O R I G I N A L A R T I C L E
Outcome Assessment of Breast Distortion Following
Submuscular Breast Augmentation
Scott L. SpearÆ Jaime Schwartz Æ Joseph H. Dayan Æ Mark W. Clemens
Received: 14 October 2008 / Accepted: 20 October 2008 / Published online: 4 December 2008 ! Springer Science+Business Media, LLC and International Society of Aesthetic Plastic Surgery 2008
Abstract
Background Animation deformity or breast distortion during pectoralis muscle contraction following subpectoral breast augmentation is a known entity, but its prevalence and significance remain unclear. The purpose of this study was to identify the incidence and severity of animation deformity as well as its effect on patient satisfaction and interference with certain activities.
Methods All procedures were performed by the senior author using a variation of a previously described dual-plane technique. The first part of this study was an evalu-ation of breast distortion by a group of independent observers in a series of 40 consecutive patients who underwent primary subpectoral breast augmentation. The second part of the study was a questionnaire sent to 195 consecutive patients asking about overall satisfaction, degree of animation deformity, and whether there was interference with any activities.
Results Of the 40 patients’ photographs that were eval-uated, 9 (22.5%) had no distortion, 25 (62.5%) had minimal distortion, 4 (10%) had moderate distortion, and 2 (5%) had severe distortion. Of the 195 questionnaires, there were 69 responses, a 35% response rate. Fifty-six (82%) described mild to no distortion, 7 (10%) were moderate,
and 5 (7%) were severe. According to the survey, the most common activities that were problematic were lifting weights and exercising (24 and 19%, respectively). Only one (1%) patient stated that she would not recommend subpectoral positioning.
Conclusion Although animation deformities do exist, nearly all patients in this study would still choose sub-pectoral positioning. Patients who may be better candidates for subglandular placement are those for whom exercise is central to their daily living. As a result of this study, sur-geons and patients should have more accurate and reliable information regarding the significance of animation deformity after subpectoral breast augmentation.
Keywords Breast distortion! Breast augmentation ! Animation deformity ! Pectoralis ! Subpectoral
Animation deformity or breast distortion during pectoralis muscle contraction following subpectoral breast augmen-tation is a known entity, but its prevalence and significance remain unclear. There have been very few reports describing possible correction of such animation deformi-ties and, remarkably, a comprehensive review of this issue has not been done [1–3].
While undoubtedly there are patients in whom distortion may be clinically significant, it is not clear how many patients are affected, how much this distortion bothers most patients, and with which specific activities this interferes. The purpose of this study was to identify how frequent are animation deformities, how such deformities affect patient satisfaction, how many patients have objective evidence of animation deformities, with what activities do such defor-mities occur, and how to measure, quantify, or grade the degree of distortion.
S. L. Spear is a paid consultant to Lifecell Corporation, Ethicon Inc., and Allergan, Inc. This study was conducted without any funding. S. L. Spear (&) ! J. Schwartz ! J. H. Dayan ! M. W. Clemens Department of Plastic Surgery, Georgetown University Hospital, 1st Floor PHC Building, 3800 Reservoir Road, NW,
Washington, DC 20007, USA e-mail: spears@gunet.georgetown.edu DOI 10.1007/s00266-008-9275-y
Materials and Methods
All procedures were performed by the senior author using a variation of a previously described dual-plane technique where the implant sits beneath the muscle superiorly and in a partly subglandular plane inferiorly [4, 5]. The procedure begins with an abbreviated sub-glandular dissection exposing the lower border of the pectoralis muscle. The amount of subglandular dissection is dependent on the degree of preexisting glandular ptosis. Patients with minimal or no breast ptosis may require only a couple of centimeters of dissection, while those with more significant ptosis may require a sub-glandular dissection up to the level of the nipple or as high as the superior border of the areola to allow for more redraping of the parenchyma over the implant. The subpectoral pocket is then developed by grasping the lower edge of the pectoralis major muscle with an Allis clamp and dividing its attachments along the inframam-mary fold under direct vision, leaving the sternal attachments intact. This prevents the pectoralis muscle from retracting superiorly while allowing the implant to fill out the lowermost portion of the breast parenchyma. The implant is placed in the subpectoral pocket but now lies in a ‘‘dual plane’’ space, partly subglandular and partly subpectoral. The dual plane is particularly advantageous in thin patients with glandular ptosis or a constricted inferior pole, where purely subglandular placement would provide more control in the initial contour of the breast but at the expense of increased implant visibility and palpability. The dual-plane tech-nique maintains the benefits of added soft-tissue
camouflage in the superior pole while providing greater contact between the implant and the lower aspects of the breast gland for better overall contour and redraping.
The first part of this study was an evaluation of breast distortion by a group of plastic surgery residents in a series of 40 consecutive primary subpectoral breast augmentation patients. To improve the objective evaluation of breast distortion we developed a grading system for breast dis-tortion using a four point scale: grade I—no disdis-tortion and unable to discern whether the implant lies in front of or behind the pectoralis muscle; grade II—one is able to tell that the implant is subpectoral, but there is minimal dis-tortion with an aesthetically pleasing result; grade III— moderate distortion but still an aesthetically acceptable result; and grade IV—severe distortion with an unattractive result during muscle contraction (Figs. 1–4). Photographs were shown of the patients both at rest and with the pec-toralis major muscles aggressively contracted. Results were tabulated for each patient.
The second part of this study was a patient satisfaction survey. Currently, there is no comprehensive and validated existing questionnaire to measure patient experiences with muscle distortion after breast augmentation. Therefore, a novel IRB-approved questionnaire was mailed to 195 consecutive patients who underwent primary subpectoral breast augmentation (without mastopexy) beginning in January 2000. The minimum time after breast augmenta-tion for patients to be surveyed was 6 months. The questionnaire involved a self-evaluation of the degree of breast distortion, its impact on various activities, and overall satisfaction.
Fig. 1 Grade I (no distortion): With flexion, one is unable to discern whether the implant lies in front of or behind the pectoralis muscle
Results
Of the 40 patients’ photographs that were evaluated, 9 (22.5%, SD = 0.44) were rated as grade I (no distortion), 25 (62.5%, SD = 0.62) were grade II (mild), 4 (10%, SD = 0.73) were grade III (moderate), and 2 (5%, SD = 0.24) were grade IV (severe). There were 69 responses from the 195 questionnaires that were sent (35% response rate). Fifty-six patients (82%) rated their breast distortion as none to mild. 7 patients (10%) rated their distortion as moderate, and 5 patients (7%) felt they had
severe distortion (Table1). One patient did not answer the question regarding severity of breast distortion. When asked if the muscle-related breast distortion was a problem, the most common affected activities reported were lifting weights and exercising (24 and 19%, respectively). None of the respondents reported any interference from animation deformities with activities of daily living (Table 2).
Overall, there was an 86% satisfaction rate with 3% of patients who were neutral, 10% felt somewhat unsatisfied and one respondent was entirely unsatisfied. When asked if they would choose subpectoral implant placement again,
Fig. 2 Grade II (mild distortion): With flexion, the breast is still aesthetically pleasing. This patient has only minimal lateral displacement of the breast implants with flexion
Fig. 3 Grade III (moderate distortion): With flexion, there is an aesthetically acceptable result. This patient illustrates an animation deformity in the lower pole of the breasts where the fold has been lowered
70% responded affirmatively, 28% were unsure, and 3% said they would not choose subpectoral implant placement. When asked if they would recommend subpectoral posi-tioning, only one patient stated she would not recommend subpectoral breast augmentation.
Discussion
Animation deformities following subpectoral implant placement may be significant in certain patients, especially if they exercise frequently or lift weights. Overall patient satisfaction was high, but it is unclear whether those patients who were unsatisfied were unhappy because of animation problems or because of other factors such as dissatisfaction with their implant size or incision place-ment. Because the questionnaires were anonymous, we were unable to further evaluate those patients who expressed dissatisfaction or correlate questionnaire results with patient photos. There are inherent limitations in con-ducting this type of study. While a response rate of 35% is acceptable, questionnaire-based studies are inherently susceptible to sampling bias and responses may not be completely representative of the greater population. Developing a reproducible scale for measuring the degree of breast distortion is difficult, and there is a certain amount of subjectivity involved. Ultimately, the patient’s satis-faction with any procedure is the most important endpoint. Although there were some patients who felt that animation distortion was a problem during activities such as exer-cising (19%), the vast majority of patients were satisfied with their results and only 3% of patients would choose not to undergo subpectoral implant placement if they could start over again. Only one patient said that she would not recommend subpectoral placement and none of the patients have elected to reposition the implants in front of the muscle.
To date, not much has been written on the subject of animation deformities. One study by Pelle-Ceravolo et al.
Table 1 Patient self-assessment of implant-related breast distortion (n = 68) Degree of animation deformity No. of patients Percentage of patients None 32 47% Minimal 16 24% Mild 8 12% Moderate 7 10% Severe 5 7% No answer 1 N/A
Table 2 Patient evaluation of animation deformities with various activities as a result of subpectoral breast augmentation
Activity No. of patients affected
Percentage of patients Activities of daily living 0 0
Lifting weights 16 24
Exercising 13 19
Yoga 6 9
Sex 3 4
Flexing 5 7
Appearance in low-cut tops 2 3
No activity 41 60
Fig. 4 Grade IV (severe distortion): With flexion, there is an unattractive result during muscle contraction. This patient is shown as an example of severe distortion but is an augmentation/mastopexy patient who was not part of this specific study
[1] classified distortion into three categories, Class I (mild), Class II (moderate), and Class III (severe), and evaluated two groups totaling 348 patients. One group of patients underwent subpectoral implant placement and the second group underwent a modified subpectoral technique whereby the inferior half of the pectoralis muscle was bisected vertically in an effort to avoid muscle-related distortion. Using the modified technique, only 5.4% of patients were classified as Class III as opposed to 47.4% in the standard subpectoral group. However, these results are compromised by the limited number and bias of the observers which included only the surgeon, nurse, and patient. Furthermore, only textured silicone implants and polyurethane-coated implants were used in that study. Although it has not been studied, it is possible that the type of implant used might have an effect on the degree of animation deformity. The unusually high incidence of Class III deformities in their standard subpectoral group (47.4%) raises the question of whether technique used by Pelle-Ceravolo et al. or the choice of implant (textured silicone or polyurethane-coated) may exacerbate the inci-dence of animation deformities as opposed to our technique and the use of smooth implants, which were used almost exclusively in the study presented here. There may also be differences in the incidence of animation deformity between silicone and saline implants as well as with the more or less cohesive gel implants.
Transecting the pectoralis major muscle seems to be excessively destructive, especially given that most of the patients in our study did not complain of muscle-related animation deformities and this maneuver may cause sec-ondary problems such as a depression or thinning in the inferior pole, especially if the patient is very thin. Other possible treatments for animation deformities include sur-gical or chemical pectoral nerve manipulation or changing the implant location [2]. The only way certain to avoid or correct animation deformity is to place the implant in front of the muscle. After investigating the incidence and sig-nificance of animation deformities, it is important to put these data into perspective. There are clearly some patients who might, from the perspective of animation deformities, be better served with a subglandular implant, namely, those in whom rigorous exercise or weight lifting is central to their daily routine. The question ultimately becomes whe-ther the owhe-ther benefits of subpectoral positioning are worth the risk of an unattractive animation deformity. The deci-sion of subpectoral or subglandular placement requires taking inventory of the pros and cons of both subglandular and subpectoral placement. The possible benefits of sub-glandular placement are little or no animation deformity and more visible implant contour in the superior pole. The potential problems with subglandular placement are sta-tistically probably a greater incidence of capsular
contracture, greater visibility of the implant in thin patients, greater incidence of visible rippling, and greater interfer-ence with mammography, which is a significant consideration given the high incidence of breast cancer [6–9]. The benefits of subpectoral positioning include improved upper-pole soft tissue, camouflage in thin patients, less visible rippling, less visibility of the implant, probably a lower rate of capsular contracture, and improved visibility of the breast parenchyma on mammo-gram. Disadvantages to subpectoral placement are the potential for increased animation deformity, possibly somewhat greater postoperative pain, and, in certain patients, less direct control of the upper breast contour. Thus, although some patients might find animation defor-mity to be a problem, many if not most might still choose subpectoral positioning. It would be interesting to conduct the same type of study in patients who underwent sub-glandular positioning and query concerns regarding visibility, palpability, and capsular contracture which are the potential weaknesses of that approach [6–8].
One must also consider local demographics in evaluat-ing the results of a study such as this. The population in this study was mostly women living in the Washington, DC, metropolitan area. The same study conducted in Nevada, Texas, or Florida might yield different conclusions. In summary, as a result of this study, surgeons and patients should have more accurate and reliable information regarding both the objective effect and subjective patient response to muscle-related animation deformities after subpectoral breast augmentation.
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