Minimally Invasive Breast Augmentation (2015)

Sir: Between 2000 and 2013, there were substantial increases in augmentation mammaplasty and minimally invasive cosmetic procedures, with a 703 percent increase in botulinum toxin type A (Botox; Allergan, Inc., Irvine, Calif.) treatments, against a 12 percent drop in total cosmetic surgical procedures in the United States.1 “Nonsurgical” breast enhancement has attracted mainstream press attention, with two treatments generating concern from board-certified plastic surgeons: “InstaBreast lunchtime lift” and “Botox breast lift.” PubMed searches revealed no studies supporting either treatment. InstaBreast is promoted by a board-certified plastic surgeon2 “for women who don’t have time for implants.” For $2500, saline is injected to increase breast volume for 24 hours. In support, the surgeon’s Web site cites one unrelated article and 24 magazine articles.2 One stated indication is implant sizing before breast augmentation. This would seem a poor alternative compared with three-dimensional digital imaging.3 Injections have risks, including infection and pneumothorax. According to media reports, some clients return for repeated injections, and the surgeon is advocating a new treatment, “vacation breasts,” injecting an undisclosed additive that lasts a few weeks. Both research4 and postpregnancy breast ptosis demonstrate that chronic tissue expansion increases skin surface area. Repeated breast expansion by injection may accelerate ptosis and cause traumatic changes such as calcification.5 The risk of carcinogenesis and impact on breast cancer surveillance are unknown. The $1500 “Botox breast lift” is advocated by a London-based “celebrity cosmetic doctor,” not on the specialist register for plastic surgery.6 The doctor has no PubMed publications and does not cite studies supporting the treatment. The concept that this may “lift” or enlarge breasts is anatomically flawed and evidentially unsupported. Breasts are unaltered by Botox, as breast parenchyma does not contain muscle. If it did, Botox would have a reducing rather than enlarging effect, because sustained use causes muscle atrophy.7 Breast volume can only reliably be increased by fat transfer and/or implant, or free tissue transfer. Correctly performed breast augmentation can lift a breast to a small degree, but significant elevation requires mastopexy. Botox would not benefit breast shape or skin excess. Aside from ineffectiveness and unwarranted risks, these procedures are expensive and temporary: repeated treatments rapidly represent false economy. Despite being around for 5 years and the promotional efforts of tabloid newspapers and cosmetic doctors, unsurprisingly, the Botox breast lift has not taken off. Patients are advised to check what most board-certified plastic surgeons are doing: a good indicator of treatment safety and efficacy. According to the Royal College of Surgeons of England, new proposals would ensure that cosmetic surgery is performed only by specialist surgeons to “stop all the cowboy behavior which goes on.”8 Regulation must focus on evidence—the foundation of patient safety. Advocating unproven treatments is immoral: medically ethical behavior rests on patient trust, beneficence, nonmaleficence, and justice.9 We are obliged to “do no harm”! So why do some doctors perform procedures with no evidential support? To be a great plastic surgeon, one must have great integrity: it is our responsibility to practice evidence-based medicine, and decry those that fly in the face of it. DISCLOSURE No external sources of support, funding, or benefits were received for this project by the authors, who have no commercial interest to disclose. Dr. Rohrich receives instrument royalties from Eriem Surgical, Inc., and book royalties from Quality Medical Publishing and Taylor and Francis Publishing. No funding was received for this article. Patrick Mallucci, F.R.C.S., F.R.C.S.Plast. The Cadogan Clinic, and Department of Plastic Surgery Royal Free Hampstead NHS Trust London, United Kingdom David H. Song, M.D., M.B.A. The University of Chicago Medicine Chicago, Ill. Olivier A. Branford, Ph.D., M.R.C.S., F.R.C.S.(Plast.) The Cadogan Clinic, and Charing Cross Hospital London, United Kingdom William A. Townley, F.R.C.S.(Plast.) Guy’s and St Thomas’ NHS Foundation Trust London, United Kingdom Fulvio Urso-Baiarda, M.R.C.S., F.R.C.S.(Plast.) Wexham Park Hospital Berkshire, United Kingdom Rod J. Rohrich, M.D. Dallas Plastic Surgery Institute Dallas, Texas