Increase of Visible Veins After Breast Augmentation. Yuri Andonakis, MD,* and Berend van der Lei, MD, PhD*

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1 BREAST SURGERY A Retrospective Analysis of 78 Consecutive Breast Augmentation Patients Yuri Andonakis, MD,* and Berend van der Lei, MD, PhD* Abstract: A retrospective study was undertaken to determine the pre- and postoperative presence of visible veins in the skin across the breast of patients seeking breast augmentation, and the impact of this phenomenon on patient satisfaction. From a series of 97 consecutive patients who underwent cosmetic breast augmentation surgery, 78 patients were available with sufficient 3-view preand postoperative (first available moment within 3 26 weeks postoperatively) photographic material available for analysis. A venous prominence scale was developed to grade the extent and amount of venous visibility in the skin across the breast and to compare the preoperative situation with the postoperative outcome. Additional information on patient s characteristics and self-reported opinions related to pre- and postaugmentation body images were obtained using a structured self-administered questionnaire. Preoperatively, minimal visibility of veins in the skin across the breast (grade 1) was already present in more than half (59%) of the patients seeking breast augmentation. After augmentation, there was an increase in visible (prominent) veins in almost all (96.2%) patients, generally by 1 or 2 grades, according to our venous prominence scale. Questionnaire analysis revealed that few patients are aware of this phenomenon, and even fewer patients dislike it. Many patients seeking breast augmentation already have minimal visibility of veins in the skin across the breast that increases in almost all patients after augmentation. It was quite striking that only few patients seemed to be aware of this phenomenon, and even fewer patients seemed to dislike it. Key Words: visible veins, vein prominence, venous prominence, venous visibility, breast, breast augmentation, augmentation mammaplasty (Ann Plast Surg 2009;63: ) Breast augmentation has become a popular and routine esthetical operation in both public hospitals as well as in private clinics. The overall outcome of breast augmentation depends on both surgical technical skills with a low rate of complications as well as patient satisfaction. Because patient satisfaction is the ultimate key factor in the success of breast augmentation, it is of utmost importance to create realistic expectations by means of extensive preoperative counseling, taking preexisting breast asymmetries and imperfections into account. Rohrich et al demonstrated that the majority (88%) of patients seeking breast augmentation have at least one parameter of breast asymmetry (such as breast mount, nippleareola complex, and chest wall asymmetries), 1 which commonly go Received September 17, 2008, and accepted for publication, after revision, December 19, From the *Departments of Plastic, Reconstructive, Aesthetic, and Hand Surgery, University Medical Center Groningen, Groningen, The Netherland; Medical Center of Leeuwarden, Leeuwarden, The Netherland; and Private Clinic Heerenveen, Heerenveen, The Netherlands. Reprints: Berend van der Lei, MD, PhD, Departments of Plastic, Reconstructive, Aesthetic, and Hand Surgery, University Medical Center Groningen, PO Box , 9700 RB Groningen, The Netherland. b.van.der.lei@plchir.umcg.nl. Copyright 2009 by Lippincott Williams & Wilkins ISSN: /09/ DOI: /SAP.0b013e dc8 unnoticed to patients. It is often until after breast augmentation, patients tend to look at their breast with more detail, and discover asymmetries and small imperfections; this may affect the outcome of patient satisfaction. We have noticed that visible veins in the skin across the breast and the possible increase in visibility after breast augmentation, is another aspect that may affect the outcome of patient s satisfaction. Thus far, this phenomenon has hardly received attention in the English-language literature. By means of this longitudinal retrospective study, using photographic analysis combined with medical record abstraction and a self-administered questionnaire in a consecutive series of 78 patients, we tried to analyze the pre- and postoperative presence of visible veins in the skin across the breast of patients seeking breast augmentation and the impact of this phenomenon on patient satisfaction. PATIENTS AND METHODS Patients This longitudinal retrospective study analyzed 97 consecutive patients who underwent cosmetic breast augmentation surgery at a private esthetical clinic (Privékliniek Heerenveen) by the senior author (BvdL), during a 4-year period. Inclusion criteria were based on a primary cosmetic breast augmentation in combination with sufficient 3-view, pre- and postoperative (first available moment within 3 26 weeks postoperatively) photographic material available for analysis. These criteria led to the exclusion of 19 patients (3 secondary augmentations; 2 augmentations after mamma reductions; 14 patients with missing or insufficient photographic material), leaving a cohort of 78 patients with an average age of 34 years (range, years) at the time of operation. In 3 cases of unilateral postoperative complications which needed reoperation (implant malposition 2 and prosthesis rupture 1 ), only the contralateral breast was evaluated. Medical record abstraction was performed using a standardized data sheet that included: birth date, date of operation, patient s length and weight, alcohol and tobacco consumption, history of pregnancy and lactation prior to the operation, prosthesis size, prosthesis type, and prosthesis pocket, dates of postoperative followups (mentioned in Table 1). Breast Augmentation All patients received extensive preoperative counseling to create realistic expectations, especially when preexisting asymmetries were present. The phenomenon of venous prominence across the skin of the breast had not been discussed with any of the patients. On the day of surgery, standardized 3-view photographs were taken. All operations took place under general anesthesia, and an inframammary incision was used to create either a submammary-, subpectoral-, or a dual plane pocket. Implants used were silicone gel-filled prostheses of the fourth and fifth generation (Inamed, McGhan; either round or anatomic, depending on patient characteristics and patient demands). The patients received perioperative antibiotic prophylaxis and remained in the clinic for 24 hours postoperatively. Wound inspection and suture removal took place 1 Annals of Plastic Surgery Volume 63, Number 6, December

2 Andonakis and van der Lei Annals of Plastic Surgery Volume 63, Number 6, December 2009 TABLE 1. Patient, Implant, and Surgery Characteristics n % Mean Range Study population Age at operation (yr) Present age (yr) Body mass index (BMI) Alcohol consumption (no. patients who consume alcohol) Tobacco consumption (no. patients who smoke tobacco) Pregnancies and lactation before breast augmentation surgery Nullipara Uni- or multipara Breast feeding Bottled milk Unknown Implant size (ml) Implant type Round model Anatomic model Implant pocket Subglandulair Dual plane Subpectoral TABLE 2. Grade 0 Grade 1 Grade 2 Grade 3 Grade 4 Venous Prominence Scale No visible veins in the skin across the Minimal, sometimes doubtful, visibility of veins in the skin across the The pathway of the veins can be (partially) followed by means of careful inspection. The visible veins are not dilated or tortuous and Limited visibility of prominent veins in the skin across the The prominent veins comprise only one or 2 quadrants of the breast or are limited periareolal. Obvious visibility of prominent veins in the skin across the The prominent veins comprise more than 2 quadrants of the breast or are located extensively periareolal with a visible pathway of the veins toward the sternum. Obvious to extreme visibility of prominent veins in the skin across the The prominent veins comprise the whole volume of the breast and are also visible peristernal and subclavicular. week after surgery. Follow-up visits were scheduled between 3 to 12 weeks, at 6 months, and 1 year after the operation for evaluation of the end result. During these follow-ups, standardized 3-view photographs were taken, just as preoperatively. Scoring of the Venous Prominence in the Skin Across the Breast Following data collection and photograph arrangement, all photographs were analyzed for visible veins in the skin across the A venous prominence scale (Table 2, Fig. 1) was developed to grade the extent and amount of venous visibility in the skin across the breast and to compare the preoperative situation with the postoperative outcome. This scoring system has a 5-point scale, ranging from 0 to 4, analogue to a simplified version of Lemperle classification of facial wrinkles. 2 All individual photographs were scored using this scale. When the venous visibility differed between a patient s breasts, the focus was shifted to the breast with the most prominent visible veins. To analyze whether an increased postoperative visibility of (prominent) veins remained stable or altered over time, we additionally categorized the patients with available long-term follow-up (defined as more than 6 months since the short-term follow-up photographs). Three observers (senior author, junior author, and 1 nonmedical female outsider) scored all the photographs. Patient Questionnaire Additional information on patient s characteristics and selfreported opinions related to pre- and postaugmentation body images were obtained using a structured self-administered questionnaire. The questions addressed: (a) pre- and postaugmentation pregnancy and lactation; (b) whether patients noticed visibility of (prominent) veins in the skin across the breast: (1) before augmentation, (2) FIGURE 1. Photographic illustrations of the venous prominence scale (grade 0 is left out) of each depicted patient, a mirrored unilateral breast is shown. The breast on the left side is shown as photographed; on the breast to the right side, the visible (prominent) veins are highlighted. during a possible preaugmentation pregnancy and lactation, and (3) after augmentation; and (c) patients were asked to give a general appreciation mark (range, 1 10) for the entire procedure and outcome of the breast augmentation. Finally, patients were asked to return to the clinic for long-term follow-up photographs. Outcome Analysis All data was analyzed with SPSS for Windows (SPSS Inc, Chicago, IL) Lippincott Williams & Wilkins

3 Annals of Plastic Surgery Volume 63, Number 6, December 2009 TABLE 3. Venous Prominence Scale Venous Prominence Scores Preoperative Short-term Follow-up* Long-term follow-up n % n % n % Grade Grade Grade Grade Grade Total number *Average of 11 weeks post augmentation (range: 3 24 wk). Average of 113 weeks post augmentation (range: ) and with an average time interval of 104 weeks (range: ) since the early postoperative follow-up photograph. See also Table 2 and Figure 1. TABLE 4. Postoperative* Venous Prominence Alteration (on the Long-term) Results n % No alterations in venous visibility Regression of venous prominence, although still visible Complete regression of venous visibility Increased venous prominence Preoperative no visible veins, postoperative neither Total *Comparing the venous visibility within 3 to 26 weeks post augmentation, with the venous visibility more than 26 weeks post augmentation and with a minimum time interval of 26 weeks since the early postoperative follow-up photograph. RESULTS Venous Visibility in the Skin Across the Breast We observed that almost all patients (96.2%; n 75) showed a development of or an increase in venous visibility in the skin across the breast after augmentation, generally by 1 or 2 grades, according to our venous prominence scale. Preoperatively, 75 patients (96.2%) had a grade 0 or grade 1 venous prominence score; the remaining 3 patients (3.8%) had a grade 2 score. There were no patients with a grade 3 or grade 4 venous prominence score (mentioned in Table 3). At short-term follow-up (average of 11 weeks), most patients (78.2%; n 61) had a grade 2 or 3 venous prominence score, while 3 patients (3.8%) had a grade 4 (extreme venous prominence) score (mentioned in Table 3, Fig. 2). Long-term follow-up was available in 23 patients (29.5%). The venous prominence scores of these 23 patients were comparable to the overall group (also mentioned in Table 3). Comparing the short-term and long-term venous prominence scores of these 23 patients (mentioned in Table 4), we observed that in half of the patients (52.2%; n 12) the venous visibility did not show any long-term alterations; that in one-third (30.4%; n 7) of the patients there was (partial) regression of the postoperative venous visibility, and that in 3 patients (13%) there was an increase in venous visibility. One patient had no visible veins in the skin across the breast prior to the breast augmentation surgery, nor after surgery. Questionnaire and Patient Observations Of the 78 mailed questionnaires, 32 were returned (41% response rate), of which 1 had to be excluded from further analysis because of insufficient data, leaving 31 patients for this part of the study. Of these 31 patients, 21 (67.7%) did not notice any venous visibility in the skin across their breast prior to the augmentation, 8 patients (25.8%) noticed venous visibility, whereas the remaining 2 patients (6.5%) did not remember whether they observed any venous visibility. Nineteen of the 31 patients (61.3%) had a history of pregnancy before the breast augmentation. Of these 19 patients, 8 patients (25.8%) remembered observing venous visibility in the skin across their breast during pregnancy and lactation. Postoperatively, 18 of the 31 patients (58.1%) did not notice any venous visibility, 11 patients (35.5%) noticed venous visibility, and 2 patients did not remember whether or not they had venous visibility in the skin across their Of the 18 patients who did not notice any postoperative venous visibility, 2 of them had a grade 0 on the venous prominence scale (no veins visible). The 11 patients who noticed venous visibility after the breast augmentation had a minimum grade 2 or higher on the postoperative venous prominence scale. Five patients (of the 11 who noticed venous visibility after the breast augmentation) mentioned that they disliked the visibility of (prominent) veins in the skin across the These 5 patients had a grade 2 or higher on our venous prominence scale within the 3 to 26 week postoperative. The average overall patient satisfaction score (expressed as a number on a 1 10 scale) of the 31 responding patients was 8.5 (SD: 1.23, range, 5 10); of the 11 patients who noticed venous visibility after the breast augmentation, the score was 8.3 (SD: 0.90, range, 7 10), and of the 5 patients who disliked the venous visibility after the breast augmentation, the score was 8.2 (SD: 0.84; range, 7 9). Risk Factors Extensive statistical analyses revealed that our studied numbers were too small to apply statistical hypothesis testing in an FIGURE 2. Example of a patient who showed an extreme increase in visible veins in the skin across the breast after augmentation. Preoperative we ve scored her a grade 1 on our venous prominence scale, while after augmentation she progressed to a grade Lippincott Williams & Wilkins 607

4 Andonakis and van der Lei Annals of Plastic Surgery Volume 63, Number 6, December 2009 attempt to discover any correlations between (1) patient characteristics, (2) implant and surgery characteristics, (3) preoperative venous visibility, and the postoperative venous prominence outcome. DISCUSSION This longitudinal retrospective study demonstrates that minimal visibility of veins in the skin across the breast was already present in more than half (59%) of the patients seeking breast augmentation, and that an increase in visible (prominent) veins in the skin across the breast occurred in almost all (96.2%) patients after breast augmentation. Only few patients seemed to be aware of this phenomenon, and even fewer patients seemed to dislike it. The general trend in our series of breast augmentation patients was an absence or a low venous prominence grade preoperatively, which progressed to a higher grade after breast augmentation (also mentioned in Table 3). In most of the patients, the amount and extent of venous visibility, increased by 1 or 2 grades, according to our venous prominence scale (Table 3); only 3.8% (n 3) of patients showed an extreme increase of visible veins in the skin across the breast after augmentation (Fig. 2, Table 3). When comparing patient s observations of veins in the skin across their breast before augmentation with our preoperative venous prominence scores, we noticed a rather low rate of correspondence. Even, an obvious increase in venous prominence after breast augmentation often went unnoticed by patients. Moreover, only 5 of the 11 patients who noticed visible veins in the skin across the breast after the breast augmentation, disliked this phenomenon. Apparently, after specific, anonymous, and indirect questioning, only few patients seem to be aware of this phenomenon, and even fewer seem to dislike it. To his best recollection, the senior author (BvdL) could only remember 2 patients who had spontaneously complained about the increase in visibility of veins in the skin across the breast after breast augmentation. Thus far, the presence of visible veins in the skin across the breast and an increase in visibility after breast augmentation has not been studied in this matter. Only a few authors have mentioned the occurrence of an increase in venous prominence in the skin across the breast after augmentation. Hammond states 3 When I have seen this (postoperative prominence of veins in the breast skin across the chest), it has been very disconcerting for the patient and has been a source of patient dissatisfaction. Bowes and Goldman state 4 This condition is particularly distressful, as the development of unsightly breast veins interferes with the reason for undergoing breast augmentation. Bowes and Goldman even described a patient that had developed multiple reticular veins after breast augmentation, for which she requested sclerotherapy. We neither recognize these findings in our study, nor in our years of practical experience. This longitudinal retrospective study demonstrates that although an increase in visible (prominent) veins in the skin across the breast after breast augmentation is the rule rather than the exception, dissatisfaction as a result of these visible (prominent) veins is the exception rather than the rule. Nevertheless, this phenomenon remains a part of the overall result of breast augmentation that cannot be denied, especially because patients tend to look at their breast with more detail after breast augmentation and may discover unsightly aspects, asymmetries, and small imperfections that might affect patient satisfaction. Analogous to the statement by Rohrich et al 1 that by explaining that breast asymmetries are the rule rather than the exception and that subtle differences preoperatively may be more obvious after breast augmentation, we feel that the phenomenon of visible (prominent) veins in the skin across the breast after augmentation could be considered to be included in preoperative patient education, so that patients will have a more realistic expectation of their final results. A challenge in the study design was to create a classificationor scoring system to score the venous visibility in the skin across the Analyzing the venous visibility, brought about 2 main aspects: (1) the extent/length of visible (prominent) veins, and (2) the extent of dilatation, tortuous, and reticular aspect. Knowing that it is difficult and imprecise to judge the extent of dilatation of (prominent) veins on retrospective standard 3-view photographs, we decided to only make a distinction between not obviously dilated or not obviously tortuous and reticular, and (partially) dilated and/or tortuous and reticular, and to further focus on the surface of the breast which was comprised by the (prominent) visible veins (Table 2, Fig. 1). We used Lemperle classification of facial wrinkles 2 as an inspiration, but simplified his classification to make it more clear and usable. Despite a cohort of 78 patients, this number was not sufficient to meet the criteria of applied statistical tests to elucidate specific risk factors (such as patient s implant and surgery characteristics or the preoperative venous prominence score) which are possibly correlated to an increase in venous visibility postoperatively. The number of patients with available long-term follow-up was limited (n 23; 29.5%). Nevertheless, it showed a trend that could possibly be extrapolated to our entire study population: in half of the patients the venous visibility did not show any alteration, in one-third there was even some regression, and in only 3 patients there was an increase in venous visibility on the long-term (mentioned in Table 4). Although all patients were invited to return to the clinic on the long-term, the majority of the patients did not show up. They were most probably satisfied with the ultimate result of the breast augmentation and did not feel the need to return to the clinic. To date, there is no information available on the etiology of an increase in venous visibility in the skin across the breast after augmentation. There is however, a remarkable resemblance with the development of prominent veins in the skin across the breast during pregnancy and lactation. 5 Also, in a condition called gigantomastia, 6 there is a similar phenomenon of increase in visibility of prominent veins in the skin across the Possible explanations in the etiology of an increase in venous visibility in the skin across the breast after breast augmentation could be the following: (1) diminished venous blood flow velocities in the mammary veins as a result of increased intramammary and perimammary pressure due to the implant, leading to venous pooling and dilatation of the veins; (2) thinning of the breast skin due to the increased intramammary volume, leading to increased visibility of the superficial (dermal) veins overlying the breast; (3) increased blood flow in the superficial veins across the breast, possibly related to a distribution of the blood flow from the deeper venous (mammary) plexus (that might be partially compressed by the implant) to the more superficial venous plexus, in which the resistance might be lower; (4) a combination of previously mentioned points or an unmentioned explanation. In conclusion, we have demonstrated that many patients seeking breast augmentation already have minimal visibility of veins in the skin across the breast, and that an increase in visibility of veins is the rule rather than the exception. Only few patients are aware of this phenomenon, and even fewer patients dislike it. Nevertheless, we feel that the phenomenon of visible (prominent) veins in the skin across the breast after augmentation could be considered to be included in preoperative patient counseling, to create a more realistic expectation of the final result after breast augmentation. Future studies applying ultrasound Doppler, angiography or an equivalent diagnostic tool, may reveal the true cause of this phenomenon Lippincott Williams & Wilkins

5 Annals of Plastic Surgery Volume 63, Number 6, December 2009 ACKNOWLEDGMENT The authors thank Roy Stewart, MSc. for the help with the statistical analyses. REFERENCES 1. Rohrich RJ, Hartley W, Brown S. Incidence of breast and chest wall asymmetry in breast augmentation: a retrospective analysis of 100 patients. Plast Reconstr Surg. 2006;118(suppl 7):7S 13S; discussion 14S, 15S 17S. 2. Lemperle G, Holmes RE, Cohen SR, et al. A classification of facial wrinkles. Plast Reconstr Surg. 2001;108: ; discussion Rohrich RJ, Hartley W, Brown S. Incidence of breast and chest wall asymmetry in breast augmentation: a retrospective analysis of 100 patients: discussion by Hammond DC. Plast Reconstr Surg. 2003;111: Bowes LE, Goldman MP. Sclerotherapy of reticular and telangiectatic veins of the face, hands, and chest. Dermatol Surg. 2002;28: Riordan J, Auerback KG. Breastfeeding and Human Lactation. Sudbury, MA: Jones and Barlett Publishers; Dancey A, Khan M, Dawson J, et al. Gigantomastia a classification and review of the literature. J Plast Reconstr Aesthet Surg. 2008;61: Lippincott Williams & Wilkins 609

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