than 30 years now. Controlled clinical trials have demonstrated that reoperations continue to be significant (15-24% at 3 years) independent of incision choice. The misbelief that the transaxillary approach is not adequate for reoperations inhibits patients' and surgeons' decisions on what incision is best in each case. METHODS: A retrospective analyses was performed seeking reoperation cases performed from January 2008 to January 2011 that used the same axillary incision as the previous transaxillary augmentation. Data on the cause for the reoperation, time between surgeries, patient age, implant volume, locality of the primary operation, and details regarding the implant type and pocket plane were gathered and analyzed. RESULTS: A total of 15 patients and 26 breasts needing reoperation were found in this period. The average time between the first surgery and reoperation was 12 months, average patient age was 36 years, and implant volume ranged from 195 to 360 cc, with an average of 283 cc. Six of these patients were previously operated on by the authors and nine were operated on by other surgeons and came to our service seeking revision. Details regarding the implant type and pocket plane are also given. The main causes for reoperation were capsular contracture (26.9%), size change (15.4%), seroma/hematoma (11.5%), infection (11.5%), axillary banding/scarring (11.5%), lower-pole deformity/high-riding (11.5%), asymmetry (7.7%), and rippling/waviness (3.8%). CONCLUSION: Transaxillary breast augmentation reoperation is feasible if certain principles are followed.

Late infection following breast augmentation with textured silicone gel-filled implants.

BACKGROUND: Infection after insertion of a breast prosthesis is an uncommon but feared complication. Previously reported infection rates vary and include reconstructive and cosmetic patients. OBJECTIVE: We sought to define the infection rate and the presentation of postoperative infection in the patient with aesthetic breast augmentation. METHODS: A prospective analysis was undertaken of 288 patients who underwent aesthetic breast augmentation with textured silicone gel-filled implants between 1998 and 2002. Patients were monitored for clinical findings of infection, and microbiological analyses were performed for each case of infection. "Early infection" was defined as signs and symptoms of infection beginning 20 days or less post-surgery; "late infection" was defined as all cases with an onset more than 20 days post-surgery. Treatment was classified as antibiotic therapy only, conservative surgical intervention (with or without implant salvage), or implant explantation and replacement. RESULTS: Early infectious complications occurred in 6 of 288 women (2.08%). Late infection complications occurred in 10 of 288 women (3.47%). Late infection occurred more often and was more severe than early infection (P < .05). For the late infection group, the length of time to infection onset was between 20 and 280 days (average, 82 days). The length of time to infection was shown to be bimodal and organism-related. The group of infections caused by Enterobacter species had a significantly longer time of onset (P < .05) than the group caused by Staphylococcus aureus. CONCLUSIONS: There is strong evidence that late infections can occur in patients who have undergone aesthetic breast augmentation using textured silicone gel-filled implants. Further studies are needed to determine whether similar late infection rates affect patients with aesthetic breast augmentation who receive saline-filled implants.