Submuscular Versus Subglandular Breast Augmentation For Complication-systematic Analysis

BackgroundThe breast is the important symbol of secondary sex characteristic and postural beauty for women. Mammary hypogenesis may result in a series of psychological and social response. Breast augmentation is one of developing plastic surgery procedures pursued by women with beauty greed, which meet with breast augmentation through surgical way, to display curved and perfect body image. The main indications of breast augmentation include primary breast hypogenesis, pathological change before puberty, atrophied breast after lactation, or secondary hypogenesis. Breast augmentation includes implant mammaplasty frequently operated in clinic, injection materials mammaplasty and autologous tissue mammaplasty. Silicone and saline is the main materials for the procedure. Axillary fold, inframammary fold, or areola could be selected for incision of placing implant according to clinic situation. The common complication of implant breast augmentation is fibrous capsular contracture associated with implant type, placement of implant, postoperative infection, postoperative hematoma or released range for implant so on. Capsular contracture is the hot and difficult topic in breast augmentation area, and previous studies have done about the relationship between implant type and capsular contracture. Some retrospective studies with small case number was doing in the relationship between placement of implant and capsular contracture, establishing in clinical method concluded from special placement of implant, difficult in significant conclusion. Meta-analysis is a statistical procedure that integrates the results of several independent studies considered to be combinable. As a popular method in clinical study, the Meta-analysis approach overcomes the drawback of independent study through combing smaller trials evaluating the same area, accurately reflects the mathematic results and achieves the interaction of literature evaluation and statistic method. Evidence based medicine was introduced in the study to explore appropriate surgical method for clinical activation.Objective1. To systematically review the submuscular versus subglandular mammaplasty for the capsular contracture.2. To systematically review the clinical difference of hematoma, implant malposition, infection, incision problem and secondary operation between submuscular and subglandular mammaplasty.Methods1. Detailed standardization of the inclusion and exclusion criteria was formed according to the systematic review, including the type of research, interventions and outcome of events.2. MEDLINE (1966-2014) was searched in English, and the keywords include subglandular, submuscular, breast augmentation and implant. Wanfang database (1989-2014) and China Hospital Knowledge Database (1994-2014) were searched in Chinese, and the keywords include breast augmentation, capsular contracture and implant. The related articles function was used to expand the search result from each relevant study identified, and quality of included studies were assessed. 3. The Meta-analysis was performed using Review Manager5.1(Co-chrane Collaboration, Oxford, UK). Heterogeneity was tested for included study. Results were estimated with relative risk (RR) analysed by fixed effect model. Publication bias was evaluated through funnel plots, and the complication data of the groups was analysed by SPSS20with Pearson chi-square test.Results1. Characteristics of the enrolled studiesAccording to inclusion and exclusion criteria,11papers were included in the study, which included2Chinese papers and9English papers,2randomized controlled trials,7cohort studies and2case control study.6studies numbered by implant included13996implants in submuscular and5371implants in subglandular group.6studies numbered by case number included1290cases in submuscular and1184cases in subglandular group.2. Capsular contracture2.1Implant numberOverall capsular contracture rate SM=2.38%, SG=8.43%。Meta-analysis results: RR=0.28,95%I(0.25,0.32), Z=15.26(P<0.00001), difference was significant.2.2Case numberOverall capsular contracture rate SM=1.55%, SG=5.15%。Meta-analysis results: RR=0.30,95%I (0.18,0.50), Z=3.80(P=0.0001), difference was significant,3. Hematoma developmentHematoma rate SM=1.16%, SG=2.76%, P=0.009。 Meta-analysis results: RR=0.42,95%CI (0.22,0.82), difference was significant.4. Implant malpositionImplant malposition rate SM=0.48%, SG=0.64%, P=0.656. Meta-analysis results:RR=0.76,95%CI (0.22,2.60), difference was negative. 5. Implant infectionImplant infection rate SM=1.86%, SG=0.40%, P=0.006。Meta-analysis results: RR=4.64,95%CI(1.38,15.64), difference was significant。6. Incision problemIncision problem rate SM=5.19%, SG=2.03%, P=0.001。Meta-analysis results: RR=2.55,95%CI(1.47,4.42), difference was significant。7. Secondary operationSecondary operation rate SM=1.83%, SG=5.72%, P<0.05. Meta-analysis results:RR=0.31,95%CI (0.18,0.52), difference was significant。8. Overall complicationOverall complication rate SM=8.5%, SG=8.0%, P=0.650。Meta-analysis results: RR=1.06,95%CI (0.82,1.38), difference was negative。Conclusions1. Submuscular breast augmentation was effective in reducing capsular contracture, and SG increased the incidence of capsular contracture about3times compared with SM.2. Submuscular breast augmentation was higher rate of implant infection and incision problem.3. Subglandular breast augmentation was higher rate of hematoma and secondary operation.4. For malposition, there is no difference between submuscular and subglandular.5. For overall rate complication, there is no difference between submuscular and subglandular.