Comparison between different methods of breast implant volume choice and degree of postoperative satisfaction

A mamoplastia de aumento é, atualmente, a cirurgia estética mais realizada no mundo1. No Brasil é a segunda cirurgia plástica estética mais realizada, correspondendo a 13,64% dos procedimentos1. Assim, taxas de complicações, que relativamente são pequenas, tornam-se grandes em números absolutos. Existem na literatura muitos artigos sobre o tema, entretanto, na sua maior parte, são estudos retrospectivos ou multicêntricos e que não focam na escolha do volume mamário. Além disso, quando retratam a escolha do implante, fazem-no por meio de uma única metodologia, sem comparações prospectivas entre os demais métodos existentes2-7. A população avaliada nesses estudos, em geral é constituída por mulheres do hemisfério norte, onde a cultura e os costumes se correlacionam intimamente com os anseios e perspectivas sobre a cirurgia2,3,7-10. Apesar de o Brasil ter sido, em 2016, o segundo em cirurgia plástica estética no mundo, existem poucos estudos que avaliam esta questão cultural no país1. A escolha do tamanho do implante mamário é uma das diversas variáveis que devem ser determinadas antes do procedimento cirúrgico. Orientar a paciente quanto às situações em que a reoperação é mandatória, como quando se evidencia um seroma tardio, por exemplo, é essencial11. Por outro lado, a troca do implante, que atualmente constitui uma das principais causas de reoperação, também deve ser discutida com a paciente, e precisa ser diminuída, através de uma abordagem mais completa no pré-operatório3,6,9,12. Poucos estudos foram conduzidos em que a paciente participa ativamente da escolha do volume do implante mamário e avalia seu grau de satisfação no pósoperatório. Por isto, faz-se necessária a avaliação de um modelo fácil, barato e universal de medição do volume do implante mamário, que envolva o poder de decisão

patient's decision power, together with the surgeon, and with excellent postoperative results.
This study aims at assessing the degree of satisfaction of patients submitted to augmentation mammaplasty, as well as to compare three different, easy, inexpensive and universal methods of preoperative choice of breast implant volume.

METHODS
This was a prospective study, carried out at the University Hospital Pedro Ernesto of the State University of Rio de Janeiro (UERJ), with 94 women from Rio de Janeiro, aged between 18 and 49 years, submitted to augmentation mammaplasty due to hypomastia.The non-inclusion factors were: patients under 18 years of age, those with indication for mastopexy, smokers, patients with psychiatric disorders, those with a prior history of breast surgery and those with systemic diseases.
The exclusion factors were: breastfeeding or pregnancy during the study, failure to perform the preoperative study and loss of postoperative follow-up.
The implants were introduced in the retroglandular space through an inframammary access.
Patients were systematically divided into three groups, for convenience: Control Group with 44 patients, MamaSize® Experimental Group with 25 patients and Silicone Experimental Group with 25 patients.All implants were textured, with a round base and high projection.
In the control group, breast implants were chosen through anthropometric measurements 13 .By measuring the basis and thickness of the patient's breast parenchyma, the silicone implant basis is calculated.
Subsequently, the product that corresponds to that base is chosen.
In the MamaSize ® Experiment group, the implants were chosen according to the MamaSize ®14 meter, where the mold is placed behind a bra without a cup, in front of a full-length mirror (Figure 1).The intersection between the mold of the patient's breast size (vertical axis) and that chosen by the patient (horizontal axis) shows the volume to be placed (Figure 1).Aiming to be similar to silicone molds, the following correlation was made between the volume chosen through MamaSize ® and the available volume to be placed: 170=175mL, 220=215mL, 240=235mL, 260=255mL, 290=285mL, 300=305mL, 330=325 mL, 360=355 mL.

Figure 1. MamaSize® Mold
In the Experimental Silicone Group, the following volume molds were used: 175mL, 195mL, 215mL, 235mL, 255mL, 285mL, 305 mL, 325mL and 355mL.The patient chose the volume using the breast implant measurer that reproduced them in their shapes and dimensions, using a bra without a cup, in front of a full-length mirror.After the choice, new tests with volumes were performed, one above and one below the chosen one, for the ratification of the decision.Satisfaction questionnaires were applied in the pre-and postoperative periods by the same evaluator, using a visual analogue scale (Figure 2), where 0 meant scar, only the postoperative period was evaluated 15,16 .very unsatisfied and 100 meant very satisfied for the four variables: shape, size, symmetry, and consistency.For the

RESULTS
The mean values of the patients' age, BMI and mammary basis did not show statistical difference between the three groups.The mean age of the groups was 28 years, the mean BMI was 21.91 (kg/m²) and the mean value of the mammary basis was 11.62cm.The results of the mean implant volume, when statistically evaluated, showed no difference between them: MamaSize ® Group: 284,04mL; Implant Group: 280.83mL;Control Group: 287.85mL (p-value: 0.6761).
Table 1 shows the comparison of the variables shape, size, symmetry and consistency in the preoperative and postoperative periods (12 th month), showing a statistical difference.However, when the groups were compared between them regarding the four variables in the 12 th postoperative month, there was no statistical difference.When comparing the patients' scores for the scar variable between the 1 st and 12 th month in all three groups, no statistical significance was observed.Figure 3 shows the preoperative and the 12 th month postoperative aspects of a patient, in the control group, with a 285mL implant.Figure 4 shows a patient in the preoperative and in the 12 th month postoperative periods, with a 285mL implant, and the methodology of choice with the silicone mold in the Silicone group.Figure 5 shows a patient in the preoperative and in the 12 th month postoperative periods, with a 285mL implant, and the methodology of choice with the MamaSize ® mold.

DISCUSSION
Because it is the second most often performed esthetic plastic surgery in Brazil and the first in the USA, augmentation mammaplasty reoperation rates due to volume exchange, which would firstly be relatively low (1.9% to 5.4%) 9,12 , are significantly higher in absolute numbers.Therefore, predicting this volume and, thus, avoiding reoperations, in addition to adding less morbidity to the patient, would avoid an expense that, in the US for instance, is around US$.5770.00 per reoperation 9,12 .
The literature shows that up to 20% of patients in the postoperative period of breast augmentation surgery complain of breast volume, although not all of them want to reoperate 17 .
There are articles that study preoperative types of breast implant volume measurement.However, despite showing good results, no studies were found comparing them prospectively 4,5,13,14,[17][18][19]  Therefore, anthropometrically similar patients were studied and compared.
When patient satisfaction was evaluated before and one year after the surgery, there was a significant increase in the degree of satisfaction in all groups, with statistical significance.This fact supports studies in the literature that show the excellent results of this intervention 2,3,5 .However, when comparing the degree of satisfaction in the postoperative evaluation between the three studied groups, there was no statistical difference, which shows that the method used to choose the implants does not interfere with the degree of satisfaction.
The scar is an important variable to be explained to the patient in the preoperative consultation, considering the change in location according to one's culture: in the USA and Brazil, inframammary scars are more common; in China the axillary scar is more frequent 6,8,9 .In our study, in the 1 st , 6 th and 12 th months, the evaluation mean was higher than 85.Additionally, there was no statistical difference when comparing the periods.This confirms the patients' acceptance of the scar, even in the first postoperative month.
The choice made through anthropometric measures has been the routine in our service for several years.On the other hand, methods that directly include the patient in this choice have proved equally effective and can facilitate decision-making, as well as the sharing of the choice responsibility.This is likely to reduce reoperation rates for breast volume dissatisfaction after a few years.On the other hand, it does not reduce Conclusão: a mamoplastia de aumento com implante teve um grande índice de satisfação entre as pacientes.No entanto, não houve diferença no grau de satisfação no período pós-operatório entre as três metodologias de mensuração de volume mamário.

Figure 2 .
Figure 2. Visual Analog Scale and Questionnaire
. Thus, what would be the measurement methodology of preoperative breast implant volume with the lowest cost and the best benefit?Is there any difference in the postoperative evaluation by the patients, if they use these different preoperative methods discussed in the literature?As satisfaction is closely related to the patient's expectations, and these vary according to the local culture, we believe that the Brazilian patients should be studied.Therefore, this study was then created, which utilized three easy, inexpensive methodologies widely used in the literature to compare the degree of patient satisfaction in the preand postoperative periods.The sample results confirm the stereotype of these patients: they are young, with a mean age of 28 years and normal BMI, whose main dissatisfaction is breast size.The mean mammary basis was 11.62cm, with an anticipated implant volume of approximately 285mL.

Table 1 .
Comparison of the Control, Silicone and MamaSize ® groups in the preoperative and postoperative periods (12 th month).