Polyurethane-Coated Implants for Prevention of Double-Bubble Effect in Breast Augmentation

Abstract

Breast augmentation is the most frequently performed cosmetic surgery in the United States, with approximately 279,000 patients every year. The so-called double-bubble effect (DBE) is a common complication in breast augmentation. This complication is characterized by folds running along the lower pole of the breast, forming distinct bubble-like protrusions above and below the fold. Factors that increase the risk of DBE include bulbous breasts and a large native breast volume. There is evidence that polyurethane-coated (PU) implants may help to reduce the risk of DBE. We describe here the case of a 47-year old patient for whom DBE has recurred in each of 4 tandem breast surgeries. PU implants ultimately appeared to prevent the DBE, leading to an aesthetically satisfying treatment result for the patient. This case adds weigh to the growing body of evidence that supports the use of polyurethane implants to prevent DBE.

Introduction

In the United States, for example, about 279,000 patients undergo breast augmentation each year, which makes breast augmentation the most frequent cosmetic surgery in the United States. ¹ Such surgery may be motivated by medical necessity (for instance, cases where mastectomy or lumpectomy is advised to prevent the spread of breast cancers), or by aesthetic desires to augment the breast shape. ² Nikolić et al. ³ investigated the motivations of women considering breast augmentation. Primary themes included a wish to feel more feminine (82.2%), to be more self-confident (75.5%) and attractive (73.3%), to experience less shyness in the presence of men (64.4%), to improve sexual experiences (46.5%), to tease history (42.2%), and to increase the chances of finding a romantic partner (11.1%) or employment (2.2%).

Theoretical Background

Women perceived to have small or abnormal breasts can suffer from elevated psychological pressure and develop the wish to augment their breasts. In modern Western society, it is normal to associate perceived attractiveness with economic success and vice versa. Historically, the female breast has functioned as a symbol for erotic attractivity and fertility. Mamma-augmentation should not only be seen as a medical means to reach perceived ideals of beauty, but to reduce psychological discomfort, especially in cases where breast shape anomalies are the result of undesired but necessary medical intervention.

A positive correlation between breast augmentation and psychological wellbeing has been demonstrated in several studies: Bruck, Kleinschmidt, and Ottomann ⁴ undertook an investigation of 58 women undergoing breast augmentation and interviewed them systemically with a standardized questionnaire 6 months pre- and post-surgery. The study revealed significant improvements in self-judged attractiveness and self-confidence, alongside enhanced sexual experiences. Another study from Badura ⁵ included interviews with 27 women both before and half a year after breast augmentation. Pre-surgery patients unanimously reported lower self-esteem and discomfort with their bodies. A substantial proportion in fact suffered from depression-like symptoms. Six months after surgery, all patients reported a significant relief from these symptoms and reported a higher quality of life compared to before surgery. Several standardized questionnaires now exist to aid investigations of breast-associated quality of life in different patient populations. One of these questionnaires often used is the BREAST-Q. ^{6 -8}

The so-called double-bubble effect describes a relatively common complication in breast augmentation. The effect is typically characterized by curved folds running along the lower pole of each breast, thereby pinching off two “bubbles”. The development of the double-bubble effect may involve several individual causes. In some cases, the fold corresponds to the native infra-mammary breast fold, and the lower ‘bubble’ is caused by the periprosthetic pocket being incorrectly placed at the time of the surgery, or by the pocket sinking after the surgery has been performed. Capsular contractures have also been associated with the formation of the double-bubble effect. ⁹ However, patients with relatively large native breast volume, glandular ptosis, or postpartum atrophy may also face increased risk of developing a double-bubble effect. ¹⁰ Patients with bulbous breasts, a narrowing of the inframammary fold, or with inframammary folds proximal to the nipple have a natural susceptibility to this effect. ¹¹ However, the condition affects patients broadly. Accurate knowledge of breast anatomy and the importance of the inframammary fold are central in avoiding the double-bubble effect.

A possible means to avoiding double-bubble formation relies upon the use of polyurethane-coated implants, presumably in part because these implants may reduce capsular contracture. ^12,13 The polyurethane coat becomes a part of the capsule and ‘tightening’, as can be seen with traditional silicone implants, can be avoided. ¹⁴

Aim of the Case Report

In the present case report, we discuss the treatment course of N.N., who was 47 years old when treatment began. The treatment lasted from April 2017 until May 2019. The patient contacted our medical department in Baden-Baden for services based on aesthetic reasons; but in April 2017, she mentioned to had undergone breast augmentation 15 years prior, with unknown subpectoral transplants now showing clear signs of a double-bubble effect. A physician- and patient-satisfying treatment was ultimately achieved with polyurethane-coated implants.

Case Report

The patient, a 47 year-old female, mentioned in April 2017 that she underwent subpectoral breast augmentation 15 years prior through the nipple with 330 cc implants of unknown origin in both breasts. She showed clear signs of the double-bubble effect, which she hoped would be corrected within the upcoming treatment. At this time, she was informed about the possible risks of surgical treatment of the former breast augmentation. In June 2017, she underwent removal of the old 330 cc implants. Removal of the implants was found to cause the double-bubble effect. The former capsule was completely dissolved and new grafts with a 430 cc volume were implanted. During this time, she received cefaclor (500 mg) and levofloxacine (500 mg) to prevent infection of the treatment site as well as methylprednisolone (16 mg) for the treatment of a facial dermatitis at the same time. The surgical site was treated lege artis, and surgical filaments were removed 2 weeks following surgery. Owing to persistent eczema, acyclovir (200 mg) was also applied. Up to this point, surgical breast treatment could be assumed as successful.

In November 2017, the patient visited the department again, showing clear signs of fibrosis in the left breast and a double-bubble effect in both breasts. Treatment was attempted by fixation of the inframammary fold to the fascia, using 3,0 vicryl surgical filament. This treatment option showed no success. Fibrosis of the left breast was successfully treated with ketanest, but the double-bubble effect in both breasts remained visible despite a subsequent attempt to resolve this situation by suturing. At this time, the patient gave consent for a third surgical treatment of her breast.

In May 2018, the patient again showed a double-bubble effect in both breasts. For further treatment, skin tightening was considered a possible option but later disregarded, since it could not be assured that this method was suitable for treating the current double-bubble effect as well as preventing its future genesis. At the end of June 2018, polyurethane-coated implants were suggested. As mentioned earlier, the polyurethane coating is assumed to reduce capsular contracture ^12,13 due to the fact that it becomes a part of the wound capsule. Thus, a potential tightening caused by previous implants, as seen in the described case, could feasibly be avoided. ¹⁴ Despite communicating this information, the patient insisted on traditional implants, which were subsequently implanted during a fourth surgical treatment taking place in October 2018. The double-bubble effect then recurred during the following months.

In February 2019, the patient was again informed about the risks and possibilities regarding the treatment of the double-bubble effect in both breasts using polyurethane-coated implants. This time, the patient consented in a fifth surgical treatment using 380 cc polyurethane-coated implants. Before surgical treatment, the patient received ceftriaxone (2 mg) to prevent bacterial infection of the wound site. During surgery the ventral capsule was removed without incident, but the dorsal part of the capsule strongly adhered to the surrounding tissue hampering its removal.

Two weeks after surgery using polyurethane-coated implants, the double-bubble symptom was alleviated (Figure 1) and patient continued to report a positive view of the result. All subsequent visits proceeded without any further diagnostic findings.

Figure 1.

Breasts with DBE and result after augmentation with PU implants.

Discussion

In this case report, we discussed the treatment course of a 47-year-old patient suffering from recurrent double-bubble effect in both breasts following breast augmentation using traditional silicone implants after four surgeries. The fifth and final surgery involved the implantation of polyurethane-coated breast implants, which appeared to alleviate the effect completely.

These findings reflect those of Vazquez, and Pellon, ¹⁴ who reported a reduced incidence of capsular contraction among receivers of polyurethane-coated breast implants (1% in a sample of initially 1,257 women, of whom 180 took part in follow-up 15 years after undergoing breast augmentation), and of Castel et al., ¹⁵ who found a significant inverse correlation between the amount of polyurethane coating on breast implants and the prevalence of capsular contraction.

Conclusion

A 47-year-old patient suffering from recurrent double-bubble effect was successfully treated using polyurethane-coated implants. This case is consistent with the limited data reporting the lowest prevalence of capsular contraction by use of polyurethane-coated implants, since this contraction is possibly responsible for double-bubble effect. This case adds weight this interpretation and stimulate further research into the causes of capsular contraction and the potential benefits of polyurethane-coated implants.