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Introduction: The aesthetic superiority of anatomical implants has not yet been demonstrated in a randomized controlled study. The purpose of this Level I intraoperative comparison was to test whether plastic surgeons and lay individuals could perceive an aesthetic difference between anatomical and round implants.
Methods: Seventy-five patients undergoing primary breast augmentation had a round implant of optimal volume placed in one breast and either an anatomical silicone sizer or actual implant of similar volume temporarily placed in the other. There were twenty-five cases each of anatomical devices used from Allergan, Mentor, and Sientra. Standardized multiple view photographs were taken with the patient sitting at 90 degrees. The anatomical device was then replaced by a second round implant to complete the procedure. An online survey instrument was designed to measure breast appearance using Qualtrics software, pretested for content validity, and administered to 10 plastic surgeon and 10 lay reviewers for blind evaluation of the 75 cases. All reviewers were asked ‘which breast was more aesthetically pleasing’ and ‘by how much’ on 5-point Likert scale ranging from “a little” to “a lot.” Plastic surgeons were also queried on the characteristics accounting for perceived aesthetic superiority and which implant shape they believed was placed in the preferred breast.
Results: Overall, no observable difference in breast aesthetics was reported between round and anatomical implants by plastic surgeons in 42.8% of cases and in lay individuals in 29.2% of cases. Of the remainder, plastic surgeons found the breast containing the round implant more aesthetically pleasing in 48.9% (mean score 1.9) and the anatomical implant in 51.1% of cases (mean score 1.9), p=0.697. Lay individuals found the breast containing the round implant more aesthetically pleasing in 53.3% (mean score 2.2) and the anatomical implant in 46.7% of cases (mean score 2.2), p=0.494. Plastic surgeons identified implant shape correctly in 26.5% of cases overall and reported not knowing which implant shape was placed in the breast they preferred in 35.0% of cases.
Conclusions: Reviewers reported no observable difference in breast aesthetics between round and anatomical implants commonly. When an aesthetic difference was perceived, reviewers did not prefer breasts with anatomical implants more often than breasts with round implants. Moreover, plastic surgeons could identify implant shape correctly in only a minority of cases and frequently reported not knowing which implant shape was producing the aesthetic superiority they perceived. Given that anatomical implants are more expensive, have an intrinsic risk of malrotation, and may pose a higher risk of late seroma and anaplastic large cell lymphoma due to aggressive texturization, a lack of proven aesthetic superiority argues against their routine use in breast augmentation.