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

Selective Capsulotomies and Partial Capsulectomy in Implant-Based Breast Reconstruction Revision Surgery

Background

Breast cancer with about 2.3 million diagnoses and 685,000 deaths globally is the most frequent malignancy in the female population. Continuous research has led to oncological and reconstructive advances in the management of breast cancer, thus improving outcomes and decreasing patient morbidity. Nowadays, the submuscular expander and prosthesis (E/P) implant-based breast reconstruction (IBR) accounts for 73% of all reconstructions. Despite its widely accepted efficacy, the technique is not free from complications and up to 28% of cases require revision surgery for mechanical complications such as capsular contracture, implant displacement/rotation, and implant rupture. With this study, the authors report their experience in the management of E/P IBR revision surgery through the technique of Selective Capsulotomies (SCs) and Partial Capsulectomy (PC).

Methods

A retrospective study was conducted on patients who had previously undergone E/P IBR and presented for revision reconstruction between January 2013 and May 2023 at the Department of Plastic Surgery of the University of Siena, Italy. Reasons for revision included capsular contracture, implant displacement/rotation, and implant rupture. Revision reconstructions involved SC and PC with implant replacement. Fat grafting was also considered. The complication rate was evaluated by analysis of patients' medical records. Patients' satisfaction with the treatment was assessed through a specific questionnaire.

Results

32 patients underwent revision surgeries. No early complication occurred. Recurrence rate was assessed at 19% with average follow-up of 59 months (range: 13-114 months). The average time between revision surgery and recurrence was 3 years (range: 1-6 years). 23 patients answered the questionnaire and were overall satisfied with the treatments (8.29/10).

Conclusions

SC possibly associated to PC is a valuable option for E/P IBR revision surgery with minimal complications, reduced surgical trauma, short operating time, and relatively low recurrence risk. In addition, treated patients are overall satisfied with the results over time.

Updated trends of breast implant surgeries: An Israeli analysis

INTRODUCTION

Breast augmentation remains one of the most prevalent procedures in plastic surgery. While most patients experience high satisfaction with the outcomes, a subset may encounter various complications or dissatisfaction with achieved results necessitating subsequent surgical intervention including implant removal or exchange.

MATERIALS AND METHODS

We collected information from three pivotal private medical centers in Israel where a considerable number of breast surgeries are performed. We examined the number of breast augmentations, implant exchange and implant removal surgeries with or without breast lift that were performed on a biannual basis for each center for the period 2018-2022. Trends in surgery types were analyzed and compared to registries in other countries.

RESULTS

Between the years 2018 and 2022, 20,075 surgeries were done in three main private medical centers in Israel. Data show a gradual increase in implant removal surgeries from 2018 (n = 80, 2.9%) to 2019 (n = 269, 9.9%), followed by a significant increase in 2020 (n = 1436, 27.3%), and a gradual decline between 2021 (n = 1019, 22.8%) and 2022 (n = 916, 18.5%). The overall number of breast implant insertion procedures (breast augmentation procedures and exchange procedures) was 2659 in 2018 (97%), 2424 in 2019 (90.0%), 3816 in 2020 (72.6%), 3437 in 2021 (77.1%), and 4019 in 2022 (81.4%).

SUMMARY

We present updated trends in breast implant surgeries in Israel. 2020 was a key year in which the rate of explantations was the highest, and the percentage rate of implantations was the lowest and a year in which the trend changed. These patterns partly align with trends seen in other countries worldwide.

The Incidence and Outcomes of Breast Implants Among 1696 Women over more than 50 Years

OBJECTIVE

To investigate the incidence of women with breast implants in 1964-2017 MATERIALS AND METHODS: All women with breast implants in Olmsted County, MN between January 1, 1992 and December 31, 2017 were identified, and a comprehensive review of individual medical records was performed, adding to a previously identified cohort of women with breast implants in 1964-1991. Incidence rates were calculated and were age- and sex-adjusted to the US white female 2010 population.

RESULTS

In 1992-2017, 948 women with breast implants were identified, totaling 1696 Olmsted County, MN women with breast implants in 1964-2017. Overall incidence was 63.3 (95% CI 60.2-66.4) per 100,000 women, but incidence varied significantly over time. Women in 1964-1991 were more likely to have implants for cosmetic reasons and more likely to have silicone implants compared to the 1992-2017 cohort. The overall standardized mortality ratio was 1.17 (95% CI 0.99-1.38) in 1964-1991 and 0.94 (95% CI 0.66-1.29) in 1992-2017. In 1992-2017, breast reconstruction patients had a significantly elevated risk of implant rupture and implant removal versus breast augmentation patients.

CONCLUSION

The incidence of breast implants among women in Olmsted County, MN has varied drastically over the past five decades, with significant changes in the trends for implant type and reason. The findings of this study may provide further insight regarding how risks associated with implants may vary over time.

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 .

What Can We Learn from Breast Implant Explantation: a 28-Year, Multicenter Retrospective Study of 1004 Explantation Cases

BACKGROUND

Implant-based breast augmentation remains popular, but the controversy over the safety and longevity of implants has continued. An event-based analysis of reasons for implant explantation may provide us with some insight into the controversy.

METHODS

Data from May 1994 to October 2022 of explantation cases from aesthetic breast augmentation in three medical centers were retrospectively reviewed. Patient characteristics, time to explantation, reasons for visit, the major reason for explantation and intraoperative findings were analyzed.

RESULTS

A total of 522 patients with 1004 breasts were included in our study. Objective explantation reasons accounted for 34.0% in primary augmentation breasts and 47.6% in revision augmentation breasts, which were significantly different (p = 0.006). The most common complaint was dissatisfaction with breast appearance, followed by concerns about implant safety, poor hand feeling and pain. 43.5% of the implants worn for more than 10 years were removed for objective reasons, which was found significantly different with the proportion of objective reasons in implants removed within 1 year and 1-5 years postoperatively (p < 0.008).

CONCLUSION

The proportion of different reasons for implant explantation varies across the times of surgeries and the years that the implant had been worn. As the years of implant wearing increase, the proportion of subjective reasons decreases in implant removal cases and objective reasons increase among them.

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 .

Periareolar Augmentation Mastopexy: Finding the Aesthetic Level of Breast Lifting

Background

Ptosis and volume atrophy of the breasts are common symptoms for various ages of women and may induce a considerable amount of stress in daily life. Periareolar augmentation mastopexy is an effective procedure for such conditions, and planning the new nipple position is very important.

Aim

To provide a simple, straightforward planning and walkthrough of this operation in a journey to find the ideal level of breast lifting for natural upper fullness.

Materials and methods

From January 2019 to December 2021, a total of 193 patients with volume deflation and ptosis of the breast received periareolar augmentation mastopexy in our institute. We retrospectively reviewed data on demographics, surgical procedures, outcomes, and complications.

Results

All operations were done with periareolar incisions, and the mean follow-up period was 29.48 ± 9.11 months. The Likert scale of outcome satisfaction scored 9.02 ± 0.61. Complications were minimal, and no symmastia or bottoming out occurred.

Conclusion

We present our basic strategies of periareolar augmentation mastopexy with a slight modification of the design. We believe that lifting the nipple to 3-4 cm above the inframammary fold (IMF) (making the top of the areola about 5-6 cm above the IMF) yields satisfactory aesthetic results.

Decreasing Time Intervals in Recurring Capsular Contracture? A Single Center Retrospective Study over 6 Years

Although breast implants of the current generation can, in principle, remain in the body for life, follow-up operations of the augmented or reconstructed breasts are regularly necessary. Capsular contracture is the leading cause for revisional surgery. The aim of this study was to evaluate indications and changes in time intervals between consecutive implant replacements with a focus on capsular contracture.

Methods

In the period from 2012 to 2017, all patients with breast implant replacements or removals at our institution were identified. From the medical file, the time of the first implantation and earlier replacements were analyzed for indication and timing of surgery.

Results

A total of 498 operations for implant replacement or removal were analyzed in 323 patients. Including prior operations, 717 procedures could be evaluated. If capsular contracture was the indication, revision surgery was performed on average 14.3 years or 8.4 years in aesthetic or reconstructive cases, respectively. In patients with more than one implant removal or replacement, we saw a reduction in the time interval between the first, second, and third follow-up operation.

Conclusions

The main indication to perform implant replacements or removals was capsular contracture recurring at increasingly shorter intervals. Patients must be informed about this possible progression when changing implants, but also before the first operation. If capsular contracture occurs after a rather short time period in reconstructive cases, the opportunity of an alternative approach (eg, autologous reconstruction) instead of a renewed implant change should be discussed with the patient.

Silicone Breast Implant Rupture is More Prevalent in the Dominant Limb Side, A Retrospective Cohort Study

BACKGROUND

Breast implant rupture is associated with multiple risk factors such as implant age, manufacturer, and a history of trauma to the breast. However, the exact mechanism of breast implant rupture remains unclear. We hypothesize that repetitive minor mechanical forces on the implant collectively play a significant role in the cascade that eventually leads to its rupture. Therefore, we expect a more significant cumulative effect on the breast implant in the dominant upper limb side. Thus, we aim to ascertain whether laterality in silicone breast implant rupture is associated with the dominant upper limb.

METHODS

A retrospective cohort study was performed on patients with silicone breast implants who underwent an elective breast implant removal or exchange. All patients had breast augmentations for cosmetic reasons. We collected data on implant rupture laterality and limb dominance together with known risk factors like patient age, implant age, implant pocket, and implant volume.

RESULTS

A total of 154 patients with unilateral implant rupture were included in the study. Among patients with a dominant right limb (n = 133), an ipsilateral rupture was found in 77 patients (58%) (p = 0.036), while in patients with a left dominant limb (n = 21), an ipsilateral rupture was found in 14 patients (67%), (p = 0.036).

CONCLUSIONS

The dominant limb was a significant risk factor for ipsilateral breast implant rupture. The prevailing theory that cyclic envelope movement carries an increased rupture risk is reinforced in this study. Extensive prospective studies are needed to clarify risk factors for implant rupture further.

Basic Strategies of Augmentation Mammoplasty in Patients with Tendencies of Pectus Excavatum and Carinatum

BACKGROUND

In this era of growing popularity of cosmetic surgeries, more women of various chest wall shapes are likely to receive augmentation mammoplasty. Pectus excavatum (PE) and pectus carinatum (PC) are the two most common chest wall deformities, and many asymptomatic patients visit the clinic. In this study, we presented various strategies for successfully performing breast augmentation in PE and PC patients without long-term complications such as symmastia.

METHODS

From January of 2019 to December of 2021, a total of 132 patients with tendencies of PE and PC received augmentation mammoplasty in our institute. We retrospectively reviewed data on demographics, surgical procedure, outcomes, and complications.

RESULTS

Among the 132 cases, 71.21% were done via inframammary approach, and 28.79% via transaxillary approach. The mean implant volume was 337.25 ± 51.46 ml, and the mean follow-up period was 16.48 ± 6.74 months. The Likert scale of outcome satisfaction scored 9.13 ± 0.48. No symmastia occurred.

CONCLUSION

We presented our basic strategies of breast surgery in patients with various chest wall anomalies. Augmentation mammoplasty can benefit PE and PC patients physically as well as psychologically, to carry out healthy positive lives.

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 .

A non-manufacturer-sponsored, retrospective study to assess 2-year safety outcomes of the BellaGel® SmoothFine as compared with its competitors in the context of the first Korean case of a medical device fraud

BACKGROUND

We conducted this study to assess preliminary 2-year safety outcomes of an implant-based augmentation mammaplasty using the BellaGel® SmoothFine in the context of the first Korean case of a medical device fraud.

METHODS

Our clinical series of the patients (n = 579; 1,158 breasts) received augmentation using the BellaGel® SmoothFine, Naturgel™, Motiva Ergonomix™, Eurosilicone Round Collection™, Natrelle® INSPIRA™, Natrelle® 410, Mentor® MemoryGel Xtra or Microthane®. The patients were evaluated for incidences of postoperative complications and Kaplan-Meier survival and hazards.

RESULTS

Overall, there were a total of 101 cases (17.4%) of postoperative complications; these include 31 cases (5.4%) of shape deformity, 21 cases (3.6%) of CC, 18 cases (3.1%) of early seroma, 8 cases (1.4%) of infection, 5 cases (0.9%) of early hematoma, 1 case (0.2%) of delayed hematoma, 1 case (0.2%) of rupture and 1 case (0.2%) of ripping. Moreover, there were also 15 cases (2.6%) of other complications. There were significant differences in incidences of postoperative complications between the breast implants from different manufacturers (P = 0.034). The Natrelle® 410 showed the longest survival (333.3±268.2 [141.5-525.1] days). A subgroup analysis showed that there were no significant differences in incidences of postoperative complications between the breast implants (P = 0.831). Moreover, the Natrelle® INSPIRA™ showed the longest survival (223.7±107.1 [-42.3-489.6] days).

CONCLUSIONS

Here, we describe preliminary 2-year safety outcomes of an implant-based augmentation mammaplasty using the BellaGel® SmoothFine in the context of the first Korean case of a medical device fraud.

Mortality Rate in Breast Implant Surgery: Is an Additional Procedure Worthwhile to Mitigate BIA-ALCL Risk?

Background

Because of poor knowledge of risks and benefits, prophylactic explantation of high BIA-ALCL risk breast implant (BI) is not indicated. Several surgical risks have been associated with BI surgery, with mortality being the most frightening. Primary aim of this study is to assess mortality rate in patients undergoing breast implant surgery for aesthetic or reconstructive indication.

Materials and Methods

In this retrospective observational cohort study, Breast Implant Surgery Mortality rate (BISM) was calculated as the perioperative mortality rate among 99,690 patients who underwent BI surgery for oncologic and non-oncologic indications. Mean age at first implant placement (A1P), implant lifespan (IL), and women’s life expectancy (WLE) were obtained from a literature review and population database.

Results

BISM rate was 0, and mean A1P was 34 years for breast augmentation, and 50 years for breast reconstruction. Regardless of indication, overall mean A1P can be presumed to be 39 years, while mean BIL was estimated as 9 years and WLE as 85 years.

Conclusion

This study first showed that the BISM risk is 0. This information, and the knowledge that BI patients will undergo one or more revisional procedures if not explantation during their lifetime, may help surgeons in the decision-making process of a pre-emptive substitution or explant in patients at high risk of BIA-ALCL. Our recommendation is that patients with existing macrotextured implants do have a relative indication for explantation and total capsulectomy. The final decision should be shared between patient and surgeon following an evaluation of benefits, surgical risks and comorbidities.

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.

Effect of Carboxymethyl Chitin on Capsule Formation around Silicone Implants: An In Vivo and In Vitro Study

BACKGROUND

Capsular contracture is a serious complication that occurs after augmentation mammaplasty. The authors previously identified that carboxymethyl chitin had an inhibitory effect on capsule formation. This study was performed to elucidate the possible molecular mechanisms through which carboxymethyl chitin inhibits the formation of a capsule around silicone implants.

METHODS

In this study, the authors cultured human dermal fibroblasts and treated them with carboxymethyl chitin in vitro. The difference in proliferation between treated and untreated cells was analyzed through the 3-(4,5-dimethylthiazol-2-yl)-2,5-diphenyltetrazolium bromide assay. Protein levels of transforming growth factor beta-1 and alpha smooth muscle actin (α-SMA) were examined by Western blot analysis. Expression levels of type I and type III collagen were checked by enzyme-linked immunosorbent assay. In vivo, silicone implants were placed under the pectoralis muscle in 12 female rabbits. The thickness of the capsule was measured by histologic analysis, and the effect of carboxymethyl chitin on α-SMA, collagen type I and III expression levels was evaluated by real-time polymerase chain reaction analysis, enzyme-linked immunosorbent assay, Western blot, and immunofluorescence analysis.

RESULTS

In the in vitro study, we confirmed that carboxymethyl chitin inhibited the proliferation of fibroblasts. The protein expression levels of collagen type I, transforming growth factor beta-1, and α-SMA were inhibited by carboxymethyl chitin treatment. In vivo, carboxymethyl chitin treatment reduced capsular thickness and the expression of α-SMA and collagen types I and III in capsules around silicone implants.

CONCLUSION

The authors' results showed that carboxymethyl chitin could influence capsule formation around silicone implants by inhibiting the fibroblast activity, interrupting fibroblast-to-myofibroblast differentiation, and decreasing collagen synthesis.

CLINICAL RELEVANCE STATEMENT

Carboxymethyl chitin influence capsule formation around silicone implants. Although more clinical studies are needed to verify the effect of carboxymethyl chitin on capsular contracture, the authors believe that it will play an effective role in the clinical application of reducing the occurrence of capsular contracture.

Is Breast Implant Associated-Anaplastic Large Cell Lymphoma linked to textured implants?

Breast Implant Associated-Anaplastic Large Cell Lymphoma (BIA-ALCL) is a distinctive type of T-cell lymphoma arising around breast implants. We performed a review of the existing literature with the aim of providing an evidence-based overview of the available data on BIA-ALCL with a standardized evaluation of the quality of the studies and investigating the potential association between textured breast implants and BIA-ALCL.We analyzed the literature reporting estimates of relative or absolute risks of BIA-ALCL in case-control, cohort studies and case series studies. The total number of BIA-ALCL cases reported in literature is very low. Furthermore, most of the reported cases have been reported in case-control studies or case series. This means that our knowledge is based on a low level of evidence. Moreover, low-medium quality scores were observed in the included case series studies. In relation to the rarity of the event, better information could only derived by international cooperation to pool together data deriving from all over the world, with the clear need of better reporting patients and implant characteristics in case series and when adding data to public registries. 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 .

Hematoma and deep surgical site infection following primary breast augmentation: A retrospective review of 1128 patients

BACKGROUND

Breast augmentation is one of the most frequently performed cosmetic surgery worldwide. Some of the most severe short-term complications after breast augmentation are hematoma and deep surgical site infection. However, these complications are relatively rare; therefore, large patient populations are required to perform statistical analyses. In this study, we provide a detailed analysis of the complications after primary breast augmentation with an emphasis on deep surgical site infection and hematoma.

METHOD

We retrospectively reviewed the medical records of women who underwent primary breast augmentation without the use of pocket irrigation between 2012 and 2019 in a single private clinic. A cumulative hazard function and a multivariate analysis on the risk of hematoma were performed.

RESULTS

We included 1128 patients in the study. Thirty patients (2.7%) developed postoperative hematoma after a median time of 14 h (IQR 5 h-9 days). Six patients (0.5%) contracted a deep surgical site infection after a median time of 14 days (range 4-41 days). Age, BMI, implant volume, or implant placement was not significantly associated with hematoma.

CONCLUSION

Our findings support that the risk of hematoma after primary breast augmentation is highest within the first 24 h after the surgery. This time period should be considered when planning postoperative care for these patients. We did not find an increased rate of deep surgical site infection compared with studies of breast augmentations with pocket irrigation. Further studies and meta-analyses are needed to explore the effect of pocket irrigation and other risk factors.

High-Resolution Ultrasound-Assisted Assessment of Preliminary Short-term Safety Outcomes of an Implant-Based Augmentation Mammaplasty Using a Bioengineered, Cell-Friendly, Smooth-Surface Device in Korean Females

BACKGROUND

The Motiva Ergonomix Round SilkSurface (Establishment Labs Holdings Inc., Alajuela, Costa Rica) is one of the representative brands of the fifth generation of a silicone gel-filled breast implant with a microtextured surface.

OBJECTIVES

In this study, the authors describe preliminary short-term safety outcomes of an implant-based augmentation mammaplasty using the Motiva Ergonomix Round SilkSurface in Korean females.

METHODS

The authors performed a retrospective analysis of medical records in a total of 69 females (n = 69) receiving an implant-based augmentation mammaplasty using the Motiva Ergonomix Round SilkSurface between September 26, 2017, and December 31, 2020. The authors analyzed incidences of postoperative complications.

RESULTS

A total of 6 cases (8.7%) of postoperative complications occurred; these include 2 cases (2.9%) of early seroma, 1 case (1.4%) of capsular contracture, 2 cases (2.9%) of alterations in the shape, and 1 case (1.4%) of foreign body sensation. Time-to-events were estimated at 266.81 ± 273.17 days.

CONCLUSIONS

The authors describe our preliminary short-term safety outcomes of an implant-based augmentation mammaplasty using the Motiva Ergonomix Round SilkSurface in Korean females. But this deserves further large-scale studies with long periods of follow-up.

LEVEL OF EVIDENCE 4

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.

Capsular Contracture in Breast Implant Surgery: Where Are We Now and Where Are We Going?

Capsular contracture is the leading complication after surgery with breast implants. A lot of progress has been made investigating this complication over the years, and knowledge has been gained on this complication. Currently, the exact cause for capsular contracture is still unclear. It has been hypothesized that immunobiological factors (i.e., immunological and bacterial factors) and several risk factors play a central role in its development. In this paper, we give an overview of the known immunological factors that have been investigated in contracted and non-contracted capsules, as well as the role of bacterial formation around breast implants. We also report on risk factors that might increase the risk of capsular development. Lastly, it provides the latest research on this matter and discusses future perspectives as follow-up research is needed to unravel the pathogenic process leading to capsular contracture. This knowledge is of interest to establish medical therapies in order to prevent such side effects. Overall, capsular contracture seems to be a multifactorial condition consisting of several risk factors. LEVEL OF EVIDENCE V: 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 .

Four-Year Interim Results of the Safety of Augmentation Mammaplasty Using the Motiva Ergonomix™ Round SilkSurface: A Multicenter, Retrospective Study

BACKGROUND

The Motiva Ergonomix™ Round SilkSurface (Establishment Labs Holdings Inc., Alajuela, Costa Rica) is the fifth generation of a silicone gel-filled breast implant that is commercially available in Korea.

OBJECTIVES

In this study, we describe 4-year interim results of the safety of augmentation mammaplasty using the Motiva Ergonomix™ Round SilkSurface in Korean women.

METHODS

In the current multicenter, retrospective study, we performed a retrospective review of medical records of a total of 1314 patients who received augmentation mammaplasty using the Motiva Ergonomix™ Round SilkSurface at our hospitals between September 1, 2016, and August 31, 2020. For safety assessment, we analyzed incidences of postoperative complications and Kaplan-Meier complication-free survival of the patients.

RESULTS

We included a total of 873 patients (1746 breasts, mean age = 32.18 ± 6.88 years) in the current study. There were a total of 111 cases (12.70%) of postoperative complications; these include 24 cases (2.70%) of early seroma, 18 cases (2.10%) of hematoma, 18 cases (2.10%) of capsular contracture, 17 cases (1.95%) of dissatisfaction with shape, 16 cases (1.83%) of dissatisfaction with size, 9 cases (1.03%) of asymmetry, 6 cases (0.70%) of infection and 3 cases (0.34%) of rippling. Moreover, time-to-events were estimated at 918.34 ± 36.22 days (95% CI 845.44-988.52).

CONCLUSIONS

Here, we describe 4-year interim results of the safety of augmentation mammaplasty using the Motiva Ergonomix™ Round SilkSurface in Korean women in a non-manufacturer-sponsored study. But further large-scale, prospective, multicenter studies with a long period of follow-up are warranted to establish our results.

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

Evaluating the Necessity of Capsulectomy in Cases of Textured Breast Implant Replacement

BACKGROUND

Capsulectomy has traditionally been recommended as a treatment for capsular contracture after breast augmentation. With the advent of breast implant-associated anaplastic large-cell lymphoma (BIA-ALCL), and the Food and Drug Administration's decision to ban Biocell textured devices, this operation has taken on new importance. This review was undertaken to better inform clinical recommendations for women with textured devices.

METHODS

An electronic search was performed using PubMed to identify all the available literature on the subject of capsulectomy and open capsulotomy (the alternative treatment).

RESULTS

Fifty-seven articles on this topic were identified. Capsulectomy was widely recommended for treatment of capsular contracture, although many authors recommended leaving thin capsular tissue behind in the absence of symptoms. En bloc resection was recommended only for women with a diagnosis of BIA-ALCL. No information supported a prophylactic role for capsulectomy in asymptomatic women with textured breast implants who are concerned regarding their future risk of BIA-ALCL. Routine pathologic examination in asymptomatic patients was not supported.

DISCUSSION

Capsulectomy adds substantially to the surgical risk, discomfort, recovery time, and expense. Implant removal or replacement without a simultaneous capsulectomy is atraumatic and poses negligible risk.

CONCLUSIONS

Capsulectomy introduces additional morbidity and is not mandatory for asymptomatic patients. Implant removal or exchange for smooth implants without a capsulectomy may be an acceptable choice for many women who do not demonstrate capsular pathology. However, any symptoms or surgical findings suggesting pathology warrant a capsulectomy. En bloc resections are reserved for patients diagnosed with BIA-ALCL.

Three-Year Intermediate Results of a Prospective Multicenter Study Investigating the use of Smooth, Semi-Smooth, Microtextured and Macrotextured Implants from a Single Manufacturer in Breast Augmentation and Reconstruction Procedures

Silicone gel-filled implants exist in a wide range of shapes and textures, and yet there are relatively few long-term large-scale studies, particularly on recently developed "semi-smooth" implants. The present study fills this gap by presenting the 3-year findings from an ongoing 10-year multicenter prospective study on breast implants with four different surface types: smooth, semi-smooth, microtextured, and macrotextured. A total of 908 patients were recruited in 15 investigational sites across Europe and divided into three groups: 653 primary augmentations in Group 1, 144 revision augmentations in Group 2, and 111 reconstructions in Group 3. All 4 types of implant shells were manufactured by the same company using the same silicone material. Surgeons were free to choose their preferred technique and implant surface, but data were collected using a standardized software and included all complications, and satisfaction levels reported by the patients at each visit. The incidence of post-operative complications was estimated based on Kaplan-Meier risk rates, on a per patient basis. At 3 years post implantation, capsular contracture (Baker grade III/IV) was the most common complication, with a per-patient risk rate of 1.5% in Group 1. Interestingly, there was no capsular contracture in this group when semi-smooth implants were used. The risk of implant rupture in Group 1 was 0.2%. The preliminary findings of this 10-year prospective study indicate that, 3 years after the operation, the four types of silicone gel-filled implants investigated were safe, with a low complication rate in comparison with the most favorable results published in other similar studies.

Capsulectomy, Implant Exchange, and Placement of Acellular Dermal Matrix Is Effective in Treating Capsular Contracture in Breast Augmentation Patients

BACKGROUND

Capsular contracture is a common complication of breast augmentation surgery and many techniques to prevent and treat it have been suggested with inconsistent or variably effective results.

OBJECTIVES

The aim of this paper was to describe a protocol for treating established capsular contracture after breast augmentation with a low recurrence rate.

METHODS

From January 2009 to December 2012, 79 previous bilateral breast augmentation patients presented for treatment of established capsular contracture. There were 135 breasts with capsular contracture: 56 were bilateral and 23 were unilateral. Ten patients opted for no treatment; 2 patients opted for implant removal. Twenty-four were treated with the ICES (implant exchange, capsulectomy, and possible exchange of site) protocol and 43 were treated with the SPICES (Strattice placement in the reconstructive position, implant exchange, capsulectomy, and possible exchange of site) protocol.

RESULTS

The 24 patients treated with the ICES protocol had a recurrent capsular contracture rate of 15%. The 43 patients treated with the SPICES protocol had a 2.7% recurrent capsular contracture incidence and an 2.7% complication rate.

CONCLUSIONS

Capsular contracture after breast augmentation, whether primary or recurrent, can be successfully treated with the SPICES protocol.

LEVEL OF EVIDENCE: 4

Simultaneous Augmentation Mammoplasty and Vacuum-Assisted Breast Biopsy for Enhanced Cosmesis and Efficacy

BACKGROUND

In this era of expanding life expectancy and popularity of aesthetic breast surgeries, more women are likely to live more years with their augmented breasts. Thus, consistent attention to general breast health is crucial, and preoperative ultrasound is helpful to locate suspicious lesions. In this study, we present a combinative procedure of augmentation mammoplasty and vacuum-assisted breast biopsy (VABB).

METHODS

From January of 2018 to December of 2019, a total of 102 patients received simultaneous augmentation mammoplasty and VABB in our institute. Only patients of primary augmentation mammoplasty who received VABB on unilateral breasts were included. We sought to investigate the results of each breast and safety of adding VABB before performing augmentation within the same incision.

RESULTS

Among 204 breasts and implants, 28.43% were done via endoscopic transaxillary approach and 71.57% via inframammary approach. The mean implant volume was 329.34 ± 44.79 ml, and the mean follow-up period was 14.23 ± 4.64 months. All of the complication rates exhibited no statistically significant differences between the two groups.

CONCLUSION

Simultaneous augmentation mammoplasty and VABB prevented unnecessary scars and pain, and the complication rates did not statistically differ from those of augmentation only group. This co-operation is a safe and simple method potentially beneficial to many women interested in breast surgery.

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 .

Short-term Safety of a Silicone Gel-filled Breast Implant: A Manufacturer-sponsored, Retrospective Study

Currently, 8 different brands of a silicone gel–filled breast implant are commercially available in Korea. But the superiority of short-term safety has not been established.

Deposition of Host Matrix Proteins on Breast Implant Surfaces Facilitates Staphylococcus Epidermidis Biofilm Formation: In Vitro Analysis

BACKGROUND

Staphylococcus epidermidis is a primary cause of breast implant-associated infection. S epidermidis possesses several virulence factors that enable it to bind both abiotic surfaces and host factors to form a biofilm. In addition S epidermidis colocalizes with matrix proteins coating explanted human breast implants.

OBJECTIVES

The authors sought to identify matrix proteins that S epidermidis may exploit to infect various breast implant surfaces in vitro.

METHODS

A combination of in vitro assays was used to characterize S epidermidis strains isolated from human breast implants to gain a better understanding of how these bacteria colonize breast implant surfaces. These included determining the (1) minimum inhibitory and bactericidal concentrations for irrigation solutions commonly used to prevent breast implant contamination; (2) expression and carriage of polysaccharide intercellular adhesin and serine-aspartate repeat proteins, which bind fibrinogen (SdrG) and collagen (SdrF), respectively; and (3) biofilm formation on varying implant surface characteristics, in different growth media, and supplemented with fibrinogen and Types I and III collagen. Scanning electron microscopy and immunofluorescence staining analyses were performed to corroborate findings from these assays.

RESULTS

Textured breast implant surfaces support greater bacterial biofilm formation at baseline, and the addition of collagen significantly increases biomass on all surfaces tested. We found that S epidermidis isolated from breast implants all encoded SdrF. Consistent with this finding, these strains had a clear affinity for Type I collagen, forming dense, highly structured biofilms in its presence.

CONCLUSIONS

The authors found that S epidermidis may utilize SdrF to interact with Type I collagen to form biofilm on breast implant surfaces.

LEVEL OF EVIDENCE: 5

The New Method of Pocket Forming for Breast Implant Placement in Augmentation Mammaplasty: Dual Plane Subfascial

Introduction:

Breast augmentation is one of the most frequently performed aesthetic surgical procedures in the world. The most important preoperative decisions which influence the final appearance of the augmented breast are the breast implant pocket choice and selection of the most appropriate implant. Described pocket locations are subglandular, subfascial, partially retropectoral, totally submuscular and dual plane.

Aim:

We have introduced a new method of pocket forming for implant placement, which is combination of Tebbett’s dual-plane 2 or 3 and Graf’s subfascial. We named it as dual plane subfascial.

Methods:

Between January 2016 and April 2018, total of 27 patients were operated using dual plane subfascial breast augmentation. The pinch test in the medial pole less than 2,0 cm and in upper pole less than 2,5 cm are indications for this technique. In our modification, in primary cases a dissected flap in front of muscle is fasciocutaneous (not cutaneous as in Tebbett’s technique). It will be finally located caudally of pectoral muscle and in front of the lower pole of implant. Fasciocutaneous flap in primary cases and two independent levels of soft tissue coverage (fascial and cutaneous) in secondary cases (subglandular to dual plane subfascial conversion) in front of the lower pole of implants provide better coverage than cutaneous flap alone.

Results:

Hematoma and infection did not occur in any patient in our study. A capsular contracture grade I/II without the need for reoperation occurred in two patients. In one patient with secondary augmentation minimal bottoming out was noticed (before reoperation patient had significant bottoming out deformity). Minimal palpability of implants is recorded in three patients.

Conclusion:

Dual plane subfascial is a good option in primary breast augmentation with a well set indication especially in the breasts with the upper pinch test less than 25 mm and medial pinch test less than 20 mm. The idea can be followed even in secondary breast augmentation (subglandular to dual plane subfascial conversion). There is additional soft tissue in front of the implant which led to a less implant palpability, especially in thin patient with smaller amount of subcutaneous fat.

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

The Tuck-in Mastopexy

BACKGROUND

Breast ptosis is an inevitable consequence of gravity and time. Every breast tends to become ptotic in different shapes and degrees. Many surgical techniques were described to solve this problematic issue. The aim of this article is to describe a mastopexy technique used for grades 1 to 2 ptosis, "tuck-in" mastopexy technique.

METHODS

Keyhole pattern was used for skin markings. All the planned skin excision areas were de-epithelialized. Breast mound was elevated as a 1-piece flap with extensive subglandular dissection. Elevated breast flap was reshaped and repositioned. Skin incisions were sutured in 2 layers.

RESULTS

Seventeen patients were operated on with this technique; average follow-up time was 10.1 months. No major complications were seen. The results were pleasing for both the patients and the surgeon.

CONCLUSIONS

The "tuck-in" mastopexy technique uses breast mound as 1-piece flap, which has great vascularity from medial, superior, and lateral pedicles. Large areas of de-epithelialization facilitate reshaping and repositioning. It permits simultaneous or secondary breast augmentation with silicone gel implants. This easy-to-do technique has low complication rates and a short learning period.

Reoperation Rate After Primary Augmentation With Smooth, Textured, High Fill, Cohesive, Round Breast Implants (RANBI-I Study)

Background

Reoperation after primary breast augmentation remains an important clinical issue.

Objective

The authors sought to evaluate incidence and causes of reoperation in patients who underwent primary augmentation.

Methods

This retrospective, noninterventional study conducted at 16 Canadian sites reviewed medical records and patient-completed questionnaires of women who underwent primary breast augmentation with smooth or textured Natrelle Inspira implants containing TruForm 1 or TruForm 2 gel. Patients were aged ≥22 years, received implants via inframammary fold incision, and returned for follow-up at 2 to 4 years.

Results

A total of 319 women received Inspira implants (smooth TruForm 2, n = 205; textured TruForm 2, n = 99; smooth or textured TruForm 1, n = 15). At follow-up, 30 women (9.4%) had undergone reoperation, including 19 (9.3%) in the smooth TruForm 2 subgroup and 9 (9.1%) in the textured TruForm 2 subgroup. The mean time to reoperation was 1.2 years; the risk rate for reoperation was 9.9% at 3 years. The most common reasons for reoperation were implant malposition (36.7%), capsular contracture (33.3%), and the patient’s request for a change in implant size or style (20.0%). Most women were very or somewhat satisfied with the initial surgery (89.3% overall; 90.7% smooth TruForm 2; 86.9% textured TruForm 2). Thirty-four women (10.7%) reported adverse events, including 20 (9.8%) in the smooth TruForm 2 subgroup and 14 (14.1%) in the textured TruForm 2 subgroup.

Conclusions

This analysis suggests that Natrelle Inspira TruForm 2 implants are safe when used in primary breast augmentation, resulting in low reoperation rates that are consistent with those for other breast implants.

Level of Evidence: 4

Plastic Surgeons Defend Textured Breast Implants at 2019 U.S. Food and Drug Administration Hearing: Why It Is Time to Reconsider

Textured breast implants were the subject of a U.S. Food and Drug Administration (FDA) hearing on March 25 and 26, 2019. Regulating agencies in other countries, including all of Europe and Canada, have already banned macrotextured implants. Patients affected by Breast Implant-Associated Anaplastic Large-Cell Lymphoma (BIA-ALCL) recounted their life-changing experiences, and requested a ban on textured devices. Plastic surgeons, many with industry ties, spoke in favor of keeping the devices available. The historical advantages of textured implants were presented, including a reduced capsular contracture rate. A 14-point plan to improve sterility at the time of implantation was promoted as an effective alternative to reduce both capsular contractures and BIA-ALCL risk. However, recent studies show that textured implants have not delivered on their early promise. Biocell implants perform worse, not better, than other implant types, and capsular contracture rates are not significantly reduced according to recent core studies. The only known risk factor for BIA-ALCL is textured implants. The lifetime risk for Biocell implants is at least 1:2, 200. There is no reliable evidence that surgical technique makes a difference in risk. This serious issue represents a case study of conflict of interest. In light of recent information, a re-analysis of the true risks and benefits of textured implants is justified. It is time for our professional societies to recognize that the device is the problem rather than surgical technique. On May 2, 2019, the FDA decided against a ban on textured breast implants.

Ten-Year Safety Data for Eurosilicone's Round and Anatomical Silicone Gel Breast Implants

Background

Although silicone breast implants have been available for over 60 years, their safety and efficacy continue to be assessed via long-term clinical and vigilance studies. Complications often associated with breast implant surgery include but are not limited to capsular contracture and rupture.

Objective

The authors investigate and evaluate the safety and performance of Eurosilicone’s (Eurosilicone S.A.S, Apt Cedex, France) Cristalline Paragel breast implants at least 10 years postimplantation.

Methods

Nine hundred and ninety-five of Eurosilicone’s textured mammary implants were implanted in 526 women undergoing primary (423 patients) and revision surgery (103 patients) at 17 centers throughout France. Complications were recorded at 3 months and annually thereafter for 10 years. Descriptive statistics were used and the Kaplan-Meier method was utilized to analyze key complications.

Results

Seventy-four women (98 implants) experienced capsular contracture across all cohorts. The Kaplan-Meier 10-year cumulative risk of capsular contracture (Baker Grade III/IV) per implant was 11.5% in the primary augmentation cohort and 25.2% in the primary reconstruction cohort. Sixteen implant ruptures were observed by surgeon examination giving a Kaplan-Meier risk of 3.8% per patient and 3.5% per implant. Surgical re-intervention (explantation/exchange) was reported 80 times resulting in a Kaplan-Meier cumulative risk of 13.3% and 31.6% for primary augmentation and primary reconstruction, respectively, per patient. Local complication rates including infection and seroma were low with risk rates of 0.6% and 0.2% by subject.

Conclusions

This multicenter clinical study demonstrates the long-term safety and efficacy profile through 10 years for Eurosilicone round and anatomical silicone gel breast implants.

Level of Evidence: 3

Six-Year Prospective Outcomes of Primary Breast Augmentation With Nano Surface Implants

Background

Motiva Implants (Establishment Labs Holdings Inc.) are a novel family of silicone breast implants using cutting-edge technologies engineered to optimize aesthetic and safety outcomes.

Objectives

The authors sought to prospectively evaluate the safety and effectiveness of SmoothSilk/SilkSurface Motiva Implants over long-term follow-up.

Methods

Surgeons at a single plastic surgery center undertook a 10-year follow-up study of SmoothSilk/SilkSurface Motiva Implants in women who underwent primary breast augmentation. Safety was assessed through identification of complications on follow-up and through magnetic resonance imaging (MRI) in a representative sample. Effectiveness outcomes were assessed by surgeons and patients using Likert scales and a Quality of Life tool.

Results

This article reports the 6-year safety and effectiveness outcomes. A total of 35 patients were implanted between September and December 2010, and 71.9% of implants were placed submuscularly using inframammary incision. During the 6-year follow-up, there were no occurrences of capsular contracture, rupture, double capsules, or late seroma. MRI evaluation identified no signs of implant-related complications. Three revision surgeries were performed, all for aesthetic reasons; there were no implant replacements for medical reasons. The level of satisfaction for both patients and surgeons was high at all follow-up visits. Patient quality-of-life scores increased following breast augmentation by an average of 0.89% at 72 months.

Conclusions

The results of this prospective long-term follow-up study demonstrate the excellent safety and effectiveness of SmoothSilk/SilkSurface Motiva Implants in primary breast augmentation through 6 years of follow-up.

Level of Evidence: 4

Clinical Results on Innovation in Breast Implant Design

Breast implants have been shadowed in controversy since their introduction to the market; however, they represent a multi-million dollar industry and play a critical role both for cosmetic augmentation and enhancement and for reconstruction following treatment for cancer. With advancements in technology, breast implants have evolved tremendously over the years. Further, with the cessation of the FDA implemented moratorium on silicone, the use of silicone implants has grown exponentially over the years. Novel designs in the outer shell, breast implant fill particularly the cohesivity of the silicone gel, texturing of the outer shell, and the shape and projection of breast implants have produced a broad array of implants that can be employed by plastic and reconstructive surgeons to maximize outcomes for patients. However, despite the innovations in breast implant design and engineering, it is unclear whether these have had any influence on outcomes and patient satisfaction. The present article aims to provide a comprehensive review of the technological advancements in breast implant technology in optimizing patient outcomes and minimizing complications associated with placement of breast implants for aesthetic as well as reconstructive procedures. The article will provide a synopsis of round versus shaped breast implants, saline versus silicone especially the advent of cohesive silicone gel implants, and the texturing of the outer shell, and how each of these components should be considered when counseling patients and deciding which implants offer the optimal benefits for each individual patient.

Sub-muscular plane for augmentation mammoplasty patients increases silicone gel implant rupture rate

BACKGROUND

Breast augmentation is one of the most common aesthetic procedures performed worldwide. One of the worst associated complications is implant rupture, a topic that will be addressed in the present study. The risk of developing silicone gel breast implant rupture following breast augmentation is associated with multiple factors, including: older generation implant, increased implant age, implant type, specific manufacturer, severe capsular contracture (Baker grade III or IV), and the presence of local symptoms. We hypothesize that the plane of the implant placement may also play a role in the development of implant rupture due to differences in opposing forces upon the implant between submuscular and subglandular planes.

OBJECTIVES

To assess the effect of potential risk factors on breast prosthesis rupture rate, focusing on implant pocket selection, capsular contracture and implant volume.

METHODS

A retrospective cohort study was performed on patients with silicone breast implants in either subglandular or submuscular plane, who underwent an elective breast implant exchange, with or without mastopexy, between January 2012 and June 2017. Data collected included patient's age, implant age, implant pocket, implant volume, capsular contracture grade, and implant status (ruptured or intact).

RESULTS

Data was collected on 362 women (700 breasts). A total of 284 women (542 breasts) met the inclusion criteria. The average age of the subjects was 43.4 ± 10.4 years. Average implant age during exchange was 10 ± 6.1. There was no difference between the characteristics of the submuscular group and the subglandular group, except from patient age. In a univariant analysis, patient's age (46.4 vs. 41.8, p < 0.001) and implant age (12.2 vs. 8.92 years, p < 0.001) were associated with significantly higher rupture rate. Among ruptured implants, the relative proportion of submuscular to subglandular implants was 64%, compared to 48% among non-ruptured implants (p < 0.0001). When controlling for potential confounders, submuscular pocket (OR = 0.1835, CI95% 1.25-2.69, p = 0.002) as well as implant size (OR = 1.004, CI95% 1.001-1.007, p = 0.005) were found to be a risk factor for implant rupture.

CONCLUSION

A sub-muscular implant pocket was identified as a significant risk factor for implant rupture. The prevailing theory that larger size implant carries an increased risk of complications, is also reinforced in this study. Large prospective studies are needed to further clarify risk factors for implant rupture.

Ten-year Core Study Data for Sientra's Food and Drug Administration-Approved Round and Shaped Breast Implants with Cohesive Silicone Gel

BACKGROUND

In March 2012, the United States Food and Drug Administration approved Sientra's application for premarket approval of its portfolio of round and shaped silicone gel breast implants based on data from the largest silicone gel breast implant study to date. This article presents the results of Sientra's Core Study at the conclusion of 10 years.

METHODS

The Sientra Core Study was a 10-year, open-label, prospective, multicenter clinical study designed to assess the safety and effectiveness of Sientra's breast implants in augmentation and reconstruction. A total of 1,788 patients (3,506 implants) were enrolled, including 1,116 primary augmentation, 363 revision-augmentation, 225 primary reconstruction, and 84 revision-reconstruction.

RESULTS

Across all cohorts, the rate of rupture by patient was 8.6%, the rate of Baker grade III/IV capsular contracture was 13.5%, and the rate of reoperation was 31.5%. The rate of capsular contracture was statistically significantly lower for textured devices [9.0%; 95% confidence interval (CI), 7.0-11.5%] compared with smooth devices (17.5%; 95% CI, 14.9-20.4%). There were no cases of breast implant-associated anaplastic large cell lymphoma. Primary reasons for reoperations included capsular contracture (18.8%), and style/size change (19.3%), with over 50% of the reoperations due to cosmetic reasons.

CONCLUSION

The 10-year results of Sientra's Core Study support a comprehensive safety and effectiveness profile of Sientra's portfolio of round and shaped breast implants.

Poly Implants Prosthèse Breast Implants: A Case Series and Review of the Literature

BACKGROUND

Silicone breast implants from the French manufacturer Poly Implants Prosthèse (PIP) were recalled from the European market after the French regulator has revealed the implants contain non-medical-grade silicone filler. In December 2011, following a large increase in reported rupture rate and a possible cancer risk, the French Ministry of Health recommended consideration of the PIP explantation, regardless of their condition. In 2012, the Israel Ministry of Health recommended to replace the implants only upon suspected implant rupture.

OBJECTIVES

The aims of this study were to characterize breast-augmented Israeli patients with PIP implants, compare their outcomes with those of breast-augmented patients with different implant types, and review the current PIP literature.

METHODS

Breast-augmented patients who underwent an elective breast implant exchange in Israel between January 2011 and January 2017 were included in the study. Data were collected from electronic and physical medical files.

RESULTS

There were 73 breast-augmented female patients with 146 PIP breast implants included in this study. Average implant age was 6.7 ± 2.79 years. Mean implant size was 342.8 ± 52.9 mL. Fourteen women (19 implants [16%]) had a high-grade capsular contracture (Baker grade 3-4). During exchange, 28 implants were found to be ruptured (19.2%).

CONCLUSIONS

Less than 10 years following breast augmentation, PIP implants demonstrated higher rupture rate compared with other implants. Our data are comparable to overall available rupture rate. Among patients with definitive rupture diagnosis, an elective implant removal should be recommended. In cases of undamaged implants, plastic surgeons should also seriously consider PIP implant explantation. When the patient does not desire to remove the implant, an annual physical examination and breast ultrasound are recommended, beginning a year after augmentation.

Risk factors for developing capsular contracture in women after breast implant surgery: A systematic review of the literature

BACKGROUND

Capsular contracture is the most frequent complication in breast augmentation or reconstruction with breast implants. The exact mechanism for this complication is not completely understood. Yet, it is most likely to be a multifactorial condition. Several patient-, surgery-, and implant-specific risk factors have been related to cause capsular contracture. This review aims to provide a clear overview of all risk factors for capsular contracture.

METHODS

A systematic literature review was performed focusing on patient-, surgery-, and/or implant-related factors related to capsular contracture in breast implants. PubMed, Embase, and Wiley/Cochrane Library databases were searched for relevant articles published from inception up to October 20, 2016. The included studies were assessed for the following main variables: study characteristics, patient characteristics, indication for surgery, type of surgery, implant characteristics, and other characteristics.

RESULTS

Data on the risk factors for the development of capsular contracture were retrieved from 40 studies. A presumptive increased risk in the development of capsular contracture is shown for the following variables: longer duration of follow-up, breast reconstructive surgery in patients with a history of breast cancer, subglandular implant placement, postoperative hematoma, and a textured implant surface. There is little, weak, or no evidence for the association of other factors with capsular contracture. This review also shows a large heterogeneity between studies and within the definition of capsular contracture.

CONCLUSION

This review provides an overview of the relationship between patient-, surgery-, and implant-specific risk factors in the development of capsular contracture.

Preliminary 3-Year Evaluation of Experience With SilkSurface and VelvetSurface Motiva Silicone Breast Implants: A Single-Center Experience With 5813 Consecutive Breast Augmentation Cases

Background

Silicone breast implants have been in use for breast augmentation for more than 50 years, but technological innovation has been lacking in implant design until recently.

Objectives

This study was designed to evaluate the complication and reoperation rates following breast augmentation utilizing the Motiva silicone breast implants.

Methods

This retrospective study evaluated the safety of Motiva implants in 5813 consecutive cases of breast augmentation. Implants with two different textured surfaces were evaluated: SilkSurface (nanotextured) and VelvetSurface (micro-textured).

Results

Implants were placed between April 2013 and April 2016. A total of 44 complications were reported, with an overall complication rate of 0.76%, and the rate of reoperation was 0.76% over an interval of 3 years. There were no late complications and no cases of primary capsular contracture. No differences in complication rates were observed because of the implant date. However, among patients who received implants 300 to 499 cc in volume, complication rates were significantly lower with SilkSurface compared with VelvetSurface implants. Advanced statistical analysis supported the validity of the low complication rate reported in this study.

Conclusions

Overall, these findings suggest that Motiva silicone breast implants are associated with very low rates of complication and reoperation, and that the nano-textured SilkSurface implant is associated with fewer complications than micro-textured implants.

Level of Evidence: 3

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.

Eight-Year Safety Data for Round and Anatomical Silicone Gel Breast Implants

BACKGROUND

The safety and efficacy of all medical devices, including breast implants, is important and consistent performance is best shown by undertaking long-term clinical and vigilance studies. Local complications such as capsular contracture and rupture are risks often associated with breast implant surgery.

OBJECTIVES

The authors investigate and evaluate the safety and performance of Eurosilicone's (Eurosilicone S.A.S, Apt Cedex, France) Cristalline Paragel breast implants at 8 years postimplantation.

METHODS

In this prospective clinical study, 995 Eurosilicone textured cohesive Cristalline Paragel mammary implants were implanted in 526 women undergoing augmentation and reconstructive surgery at 17 centers across France. Complications were recorded at 3 months and annually thereafter for 8 years. Descriptive statistics were used and key complications were analysed using the Kaplan-Meier method.

RESULTS

Capsular contracture was reported in 8.5% of implants across all cohorts through 8 years. The Kaplan-Meier risk of capsular contracture (Baker Grade III/IV) per implant was 8.4% in the primary augmentation cohort and 18.0% in the primary reconstruction cohort. Eight implant ruptures were identified by surgeon examination during this follow-up period. The Kaplan-Meier risk of rupture occurring within 8 years postimplantation, across all cohorts, was 1.4% per patient and 0.9% per implant. Actual implant removal rate (explantation/exchange) was 6.0% and 13.8% for primary augmentation and primary reconstruction, respectively. Actual rates of local complications including infection and seroma were low with risk rates of 0.6% and 0.2% by subject.

CONCLUSIONS

This multicenter clinical study involving Eurosilicone's silicone gel breast implants in both round and shaped profiles demonstrates an excellent safety and efficacy profile through 8 years.

Capsular Contracture Rate After Breast Augmentation with Periareolar Versus Other Two (Inframammary and Transaxillary) Incisions: A Meta-Analysis

BACKGROUND

Capsular contracture has been the most common complication of cosmetic breast augmentation. The effect of incision pattern on capsular contracture is still unclear. This meta-analysis demonstrates current evidence with regard to the comparison of capsular contracture rate between periareolar and other two (transaxillary and inframammary) incisions.

METHODS

PubMed, EMBASE, and Cochrane databases were searched up to January 2017. The results of selected studies were meta-analyzed to obtain a pooled odds ratio of the effect of periareolar versus other two incision patterns (transaxillary or inframammary incision) of breast augmentation on capsular contracture rates. In addition, subgroup analyses were performed on periareolar versus transaxillary groups and periareolar versus inframammary groups with regard to capsular contracture rate.

RESULTS

Seven comparative studies were selected and meta-analyzed. Five of the seven studies reported a higher rate of capsular contracture on patients with periareolar incisions. The results showed a significantly higher rate of capsular contracture with periareolar incisions compared with other two incisions (OR, 1.83; 95% CI, 1.06-3.15, p = 0.03). Subgroup results showed no significant difference of capsular contracture between periareolar incisions and transaxillary incisions (OR, 0.94; 95% CI, 0.52-1.64, p = 0.79) and showed a significantly higher rate of capsular contracture in periareolar incisions compared to inframammary incisions (OR, 1.91; 95% CI, 1.06-3.43, p = 0.03).

CONCLUSION

The results of this meta-analysis demonstrate the contributing effects of periareolar breast augmentation on the rate of capsular contracture. However, more studies with longer tracking periods and higher quality should be conducted to further verify this conclusion.

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 .

Low rate of capsular contracture in a series of 214 consecutive primary and revision breast augmentations using microtextured implants

Capsular contracture is the most common major complication after implant-based breast augmentation. The aetiology of capsular contracture is multifactorial. The author reports a retrospective personal series of patients managed over a seven-year period with a nearly unchanged surgical strategy implementing most of known measures for capsular contracture prevention. A microtextured silicone gel-filled implant from a single manufacturer was used in all cases.

There were 214 consecutive patients (126 primary augmentations and 88 revision augmentations) operated on over the study period. Mean age of the population was 40.0 years, and mean BMI was 22.0 kg/m². Of the patients in the revision cohort, 44.3% were reoperated on because of previous capsular contracture.

Average follow-up was 20.2 months. There was a 0% capsular contracture rate in the primary augmentation cohort and a 3.4% capsular contracture rate in the revision cohort. At last follow-up, 91.2% of breasts received a Baker I grading.

Although the follow-up was relatively short, this rate of capsular contracture would still be considered very low. Determining the reason for such a low rate of capsular contracture on Multivariate Analyses would be difficult due to the potential myriad of confounding variables. However, given the constancy of the technique and implant type employed by a single surgeon, the author is of the opinion that the microtexturing topography on the implant surfaceused in this series contributed to the low rate of capsular contracture formation. However, this would need to be tested in arandomized controlled trial comparing microtextured devices with implants that have macrotextured surfaces.

Long-Term Safety of Textured and Smooth Breast Implants

In this review, the authors provide a 20-year review and comparison of implant options and describe the evolution of breast implant surface textures; compare available implant surfaces; present long-term safety data from the 10-year US-based Core clinical studies; list the key benefits and risks associated with smooth and textured implants; and provide perspectives on breast implant-associated anaplastic large cell lymphoma (BIA-ALCL). The authors explore the key benefits and risks associated with all available devices so that optimal and safe patient outcomes can be achieved.

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.