Our experience with retro-glandular breast implants: a 14-year review and analysis of 1,043 consecutive cases

Introduction

In aesthetic surgery, breast augmentation accounts for approximately 16% of plastic surgeries worldwide, with over 1.6 million procedures performed globally in 2020 (1). Reflecting this demand, numerous techniques for implant type and placement (e.g., micro- or macro-textured vs. smooth surface implants; submuscular, subglandular, partial, or dual-plane placement) have evolved in the past two decades. This study, encompassing 1,043 retro-glandular implant placements from 2009 through December 2023, aimed to evaluate a single implant placement plane (retro-glandular) while varying the surgical access points according to implant type (shape, texture, size, and brand) (Figure 1). We present this article in accordance with the STROBE reporting checklist (available at https://gs.amegroups.com/article/view/10.21037/gs-2026-1-0018/rc).

Figure 1 Example of a result after breast augmentation with anatomical retro-glandular implants. (A) The patient before the surgery. (B) The same patient at 1 year after the surgery.

Methods

Each patient was clinically assessed, with a focus on the pinch test, conducted with the patient in a standing position with hands placed close to the sternum. During the test, pectoral muscles were contracted, and the thickness of the subcutaneous fold was measured with calipers at the upper breast quadrants (2,3). The Average age of patients was 37 years (Figure 2).

Figure 2 Lateral view before breast augmentation surgery.

A diverse selection, including Polytech (model Replicon, Optimam, Opticon, Dieburg, Germany), Allergan Natrelle (Dublin, Ireland), Mentor CPG (Minneapolis, Minnesota, USA), Motiva Ergonomix, Sebbin (round and anatomical, Paris France), and GC Aesthetic Perle has been used.

The surgical approach consisted by two different anatomical sites.

Five hundred and thirty-four patients received an infra-areolar incision and the remaining 509 underwent an inframammary approach. For areolas smaller than 3.8 cm, an inframammary incision was preferred.

All patients underwent pre-surgical breast ultrasounds (under 40 years) or mammograms plus ultrasounds (over 40 years), ensuring no presence of neoplastic lesions and providing glandular thickness data for appropriate surgical planning.

The equipment used included a MYLAB70 ultrasound machine with a high-frequency linear probe (15 MHz, Esaote, Genoa, Italy) and a LORAD digital mammography system (Hologic, Massachusetts, USA).

The anthropometric measurements were collected in two main parameters among the 1,043 patients: the pinch test and age distribution, reported as follow.

Pinch test values:

• 590 had greater than 2 cm.
• 201 between 1.5 and 2 cm.
• 136 between 1 and 1.5 cm.
• 116 under 1 cm but above 0.5 cm.

Age distribution:

• 23–35 years: 433 patients.
• 36–48 years: 487 patients.
• 49–65 years: 123 patients.

The surgical procedure in all cases involved accessing Chassignac’s space, anatomically located between the deep fascia of the mammary gland and the fascia of the pectoralis major muscle, where the implant was placed (4). No drainage was used in any case. General anesthesia was administered in 347 cases, while 696 cases involved deep sedation combined with local anesthesia. All patients were classified as ASA 1 by the team anesthetists, and the choice of anesthesia was made in agreement with each patient based on their preferences prior to surgery. From a surgical perspective, the management is the same regardless of the anesthesia type. However, deep sedation with local anesthesia has the advantages of faster post-operative cognitive recovery, allowing for quicker discharge.

The local anesthetic was prepared as follows: 150 cc saline solution, 20 cc lidocaine, 1 vial (1 cc) of 1:100,000 epinephrine. In some cases, 1 vial of 7.5 mg ropivacaine was also included. Patients who underwent general anesthesia were hospitalized for 24 hours. For deep sedation cases, 354 required 24-hour hospitalization, while the rest were discharged within 6 hours post-surgery, based on post-operative hemorrhagic risk.

Antibiotic treatment with 1 g Augmentin (amoxicillin and clavulanic acid) began 48 hours pre-surgery and continued for 96 hours post-surgery (1 tablet every 12 hours). No adverse reactions to antibiotics were recorded, and a detailed preparatory history was taken to assess for any known allergies. Starting from the second day post-surgery, patients took a 10 mg tablet of a leukotriene receptor antagonist, Montelukast sodium (brand name: Singulair), for 28 days.

The surgical incision site was treated with a hydrogen peroxide cream compress one hour pre-surgery. Skin disinfection involved benzalkonium chloride g 0.175 (Citrosil) or 10% iodine povidone (Betadine). The average surgery duration was about 65 minutes, ranging from 50 to 80 minutes, largely depending on breast size and any additional bleeding, often associated with the menstrual cycle.

In 401 cases, the Keller Funnel was used for implant placement. The Adams 14-Point plan has been used to minimize the bacterial contamination risk, except for the surgical incision and division of the breast parenchyma for implant placement.

The decision on implant size and shape was made in complete agreement with the patients, based on expected outcomes and data from the pinch test and pre-operative ultrasound. For patients with an upper pole tissue thickness ≥1.5 cm, either anatomical or round implants were proposed, considering aesthetic outcomes. Patients with tissue thickness between 1 and 1.5 cm were offered anatomical implants or round Motiva Ergonomix (New York, USA) or GC Aesthetic-Perle implants. For patients with thickness below 1 cm, anatomical implants were preferred, due to their favorable gel consistency and shell rigidity (90% Mentor, 10% Allergan, with the latter phased out from 2019).

Anthropometrically, patients with an ultrasound-measured tissue thickness below 1 cm were typically very lean or engaged in significant sports activity, including some internationally competing professional athletes with high upper limb and trunk muscle mass (5-7).

The radiologist specializing in breast imaging evaluated the patients as part of routine annual check-ups through ultrasound (and additionally mammography if over 40 years old). During these check-ups, they reassessed tissue thicknesses at the same points evaluated preoperatively (i.e., in all four quadrants) and reported in 301 cases an average thinning of approximately 5 mm in the cleavage planes (range, 3–7 mm) across various quadrants, starting from the fourth year of follow-up.

In all cases, this variation remained stable up to the thirteenth year of control (for patients with a ten-year follow-up). This variation was more pronounced in patients who had entered menopause post-surgery or were already in this condition preoperatively (8). In the remaining cases, no significant changes in thicknesses were observed (less than 2 mm). This study was conducted in accordance with the Declaration of Helsinki and its subsequent amendments. Informed written and signed consent was obtained from all of the patients.

Results

Patients were monitored at 7 days, 14 days, 30 days, 90 days, 6 months, and annually post-operation. All follow-ups assessed patient satisfaction on the appearance, size, implant palpability, and sensitivity (Figure 3).

Figure 3 Lateral view of the same patient after breast augmentation surgery with anatomical retro-glandular implants.

In follow-up imaging studies, there was a reported mean thinning of 5 mm in cleavage planes (range, 3–7 mm) over 301 cases after four years, more pronounced among post-menopausal patients. Other cases showed negligible changes (under 2 mm). The Complications were divided in immediate and delayed. The only immediate complication was the hematoma that occurred in 3 patients, with immediate drainage required in 2 cases and delayed intervention in one. The delayed complications were capsular contracture, implant rotation and wrinkling. The capsular contracture occurred in 3 patients out of 1.043 (0.3%) (1 moderate, 2 severe), all requiring reoperation. Two cases showed no recurrence, while a minor contracture persisted in one patient. Implant rotation was observed in nine cases, linked to traumatic events or inflammation-related seromas. Laboratory tests ruled out lymphoma, although there was evidence of reabsorbing hematomas in one case. Wrinkling was detected in five patients with less than 1 cm glandular thickness, mostly in lower quadrants. At each visit from the sixth month onward, all patients were given a very simple and intuitive questionnaire (see figure) to assess their satisfaction with the aesthetic outcome and any complications at each follow-up.

The satisfaction test criteria focused on the following aspects of the post-surgical results:

• The outcome in terms of shape.
• The outcome in terms of size.
• Naturalness of the implants (whether they are visible or not).
• Consistency to the touch.
• Preservation of superficial and deep sensitivity.

Out of 1,043 patients, 23 expressed dissatisfaction due to a preference for larger breast size. Additionally, in a random sampling of 100 cases, external plastic surgeons rated the aesthetic outcome as “very good” (4 out of 5) with no negative feedback.

Discussion

From mammographic/ultrasound investigations, findings in three patients (therefore excluded from our case series) revealed one case of sclerosing adenosis (classified as B3, appearing on tomosynthesis as a large distorted area), one case of malignant phyllodes tumor (classified as B5b), and one case of infiltrating ductal carcinoma (classified as B5b, N0) (9,10). All mentioned patients underwent surgery, and currently only the latter two remain in treatment.

The surgical team noted 3 cases of capsular contracture (1 medium-grade case and 2 severe cases), which required reoperation with the same surgical access, partial radial capsulectomy, pocket irrigation with gentamicin, and prosthesis repositioning (same brand and model). Of these patients, two did not experience a recurrence after about 2 years, while one case showed a mild unilateral contracture treated with repeated sessions of manual therapy by specialized physiotherapists. This single patient with capsular contracture currently reports no pain but has minor hardening in the outer quadrants and is unwilling to undergo further surgery (Figure 4).

Figure 4 The ultrasound image, in a patient with a positive clinical outcome, highlights a tortuous progression of the prosthetic profile, confirming the diagnosis of capsular contracture.

In nine cases within our series, we found prosthetic rotation within the surgical pocket: 4 due to sudden strain or accidental movements by the patients (e.g., road or sports trauma) and 5 due to the presence of a large inflammatory seroma. These patients underwent pocket revision and repositioning of the prosthesis (which had rotated) after performing all laboratory tests to rule out anaplastic large cell lymphoma, which was fortunately excluded. However, traces of erythrocytes were found, likely due to a resorbing hematoma; only one of the affected patients reported a weightlifting-related sports trauma during CrossFit activity.

We observed hematomas in three cases: in 2 patients, they were unilateral and within 12 hours postoperatively, promptly drained by bringing the patient back to the operating room, while in one case, the unilateral hematoma appeared 7 days after surgery, likely related to physical exertion as reported by the patient, who underwent reoperation the day after diagnosis (Figure 5) for hematoma drainage.

Figure 5 The MR image in STIR sequence on the sagittal plane highlights conspicuous serum-blood liquid effusion in the periprosthetic site with a different signal from that of the silicone inside the prosthesis, which appears intact. MR, magnetic resonance; STIR.

Among the complications in our series, we finally describe 5 cases of wrinkling: detected in all patients with an ultrasound thickness value of less than 1 cm in the upper quadrants of the breast. This complication appeared in 3 out of 5 cases in the lower pole and in the medial quadrants in the remaining 2 cases. Reassessing this data and asserting that even retro-muscular or dual-plane positioning would not have provided greater tissue coverage in the inferior quadrants, wrinkling would have occurred in 3 cases despite changing the anatomical plane.

The remaining two cases of wrinkling in the medial region are attributed either to an excessively superficial dissection, compromising the tissue coverage, or to a choice of implant base that was too wide for the characteristics of the augmented breast.

The capsular contracture occurred in only 3 cases (0.3%). This data may suggest that the position of the implant, the rapid timing of the surgical procedure and the retroglandular anatomical dissection may play an important role in reducing capsular contracture.

A total of 23 patients expressed partial dissatisfaction with the outcome, as they would have preferred larger breast volumes. Five years after breast augmentation surgery, we randomly selected 100 pre- and postoperative cases and showed photos to two independent plastic surgeons, asking them to assess whether they could identify the anatomical placement of the implant and, more importantly, to provide an aesthetic rating on a scale of 0 (insufficient) to 5 (excellent). The average rating was very good (4), with no indication of dissatisfaction cases (scale values: 0-1-2) (Figure 6).

Figure 6 Comparison before (A) and after (B) breast augmentation surgery with anatomical retro-glandular implants.

The two plastic surgeons selected for the evaluations were chosen by the principal investigator and had no direct acquaintance. Selection criteria were based on at least 10 years of experience in aesthetic breast plastic surgery.

One of the main limitations of this study is the lack of a scientifically validated questionnaire (e.g., Breast-Q). This is due to the lack of a scientifically validated questionnaire when the study began.

Another limitation of this study is the descriptive nature of the study itself, which does not allow comparisons with control groups and consequently complete statistical analysis.

Conclusions

Our findings underscore the importance of a dedicated multidisciplinary team. The preoperative radiological assessments reduce oncological risks, as evidenced by the detection of suspicious lesions in three cases. With recent advancements in implant technology, excellent aesthetic results were achievable even in borderline cases for retro-glandular placement. This approach enabled faster recovery, early discharge, and minimized the need for general anesthesia. Retro-glandular positioning does not appear to increase complication rates when carefully selecting implant size and placement, demonstrating its reliability as a breast augmentation approach.

Furthermore, it is essential to continue diagnostic checks, based on the different age groups, in order to monitor any prosthetic complications and exclude the onset of neoplastic pathologies. The use of breast magnetic resonance imaging without contrast medium (according to the current EUSOMA guidelines) occurs only in case of clinical or instrumental suspicion of prosthetic complications (11).

Overall, in our experience, surgery with prosthetic implantation in this retroglandular appears simpler to evaluate with ultrasound, while with regard to magnetic resonance imaging, therefore its wide field of view, no significant differences can be appreciated.

Acknowledgments

None.

Footnote

Reporting Checklist: The authors have completed the STROBE reporting checklist. Available at https://gs.amegroups.com/article/view/10.21037/gs-2026-1-0018/rc

Data Sharing Statement: Available at https://gs.amegroups.com/article/view/10.21037/gs-2026-1-0018/dss

Peer Review File: Available at https://gs.amegroups.com/article/view/10.21037/gs-2026-1-0018/prf

Funding: None.

Conflicts of Interest: All authors have completed the ICMJE uniform disclosure form (available at https://gs.amegroups.com/article/view/10.21037/gs-2026-1-0018/coif). The authors have no conflicts of interest to declare.

Ethical Statement: The authors are accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved. This study was conducted in accordance with the Declaration of Helsinki and its subsequent amendments. Informed written and signed consent was obtained from all of the patients.

Open Access Statement: This is an Open Access article distributed in accordance with the Creative Commons Attribution-NonCommercial-NoDerivs 4.0 International License (CC BY-NC-ND 4.0), which permits the non-commercial replication and distribution of the article with the strict proviso that no changes or edits are made and the original work is properly cited (including links to both the formal publication through the relevant DOI and the license). See: https://creativecommons.org/licenses/by-nc-nd/4.0/.

References

1. Lund HG Jr, Kumpf AL. Aesthetic breast surgery: emerging trends and technologies. Mo Med 2010;107:203-9.
2. Bolletta E, Mcgoldrick C, Hall-Findlay E. Aesthetic Breast Surgery: What Do the Measurements Reveal? Aesthet Surg J 2020;40:742-52. [Crossref] [PubMed]
3. Mejia Jimenez N, Patrón Gómez AS. Breast Aesthetic Preferences: Analysis of 1294 Surveys. Aesthetic Plast Surg 2021;45:2088-93. [Crossref] [PubMed]
4. Mallucci P, Branford OA. Concepts in aesthetic breast dimensions: analysis of the ideal breast. J Plast Reconstr Aesthet Surg 2012;65:8-16. [Crossref] [PubMed]
5. Atiye B, Chahine F. Metrics of the Aesthetically Perfect Breast. Aesthetic Plast Surg 2018;42:1187-94. [Crossref] [PubMed]
6. Isaac KV, Murphy BD, Beber B, et al. The Reliability of Anthropometric Measurements Used Preoperatively in Aesthetic Breast Surgery. Aesthet Surg J 2016;36:431-7. [Crossref] [PubMed]
7. Spear SL, Bulan EJ, Venturi ML. Breast augmentation. Plast Reconstr Surg 2004;114:73E-81E.
8. Kim MS, Sbalchiero JC, Reece GP, et al. Assessment of breast aesthetics. Plast Reconstr Surg 2008;121:186e-94e.
9. Yang S, Klietz ML, Hirsch T, et al. Volumetry in Breast Reconstruction: Always New, Always Better? Aesthetic Plast Surg 2022;46:2067-9. [Crossref] [PubMed]
10. Siqueira HFF, Teixeira JLA, Lessa Filho RDS, et al. Aesthetic assessment instrument for breasts reconstruction. J Plast Reconstr Aesthet Surg 2024;95:242-9. [Crossref] [PubMed]
11. Sardanelli F, Boetes C, Borisch B, et al. Magnetic resonance imaging of the breast: recommendations from the EUSOMA working group. Eur J Cancer 2010;46:1296-316. [Crossref] [PubMed]