Why do We Need Anatomical Implants? Science and Rationale for Maintaining Their Availability and Use in Breast Surgery

Dear Sir, We read with great interest the article titled ‘‘Why do we need anatomical implants? Science and rationale for maintaining their availability and use in breast Surgery’’ by Montemurro P. et al. in which the authors report a brilliant dissertation on the use of anatomical prosthesis in breast surgery, analysing in detail their specific indications, including advantages and disadvantages. We congratulate the authors for their large experience in breast surgery, especially in breast augmentation, and for the evident methodological approach reported in the paper. We completely agree with the authors that in the toolbox of every plastic surgeon there must be both anatomical and round implants, but we have some elements to discuss. Nowadays, implant-associated anaplastic large-cell lymphoma (BIA-ALCL) is a very sensitive item and, since it seems to be related to the implant texture, it should be seriously taken into account, especially in patients who undergo breast surgery for aesthetical purposes. Moreover, in reconstructive surgery, after mastectomy, anatomical prostheses show an evident more natural result ompared to round implants; during breast augmentation for aesthetical purposes, round implants filled with a very soft gel can show outcomes very similar to anatomical prosthesis, especially in moderate increment of volume. In our opinion, the real difference between anatomical and round implants is particularly evident during large increment of breast volume. Regarding tuberous breast correction, in our practice, correction of the breast deformity is the most important factor rather than volume increment. Tuberous breast is a deformity appearing with very wide aspects showing in common elements such as a constricted mammary base, a very high inframammary fold and areola disorders (Fig. 1). Recently, we published an article proposing a new classification system of the deformity taking into account both the localization of the defect and the consistency of the breast tissue [1]. In our experience, even if sub-glandular anatomical implants may result in better projections of the lower pole, it is not always possible according to the thickness of upper-pole pinch test. Dual-plane location of a soft-gel round implant allows a satisfactory coverage of upper pole of prosthesis. The pressure of the muscle to the upper part of the round implant, displacing downwards the silicone gel, allows it to expand outwards, thus increasing the projection of the inferior mammary pole making it similar to an anatomical implant (Fig. 2), avoiding risk of implant rotation and decreasing incidence of capsular contraction. Glanuloplasty defines the new inframammary fold [2–5].