Comparison of round smooth and shaped micro-textured implants in terms of quality of life and aesthetic outcomes in women undergoing breast reconstruction: a single-centre prospective study

Advances on Capsular Contracture-Prevention and Management Strategies: A Narrative Review of the Literature

Capsular contracture (CC) is the most relevant complication of both aesthetic and reconstructive breast implant surgery. For many years, experimental and clinical trials have attempted to analyze CC risk factors, clinical features, and appropriate management strategies. It is commonly accepted that a multifactorial etiology promotes CC development. However, the heterogeneity in patients, implants and surgical techniques make it difficult to suitably compare or analyze specific factors. As a consequence, discordant data are present in literature, and a true systematic review is often limited in its conclusions. Hence, we decided to present a comprehensive review of current theories on prevention and management strategies, rather than a specific "solution" to this complication.

Methods

The PubMed database was searched for literature regarding CC prevention and management strategies. Pertinent articles in English, published before December 1, 2022, were compared with selection criteria and eventually included in this review.

Results

Through the initial search, 97 articles were identified, of which 38 were included in the final study. Several articles explored different medical and surgical preventive and therapeutic strategies, showing numerous controversies on appropriate CC management.

Conclusions

This review provides a clear overview of the complexity of CC. The wide variety of clinical situations in term of patients, implants, and surgical techniques prevent the standardization of CC management strategies. By contrast, a patient-customized approach should be preferred, and different strategies should be considered depending on the specific case. Further research is desirable to better ascertain evidence-based protocols with regard to CC prevention and treatment.

A Comparison of Smooth and Microtextured Breast Implants in Breast Augmentation: A Retrospective Study

Background  The number of cosmetic and reconstructive surgeries that use breast implants is increasing in Korea. Recently, it has been reported that breast implant-associated anaplastic large-cell lymphoma is related to textured breast implants, and interest in classification according to the texture of breast implants is increasing. However, there is currently no clear and unified classification. In particular, the definition of “microtextured” is highly varied. In this study, we retrospectively investigated and analyzed the clinical outcomes of smooth and microtextured breast implants.

Methods  A retrospective chart review of all patients who underwent breast augmentation surgery with smooth and microtextured silicone gel implants between January 2016 and July 2020 was performed. We retrospectively analyzed implant manufacturer, age, body mass index (BMI), smoking status, incision location, implant size, follow-up period, complications, and reoperation rate.

Results  A total of 266 patients underwent breast augmentation surgery, of which 181 used smooth silicone gel implants and 85 used microtextured silicone gel implants. Age, BMI, smoking status, implant size, and follow-up period were not significantly different between the two groups. Similarly, complications and reoperation rates were not significantly different between the two groups.

Conclusion  It is important to provide information regarding the clinical risks and benefits of breast implants to surgeons and patients through a clear and unified classification according to the texture of the breast implant.

Best Practices for BREAST-Q Research: A Systematic Review of Study Methodology

BACKGROUND

Data heterogeneity and methodologic errors hinder the ability to draw clinically meaningful conclusions from studies using the BREAST-Q Reconstruction Module patient-reported outcome measure. In this systematic review, the authors evaluate the quality of BREAST-Q Reconstruction Module administration in relation to the BREAST-Q version 2.0 user's guide and the reporting of key methodology characteristics. The authors also describe a framework for improving the quality of BREAST-Q data analysis and reporting.

METHODS

The authors conducted a systematic search of PubMed, Embase, Cochrane CENTRAL, and Ovid HAPI databases to identify articles on the BREAST-Q Reconstruction Module to assess postmastectomy breast reconstruction outcomes. The authors registered the protocol before study implementation on Open Science Framework ( https://osf.io/c5236 ) and adhered to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Data on mode of BREAST-Q administration, time horizon justification, and sample size calculation were collected.

RESULTS

The authors included 185 studies in the analysis. Errors in BREAST-Q administration were identified in 36 studies (19.5 percent). Appropriate administration of the BREAST-Q could not be determined in 63 studies (34.1 percent) because of insufficient reporting. Time horizon for the primary outcome was reported in 71 studies (38.4 percent), with only 17 (9.2 percent) reporting a sample size calculation.

CONCLUSIONS

The authors identified important yet actionable shortcomings in the BREAST-Q literature. Researchers are encouraged to review the BREAST-Q user's guide in the study design phase to mitigate errors in patient-reported outcome measure administration and reporting for future trials using the BREAST-Q Reconstruction Module. Adhering to these guidelines will allow for greater clinical utility and generalizability of BREAST-Q research.

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

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.

Suppression of the fibrotic encapsulation of silicone implants by inhibiting the mechanical activation of pro-fibrotic TGF-β

The fibrotic encapsulation of implants involves the mechanical activation of myofibroblasts and of pro-fibrotic transforming growth factor beta 1 (TGF-β1). Here, we show that both softening of the implant surfaces and inhibition of the activation of TGF-β1 reduce the fibrotic encapsulation of subcutaneous silicone implants in mice. Conventionally stiff silicones (elastic modulus, ~2 MPa) coated with a soft silicone layer (elastic modulus, ~2 kPa) reduced collagen deposition as well as myofibroblast activation without affecting the numbers of macrophages and their polarization states. Instead, fibroblasts around stiff implants exhibited enhanced intracellular stress, increased the recruitment of α_v and β₁ integrins, and activated TGF-β1 signalling. In vitro, the recruitment of α_v integrin to focal adhesions and the activation of β₁ integrin and of TGF-β were higher in myofibroblasts grown on latency-associated peptide (LAP)-coated stiff silicones than on soft silicones. Antagonizing α_v integrin binding to LAP through the small-molecule inhibitor CWHM-12 suppressed active TGF-β signalling, myofibroblast activation and the fibrotic encapsulation of stiff subcutaneous implants in mice.

Prevention of Breast Implant Displacement Using the Acellular Dermal Matrix Garter Belt

BACKGROUND

Since the issue of breast implant-associated anaplastic large cell lymphoma, smooth breast implants tend to be the more preferred option in implant-based breast reconstructions, compared to its use previously. The most unfavorable aspect of smooth implants is lateral and inferior displacements, which are more common in patients who undergo breast reconstruction compared to augmentation mammoplasty. Hence, we introduce a prevention method for implant displacement using an acellular dermal matrix garter belt.

METHODS

This study is a retrospective review of patients who had undergone implant-based breast reconstruction between April 2019 and December 2020. Some patients who have highly possibility of implant displacement, had undergone the application of an ADM garter belt to prevent lateral or superior displacement. Implant displacement was assessed before and at least 6 months postoperatively.

RESULTS

A total of 155 IBR cases were recorded. ADM garter belts were applied in 27 patients (17.4%) who had a high tendency of implant displacement for several reasons, which could be classified into two categories: wide breast pocket (56%) and tight inferomedial breast pocket (44%). The intraoperative average distance of lateral slipping on patients' reconstructed breasts from the chest wall midline in supine position was 3.02 ± 0.81 cm and corrected to1.54 ± 0.69 cm at least 6 months postoperative follow-up.

CONCLUSIONS

We utilized an ADM strap as an internalized garter belt to minimize implant displacement. This ADM garter belt combined with capsuloplasty might be an effective way to prevent the displacement of smooth implants in the patients with a greater risk of implant displacement.

LEVEL OF EVIDENCE IV

This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors   www.springer.com/00266.

Smooth versus Textured Implant Breast Reconstruction: Patient-Reported Outcomes and Complications

BACKGROUND

The association between textured surface breast implants and breast implant-associated anaplastic large cell lymphoma has led to an increase in surgical procedures to exchange textured devices to smooth surface implants. Because patient satisfaction is an integral part of breast reconstruction, the purpose of this study was to compare patient-reported outcomes between smooth and textured implant recipients.

METHODS

Patients aged 18 years or older who underwent implant-based postmastectomy breast reconstruction with either smooth or textured devices from 2009 to 2017 and completed the BREAST-Q patient-reported outcome measure following reconstruction were included in this analysis. The primary outcomes of interest were mean and median BREAST-Q scores and postoperative complications.

RESULTS

Overall, 1077 patients were included-785 who underwent breast reconstruction with smooth implants and 292 who underwent breast reconstruction with textured implants. No statistical differences were observed between the textured and smooth implant groups for any of the BREAST-Q domain scores at any of the early (3-month) to late (2-year) postoperative time points. Smooth implant recipients reported significantly more rippling (p = 0.003) than textured implant recipients. In contrast, textured implant recipients had a higher rate of cellulitis than smooth implant recipients (p = 0.016).

CONCLUSIONS

These data suggest that postoperative satisfaction with breasts or health-related quality of life following immediate postmastectomy implant-based breast reconstruction is likely independent of implant surface type. However, smooth breast implants may result in more rippling. The authors' findings represent an important aid in counseling patients who have questions about the risks and benefits of replacing their textured implants with smooth surface devices.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Therapeutic, III.

Major Complications After Textured Versus Non-textured Breast Implants in Direct-to-Implant Breast Reconstruction: A Propensity Score Analysis

BACKGROUND

While the risks and benefits of smooth versus textured implants for breast reconstruction and primary breast augmentation are thoroughly supported in the literature, few studies have examined the relationship between implant shell texture and complications following direct-to-implant (DTI) breast reconstruction.

OBJECTIVES

The present study examines the relationship between implant shell texture and complications in patients receiving DTI breast reconstruction.

METHODS

Retrospective chart review of patients undergoing DTI breast reconstruction between 2011 and 2018 by a single surgeon was performed. A propensity score matching algorithm was used to eliminate unwanted bias stemming from clinical covariates. Chi-squared and Fisher's exact tests were used to examine the association between implant shell texture and the following major postoperative complications: capsular contracture, hematoma, seroma, necrosis, infection, and implant loss.

RESULTS

A total of 402 unique patients (751 breasts) were included. The majority received smooth implants compared with textured implants (80.3% vs. 19.7%, respectively); 444 breasts were included for comparative analysis after 2:1 propensity score matching (296 smooth implants, 148 textured implants). The only statistically significant difference in outcomes between the two groups was a higher incidence of hematoma in the textured group (2.0% vs 0.0%), Fisher's Exact Test p = 0.04. Additionally, the matched cohort revealed a very low overall rate of capsular contracture (1.0%) for smooth implants.

CONCLUSIONS

Our data demonstrated non-significant differences for most major complication rates or revision surgery rates for smooth versus textured implants after matching. DTI breast reconstruction with smooth implants remains a safe and effective reconstructive option for select patients.

LEVEL OF EVIDENCE III

This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine Ratings, please refer to Table of Contents or online Instructions to Authors www.springer.com/00266 .

Current Concepts in Capsular Contracture: Pathophysiology, Prevention, and Management

Over 400,000 women in the United States alone will have breast implant surgery each year. Although capsular contracture represents the most common complication of breast implant surgery, surgeons continue to debate the precise etiology. General agreement exists concerning the inflammatory origin of capsular fibrosis, but the inciting events triggering the inflammatory cascade appear to be multifactorial, making it difficult to predict why one patient may develop capsular contracture while another will not. Accordingly, researchers have explored many different surgical, biomaterial, and medical therapies to address these multiple factors in an attempt to prevent and treat capsular contracture. In the current paper, we aim to inform the reader on the most up-to-date understanding of the pathophysiology, prevention, and treatment of capsular contracture.

Does Age Matter? Estimating Risks of Locoregional Recurrence After Breast-conservative Surgery

BACKGROUND/AIM

In 2016, in the United States, more than 50% of breast cancer (BC) cases were diagnosed in patients older than 60 years of age. Our study aimed to estimate the risk of locoregional recurrence (LR) in patients who underwent breast-conservative treatment (BCT), according to age.

PATIENTS AND METHODS

This retrospective monocentric study analyzed 613 cases of patients who underwent BCT between 2003 and 2014. Patients were divided into groups according to age: Under70 (under 70 years old) and Over70 (above 70 years old). Margins width, histology results, prognostic and predictive factors were compared. Subgroup analysis was performed for patients who experienced LR.

RESULTS

LR Incidence among Under70 and Over70 was 5.4% and 1.7%, respectively (p<0.01). Group Over70 is characterized by larger tumors and a lower Ki67 index (p<0.01).

CONCLUSION

Operation time reduction, better aesthetic results and reduced LR risk support BCT. The Over70 group exhibited better outcomes in terms of LR despite larger tumor dimensions.

Awake breast cancer surgery: strategy in the beginning of COVID-19 emergency

Introduction

COVID-19 is a declared worldwide pandemic. In our country, due to shortage of hospitals and beds in intensive care unit, oncological and breast cancer (BC) resources are temporarily shifted to COVID-19 patients. In addition, risk of cross-infections should be considered in these frail patients. To accomplish more surgical procedures and to reduce the length of hospital stay (LOS), fast track awake BC surgery should be implemented. The aim of the study is to estimate the effects of surgical shift in our facility during the early COVID-19 outbreak.

Materials and methods

From 30th January 2020 to 30th of March 2020, 86 consecutive patients were retrospectively enrolled and divided into pre-COVID-19-BC and COVID-19-BC. Clinical parameters and anamnestic data were collected and analyzed. Surgical procedures, relative complications and type of anaesthesia were reported. The effect on surgical time (ST), operative room time (ORT) and length of stay (LOS) were described and examined.

Results

No statistical difference was found in complications rate, clinical data and surgical procedures (p > 0.05). Awake breast conservative surgery (BCS) was the most frequent procedure in COVID-19-BC (p = 0.006). A statistically significant decrease in ORT and LOS was reported in COVID-19-BC (p = 0.040 and p = 0.0015 respectively), while comparable time resulted for ST (p = 0.976). Mean ORT and LOS reduction were 20.79 min and 0.57 hospital bed days.

Conclusion

In the “COVID-19 era”, fast track awake breast surgery provides a reduction of ORT, LOS and potentially surgical treatment for a wider number of oncological patients.

Ulcerated breast cancer with single brain metastasis: A combined surgical approach. Clinical presentation at one year follow up - A case report

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Solitary brain metastasis of breast cancer in a patient with neurological symptoms as first presentation is a rare complication.

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Simultaneously perform a metastasectomy surgery plus right mastectomy, right axillary dissection and immediate breast reconstruction is unusual event.

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Successful combined surgical approach in a stage IV de novo breast cancer patient with single site brain metastasis at one year follow-up.

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Combined surgical approach offers the opportunity to treat two different oncological urgencies, reducing the unnecessary repeated surgical and anesthesiologic trauma.

Introduction

Breast cancer is the most common malignancy in woman. Approximately 5–10% of breast cancer occurs as de novo stage IV and some studies have shown that from 10% to 30% of those patients presents Brain Metastasis.

Presentation of case

In this study, we report a case of solitary brain metastasis of breast cancer in a 63-year-old Italian Caucasian woman with neurological symptoms as first clinical presentation. After the correct diagnosis and multidisciplinary meeting it was decided to simultaneously perform a metastasectomy surgery plus right mastectomy, right axillary dissection and immediate breast reconstruction. In our clinical practice we report a successful combined surgical approach in a stage IV de novo breast cancer patient with single site brain metastasis at one year follow-up.

Discussion

Metastasectomy plus mastectomy provided neurological control of acute complication of metastatic disease and complete breast cancer local control. One-time operation could be the best option when diagnosis of breast cancer is made thanks to the onset of oncological emergency like intracranial hypertension due to single brain metastasis.

Conclusion

Combined surgical approach offers the opportunity to treat two different oncological urgencies, reducing the unnecessary repeated surgical and anesthesiologic trauma.

The Effect of Coronavirus (COVID-19) on Breast Cancer Teamwork: A Multicentric Survey

BACKGROUND/AIM

Despite the large amount of clinical data available of Coronavirus-19 (COVID-19), not many studies have been conducted about the psychological toll on Health Care Workers (HCWs).

PATIENTS AND METHODS

In this multicentric descriptive study, surveys were distributed among 4 different Breast Cancer Centers (BCC). BCCs were distinguished according to COVID-19 tertiary care hospital (COVID/No-COVID) and district prevalence (DP) (High vs. Low). DASS-21 score, PSS score and demographic data (age, sex, work) were evaluated.

RESULTS

A total of 51 HCWs were analyzed in the study. Age, work and sex did not demonstrate statistically significant values. Statistically significant distribution was found between DASS-21-stress score and COVID/No-COVID (p=0.043). No difference was found in the remaining DASS-21 and PSS scores, dividing the HCWs according to COVID-19-hospital and DP.

CONCLUSION

Working in a COVID-19-hospital represents a factor that negatively affects psychosocial well-being. However, DP seems not to affect the psychosocial well-being of BCC HCWs. During the outbreak, psychological support for low risk HCWs should be provided regardless DP.