Evolving Trends in Breast-Implant-Based Procedures in Israel: A National Survey

Abstract

Rare reports linking textured breast implants to anaplastic large-cell lymphoma have generated controversies regarding their relative advantage over smooth implants. To evaluate trends in implant use in Israel, we sent a seven-item questionnaire to all active board-certified breast plastic surgeons in the country. About half responded. Approximately 60% of responders reported a moderate-to-considerable decrease in both the relative number of augmentation mammoplasty procedures and the use of implants during mastopexies in the last year. Nearly 40% had switched from textured to smooth implants to some extent. More than 40% still used textured implants for aesthetic procedures, and reconstructive procedures. Surgeons with more experience demonstrated a greater preference for smooth implants. The uncertainty regarding the safety of textured breast implants has led to a partial transition to the use of smoother implants and, importantly, to a general reduction in all breast-implant-based procedures.

Historically, breast implants have played an integral role in the practice of plastic surgery. Breast augmentation is the most commonly performed aesthetic procedure in the world, and implant-based reconstruction is the most popular technique in patients after mastectomy. ^{1 2 3 4 5 6} Since their introduction over 60 years ago, breast implants have been dogged by controversy.

Breast prostheses may be grossly categorized as smooth or textured based on their shell surface. Textured implants were developed for the dual purpose of stabilizing the implant in its pocket and decreasing the rate of capsular contracture. ^{7 8} Although initial studies showed a clear advantage of textured over smooth implants, more recent ones were unable to corroborate these findings. ^{9 10 11 12 13 14 15 16} Textured implants also have the disadvantages of contour irregularities such as rippling and palpable edges as well as double capsules. ¹⁷ Moreover, concerns have been raised by findings linking textured breast implants to anaplastic large-cell lymphoma (BI-ALCL) in rare cases. ¹⁸ As a result of these findings, numerous regulatory agencies have taken steps to limit their use in aesthetic and reconstructive surgery. ^{19 20 21 22}

Historically, surgeons in the United States have preferred smooth implants, while surgeons in Europe and Australia reported greater use of textured implants for both aesthetic and reconstructive purposes. ^{23 24 25 26 27} According to the 2019 clinical review of Zingaretti et al, textured implants accounted for only 13% of all breast implants in the United States compared with 90% in Europe prior to their recall. ¹ In 2020, Buonomo et al reported that more than 95% of breast surgeons in Italy use macrotextured implants for reconstructive purposes. ²⁸ Given the varying geographic preferences for the type of breast implant in the literature, we sought to describe current trends in implant use in aesthetic and reconstructive procedures among Israeli plastic surgeons.

Methods

In March 2021, an anonymous seven-item questionnaire titled “Breast Implant Use by Israeli Plastic Surgeons” was created on surveymonkey.com and distributed by text message to all active board-certified members of the Israeli Association of Plastic Surgery with an accompanying note explaining the purpose of the study and asking the surgeon to participate. The survey consisted of seven multiple choice questions that evaluated for recent changes in volume of implant-based procedures and selection of smooth versus textured implants ( Appendix I ). A pretest was performed ( n  = 5) to check for clarity of the items and potential errors. Results were stratified by the surgeon's level of experience and analyzed using descriptive statistics. The mean score for each item in the questionnaire was calculated. Kruskal–Wallis test was used to compare responses by seniority. Significance was set at p  < 0.05.

Results

Demographics

Fifty-six physicians completed and submitted the questionnaire, accounting for about half of all active plastic surgeons who perform breast surgery in Israel. The participants were divided by years of experience in breast plastic surgery as follows: up to 5 years, 5.8%; 5 to 10 years, 30.8%; 10 to 20 years, 28.9%; more than 20 years, 34.5%.

Changes in Implant-Based Procedures

Review of survey responses found that most surgeons reported a notable decrease in overall volume of implant-based breast augmentation surgeries over the last year with 27% of surgeons reporting a considerable decrease, 34% a moderate decrease, and 24% a slight decrease in total augmentation surgeries performed in the last year as compared with prior years. Only 15% of participants reported no change. Additionally, more than half the respondents (58%) reported that as compared with their prior practice norms they would prefer to avoid the use of silicone implants entirely when performing a mastopexy. These findings did not differ across the respondent groups.

Less than half (43%) of surgeons reported a continued preference for textured implants. Within this group, the majority (57%) of responses were from surgeons with less than 10 years of experience. The remaining responses revealed that 38% of surgeons mostly switched to using smooth implants, while 19% either always preferred smooth implants or to some extent switched to smooth implants ( Table 1 ). Notably, the more experienced the surgeon, the greater the inclination to use smoother implants ( p  < 0.0001).

Table 1. Responses to questionnaire item 3 by years of experience: recent change in type of implant used for breast augmentation.

Years of experience	Still using textured implants	Always preferred smooth implants	Switched to smooth implants to some extent	Mostly switched to smooth implants	Total
Up to 10 years	13	1	0	7	21
10–20 years	5	1	3	5	14
More than 20 years	5	2	3	8	18
Total	23 (43.3%)	4 (7.5%)	6 (11.3%)	20 (37.7%)	53

Senior physicians (>20 years' experience) versus others: p  < 0.0001.

Sixty percent of surgeons reported that they would not change their choice of implant by the plane of insertion (subglandular, subpectoral). Of these respondents, 35% would use textured implants for both planes and 25% would use smooth or silk-surface implants for both planes ( Table 2 ). An additional 20% preferred textured implants in the subglandular plane and smooth implants in the submuscular plane. The remaining 20% of surgeons reported categorically avoiding implant placement in either the subglandular plane (13%) or the subpectoral plane (7%). On analysis by years of experience, 33% of surgeons with under 10 years of experience would change their implant choice according to the plane of insertion. In contrast, 20% of surgeons with 10 to 20 years of experience and 5.5% of surgeons with more than 20 years of experience would use the plane of insertion to determine product selection ( p  = 0.014).

Table 2. Responses to questionnaire item 5 by years of experience: influence of plane of reconstruction on implant type used.

Years of experience	Subglandular—textured Subpectoral—smooth	Textured in both planes	Smooth in both planes	Don't use implants in subglandular plane	Don't use implants in subpectoral plane	Total
Up to 10 years	7 (33%)	7	4	3	1	22
10–20 years	3 (20%)	7	2	2	1	15
More than 20 years	1 (5.5%)	5	8	2	2	18
Total	11 (20%)	19 (34.5%)	14 (25.4%)	7 (12.7%)	4 (7.3%)	55

Percentages out of total for oldest group.

Senior physicians (>20 years' experience) versus others, p  = 0.014.

Regarding breast reconstruction, 20% of surgeons were still using anatomical textured implants, whereas 18.5% had switched to smooth implants and 13% to ergonomic silk-surface implants. The rest did not perform breast reconstructive surgery ( Table 3 ). Among the reconstructive surgeons, 58.6% preferred the submuscular plane and 41.4% the prepectoral plane. The extent of the switch to smooth or silk-surface from textured implants was significantly greater among the more experienced surgeons, whereas the less experienced ones tended to prefer textured anatomical implants ( p  = 0.001).

Table 3. Responses to item 6 by years of experience: change in type of implant for breast reconstruction.

Years of experience	Still use textured implants	Switched to smooth implants	Switched to ergonomic implants	Don't perform reconstructive surgery	Total
Up to 10 years	8	2	2	10	22
10–20 years	2	3	3	6	14
More than 20 years	1	5	2	10	18
Total	11 (20.4%)	10 (18.5%)	7 (13%)	26 (48.1%)	54

Senior physicians (>20 years' experience) versus others, p  = 0.001.

Discussion

The controversy regarding the advantages of textured breast implants in preventing capsular contracture remains unresolved; however, the risk of BI-ALCL has become increasingly evident in the literature. ^{1 15 29 30 31} Since the first report of BI-ALCL in 1997, the number of cases in the literature has increased alongside the increased use of textured implants. In an effort to prevent BI-ALCL, the use of textured implants by plastic surgeons has dramatically decreased around the globe.

In 2017, the United States Food and Drug Association issued a statement connecting textured breast implants with a risk of BI-ALCL, and in 2019, it requested that Allergan recall its textured BIOCELL implants from the market. ^{32 33} Although the Israeli Ministry of Health has not yet published any new regulations concerning textured implants, our survey found that the majority of the surgeons (56%) had either always preferred or switched to smooth or silk-surface implants to some extent in the last year. However, 40% still used textured implants for aesthetic purposes. Textured implants were preferred for subglandular insertion by more than half the surgeons, and for subpectoral insertion by about one-third of the surgeons. Among the reconstructive plastic surgeons, 40% still used textured anatomical implants in all cases.

At the same time, the BI-ALCL controversy appears to have grossly affected the field of breast aesthetic surgery in Israeli as a whole. Sixty percent of the surgeons participating in the survey reported more than a slight decrease in the number of augmentation mammoplasty procedures performed in the last year, and over one-fourth reported a major decrease. This finding might reflect a drop in patient requests for breast augmentation and/or more rigorous patient selection and lack of enthusiasm for the procedure on the part of surgeons. The latter assumption is supported by our finding that almost 60% of the participating surgeons were reluctant to use implants in mastopexy procedures. This finding also implies that the impact of the latest controversy extends beyond the use of a specific type of implant to surgeons' perceptions of silicone implants as a whole.

Interestingly, analysis by years of experience showed that the senior, more experienced surgeons were more like to switch to smooth implants for both aesthetic and reconstructive purposes, whereas younger surgeons were more flexible in adapting the texture of the implant to the plane of insertion.

Conclusion

In contrast to the North American and European markets, the lack of exterior intervention from regulatory health guidelines regarding the use of breast implants in Israel has allowed the country's plastic surgeons greater freedom of product selection, resulting in the persistent use of textured implants. In what used to be a highly dominant textured implant market, the recent concerns regarding the safety of textured breast implants have led to a considerable shift toward smooth implants. As surgeons continue to gain experience and become more informed about risks of BI-ALCL and textured implants, we anticipate that this marked reduction in utilization will expand throughout the entire field of aesthetic surgery.

Appendix I: Breast implant questionnaire.

1. How many years of experience do you have in plastic surgery?

   • a) ≤5 years

   • b) 5–10 years

   • c) 10–20 years

   • d) ≥20 years

2. Has the number of breast augmentation surgeries in your clinic decreased in the last year compared with previous years?

   • a) Yes, to a minimal extent

   • b) Yes, to a moderate extent

   • c) Yes, to a large extent

   • d) Not at all

3. Have you recently changed the type of implant used for breast augmentation compared with previous years?

   • a) No, I still use mostly textured implants

   • b) No, I always preferred smooth implants

   • c) Yes, I started using smooth or silk-surface (Motiva) implants instead of textured implants to some extent

   • d) Yes, I started using mostly smooth or silk-surface (Motiva) implants instead of textured implants

4. Do you currently prefer to avoid silicone implants for mastopexy more than before?

   • a) Yes, I prefer to avoid them if possible

   • b) No, I use silicone implants to the same extent

5. Does the plane of the implant (subglandular, subpectoral) in breast augmentation impact your choice of implant type?

   • a) Yes, I use textured implants in the subglandular plane and smooth or silk-surface (Motiva) implants in the subpectoral plane

   • b) No, I use textured implants in both planes

   • c) No, I avoid textured implants in both planes

   • d) I usually do not use implants in the subglandular plane

   • e) I usually do not use implants in the subpectoral plane

6. Have you changed the type of implants used (smooth, textured, ergonomic) for breast reconstructive surgeries?

   • a) No, I still use textured implants

   • b) Yes, I started using round smooth or silk-surface (Motiva) implants

   • c) Yes, I started using ergonomic implants

   • d) I do not perform breast reconstructive surgery.

7. If you perform breast reconstructive surgeries, what is your preferred plane in most cases?

   • a) Mostly submuscular

   • b) Mostly subpectoral