Types of Errors Made During Breast Augmentation with Polyurethane Implants: A Systematic Review

Comparing International Revision Incidence of Commonly Used Breast Implants

Importance

Despite the widespread use of breast implants, to date, no large-scale international studies on long-term revision incidence of different implant types have been conducted.

Objective

To determine whether international data could be combined using a harmonized dataset to increase power and investigate clinically relevant differences in complication-related revision incidence between breast implant types.

Design, Setting, and Participants

This multicenter, population-based cohort study used data from the Australian Breast Device Registry and the Dutch Breast Implant Registry from 2016 to 2021. Time-to-event analysis was performed using a frailty Cox proportional hazards regression model with pooled data. The study included all permanent breast implants that were inserted for primary postmastectomy or benign breast reconstruction or cosmetic augmentation. Data were analyzed from January 1, 2016, through December 31, 2021.

Exposure

Permanent breast implants grouped based on implant shape, shell, and fill.

Main outcomes and measures

Complication-related revision incidence between breast implant types.

Results

Data exchange between registries was successful. In total, 21 115 reconstructive and 129 854 cosmetic breast implants inserted in patients with a median (IQR) age of 47 (38-55) years and 31 (25-38) years, respectively, were included. Overall complication-related revision was 6.3% for reconstructive and 1.2% for cosmetic implants. For reconstructive implants, hazard ratios (HRs) for implant types showed no significant differences compared with anatomical textured-silicone implants. For cosmetic implants, anatomical polyurethane-silicone implants showed a lower risk of revision (HR, 0.38; 95% CI, 0.22-0.64) compared with anatomical-textured-silicone implants. At 5 years, no significant differences in cumulative revision incidence were observed between implant types for either reconstructive or cosmetic implants.

Conclusions and relevance

This study showed that international datasets can be pooled to assess real-world incidence of breast implant revision, which is anticipated to generate a foundation on which future breast implant studies can be based.

Nonadherence of Polyurethane Implants: A Retrospective Cohort Study

Background  Biointegration of polyurethane (PU) implants providing their stable position years after surgery ensures predictable results of breast augmentation and reconstruction almost eliminating implant factor as a cause of complications. However, in rare cases PU implants appear to be not connected to the surrounding tissues. The aim of the study was to determine the incidence of PU implant nonadherence after primary breast augmentations and augmentation mastopexies with dual plane implant position, to analyze possible causes, and to propose preventive measures and treatment possibilities of this complication. Methods  The results of primary aesthetic surgeries in 333 patients with dual plane PU implant placement were analyzed. Patients were evaluated clinically, and pictures and videos taken in different periods after the surgery were compared. Particular attention was given to the changes in implant position and the appearance of asymmetries over time. Results  PU implant nonadherence was found in seven patients. It can be divided into primary and secondary and may be complete or partial. Primary nonadherence was found in two cases (0.6%), and secondary in five (1.5%) cases. Possible influencing factors could have been traumatic surgical technique, seroma, hematoma, or physical trauma. The average follow-up was 33 months (1 month-15 years). Conclusion  Biointegration is mandatory for the long-term predictable results with PU implants. PU implant nonadherence leads to implant malposition and may cause typical complications connected to non-PU implants. Improvements in surgical maneuvers, manufacturing process, and weight reduction of the implant may be beneficial for the stability of the results. Level of Evidence  V.

When to Consider Prepectoral Implant Conversion After Subpectoral Implant Breast Reconstruction and How to Plan It

Many deformities occur after subpectoral implant-based breast reconstruction. Today, immediate prepectoral reconstruction with implants shows a significant increase in popularity because it has many advantages over subpectoral positioning: absence of muscle deficit and breast animation deformity, reduced implant dislocation, and less postoperative pain and easy recovery. Implant pocket conversion from the submuscular to prepectoral plane has become our preferred strategy for solving most problems related to the submuscular implant position. The authors performed a retrospective review (from June 2018 to December 2022) of patients who underwent prepectoral implant conversion for correction of animation deformity, dysfunctional chronic pain, or to ameliorate poor cosmetic results. Acellular dermal matrix (ADM) was utilized in the first 7 cases; in the remaining 56 patients polyurethane-covered implants were placed. Resolution of animation deformity and chronic pain were evaluated, as were cosmetic results and any postoperative complications. Sixty-three patients (87 breasts) underwent prepectoral implant conversion with complete resolution of animation deformity and chronic pain as well as improved cosmetic results. Preventive lipofilling was done in 18 patients. Complication rate included 3 periprosthetic seromas in ADM group. All resolved after ultrasound-guided aspiration. Rippling was noted in 3 patients, and edge visibility was documented in 1 patient. There were no incidences of grade 3 or 4 capsular contracture. The prepectoral implant conversion improves functional and aesthetic results, reaching excellent outcomes. Preparation for this surgery with fat grafting is considered a complementary procedure that increases the indications for prepectoral implant conversion.

LEVEL OF EVIDENCE: 4

Polydioxanone Internal Support Matrix: A Rationale for Prophylactic Internal Bra Support in Breast Augmentation

Background

Textured breast implants have been used in aesthetic breast surgery to decrease the rates of implant malposition. A recent analysis of a large-volume single-surgeon experience found statistically similar rates of malposition in smooth vs micro-textured breast implants.

Objectives

Prophylactic use of a polydioxanone (PDO) internal support matrix in breast augmentation was hypothesized to prevent scar malposition and increase pocket control.

Methods

In total, 200 patients received silicone gel primary augmentations performed by a single surgeon from January 2018 to December 2020; 84 patients received smooth implants alone; 49 patients received micro-textured implants; and 67 patients received smooth implants plus PDO internal support matrix. All surgeries were performed in the dual plane using an inframammary incision. Implant-related complications and scar malposition were recorded and compared.

Results

No significant difference in implant-related complication rates was found between shell types (3.57% for smooth devices alone and 2.04% for textured devices [P = 0.62; 95% CI −0.06 to 0.01]). There were zero complications in the smooth plus mesh study arm. A comparison of scar malposition rates between the smooth alone and textured groups revealed no significant difference (15.4% for smooth devices and 8.16% for textured devices [P = 0.23; 95% CI −0.12 to 0.01]). The smooth implant group with the prophylactic placement of PDO mesh had the lowest scar malposition rate of 4.48%, a significant difference compared with the smooth devices alone (P = 0.03; 95% CI −0.21 to −0.01).

Conclusions

Micro-textured devices show a trend toward decreased scar malposition, although not significant. Prophylactic use of PDO internal support matrix in silicone gel breast augmentation is safe and has the lowest incidence of scar malposition.

Level of Evidence: 3