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Orange County Breast Augmentation
What I Have Learned from Evidence Based Medicine

Breast Augmentation is one of the most common cosmetic surgery procedures performed. During the past ten years, some of the techniques I have used and the care of the patient has been based on experience, trial and error, and my training.

Over the past few years, there has been a push towards evidence based medicine: using data to guide our practice.

We are fortunate to have evidence based medicine information now available for breast augmentation surgery (Journal of Plastic and Reconstructive Surgery, volume 126, Number 6, 2010).

There are four levels of strength when looking at research papers:

  • Level I-High quality, multicenter or single center study. This is as good as it gets.
  • Level II-Lesser quality study, but still of great value.
  • Level III-Retrospective chart review study, case control study, or review of these studies
  • Level IV-Case series study
  • Level V-Expert opinion, case report or clinical example

Ideally, all studies should be level I in terms of strength. However, some procedures are very difficult to design strong research around, due to multiple factors involved. Levels 2-5 are still of interest and value, but less than level I.

One major point of the article is the use of steroid (125mg of methylprednisolone) given intravenously before making the first incision has been shown to reduce nausea, vomiting, and lessen the need for pain medication (level I, II evidence).

Infiltrating Bupivacaine (a numbing medication from the same family as Xylocaine-used to numb your teeth at the dentist office) into the pocket before placing the implant will also decrease the need for pain medication after surgery (Level I,II). For the past five years, I have been irrigating the pocket with Bupivacaine, and it is reassuring to know the data support my practice.

I have always been unhappy with the use of Vicodin for pain control after breast augmentation. The patients never seemed comfortable for the first 1-2 weeks. Two years ago, I switched to Flexeril (a muscle relaxant-my thought process being the divided muscle goes into spasm) and ibuprofen (an anti-inflammatory medication). Although I never did a formal study, the patients seem more comfortable. There is now evidence celecoxib (Celebrex-an anti-inflammatory medication similar to ibuprofen) decreases the need for narcotic medication after surgery (Level II).

During the past 10 years, I have used the peri-areolar, trans-axillary (arm pit), and the inframmary fold (incision under the breast fold) for my breast augmentation. Over the past 5 years, I have used the inframmary fold almost exclusively, since it made sense to me from an anatomic stand-point. It is now reassuring to know the inframmamary fold incision has a lower rate of capsular contracture (0.59 percent versus 9.5 percent) than the peri-areolar incision (the study involved over 400 patients).

In a study involving 1600 patients, no evidence was found to support additional antibiotic use other than the initial dose given before surgery. To be honest, most surgeons, including me, give post-operative antibiotics because it makes us feel better!

There is no evidence (level I) to support the use of textured breast implant in a sub-muscular plane decreases the risk of capsular contracture. The risk is less (Level I), however, if the textured implant is placed above the muscle (sub-glandular). Implants in the sub- glandular position, however, interfere significantly more with mammography. If the implant is placed in the sub-glandular plane, ultra-sound examination has been shown to be more accurate than mammography (Level II). I have never used textured implants, since I have always placed the implant in the sub-muscular plane.

Breast augmentation does not affect lymphatic drainage in the breast tissue (Level II) and does not increase the risk of breast cancer compared to patients who have never had breast augmentation (Level II).

Over-all, I am pleased with my approach to breast augmentation surgery. However, there is still room for improvement! I will give one dose of steroid before surgery, since it decreases nausea, vomiting and the degree of pain after surgery. I will also stop giving patients antibiotics after surgery, as there is no data to prove their use is beneficial.

Have Questions?

Michael A. Jazayeri, M.D. is a board certified plastic surgeon with over 10 years of experience. His office is located in Orange County, California. To schedule a complimentary consultation, please call 714-834-0101.