PRS Journal Club: Evolving Trends in Planes and Prophylaxis

Given the concerns regarding breast implant–associated anaplastic large-cell lymphoma, the transition to smooth implants for breast augmentation has spurred the development of techniques to limit malposition. Although implants are less popular than fat grafting for buttock augmentation, those with inadequate donor fat opt for implant augmentation. Questions remain, however, about the relative safety of textured versus smooth gluteal implants and the optimal plane for their placement. Antibiotic prophylaxis duration for all of these procedures, including breast reduction, remains debated. The articles in the December Journal Club shed light on evolving trends in these 3 domains. Smooth implants are plagued by instability contributing to rippling, malposition, and bottoming out using conventional dual-plane techniques, especially in extremely thin patients or those opting for large implants.1 The majority of implants placed are larger than 300 cc, and approximately 80% of surgeons prefer a partial submuscular placement of breast implants, but these techniques vary widely.2 Previous dual-plane techniques provided inadequate inferior support for smooth implants.3 In the first Journal Club article, “A Modified Bimuscular Flap Technique for Breast Augmentation: Does Extra Muscle Support Enhance the Stability of Smooth Implants?” Xia et al. introduce a modified bimuscular flap in which the pectoralis major is released with an inverted T-shaped incision such that it provides a superior/medial muscle flap for coverage and an inferior/lateral muscle flap for support.4 This technique resulted in significantly lower rates of lateral rippling, implant malposition, and bottoming out compared with the traditional dual-plane technique, overall as well as in stratified subgroup analyses of patients with low BMI (<18.5 kg/m2) and patients with large implants (≥300 cc). Although anaplastic large-cell lymphoma has traditionally been associated with textured breast implants, it has also been noted in patients with textured gluteal implants,5 yet surgeons continue to use both textured and smooth gluteal implants and remain uncertain about their long-term complication profiles. Autologous fat grafting remains the mainstay of buttock augmentation, yet those with inadequate donor fat and those desiring predictable durable results without fat resorption opt for buttock implant augmentation. Submuscular buttock implant placement has been demonstrated to be safe and reliable,6 but it is unclear whether surface texture and placement plane influence outcomes.7 In the second Journal Club article, “Complications following Primary Implant-Based Gluteal Augmentation: A Systematic Review and Meta-Analysis,” Elsaftawy et al. found that smooth buttock implants (compared with textured implants) had lower rates of seroma and dehiscence.8 In addition, they found that subfascial placement (compared with submuscular and intramuscular placement) had higher rates of seroma, dehiscence, and capsular contracture. Utilization of drains did not decrease seroma rates, and concurrent augmentation with autologous fat grafting did not significantly increase complication rates. Current guidelines emphasize the importance of perioperative antibiotics for breast reduction surgery, but prolonged antibiotic prophylaxis could introduce unnecessary risk (eg, microbial resistance) and remains controversial.9 A nationwide survey of plastic surgeons demonstrated that 98% use intravenous antibiotics at the beginning of the procedure, and 58.2% of surgeons use additional postoperative antibiotics.10 A recent prospective randomized study demonstrated that there is no difference in the incidence of surgical-site infection in patients undergoing breast reduction surgery treated with 7 days versus 24 hours of antibiotic prophylaxis,11 but it remains unclear whether a single preoperative dose is adequate. In the third Journal Club article, “Single-Dose versus 24-Hour Antibiotic Prophylaxis in Reduction Mammaplasty: A Randomized Controlled Trial,” Veiga et al. report that extending prophylactic antibiotics beyond a single preoperative dose does not significantly reduce the incidence of surgical-site infections.12 In conclusion, the articles discussed in the December edition of PRS Journal Club highlight novel trends in planes and prophylaxis for aesthetic breast and gluteal surgery. Implant-based breast augmentation has completely transitioned from textured to smooth implants, and this paradigm shift has spurred technique modifications to better support these implants, which are otherwise prone to malposition. Meanwhile, both textured and smooth implants continue to be used in gluteal augmentation, and there remains debate about the preferred plane. Although evidence suggests that intramuscular and submuscular techniques may be safer, these approaches may be more technically demanding for inexperienced surgeons. Finally, those seeking breast reduction surgery now have high-level evidence that a single perioperative dose is sufficient for prophylaxis of surgical-site infections. Similar studies will be necessary in implant-based breast augmentation and gluteal augmentation to optimize outcomes. DISCLOSURE The authors have no financial or nonfinancial conflicts of interest to disclose.