Does Implant Insertion with a Funnel Decrease Capsular Contracture? A Preliminary Report

Preventing Bacterial Contamination of Breast Implants Using Infection Mitigation Techniques: An In Vitro Study

BACKGROUND

Bacterial contamination of implants has been linked to biofilm formation and subsequent infection, capsular contracture, and breast implant-associated anaplastic large cell lymphoma. Reducing contamination during implant insertion should therefore reduce biofilm formation disease sequelae.

OBJECTIVES

The aim of this study was to compare levels of contamination between preventative techniques.

METHODS

A model to simulate the passage of implants through a skin incision was designed that utilized a sterile textured polyvinyl plastic sheet contaminated with Staphylococcus epidermidis. In the first stage of the polyvinyl contamination model, implants were subject to infection-mitigation techniques and passed through the incision, then placed onto horse blood agar plates and incubated for 24 hours. In the second stage of the study the same contamination was applied to human abdominal wall specimens. A 5 cm incision was made through skin and fat, then implants were passed through and levels of contamination were measured as described.

RESULTS

Smooth implants grew a mean of 95 colony-forming units (CFUs; approximately 1 CFU/cm2) and textured implants grew 86 CFUs (also approximately 1 CFU/cm2). CFU counts were analyzed by the Mann-Whitney U-test which showed no significant difference between implant types (P < .05); independent-sample t-tests showed a significant difference. The dependent-variable techniques were then compared as groups by one-way analysis of variance, which also showed a significant reduction compared with the control group (P < .01).

CONCLUSIONS

This in vitro study has shown the effectiveness of antiseptic rinse and skin/implant barrier techniques for reducing bacterial contamination of breast implants at the time of insertion.

Twelve Years and over 2400 Implants Later: Augmentation Mammoplasty Risk Factors Based on a Single Plastic Surgeon's Experience

Background

Breast augmentation is one of the most commonly performed aesthetic surgery procedures. Yet, few reports in the literature analyze individual surgeon experiences with a unified surgical method on a large group of patients. This study aimed to analyze a single surgeon's complications rate and experience with the Akademikliniken augmentation mammaplasty method from the beginning of his career.

Methods

A retrospective outcome analysis of all patients (n = 1646) who underwent breast augmentation between 2009 and 2021 performed by a single surgeon was conducted. Complications and reoperation rates were evaluated. In addition, correlations with the patient and implant characteristics and insertion-method-related risk factors were analyzed.

Results

In total, 1212 female patients (mean age, 31.47 years) were analyzed. The minimal follow-up for every patient was 6 months (mean follow-up, 18.35 months). The total complication rate was 7.1%, and the most common complication (2.64%) was capsular contracture (Baker scale III/IV). Implant insertion with a funnel significantly lowered the overall risk of complications (P = 0.009). Statistical analysis indicates that the single independent risk factors for primary breast augmentation are patient age younger than 27 years, initial breast size B and C, and tobacco smoking.

Conclusions

This study indicated that capsular contracture and implant rotation are the most common complications of analyzed primary augmentation mammoplasty. It also identifies various risk and protection factors, such as funnel usage, which should be considered by the surgeon when performing this type of procedure.

Devil's Advocate: Evidence-Based Recommendation for "One Breast-One Insertion Funnel" Policy

BACKGROUND

Rates of capsular contracture have reduced significantly since the use of insertion funnels to place breast implants became routine. However, due to financial constraints, the same funnel is usually used for implantation of both sides.

OBJECTIVES

The aim of this study was to determine whether the risk of capsular contracture is higher for the second breast when the same insertion funnel is used for both breasts.

METHODS

The authors collected a sample of the insertion funnel tip immediately after removing the funnel from its sterile packaging and another tip sample after the funnel had been used to insert the first implant. These samples were sent for microbiological culture evaluations. Capsular contracture rates in the first implanted breast vs the second implanted breast were then retrospectively analyzed.

RESULTS

All samples taken from the funnel before the first implantation showed no bacterial growth. All 10 samples taken from the funnel after the first implantation showed organism growth (8 were positive for Staphylococcus epidermidis and 2 for Cutibacterium acnes). Retrospective analysis of the results revealed that the overall capsular contracture rate had reduced after the authors began to use insertion funnels. However, this complication was still more common on the second implanted breast.

CONCLUSIONS

Surgeons should consider the use of separate insertion funnels for each breast. This might help to slightly reduce the incidence of capsular contracture.See the abstract translated into Hindi, Portuguese, Korean, German, Italian, Arabic, and Chinese (Simplified and Traditional) online here: https://doi.org/10.1093/asj/sjad288.

LEVEL OF EVIDENCE: 4

Reducing Peri-implant Capsule Thickness in Submuscular Rodent Model of Breast Reconstruction With Delayed Radiotherapy

INTRODUCTION

Capsular contracture remains the most common complication following device-based breast reconstruction, occurring in up to 50% of women who also undergo adjuvant radiotherapy either before or after device-based reconstruction. While certain risk factors for capsular contracture have been identified, there remains no clinically effective method of prevention. The purpose of the present study is to determine the effect of coating the implant with the novel small molecule Met-Z2-Y12, with and without delayed, targeted radiotherapy, on capsule thickness and morphologic change around smooth silicone implants placed under the latissimus dorsi in a rodent model.

METHODS

Twenty-four female Sprague Dawley rats each had 2 mL smooth round silicone breast implants implanted bilaterally under the latissimus dorsi muscle. Twelve received uncoated implants and twelve received implants coated with Met-Z2-Y12. Half of the animals from each group received targeted radiotherapy (20 Gray) on postoperative day ten. At three and 6 months after implantation, the tissue surrounding the implants was harvested for analysis of capsular histology including capsule thickness. Additionally, microCT scans were qualitatively analyzed for morphologic change.

RESULTS

Capsules surrounding Met-Z2-Y12-coated implants were significantly thinner (P = 0.006). The greatest difference in capsule thickness was seen in the irradiated 6-month groups, where mean capsule thickness was 79.1 ± 27.3 μm for uncoated versus 50.9 ± 9.6 μm for Met-Z2-Y12-coated implants (P = 0.038). At the time of explant, there were no capsular morphologic differences between the groups either grossly or per microCT.

CONCLUSIONS

Met-Z2-Y12 coating of smooth silicone breast implants significantly reduces capsule thickness in a rodent model of submuscular breast reconstruction with delayed radiotherapy.

Management of Biofilm with Breast Implant Surgery

LEARNING OBJECTIVES

After studying this article, the participant should be able to: 1. Understand how bacteria negatively impact aesthetic and reconstructive breast implants. 2. Understand how bacteria infect breast implants. 3. Understand the evidence associated with common implant infection-prevention strategies, and their limitations. 4. Understand why implementation of bacteria-mitigation strategies such as antibiotic administration or "no-touch" techniques may not indefinitely prevent breast implant infection.

SUMMARY

Bacterial infection of aesthetic and reconstructive breast implants is a common and expensive problem. Subacute infections or chronic capsular contractures leading to device explantation are the most commonly documented sequelae. Although bench and translational research underscores the complexities of implant-associated infection, high-quality studies with adequate power, control groups, and duration of follow-up are lacking. Common strategies to minimize infections use antibiotics-administered systemically, in the breast implant pocket, or by directly bathing the implant before insertion-to limit bacterial contamination. Limiting contact between the implant and skin or breast parenchyma represents an additional common strategy. The clinical prevention of breast implant infection is challenged by the clean-contaminated nature of breast parenchyma, and the variable behavior of not only specific bacterial species but also their strains. These factors impact bacterial virulence and antibiotic resistance.

Antiseptic Techniques in Breast Implant Surgery: Insights From Plastic Surgeons in Saudi Arabia

Background

Breast implant surgery is a popular procedure worldwide, and the same holds true for Saudi Arabia. Ensuring a sterile surgical environment is crucial to avert postoperative infections. This study explores the various antiseptic techniques adopted by Saudi plastic surgeons during breast implant procedures.

Objectives

This study aims to assess Saudi plastic surgeons' adherence to antiseptic measures in breast implant surgery, and determine what types of antiseptic measures are most commonly used among Saudi plastic surgeons.

Methods

The authors conducted a cross-sectional survey among board-certified plastic surgeons in Saudi Arabia, collecting data through a self-administered online questionnaire. This questionnaire, which covered their demographic information and their antiseptic practices during breast implant surgery, was disseminated via a WhatsApp (Menlo Park, CA) broadcast message from May 15 to June 27, 2023.

Results

Of the 52 Saudi plastic surgeons who completed the questionnaire, all reported employing preoperative antibiotics and skin disinfection. Other measures included pocket irrigation (86.5%), implant irrigation (92.3%), sleeve/funnel usage (65.4%), nipple shield usage (51.9%), and glove change during the procedure (96.2%). Nearly, all respondents used only a surgical cap for head cover (96.2%) and postoperative antibiotics as prophylaxis (98.1%). However, more than half of them did not minimize door movement during the procedure (51.9%).

Conclusions

This study offers a valuable insight into the antiseptic practices during breast implant surgery in Saudi Arabia. The findings underline the need for further research to establish evidence-based guidelines for antiseptic practices in this field.

Level of Evidence 5

Breast Augmentation: A Cross-Sectional Survey of UK and Irish Aesthetic Surgeons

Background

Breast augmentation surgery is the most frequently performed aesthetic surgical procedure within the United Kingdom year on year. However, many variations exist among surgeons regarding various aspects of implant usage and technique.

Objectives

The aim of this study was to evaluate current trends and practices in breast augmentation, within the United Kingdom and correlate them to evidence-based literature.

Methods

An electronic survey of 41 questions was sent to 201 surgeons performing breast augmentation within the United Kingdom and Republic of Ireland. The survey inquired about the surgeons themselves, their practice, implant choice, surgical technique, post-op care, revision surgery, and impact of breast implant-associated anaplastic large cell lymphoma among several other questions.

Results

There were a total of 166 respondents, with 146 completing the survey fully, equaling a response rate of approximately 73%. Overall, there were specific trends in certain aspects such as type of practice, number of augmentations performed per surgeon per year, preferred implant manufacturer, and implant characteristics. That said, there has been a change in other aspects such as implant texture with an increase in the use of smooth implants. The United Kingdom and Ireland concur with certain internationally dominant practice preferences, including the use of inframammary incisions and post-op bra use.

Conclusions

This survey suggests that many aspects of breast augmentation surgery in the United Kingdom are approaching standardization. There are, however, some variations in practice and controversies remaining as expected. It is our belief that further standardizing this very common aesthetic surgical procedure according to evidence-based guidelines will help to improve outcomes for patients.

Peer Review: How to Review a Plastic Surgery Manuscript

ABSTRACT

Little information is available regarding how to review a plastic surgery manuscript. This vital responsibility ensures that publications meet an acceptable scientific standard. Thoughtful and thorough reviews are essential to protect patients and surgeons from unscientific practices and products. This discussion provides information for the reviewer, gained from the author's experience, including examples of a thorough review, likely to be useful to the editor, and a cursory one that is unhelpful.The first consideration is relevance. Prerequisites for publication include institutional review board approval, disclosure of financial conflicts, and discussion of the regulatory status of devices. Particular attention is needed to check for conflicts of interest, which are endemic in plastic surgery today. In view of the common practice of using computer-generated imaging, reviewers need to be especially vigilant for inauthentic "photoshopped" photographs. Examples of published images that have been digitally altered are provided.If data are available, it may be possible to check the statistical tests. Reviewers need to be aware of the practice of p-hacking. A quick literature search can identify relevant but unreferenced publications. The manuscript needs to be properly organized into sections. Minor points may be made regarding style. The study design and methodology need to be evaluated to be sure that the conclusions are well supported by data. Randomized studies are rarely feasible. Fortunately, well-done prospective observational studies in consecutive patients can be just as useful. Realistic complication rates are expected. Meta-analyses in plastic surgery are often subject to confounding variables. Comments should be available to the authors; confidential comments hidden from authors are discouraged. Like honesty, transparency is the best policy. Manuscripts should be evaluated solely for merit, not the identity of the author or institution. Timeliness of submission of the review is appreciated by authors.Evidence-based medicine is concerned solely with the facts. The 2 basic criteria are a solid scientific basis and reliable evidence of efficacy. Reviewers need to keep an open mind. Studies that challenge the status quo are often the most valuable ones and are needed for the advancement of the specialty.

Defining the Relationship Between Pocket and Breast Implant Surface Area as the Basis for a New Classification System for Capsular Contracture

BACKGROUND

The precise etiology and treatment for capsular contracture remains uncertain at least partially due to the fact that there is no reliable quantitative measurement tool. To address this, it is postulated that the surface area of an implant as defined by the surrounding pocket may provide a quantifiable variable that can be measured to evaluate the degree of capsular contracture.

METHODS

A bench model for capsular contracture was developed. The surface area of a series of spherical test objects and non-contracted and contracted breast implants was measured using a wax coating technique as well as three-dimensional reconstructions created from CT scan images.

RESULTS

Comparison of the mathematically calculated surface areas to the wax and CT results for spheres of known dimension provided nearly identical values documenting the accuracy of the two experimental methods. Comparison of the surface area measurements between the test groups showed that the average decrease in surface area for all implants was 20%, ranging from a high of 30.9% for a low profile implant to a low of 14.1 % for a high profile implant. The anatomically shaped devices demonstrated nearly uniform degrees of surface area change over three different heights with volume and projection held relatively constant.

CONCLUSIONS

The described bench model provides a useful tool for the study of capsular contracture. Surface area is a descriptive variable that can assess the degree of capsular contracture that is present. A classification system based on surface area is presented.

Intraoperative Assessment of Endogenous Microbiota in the Breast

OBJECTIVE

 Breast surgery is considered a clean surgery; however, the rates of infection range between 3 and 15%. The objective of the present study was to intraoperatively investigate the presence of autochthonous microbiota in the breast.

METHODS

 Pieces of breast tissue collected from 49 patients who underwent elective breast surgery (reconstructive, diagnostic, or oncologic) were cultured. The pieces of breast tissue were approximately 1 cm in diameter and were removed from the retroareolar area, medial quadrant, and lateral quadrant. Each piece of tissue was incubated in brain heart infusion (BHI) broth for 7 days at 37°C, and in cases in which the medium became turbid due to microorganism growth, the samples were placed in Petri dishes for culturing and isolating strains and for identifying species using an automated counter.

RESULTS

 Microorganism growth was observed in the samples of 10 of the 49 patients (20.4%) and in 11 of the 218 pieces of tissue (5%). The detected species were Staphylococcus lugdunensis, Staphylococcus hominis, Staphylococcus epidermidis, Sphingomonas paucimobilis, and Aeromonas salmonicida. No patient with positive samples had clinical infection postoperatively.

CONCLUSION

 The presence of these bacteria in breast tissue in approximately 20% of the patients in this series suggests that breast surgery should be considered a potential source of contamination that may have implications for adverse reactions to breast implants and should be studied in the near future for their oncological implications in breast implant-associated large-cell lymphoma etiology.

Higher Prevalence of Capsular Contracture with Second-side Use of Breast Implant Insertion Funnels

Breast implant insertion funnels have become popular adjuncts to breast implant surgery to reduce access incision length and contact of the implant with the skin of the breast. Although labeled as single-use devices, due to cost considerations, many surgeons use a new breast implant insertion funnel with each patient rather than each breast. The purpose of this study was to evaluate the prevalence of capsular contracture of the first augmentation side and compare it to the second side utilizing one insertion funnel per patient.

Pre-Lubricated Polypropylene Injector for Breast Implant Delivery

Breast augmentation is a common esthetic surgery, and there are two major surgical methods for breast implant delivery: the finger method and the plastic film method. Each method has its advantages and disadvantages, and we have developed a prelubricated polypropylene (PP) injector that might be the most suitable device for delivering breast implants. By covering the interior surface of the injector with a hydrophilic coating, the friction coefficient was significantly reduced when a silicone sled was slid against the prelubricated PP injector. To confirm if the prelubricated PP injector would not damage the breast implant, fatigue testing was performed, and the results showed that the injector did not cause rupture or microleakage of the breast implant. In addition, the cell viability result demonstrated that the prelubricated PP injector was biocompatible. In addition, the prelubricated PP injector provides a small incision site and stability during breast implant delivery. Our results provided evidence that the prelubricated PP injector is a smooth and safe method for breast implant delivery.

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.

Safety of a Protective Funnel in Primary Breast Augmentation: A Retrospective Analysis of 380 Multicenter Cases in the United States

BACKGROUND

Protective funnel devices are commonly used to deliver implants in primary breast augmentation (BA) yet there is a paucity of evidence-based data describing their safety in the literature.

OBJECTIVES

The purpose of this study was to assess the safety of protective funnels in primary BA within the first 30 days postoperatively.

METHODS

This multicenter, Level 3 study retrospectively reviewed the surgical records of 380 consecutive patients (760 breasts) who underwent primary BA by 9 board-certified plastic surgeons using the iNPLANT Funnel (Proximate Concepts LLC, Allendale, NJ) for implant delivery between November 2019 and December 2020. Data were collected pertaining to demographics, implant information, surgery details, and postoperative complications.

RESULTS

The mean patient age was 33 years and 76% of patients had a BMI <25 kg/m2. Of this cohort, 11.4% were smokers, 0.8% had diabetes, and 83% were ASA Class 1. All patients received smooth implants with a median volume of 375 cc. A total of 8 (2.1%) complications were reported, including 3 hematomas (0.79%), 1 seroma (0.26%), and 1 superficial infection (0.26%). No patient required explantation. We identified ASA class, BMI, surgery duration, and implant size as potential risk factors.

CONCLUSIONS

The data suggest that the use of protective funnels, such as the iNPLANT Funnel, in primary BA is a safe option when these are utilized according to the manufacturer's Instructions for Use. The use of this device led to a low infection rate (0.26%) and a complication rate of (2.1%) consistent with the average reported in the literature (2%-2.5%).1 Implications for clinical practice are encouraging and future research will include a prospective analysis with a larger case series and potentially a control group.

LEVEL OF EVIDENCE: 3

Revision Breast Augmentation

Breast augmentation is consistently one of the most commonly performed aesthetic operations every year. Unfortunately, revision rates following primary augmentation remain as high as 36%. There are several causes for revision breast augmentation; however, the most common and challenging of these include capsular contracture, implant malposition, and ptosis of the aging breast following augmentation. Successful management of these problems requires knowledge on how to best treat the implant and capsule with the corresponding soft tissue simultaneously. While surgical management is important, understanding the pathological causes of these entities during the primary operation can reduce the need for revision. This article utilizes the most up-to-date literature to review the appropriate clinical evaluation and surgical management of these complex cases.

Controllable Factors to Reduce the Rate of Complications in Primary Breast Augmentation: A Review of the Literature

BACKGROUND

Aesthetic augmentation mammoplasties are one of the most demanded procedures performed in the aesthetic surgical sector. Because of the high epidemiological impact, the evaluation of measures to reduce the risk of complications is highly needed. The goal of this review is to evaluate the current literature for successful actions to reduce the risk of complications in aesthetic breast augmentation.

METHODS

We searched Medline-listed journals for "complications primary breast augmentation" and defined surgeon-dependent and patient-dependent factors within those.

RESULTS

Most of the strategies to reduce the risk of any complication are based on meticulous hygienic precautions and adequate training of the surgeon. The current literature suggests complications such as capsular contracture, infection and BIA-ALCL are closely linked with bacterial contamination and therefore can be avoided with different hygienic measures.

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 the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Breast Device Surgery in Australia: Early Results from the Australian Breast Device Registry

BACKGROUND

The Australian Breast Device Registry (ABDR) is a clinical quality registry designed to monitor the performance of breast devices; and the quality and safety of breast device surgery.

OBJECTIVE

To report on breast device surgery characteristics across Australia.

METHODS

Participants were registered patients in the ABDR from 2012 to 2018. Results are described using percentages, mean and median. Revision rates were calculated using survival analysis methods.

RESULTS

A total of 37,603 patients were registered and had undergone reconstruction (post-cancer 15.1%, risk-reducing mastectomy 3.4% and developmental deformity 2.4%) or cosmetic augmentation (74.7%) procedures. The majority of breast implant devices were silicone filled with textured surface (reconstruction 74.0% and augmentation 64.0%). Sub-pectoral plane was the most common for both reconstruction (60.1%) and augmentation (76.6%) procedures. For reconstruction surgery, the most common surgical incision was previous mastectomy scar (44.0%) and inframammary (31.8%), and for augmentation, it was inframammary (83.4%). Intraoperative/postoperative antibiotic usage for reconstruction was 85.8% and augmentation was 89.4%. Revision incidence due to complication at 12 months post-cancer reconstruction was 5.1%, risk-reducing reconstruction 5.7% and developmental deformity implants 4.5%. Revision incidence due to complication at 12 months after augmentation procedure was 1.1%. Patient-reported outcome measures (PROMs) indicate high levels of satisfaction at 1 year for augmentation and reconstruction procedures.

CONCLUSION

We report on early data from the ABDR and reflect on the uptake of the registry by surgeons and patients. The registry also benefits from international collaborative approaches to addressing challenges and is committed to facilitate international post-market surveillance.

Silicone Breast Implant Injector: A Retooled Breast Augmentation Device

Silicone breast implants are used worldwide for breast augmentation. After an axillary, periareolar or inframmary incision has been made to create an adequately sized pocket; the surgeon usually uses his or her fingers to insert the implant. The use of fingers makes the insertion process time-consuming, a few minutes or more. There are some complications, including need to ensure that the incision is long enough for the implant to be inserted, scar hypertrophy caused by implant insertion friction damage to the edge of incision, and the occasional need to ask the surgical assistant to lend more fingers to facilitate satisfactory insertion and placement. In addition, the use of gloved fingers to repeatedly push on the implant can increase the risk of contamination, postoperative silicone microleakage, and capsular contracture. To resolve these problems, we developed an improved silicone breast implant injector (reusable stainless steel 2007; single use polypropylene 2018) that can be used more easily than fingers and other "no touch" devices. From 2013 to 2017, the first author, a plastic surgeon at our clinic, used the 2007 reusable stainless steel injector to perform breast augmentations in 53 patients (Ave. age 23.8 years; range 19-67 years), 5 (8.8%) receiving 250-ml implants, 41 (77.4%) 251-300-ml implants, and 7 (13.8%) 301-400-ml implants. Overall, results were satisfactory except for two patients (3.7%) in whom capsular contracture occurred. There were no ruptures. Use of the injector made it possible to shorten the length of the incisions from the traditional 4-7 to 3-4 cm and expedited insertion time from a few minutes to a few seconds. This "no touch" insertion technique reduced implant damage caused by finger pushing, leading to a decrease in silicone microleakage and capsular contracture rate. It was performed with no friction trauma to the incision edge or harm to the surgeon's fingers. It was found to be an effective alternative operative tool for the insertion of silicone breast implants.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 .

Funnel usefulness in direct-to-implant breast reconstruction using periareolar incision with prepectoral implant placement and complete coverage with acellular dermal matrix

BACKGROUND

The funnel has been used in esthetic breast surgery that requires a small incision. Recent advances in minimally invasive surgical techniques have led to more cases of nipple-sparing mastectomy (NSM) through periareolar incision. However, prepectoral implant placement and complete coverage with acellular dermal matrix (ADM) is almost impossible with the periareolar approach. Funnels can also be useful for direct-to-implant breast reconstruction.

METHODS

NSM with periareolar incision and direct-to-implant breast reconstruction were performed with prepectoral implant placement between January 2017 and July 2019. The ADM full-wrapped anatomic textured implant was inserted using a funnel without additional incisions during surgery.

RESULTS

A total of 21 patients were enrolled, including 2 who received bilateral breast reconstruction. All operations were successfully performed using funnels with minimal periareolar incisions. Anatomic textured implants (mean: 251.7 cc, range: 90-450 cc) wrapped in ADM can be effectively inserted in the prepectoral plane using a funnel. Two patients experienced delayed wound healing of the areola that was treated by conservative wound management. Patients also experienced less pain overall, and the cosmetic result was very good. Patient satisfaction scores were also very high.

CONCLUSIONS

While the periareolar incision is esthetically pleasing, additional resection is often necessary. However, the use of funnels ensured that no additional incision was needed even in large implants. This subsequently led to better results in terms of pain and scarring. Prepectoral breast reconstruction involving complete implant coverage with ADM using a funnel through the periareolar approach represents a good alternative to the traditional dual plane subpectoral method. This method provides good patient satisfaction without adverse outcomes.

The Reversed Glove Sleeve: A Readily Available and Cost-effective Way to Achieve "No Touch" Breast Implant Insertion

The reversed glove sleeve technique is a simple, available, reproducible, and cost-effective method of achieving “no touch” breast implant insertion. It allows a new glove to be used for each side, thus reducing the risk of contamination by reusing a sleeve/funnel for the subsequent implant insertion. The link between bacterial contamination of breast implants and capsular contracture is established. Further prospective evaluation of this technique is underway to show if there is benefit in reducing the risk of capsular contracture.

A Simple Alternative: A Minimal-Touch Technique for Placing Breast Implants

This is a single-surgeon experience detailing the senior author’s (J.G.) minimal-touch technique for placement of breast implants. Adams et al. 14-point plan has been incorporated into the technique, and the implant box paper cover sheet is used as a barrier between the patient and the implant near the incision during placement. Over a period of ten years, the senior author reports a less than 1% development in capsular contracture using this technique and no implant fractures. These findings elucidate the importance of describing this alternative technique to other barriers currently on the market.

Level of Evidence: 4

Does Implant Surface Texture Affect the Risk of Capsular Contracture in Subglandular Breast Augmentation and Breast Augmentation-Mastopexy?

BACKGROUND

Previous studies have reported decreased rates of capsular contracture associated with the use of textured surface breast implants placed in the subglandular plane during breast augmentation. However, since the publication of these studies, our understanding of the pathophysiology of capsular contracture, as well as the surgical techniques utilized to minimize bacterial contamination of the implant, have advanced considerably.

OBJECTIVES

The purpose of this study was to re-evaluate the relation between implant surface texturization and capsular contracture rates for breast implants placed in the subglandular plane during primary breast augmentation.

METHODS

Retrospective chart review was performed of all primary subglandular breast augmentation procedures involving the use of either smooth or textured round silicone gel implants, with or without simultaneous mastopexy. The primary outcome measures included clinically significant capsular contracture (Baker grade III/IV) and revision surgery for capsular contracture.

RESULTS

Between 2010 and 2017, 526 patients underwent primary subglandular breast augmentation with either smooth (n = 212) or textured (n = 314) round silicone gel implants; 248 patients underwent breast augmentation, whereas 278 underwent breast augmentation-mastopexy. Average follow-up was 756 days in the textured group and 461 days in the smooth group. Five cases of capsular contracture were observed in the textured group, and 7 cases of capsular contracture were observed in the smooth group (P = 0.20).

CONCLUSIONS

Smooth surface implants placed in the subglandular plane were not at a significantly increased risk of capsular contracture compared with textured surface implants. We suggest that adherence to a surgical technique focused on minimizing bacterial contamination of the implant is of greater clinical significance than implant surface characteristics when discussing capsular contracture.

LEVEL OF EVIDENCE: 4

Popcorn Capsulorrhaphy in Revision Aesthetic Breast Surgery

BACKGROUND

Control of the pocket in revisional breast surgery can be technically challenging and unpredictable. A capsulorrhaphy technique has been utilized in altering capsules in secondary aesthetic breast surgery.

OBJECTIVES

The authors sought to determine the effectiveness of popcorn capsulorrhaphy in revisional breast surgery.

METHODS

A retrospective chart review of revisional breast cases utilizing popcorn capsulorrhaphy was conducted between September 2015 and August 2017. Only aesthetic breast cases were included. Data were collected for 149 patients.

RESULTS

One hundred forty-nine patients representing 266 breasts were operated on. The average patient age was 42 years and the mean body mass index was 24.2 kg/m2. The average time from their original surgery to the popcorn capsulorrhaphy secondary procedure was 9.3 years. Indications for capsulorrhaphy included malposition in 163 breasts (61.3%), implant positioning for breast ptosis in 34 breasts (12.8%), pocket adjustment for implant size change in 49 breasts (18.4%), and postexplantation pocket reduction in 20 breasts (7.5%). Of the 266 implants, 145 (54.5%) were smooth, 101 (38%) textured, and 20 (7.5%) were explanted. The average original implant size was 405 cc and the average size placed at the time of capsulorrhaphy was 422 cc. Two hundred thirty-six (88.7%) were in a submuscular pocket and 30 (11.3%) were subglandular. The total number of complications was 39 (14.7%), and 16 (6%) required some type of operative revision.

CONCLUSIONS

Popcorn capsulorrhaphy can provide pocket control and stability with low complication and revision rates. The addition of a mesh or biologic at the time of popcorn capsulorrhaphy can further lower the complication and revision rates.

LEVEL OF EVIDENCE: 4

One-Stage Augmentation Mastopexy: A Retrospective Ten-Year Review of 2183 Consecutive Procedures

BACKGROUND

Although numerous studies supporting breast augmentation with simultaneous mastopexy have been reported, concerns persist among surgeons regarding the safety of this procedure.

OBJECTIVES

The authors sought to evaluate the safety and effectiveness of 1-stage augmentation mastopexy by analyzing long-term complication and reoperation rates.

METHODS

The authors conducted a retrospective review of 1131 patients who underwent 2183 consecutive 1-stage augmentation mastopexy procedures from January 2006 to August 2016. Patient demographics, operative technique, and implant specifications were measured and analyzed with surgical outcomes. Long-term complication and reoperation rates were noted.

RESULTS

Over a mean follow-up period of 43 months (range, 4-121 months), the overall complication rate was 15.3% (n = 173) with a reoperation rate of 14.7% (n = 166). Tissue-related complications included hypertrophic scarring in 2.5% (n = 28) and recurrent ptosis in 2.1% (n = 24). The most common implant-related complication was capsular contracture (Baker III or IV) in 2.8% (n = 32). The most common indications for reoperation were recurrent ptosis in 3.5% (n = 40 patients) and desire to change implant size in 3.2% (n = 36 patients). Circumareolar augmentation mastopexy technique was associated with a higher reoperation rate of 25.7% (P < 0.0005). Patients with a history of smoking had a higher incidence of complications (26.1%) and reoperations (22.5%; P < 0.0005). There were no cases of significant skin flap necrosis (>2 cm).

CONCLUSIONS

One-stage augmentation mastopexy can be safely performed with a reoperation rate that is significantly lower than when the procedure is staged. The effectiveness of this procedure is defined by a low complication rate and a reduced number of operations for the patient.

LEVEL OF EVIDENCE: 4

Surgical Site Infections in Aesthetic Surgery

Surgical site infections represent one of the most common postoperative complications in patients undergoing aesthetic surgery. As with other postoperative complications, the incidence of these infections may be influenced by many factors and varies depending on the specific operation performed. Understanding the risk factors for infection development is critical because careful patient selection and appropriate perioperative counseling will set the right expectations and can ultimately improve patient outcomes and satisfaction. Various perioperative prevention measures may also be employed to minimize the incidence of these infections. Once the infection occurs, prompt diagnosis will allow management of the infection and any associated complications in a timely manner to ensure patient safety, optimize the postoperative course, and avoid long-term sequelae.

Implant Insertion Time and Incision Length in Breast Augmentation Surgery with the Keller Funnel: Results from a Comparative Study

BACKGROUND

The Keller funnel is an easy-to-use mechanical device that aids breast implant insertion. This study analyzed implant insertion time and incision length using the Keller funnel versus conventional manual insertion.

METHODS

This was an analysis of two cohorts of adult patients undergoing primary breast augmentation with anatomical implants at a single center. In the 'insertion time cohort' (N = 20), implants were inserted with a Keller funnel on one side and manually on the other; follow-up lasted 4 years. In the 'incision length cohort,' both implants were inserted with a Keller funnel (N = 50) or manually (N = 50), with follow-up lasting 12 months.

RESULTS

In the insertion time cohort, mean total insertion time (from implant sterile-package opening to final positioning in the pocket) was 35 s (range 13-76 s) with the Keller funnel and 25 s (range 13-43 s) using manual insertion (p = 0.07); the mean time needed to push the implant through the incision was 6 s (range 3-10 s) with the Keller funnel and 16 s (range 13-40 s) with manual insertion (p = 0.04). In the incision length cohort, mean incision length was shorter with the Keller funnel versus manual insertion (35.5 ± 2.1 mm vs. 46.2 ± 3.2 mm; p < 0.001). There were no differences in complications based on insertion method.

CONCLUSION

The Keller funnel was associated with decreased incision length and reduced time to push the implant through the incision. This brings potential clinical advantages in minimizing scarring and reducing contamination of the device.

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 the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Modern Primary Breast Augmentation: Best Recommendations for Best Results

LEARNING OBJECTIVES

After reading this article, the participant should be able to: 1. Develop a practical method for preoperative implant size selection. 2. List characteristics and examples of fourth- and fifth-generation silicone implants. 3. Recognize the differences in "profile" designations across implant manufacturers. 4. Recall updated statistics on breast implant-associated anaplastic large cell lymphoma and describe current guidelines on disease diagnosis and treatment. 5. Apply atraumatic and aseptic surgical techniques in primary breast augmentation.

SUMMARY

Modern primary breast augmentation requires an intimate knowledge of the expanding breast implant market, including characteristics of current generation silicone implants and "profile" types. Optimal implant size selection requires balancing patient desires with tissue qualities. Evidence and awareness of breast implant-associated anaplastic large cell lymphoma continue to grow, and patients and surgeons alike should be informed on the most updated facts of the disease entity. Atraumatic surgical technique and aseptic adjuncts are critical in reducing periprosthetic inflammation and contamination, both of which are known instigators of capsular contracture and potentially breast implant-associated anaplastic large cell lymphoma.

Periprosthetic Capsule Formation and Contracture in a Rodent Model of Implant-Based Breast Reconstruction With Delayed Radiotherapy

INTRODUCTION

Capsular contracture (CC) is the most common complication of breast implantation, with an incidence of nearly 50% in patients undergoing breast reconstruction with subsequent radiotherapy. Although the move toward submuscular (SM) device placement led to a decreased incidence of CC, subcutaneous (SQ) implantation has seen a resurgence. The purpose of this study was to use a rodent model of breast reconstruction with smooth silicone implants and delayed radiotherapy to assess the occurrence of CC in SQ versus SM implantation.

METHODS

Custom 2 mL smooth round silicone implants were placed bilaterally into 12 female Sprague Dawley rats that were randomized into 4 groups of 3, with each group differing by implantation plane (SQ vs SM) and irradiation status (irradiated vs nonirradiated). Rats from the SQ group received implants bilaterally underlying the skin on the flank. Rats in the SM groups received implants bilaterally under the latissimus dorsi muscle. Irradiated rats received 20 Gy localized to each implant on postoperative day 10. One rat from each group was imaged with a micro-computed tomography scanner at baseline and at explant 3 months later, whereupon capsules from all rats were examined histologically.

RESULTS

Rats in the SQ group showed evidence of contracture on gross examination and greater evidence of morphologic disruption per micro-computed tomography scan. There was no evidence of contracture or morphologic disruption in either SM group. Mean ± SD capsule thickness was 39.0 ± 9.0 μm in the SQ versus 37.6 ± 9.8 μm in the SM nonirradiated groups and 43.9 ± 14.9 μm in the SQ versus 34.3 ± 8.3 μm in the SM irradiated groups (all P > 0.05).

CONCLUSIONS

In a rodent model of smooth silicone breast implantation and delayed radiotherapy, although there did not appear to be differences in capsule thickness regardless of device placement plane, SQ implants demonstrated gross evidence of CC. These data indicate that capsule thickness is only part of a larger pathogenetic picture, which should take into consideration the contribution from all peri-implant tissue.

The Detection of Bacteria and Matrix Proteins on Clinically Benign and Pathologic Implants

Supplemental Digital Content is available in the text.

Background:

Bacterial contamination of breast implants causes infection, can lead to capsular contracture, and is implicated in breast implant-associated anaplastic large cell lymphoma. Bacteria, however, also colonize clinically benign breast implants and little is known about the biologic signals that trigger the switch from a benign to pathologic state.

Methods:

Explanted smooth as well as Biocell and Siltex textured breast implants associated with clinically normal and pathologic conditions were analyzed in this observational study. Immunofluorescence and bacterial culture techniques were performed. To avoid sampling bias, implant surfaces >25 sq cm were analyzed.

Results:

Bacteria were detected on 9 of 22 clinically normal explanted devices or periprosthetic capsules, including 40% of Biocell tissue expanders and 75% of Biocell textured implants. Staphylococcus epidermidis was identified in 67% of the bacteria-positive capsular contractures. Fibrinogen was present on 17 of 18, and collagen on 13 of 18 analyzed breast implants. S. epidermidis co-localized with collagen, while group B streptococci and Klebsiella pneumoniae co-localized with fibrinogen.

Conclusions:

Bacteria are often detectable on clinically benign breast implants when a multimodal approach is applied to a substantial proportion of the device surface to avoid sampling bias. The impact of bacteria on breast implant pathology should be studied in the presence of an adequate negative control group to account for clinically benign bacteria. Disruption of the interaction of bacteria with matrix proteins coating the surface of breast implants may represent a nonantibiotic strategy for the prevention of breast implant bacterial contamination.

Single stage, direct to implant pre-pectoral breast reconstruction

BACKGROUND

Given the current trends in skin preservation during mastectomy, improved biofilm reduction algorithms, and advancements in tissue bioengineering and perfusion assessment, acellular dermal matrix (ADM)-reinforced single stage, direct to implant insertion in the pre-pectoral space has become a viable alternative to two-stage expander-based, sub-pectoral reconstruction.

METHODS

The authors performed a retrospective review of their pre-pectoral cases evaluating outcomes for all single stage, direct to implant procedures. Outcomes reviewed included hematoma, seroma, infection, device loss or change, animation deformity and revisional procedures such as fat grafting. The anterior tenting surgical technique is also reviewed.

RESULTS

The authors have carried out 305 direct to implant pre-pectoral breast reconstructions using an anterior tenting technique with low complication rates and superior clinical and functional outcomes. The benefits of this technique include less patient discomfort, no need for postoperative expansion, virtually no subjective negative impact on upper extremity function and elimination of animation deformity. Longer-term follow-up demonstrates maintenance of the integrity and quality of the reconstructions over time.

CONCLUSIONS

The authors consider single stage, pre-pectoral direct to implant breast reconstruction to be a state-of-the-art breast reconstruction technique and have found it to be safe and reproducible. This technique is their primary choice for immediate implant-based reconstruction following mastectomy.

Current Trends in Breast Augmentation: An International Analysis

BACKGROUND

Breast augmentation surgery remains the most frequently performed aesthetic surgical procedure worldwide. However, many variations exist regarding preoperative planning, surgical management, and postoperative care.

OBJECTIVES

The goal was to evaluate current trends and practices in breast augmentation, with a focus on international variability.

METHODS

A questionnaire was sent to over 5000 active breast surgeons in 44 countries worldwide. The survey inquired about current controversies, new technologies, common practices, secondary procedures, and surgeon demographics. The findings and variations were evaluated and correlated to evidence-based literature.

RESULTS

There were a total 628 respondents equaling a response rate of approximately 18%. While certain approaches and common practices prevail also on an international basis, there exist several geographic controversies. For example, while almost fifty percent of surgeons in the United States and Latin America never use anatomically shaped implants, in Europe and Oceania most surgeons use them. Similarly, in Latin America, Europe, Asia, and Oceania, over 80% of surgeons use silicone implants only, whereas in the United States only 20% use them - meanwhile US surgeons use the largest implants (78% > 300 cc). Internationally dominant practice preferences include preoperative sizing with silicone implants, as well as the use of inframammary incisions and partial submuscular pockets.

CONCLUSIONS

Significant differences exist when comparing most common surgical breast augmentation approaches on an international basis. While certain techniques seem to be universal standards, there still remain several controversies. Further standardizing this most common aesthetic surgical procedure according to evidence-based guidelines will help to improve outcomes.

Evidence-Based Medicine: Breast Augmentation

LEARNING OBJECTIVES

After reading this article, the participant should be able to: 1. Understand the key decisions in patient evaluation for cosmetic breast augmentation. 2. Cite key decisions in preoperative planning. 3. Discuss the risks and complications, and key patient education points in breast augmentation.

SUMMARY

Breast augmentation remains one of the most popular procedures in plastic surgery. The integral information necessary for proper patient selection, preoperative assessment, and surgical approaches are discussed. Current data regarding long term safety and complications are presented to guide the plastic surgeon to an evidence-based approach to the patient seeking breast enhancement to obtain optimal results.

The Supra-Inframammary Fold Approach to Breast Augmentation: Avoiding a Double Bubble

Supplemental Digital Content is available in the text.

The inframammary incision for breast augmentation is commonly made at or below the existing inframammary fold (IMF) in an effort to keep the scar in the crease. In recent studies, surgeons inferiorly relocate the IMF, center the implant at nipple level, and attempt to secure the new IMF with sutures. The fascial attachments (also called ligaments) holding the IMF are released, risking a bottoming-out deformity or a double bubble.

Nine-Year Core Study Data for Sientra's FDA-Approved Round and Shaped Implants with High-Strength Cohesive Silicone Gel

BACKGROUND

Since approval in March 2012, data on Sientra's (Santa Barbara, CA) silicone gel implants have been updated and published regularly to provide immediate visibility to the continued safety and performance of these devices. The 9 year follow-up data support the previously published data confirming the ongoing safety and efficacy of Sientra silicone gel breast implants.

OBJECTIVES

The authors provide updated 9 year study data for Sientra's round and shaped silicone gel breast implants.

METHODS

The Core Study is an ongoing 10 year study that enrolled 1788 patients with 3506 Sientra implants across four indications (primary augmentation, revision-augmentation, primary reconstruction, and revision-reconstruction). For the safety analysis, Kaplan-Meier risk rates were calculated to evaluate postoperative complications, including all breast implant-related adverse effects. For the effectiveness analyses, results were presented through 8 years as patient satisfaction scores were assessed at even years.

RESULTS

Through 9 years, the overall risk of capsular contracture was 12.6%. Smooth devices (16.6%, 95% CI, 14.2%, 19.5%) had a statistically significantly higher rate of capsular contracture compared to textured devices (8.0%, 95% CI, 6.2%, 10.4%). Out of the 610 reoperations in 477 patients, over half of all reoperations were due to cosmetic reasons (n = 315; 51.6%). Patient satisfaction remains high through 8 years, with 90% of primary augmentation patients indicating their breast implants look natural and feel soft.

CONCLUSIONS

The 9-year follow-up data from the ongoing Core Study of the Sientra portfolio of HSC and HSC+ silicone gel breast implants reaffirm the very strong safety profile as well as continued patient satisfaction.

LEVEL OF EVIDENCE

2 Therapeutic.