Expert Consensus on the Use of a New Bioengineered, Cell-Friendly, Smooth Surface Breast Implant

The Study of the Safety and Effectiveness of Motiva SmoothSilk Silicone Gel-Filled Breast Implants in Patients Undergoing Primary and Revisional Breast Augmentation: Three-Year Clinical Data

BACKGROUND

Silicone breast implant design has evolved over the last 50 years. Regulatory bodies including the FDA require data to support the modifications designed to improve the safety, efficacy, longevity, and biocompatibility of breast implants.

OBJECTIVES

The authors reviewed the 3-year data on the safety and effectiveness of Motiva (Establishment Labs Holdings, Inc., Alajuela, Costa Rica) SmoothSilk silicone gel-filled breast implants submitted to the FDA. The current submitted data include the primary breast augmentation and revisional augmentation cohorts.

METHODS

The Motiva IDE is a prospective, single-arm, multicenter, 10-year pivotal study in which data are collected on breast augmentation, reconstruction, and revisional surgery. Three-year data were submitted to the FDA on adverse events, reoperations, patient and physician satisfaction, connective tissue diseases, and quality of life validated instruments. A subset of the patients underwent annual magnetic resonance imaging (MRI) at years 1, 2, and 3 to screen for implant rupture.

RESULTS

A total of 451 patients were implanted in the primary augmentation cohort and 109 patients in the revisional augmentation cohort. There were 218 patients enrolled in the MRI cohort. Reported rates for reoperation for any reason were 6.1% in the primary augmentation cohort (92.4% follow-up) and 25.8% in the revisional augmentation cohort (88.7% follow-up).

DISCUSSION

Motiva implants were first introduced in 2010. The 3-year Motiva data suggests that the leading cause of revisional surgery has shifted from capsular contracture and rupture to more subjective indications for reoperation such as malposition and size change.

CONCLUSIONS

Three-year data from the primary augmentation and revisional augmentation cohorts submitted to the FDA demonstrate the safety and efficacy of the Motiva implants. There were low complication rates for implant-related complications and high surgeon and patient satisfaction.

LEVEL OF EVIDENCE: 2

Outcome analysis and assessment of the lower pole expansion following breast augmentation with ergonomic implants: Optimizing results with patient selection based on 5-year data

BACKGROUND

Silicone implants have gone through adaptations to improve esthetic outcomes. With the progress of technology, including gel rheology, different properties have been introduced. Ergonomic style implants (ESI) feature enhanced rheological properties and provide a shaped contour with a round base.

OBJECTIVES

This study investigated outcomes for ESI in breast augmentation concerning lower pole stretching (LPS) and implant stability and describes an algorithm to assist in decision-making.

METHODS

A total of 148 patients (296 breasts) underwent breast augmentation with ESI; this procedure was indicated in patients with good skin quality and <6 cm between the nipple-areola complex and the inframammary fold.

RESULTS

The mean patient age was 29.6 years (range: 19-39), and 93 patients (62.8%) underwent primary breast augmentation with demi/full projection (average volume of 245 cc [175-375 cc]). Axillary incision and subfascial pocket were indicated in 115 (77.7%) and 72 (48%) cases, respectively. Average LPS values were 32.2% (24.91 mm) and 10.86% (9.42 mm) at up to 10 days and 10 days to 12 months postprocedure, respectively. Patients were followed for a mean of 29.9 ± 26.4 months (range: 6-66). Complication rates per breast and per patient were 5% and 10%, respectively, and included subcutaneous banding in the axilla (1.6%), implant displacement (1.2%), and wound dehiscence (0.8%). No cases of infection, seroma, or rippling complications were observed.

CONCLUSIONS

The present decision-making algorithm summarizes the process involved in breast augmentation using ESI and is intended to help standardize decisions. With correct planning, long-lasting outcomes can be achieved due to favorable interactions between ESI and the patient's tissues.

Assessing the Efficacy of the S-PECS Block in Breast Augmentation Surgery: A Randomized, Double-Blind, Controlled Trial

BACKGROUND

Postoperative acute and chronic pain following breast surgery is a common complication that needs resolving to allow for improved patient outcomes. Previously, thoracic epidurals and paravertebral blocks have been the accepted standard administered intraoperatively. However, more recently the introduction of the pectoral nerve block (PECS and PECS-2 blocks) has appeared promising to control the pain more effectively, but further robust analysis is required to prove its efficacy. The authors aim to study the efficacy of a new block, S-PECS, that combines a serratus anterior and a PECS-2 block.

METHODS

In this study, the authors performed a single-center, randomized, controlled, double-blind group trial in 30 female patients undergoing breast augmentation surgery with silicone breast implants and the S-PECS block. Divided into two groups of 15, the PECS group received local anesthetics and the no-PECS control group received a saline injection. All participants were followed up at recovery and at 4, 6, and 12 hours postoperatively.

RESULTS

The authors' results showed that the pain score in the PECS group was significantly less than in the no-PECS group across all time points: recovery, and at 4, 6, and 12 hours. Furthermore, the patients who received the S-PEC block were 74% less likely to request pain medications compared with the no-PECS group ( P < 0.05).

CONCLUSION

Overall, the modified S-PECS block is an effective, efficient, and safe method of controlling pain in patients undergoing breast augmentation surgery, with additional applications yet to be explored.

Reoperative Transaxillary Subfascial Breast Augmentation and Fat Grafting: Technical Highlights and a Step-by-Step Video Guide

SUMMARY

Reoperative procedures after breast augmentation are frequently more complex than primary cases because of local complications and insufficient soft-tissue coverage. Although the transaxillary incision is often indicated in primary breast augmentation, limitations of this approach include secondary surgery and correcting complications after using this approach via the same incision. Combining the transaxillary technique with a subfascial pocket has been suggested to avoid breast scarring and the limitations of submuscular pockets represented by breast animation. With advances in autogenous fat grafting (AFG) techniques, implant coverage alternatives and more natural outcomes have been reported from more superficial implant pockets. Simultaneous AFG with silicone implants (defined as hybrid breast augmentation) has been evaluated recently as an attractive procedure. These two techniques combine to provide breast projection and natural cleavage while camouflaging implant edges. AFG is also important to reduce the intermammary distance and achieve a smoother transition between the breasts. The transaxillary approach can be useful in reoperative breast augmentation and avoids additional scarring on the breast. This article and the accompanying videos provide a detailed, step-by-step guide to reoperative hybrid breast augmentation using a subfascial transaxillary approach, with a predictable and optimized surgical outcome.

Imaging of the Reconstructed Breast

The incidence of breast cancer and, therefore, the need for breast reconstruction are expected to increase. The many reconstructive options available and the changing aspects of the field make this a complex area of plastic surgery, requiring knowledge and expertise. Two major types of breast reconstruction can be distinguished: breast implants and autologous flaps. Both present advantages and disadvantages. Autologous fat grafting is also commonly used. MRI is the modality of choice for evaluating breast reconstruction. Knowledge of the type of reconstruction is preferable to provide the maximum amount of pertinent information and avoid false positives. Early complications include seroma, hematoma, and infection. Late complications depend on the type of reconstruction. Implant rupture and implant capsular contracture are frequently encountered. Depending on the implant type, specific MRI signs can be depicted. In the case of myocutaneous flap, fat necrosis, fibrosis, and vascular compromise represent the most common complications. Late cancer recurrence is much less common. Rarely reported late complications include breast-implant-associated large cell anaplastic lymphoma (BIA-ALCL) and, recently described and even rarer, breast-implant-associated squamous cell carcinoma (BIA-SCC). In this review article, the various types of breast reconstruction will be presented, with emphasis on pertinent imaging findings and complications.

Predicting the expansion of the lower pole of the breast following smooth breast implant augmentation: A novel shear wave elastography study

OBJECTIVES

This study aimed to educate and demonstrate how the use of shear wave elastography (SWE) can be used to determine the elasticity of patient tissues preoperatively, which can then be used to predict the level of lower pole expansion postoperatively, following breast augmentation surgery.

MATERIALS AND METHODS

This study evaluated 60 breasts in 30 patients that were divided in 3 equal groups (n = 20) according to their predefined elastography criteria measured via SWE (loose, moderate, and tight tissue elasticity). All measurements were taken under maximum stretch between the inferior border of the nipple alveolar complex (NAC) and inframammary fold (IMF) using a measuring tape in millimetres (mm). The follow-up appointments for routine assessments and measurements were done at 3, 6, 12, 18, and 24 months.

RESULTS

The study engaged 38 patients over 4 years, but only 10 patients in each group attended all the appointments. Statistical analysis showed the elastic skin types (loose, moderate, and tight) had significantly different rates of lower pole expansion, and the rate of expansion increased significantly after 6 months postoperatively, whereas prior to 6 months, the rates were comparable (p < 0.05).

DISCUSSION

The results showed that increasingly elastic skin types have a greater rate of lower pole expansion. This is important for the operating surgeon to be aware of as looser skin types will be more prone to lower pole expansion, and thus, a higher surgical IMF suture may be advised to manage patient expectations.

CONCLUSION

This study can be used as a guideline for surgeons, which will allow for a more predictable surgical planning system that will ultimately lead to fewer revisions and risks for patients worldwide.

Feasibility of Imaging Modalities Combined with a Silicone Gel-Filled Breast Implant in Korean Women

With the occurrence of breast implant crises in Korea, it has become increasingly important to detect complications earlier in patients receiving a device. We have therefore combined imaging modalities with an implant-based augmentation mammaplasty. In this study, we assessed the short-term treatment outcomes and safety of the Motiva ErgonomixTM Round SilkSurface (Establishment Labs Holdings Inc., Alajuela, Costa Rica) in Korean women. A total of 87 women (n = 87) were included in the current study. We compared preoperative anthropometric measurements between the right side and the left side of the breast. Moreover, we also compared the thickness of the skin, subcutaneous tissue and the pectoralis major measured on a breast ultrasound preoperatively and 3 months postoperatively. Furthermore, we analyzed the incidences of postoperative complications and the cumulative complication-free survival. Preoperatively, there was a significant difference in the distance from the nipple to the midline between the left and right side of the breast (p = 0.000). Both sides of the breast showed significant differences in the thickness of the pectoralis major preoperatively and 3 months postoperatively (p = 0.000). A total of 11 cases (12.6%) of postoperative complications occurred; these included five cases (5.7%) of early seroma, two cases (2.3%) of infection, two cases (2.3%) of rippling, one case (1.1%) of hematoma and one case (1.1%) of capsular contracture. Time-to-events were estimated at 386.68 ± 27.79 days (95% CI 334.11-439.27). Here, we describe our experience with imaging modalities in combination with the Motiva ErgonomixTM Round SilkSurface in Korean women.

Complication Rates after Breast Surgery with the Motiva Smooth Silk Surface Silicone Gel Implants-A Systematic Review and Meta-Analysis

BACKGROUND

In an era where textured devices are being phased out due to concerns about BIA-ALCL, the Motiva SilkSurface breast implants intend to alleviate historical prosthesis-related complications. However, its safety and feasibility remain unelucidated.

METHODS

An analysis of Pubmed, Web of Science, Ovid, and Embase databases was performed. A total of 114 studies were identified initially, and 13 of these met the inclusion criteria and were assessed regarding postoperative parameters such as complication rate or follow-up period.

RESULTS

In 4784 patients who underwent breast augmentation with Motiva SilkSurface breast implants, a total of 250 (5.2%) complications were observed. Short- and medium-term complication rates ranged from 2.8-14.4% and 0.32-16.67%, respectively. The most common complication was early seroma (n = 52, overall incidence = 1.08%), followed by early hematoma (n = 28, overall incidence = 0.54%). The incidence of capsule contracture was 0.54% and breast implant-associated-anaplastic large cell lymphoma was not observed.

DISCUSSION

Although the majority of the studies in the current literature suggest the distinction of the Motiva SilkSurface breast implants in terms of postoperative complications and capsular contracture, its safety and feasibility need to be further elucidated with well-designed, large-scale, multicenter, prospective case-control studies. Other: No funding was received.

Six-Year Evaluation of Motiva Round and Ergonomix SmoothSilk Surface Silicone Breast Implants: A Two-Center, Two-Surgeon Outcome Analysis of 1053 Primary and Secondary Breast Augmentations and Augmentation Mastopexy

BACKGROUND

The emerging concerns around breast implant-associated anaplastic large cell lymphoma and other chronic inflammatory-related conditions have instigated a wider use of smooth devices.

OBJECTIVES

The authors aimed to present 6-year data following the introduction of Motiva implants (Establishment Labs Holdings Inc.; Alajuela, Costa Rica) into their previously texture-dominated practice. Additionally, the authors aimed to provide technical recommendations on how to efficiently incorporate these devices into surgical practice and minimize the learning curve.

METHODS

Data of 1053 primary and secondary breast augmentations conducted between April 2015 and December 2020 in 2 centers (Victoriakliniken in Sweden and the European Institute of Plastic Surgery in Cyprus) were retrospectively evaluated to obtain data on chosen implant characteristics and complications that led to reoperation, prior to and following modifications to surgical practice in 2018.

RESULTS

The data from 6 consecutive years demonstrate a low device-related complication rate with Motiva implants. In 2018, following adaptions in surgical practice, the complication rate significantly declined.

CONCLUSIONS

Motiva implants demonstrate a low complication rate and safety profile for women undergoing primary and secondary breast augmentation procedures. However, to reap the benefits of the antifibrotic profile, technical adaptions and optimal patient planning based on the patient and device characteristics are instrumental. Employing the key principles laid out in this study provides a means for delivering both clinically safe options to patients with aesthetically pleasing long-term results.

LEVEL OF EVIDENCE: 4

Breast Surgery with Smooth Anatomical Implants with Fixation System: A Review of the World's Largest Series of Cases

BACKGROUND

Anatomical implants continue to be a particularly useful tool in breast surgery, offering an excellent result for certain indications. However, to ensure fixation and prevent rotation, traditional alternatives have medium to high surface roughness and have been controversial in recent years.

METHODS

A retrospective assessment of 122 prosthetic augmentation and reconstruction patients over a period of 5 years was conducted. Patients were treated with tabbed anatomical implants with a smooth surface and followed up for a period of 12 months. Demographics, complications, and patient satisfaction were captured. A subgroup of 101 patients were assessed with chest radiographs at 1-year follow-up. Technical recommendations are discussed.

RESULTS

Primary breast augmentation, revision augmentation, augmentation-mastopexy, and breast reconstruction were the main indications for surgery. All implants were inserted through an inframammary incision and placed in the subpectoral space using dual-plane techniques, except in one mastectomy case. Rotation of the implants was radiographically observed in only two cases of revision augmentation. None of the 122 patients developed capsular contracture, seroma, rupture, infection, hematoma, or malposition following breast surgery.

CONCLUSIONS

Smooth anatomical implants with a fixation system offer reliable and satisfactory results for patients with various diagnoses and indications. The tab system and the fixation technique are essential to provide long-term stability, which was verified by radiographs because of the radiopaque lines present in the device for that purpose.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Therapeutic, IV.

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.

Efficacy of a 4-Week Nurse-Led Exercise Rehabilitation Program in Improving the Quality of Life in Women Receiving a Post-Mastectomy Reconstruction Using the Motiva ErgonomixTM Round SilkSurface

We assessed the efficacy of a 4-week nurse-led exercise rehabilitation (ER) program in improving the quality of life (QOL) of breast cancer survivors (BCS) receiving an implant-based breast reconstruction. The eligible patients were equally randomized to either of both groups: the intervention group (n = 30; a 4-week nurse-led ER program) and the control group (n = 30; a 4-week physical therapist-supervised one). Both after a 4-week ER program and at baseline, the patients were evaluated for the European Organization for Research and Treatment of Cancer Quality of Life Questionnaire Core 30 (EORTC QLQ-C30) and Fatigue Severity Scale (FSS) scores. There was a significantly higher degree of increase in global health status/QOL scores, physical functioning scores, role functioning scores, and emotional functioning scores at 4 weeks from baseline in the intervention group as compared with the control group (p = 0.001). However, there was a significantly higher degree of decrease in fatigue scores, nausea/vomiting scores, pain scores, dyspnea scores, and FSS scores in the intervention group as compared with the control group (p = 0.001). In conclusion, our results indicate that a 4-week nurse-led ER program might be effective in the QOL in BCS receiving a post-mastectomy implant-based reconstruction using the Motiva Ergonomix^TM Round SilkSurface.

Hybrid breast augmentation: our surgical approach and formula for preoperative assessment of fat graft volume

Background

Autogenous fat grafting (AFG) is a well-known procedure utilized in addition to breast augmentation (BA) to improve breast appearance. Plastic surgeons usually estimate the ideal AFG volume relying on their personal experience based on similar previous cases: inaccurate predictions could result in incorrect evaluation of donor sites and even needless fat transfer. The purpose of this paper is to describe and prove the validity of our surgical technique and provide a simple and easy-to-use mathematical formula to assess the adequate proportion, between the volume of the implants and of the AFG, in order to obtain a natural shape and a proper volume in BA.

Methods

One hundred and twenty-two patients (244 breasts) were subjected to primary/secondary hybrid BA (HBA). A formula was utilized to assess the volume of fat graft. Data about their age, body mass index (BMI), incision and implants were collected. Follow-up for analysis was fixed at less than 15 days, 1, 3, 6 and 12 months for analysis. Preoperative photographs were compared with postoperative at 12 months. Pre and postoperative Breast-Q^© were administered to every patient. A statistical analysis was performed comparing Breast-Q^© preoperative means with postoperative ones through t-student test. We globally defined the patients as follows: "very dissatisfied" if total score 0-25; "somewhat dissatisfied", score 26-50; "somewhat satisfied", score 51-75; "very satisfied", score 76-100.

Results

All patients received Ergonomix-style Motiva Smooth/SilkSurface with low/high projection (range, 120-225 mL, mean 170 mL) and an average AFG volume of 600 mL (range, 480-720 mL). Breast-Q^© analysis showed a statistically significant difference between preoperative and postoperative modules; 122 (100%) patients were "very satisfied". Thirteen cases of complications presented in 12 patients (10.65%): 5 hypertrophic scarring (4.09%), 3 wound dehiscence (2.46%), 3 hematomas (2.46%), 1 seroma (0.82%), 1 fat necrosis (0.82%).

Conclusions

Our surgical technique proves low complication rate and short recovery times. Our mathematical formula to calculate the AFG seems to be both predictive and a precise guide for surgical decision-making in planning the treatment of patients candidated for HBA. In fact, the analysis of Breast-Q^© questionnaires shows a high grade of satisfaction among patients. Further investigations should be performed in order to study a wider population and different type of implants.

HISTORY OF BREAST IMPLANTS: BACK TO THE FUTURE

Modern breast implants are a staple of plastic surgery, finding uses in esthetic and reconstructive procedures. Their history began in the 1960s, with the first generation of smooth devices with thick silicone elastomer, thick silicone gel, and Dacron patches on the back. They presented hard consistency, high capsular contracture rates and the patches increased the risk of rupture. In the same decade, polyurethane coating of implants was implemented. A second generation was introduced in the 1970s with a thinner shell, less viscous gel filler and no patches, but increased silicone bleed-through and rupture rates. The third generation, in the early 1980s, featured implants with a thicker multilayered elastomer shell reinforced with silica to reduce rupture risk and prevent silicone bleed-through. A fourth generation from the late 1980s combined thick outer elastomer shells, more cohesive gel filler, and implemented for the first-time outer shell texturing. In the early 1990s, the fifth generation of devices pioneered an anatomical shape with highly cohesive form-stable gel filler and a rough outer shell surface. Surface texturing was hampered by the discovery of Breast Implant Associated-Anaplastic Large Cell Lymphoma and its link with textured devices. From the 2010s, we have the era of the sixth generation of implants, featuring innovations regarding the surface, with biomimetic surfaces, more resistant shells and variations in gel consistency. The road to innovation comprises setbacks such as the FDA moratorium in 1992, the PIP scandal, the Silimed CE mark temporary suspension and the FDA-requested voluntary recall of the Allergan BIOCELL implants.

Reoperative Augmentation Mammoplasty: An Algorithm to Optimize Soft-Tissue Support, Pocket Control, and Smooth Implant Stability with Composite Reverse Inferior Muscle Sling (CRIMS) and its Technical Variations

BACKGROUND

Reoperative augmentation mammoplasty (RAM) is a challenging procedure, with the highest rates of complications and revision. Complications include implant malposition, lateral displacement, bottoming out, and rotation. These deformities can be addressed with various procedures, but the pocket control and stability of the new smooth implant surface may present limitations.

OBJECTIVES

This study revisits a previously described predictable approach in primary breast augmentation and defines a surgical treatment algorithm for RAM technique selection.

METHODS

Between 2017 and 2021, 72 patients (144 breasts) underwent RAM with composite reverse inferior muscle sling (CRIMS) technique and its technical variations (types I-IV). CRIMS technique involves placing a silicone gel implant into the submuscular (SM) pocket with an inferior sling of the pectoralis major muscle based on the dimensions of the implant, in combination with support points/dermal bridge sutures to stabilize the implant and glandular tissue at the lower breast pole (LBP). Reasons for surgery were ptosis (92%), implant and malposition (59.6%). Patients were followed for at least 6 months in 5 cases (6.9%), at least 12 months in 50 cases (69.4%), for at least 36 months in 10 cases (13.8%), and more than 36 months in 7 cases (9.7%) (mean 34 months; range 6-48 months). Patients were evaluated in terms of resolution of symptoms, satisfaction, and complications. Three-dimensional imaging (3DI) obtained from the Divina scanner system was used and followed up for 1 year to evaluate breast position, lower pole stretch (LPS), and intermammary distance (IMD).

RESULTS

Eleven cases of minor complications were observed in 9 patients (12.5%): hypertrophic scarring in 4 (5.5%), wound dehiscence in 4 (5.5%), Baker II/III capsular contracture in 1 (1.3%). SmoothSilk surface silicone implants were used in all cases, with an average volume decrease of 120 cc. Sixty-eight patients (94.4%) were either very satisfied/satisfied with their aesthetic result. Breast images were performed in a group of 65 patients (90.2%), and in 7 breasts (10.7%), localized oil cysts were observed. The value for LPS was 7.87% (p <0.0001) between 10 days and 1 year, with the majority occurring early in the first 3 months, indicating that the LBP/implant remains steady during the last months of follow-up. No cases of fat necrosis/seroma were observed. There were no signs of intra/extracapsular ruptures, capsular contracture. There were 2 cases (3%) of minimal implant displacement and no cases of rotation.

CONCLUSIONS

CRIMS and its variations can be performed successfully in RAM. An algorithmic approach can facilitate the pre- and intraoperative decision-making process and provide the new pocket control and implant stability with acceptable complication rates. Further accurate evaluation is recommended to understand the benefits or disadvantages of CRIMS compared to other RAM techniques.

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 .

Clinical and MRI Evaluation of Silicone Gel Implants with RFID-M Traceability System: A Prospective Controlled Cohort Study Related to Safety and Image Quality in MRI Follow-Up

BACKGROUND

SmoothSilk implants (SSI) are the first generation of implants to incorporate a radio-frequency identification device (RFID-M), a non-invasive traceability system. Although the RFID-M is considered compatible with magnetic resonance imaging (MRI), the size of the artifact and its influence on breast tissue vary. This prospective study assessed safety and MRI issues in a cohort of breast reconstruction patients.

METHODS

Forty-four SSI were used for breast reconstruction in patients undergoing treatment for breast cancer. All patients were evaluated for magnetic field interactions, MRI-related heating and artifacts in a 1.5-T MRI unit using standard T1/T2-weighted sequences utilized in clinical assessment of breast tissue/implants.

RESULTS

Mean patient age was 41.5 years (27-53ys) and body mass index was 28+-6.44 kg/m². In 18/22 patients (81.8%), mastectomies were unilateral. No patients reported local heat/discomfort. All implants showed RFID-M-related artifacts with an estimated mean volume in T1 of 42.9cm³ (26.2-63.6cm³; SD±8.6 and 95% CI, 40.37-45.45) and in T2 of 60.5cm³ (35.4-97.2cm³; SD±14.7 and 95% CI, 56.29-65.01). Artifact volume was smaller in T1 than in T2, to a statistically significant degree (p <0.001). There were no statistically significant differences in artifact volume according to surgical indication, breast side or implant volume. There were 4/44 (9%) cases of minor rotation (<45°). In all cases, adequate analysis of the breast tissue was performed.

CONCLUSIONS

The results demonstrate that SSI with RFID-M technology presented an artifact volume of 42.9cm³ and 60.5cm³ in T1 and T2 images, respectively. Our findings provide detailed information on the quality and location of MRI artifacts in a reconstructed cohort which can help guide clinical decision-making for patients. To our knowledge, this is the first time RFID-M breast implants have been prospectively evaluated for clinical and MRI issues in a cohort of reconstructive patients.

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 .

Optimizing Surgical Outcomes with Small-Volume Silicone Implants Associated with Autogenous Fat Grafting in Primary and Revision Breast Augmentation Surgery: Soft Weight Hybrid (SWEH) Concept

BACKGROUND

Simultaneous association of autologous fat grafting (AFG) with silicone implants, defined as a hybrid procedure, has been proposed for breast augmentation (BA). In some patients, larger-volume implants may result in larger incisions, with long-term effects including implant palpability, soft tissue atrophy, and secondary ptosis. Some patients do not want large volume implants, or have insufficient soft tissue coverage. Recent improvements in AFG have led to new surgical options in BA for addressing these cases.

OBJECTIVES

This study combines AFG in BA using small-volume implants, known as the SWEH (soft weight hybrid) approach, and evaluates aesthetic advantages and outcomes following primary/secondary BA.

METHODS

25 patients (50 breasts) underwent SWEH procedures; this approach was indicated when the overlying tissue was insufficient to adequately cover the implant and patients refused large-volume implants. Three-dimensional images were obtained using a Divina 3D scanner system (AX3 Technologies, Miami, USA) to assess breast volume (BV) and intermammary distance (IMD) during follow-up.

RESULTS

Mean patient age was 29.3 years (range: 21-42) and mean body mass index was 19.3 kg/m² (15.3-27.2). The most common implant (SmoothSilk surface Round/Ergonomix style) volume was 180 cc (175-215), and patients received a mean volume of 125 cc of fat (89-168)/breast in the subcutaneous tissue. Preoperative average BV measurements were 236.85 cc (170-335). At 3 and 12 months post-procedure, the average BV values were 488.82 and 478.73cc, respectively (p=0.475). The average preoperative IMD was 31.76 mm (range, 22-43); at 3 and 12 months post-procedure, the average IMD was 20.47 and 20.94 mm, respectively (p=0.61). Postoperative complications included subcutaneous banding in the axilla (n = 1; 4%) and hypertrophic scarring (n = 1; 4%). Breast imaging exams were performed; in 2 breasts (8%) localized oil cysts were observed; no cases of suspicious calcifications, fat necrosis, or lumps were seen. Fat retention rate (1 year) was calculated by the difference between the BV expected with 100% fat intake and the real BV observed. In our sample we observed an average of 72.7 (range: 69.2-77.3, SD: 2.63) and 76.7 (range: 72.3-79.9, SD: 2.18) percent of fat intake on the right and the left breast respectively. No rippling, implant malposition, or infection was observed during a mean follow-up of 22 months (6-40).

CONCLUSIONS

SWEH is a useful surgical alternative that combines the benefits of AFG and implant-based augmentation, particularly with regard to soft tissue coverage, and avoids the limitations of larger-volume implants. The association of small-volume gel implants and smaller scars can yield satisfactory aesthetic outcomes.

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 http://www.springer.com/00266 .

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

Hybrid Implant and Grafted Fat Breast Augmentation: Designing the Pathway to a Future With Breasts Free of Silicone Breast Implants

BACKGROUND

Fat grafting in breast augmentation surgery is becoming increasingly popular, allowing surgeons to fill the gaps that implant augmentation alone cannot. However, one of the current issues surrounding fat grafting is the lack of standardization.

OBJECTIVES

The objective of this study was to validate and summarize expert-based advice to help plastic surgeons better understand the benefits of utilizing fat grating to reduce implant size in their surgical planning.

METHODS

This was a prospective study of fat grafting in 56 patients who underwent fat transfer together with silicone breast implants. A 3-dimensional planning system was used to plan the procedure and also to analyze the fat retention and resorption rates. Pictures served as a basis for a questionnaire in which both patients and physicians were asked to rate their satisfaction.

RESULTS

Patients reported a satisfaction rate of "excellent" in 83.3% of cases and "good" in 16.7%. Physician satisfaction was rated as "excellent" in 84.5% of cases, "good" in 13.3%, and "fair" in 4.2% of cases. The mean fat volume grafted per breast was 113.63 mL. The mean absorption rate was 4.53%.

CONCLUSIONS

The procedure presented consistent and reproducible results. Hybrid breast augmentation can help design a pathway for a future with breasts free of silicone. This information is particularly relevant for women who have their first breast augmentation at an early age and will probably have 2 to 5 additional surgeries in their lifetime due to the nature of current silicone breast technology.

LEVEL OF EVIDENCE: 4

Expert consensus on the facial rejuvenation using the Mint Lift® in Koreans: Perspectives of plastic surgeons

BACKGROUND

It would be mandatory for plastic surgeons to consider anthropometric and anatomical differences between Asians and Caucasians in performing facial rejuvenation procedures using absorbable threadlifts in Asians.

METHODS

A consensus meeting was convened to discuss indications, treatment procedures, possible combination treatments, clinical outcomes, and safety of an absorbable polydioxanone (PDO) monofilament threadlift (Mint Lift® ; HansBiomed Co. Ltd., Seoul, Korea), for which the "Mint Aesthetics Expert Group" was organized with four Korean board-certified specialists in plastic and reconstructive surgery.

RESULTS

Our recommendations are as follows: First, the entry and exit points should be determined considering anatomical characteristics of the face (Level of evidence III). Second, treatment procedures may vary depending on indications (Level of evidence III). Third, short-term efficacy and safety of facial rejuvenation using the Mint Lift® have been well documented (Level of evidence I and III). Third, facial rejuvenation using the Mint Lift® may be combined with a liposuction (Level of evidence III).

CONCLUSIONS

Here, we propose expert consensus on facial rejuvenation using a novel absorbable PDO monofilament threadlift in Koreans. Of note, this is the only expert consensus prepared by board-certified specialists in plastic surgery in Korea. But more evidence-based efforts should be made to update and to expand the current recommendations.

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 .

Subfascial Ergonomic Axillary Hybrid (SEAH) Breast Augmentation: A Surgical Approach Combining the Advantages of Incision, Pocket, Silicone Gel, and Fat Grafting in Primary and Revision Breast Augmentation Surgery

BACKGROUND

Simultaneous application of the axillary approach (AA) with the subfascial pocket (SF) has been proposed for breast augmentation (BA) surgery. New silicone implant technology and recent improvements in autologous fat grafting (AFG) have ushered in a new era for BA.

OBJECTIVES

The aim of this study was to present the combined subfascial ergonomic axillary hybrid (SEAH) method and evaluate its aesthetic benefits after primary/secondary BA.

METHODS

In total, 42 patients (84 breasts) underwent BA with the SEAH technique; this approach was indicated when the overlying tissue was insufficient to adequately cover the implant.

RESULTS

Mean patient age was 34.6 years (range, 28-56 years), mean BMI was 18.8 kg/m2 (range, 14.4-26.1 kg/m2). The most common implant (Motiva SmoothSilk surface Ergonomix style) volume was 255 cc (range, 175-355 cc), patients received a mean fat volume of 96 mL (range, 60-145 mL) per breast in the subcutaneous tissue. The average lower pole stretch value was 40.5% (21.75 mm) and 13.1% (9.9 mm) for preoperative to 10 days postprocedure and 10 days to 18 months postprocedure, respectively. Postoperative complications included subcutaneous banding in the axilla (n = 3, 7.1%), small wound dehiscence (n = 1, 2.3%), and hypertrophic scarring (n = 1, 2.3%). No rippling, implant malposition, infection, or fat necrosis was observed during a mean follow-up of 18 months (range, 6-32 months).

CONCLUSIONS

SEAH is a useful and versatile technique combining the benefits of AFG and implant-based augmentation, particularly with regard to soft tissue coverage, and avoids the limitations of the submuscular position. The combination of ergonomic gel implants and a SF pocket can yield satisfactory aesthetic outcomes.

LEVEL OF EVIDENCE: 4

[Impact of breast dimension in one-stage augmentation mastopexies on implant selection: review of 103 consecutive breast augmentations with nanotextured silicone implants]

INTRODUCTION

According to current studies, one-stage augmentation mastopexy (AM) is associated with only minor complications and a lower reoperation rate compared with a staged procedure. In AM, breast dimension can differ notably compared with those cases without simultaneous mastopexy. However, these differences have only been insufficiently investigated. This study aims to quantify the differences and then evaluate the effect of breast dimension on implant selection. In addition, it evaluates the influence of mastopexy on the outcome of augmentation mammoplasties with round nanotextured silicone gel implants.

PATIENTS AND METHODS

Over a two-year period, all patients with primary augmentation mammoplasties using nanotextured implants were included in the study. Patients' demographic data, breast measurements, specifications of the implants placed, and complications in the breast augmentation group without mastopexy were compared with those of the group with AM. The satisfaction of patients and surgeons was documented using Likert scales.

RESULTS

A total of 206 breast augmentations were performed in n = 103 patients. The mean follow-up was 24.0 ± 4.3 months. Compared with augmentations without an indication for simultaneous mastopexy, the AM group had wider breast bases and larger preoperative cup sizes; p < 0.001. As a result, implants selected for AM had greater diameters and lower volumes (p < 0.05) and were associated with smaller projections; p < 0.001. The total revision rates after augmentations without (n = 51) and with combined mastopexy (n = 52) were 5.9 % and 19.2 % (p < 0.05), respectively. AM increased tissue-related revisions from 2.0 % to 13.4 % (p < 0.05) without having an impact on implant-related revisions (3.9 % vs. 5.8 %, p = 0.663). The overall incidence of capsular contracture was 1.9 %. Satisfaction levels were approximately equal in both groups.

CONCLUSION

In comparison to augmentations without mastopexy, wider breast bases and larger breast volumes before surgery lead to the selection of significantly different implant dimensions in AM. Nanotextured silicone implants are associated with low complication rates, while an increased risk for tissue-related revisions of the combined procedure remains. Further studies are necessary in order to evaluate possible advantages and disadvantages over established implants.

[Minimal Scar Breast Augmentation: Experience with over 500 implants]

INTRODUCTION

In plastic breast surgery minimal scar techniques are usually associated with some advantages in terms of the aesthetics associated with scar formation and scar visibility. They can also bring benefits in terms of healing and recovery time, which is why minimal scar techniques for breast reduction and mastopexy have long been established. Modern implants and new, adapted surgical techniques enable it now to use minimal scar techniques for breast augmentation with similar advantages.

METHOD

252 patients were included in a retrospective study, which underwent a minimal scar breast augmentation via an inframammary approach over a period of two years. The investigations included the location, the size, the shape and any postoperative complications. In addition, all patients were interviewed about their experiences before and one year after the operation using the Breast-Q Questionnaire (Augmentation Module). The focus was on self-esteem (pre- and postoperative) and satisfaction with the outcome of breast augmentation involving the scar.

RESULTS

The assessment of the surgical outcome and the scar were consistently positive. There were no complications with regard to surgical access, the scar or the implant. All patients showed a significant increase in quality of life on the Breast-Q scale from 0-100 (psychological well-being: 44 to 77) and were satisfied with the outcome of breast enlargement (satisfaction with the breasts: 28 to 80; satisfaction with the result: 89 out of 100) involving the scar.

CONCLUSION

Minimal scar breast augmentation requires greater technical effort and operative experience. However, the results are consistently positive and promising, both clinically and psychologically.

Male-to-female gender affirmation surgery: breast reconstruction with Ergonomix round prostheses

People with gender dysphoria are becoming more prevalent and more universally accepted. Social, hormonal, and surgical gender transition are able to substantially improve their quality of life. Various gender affirmation surgery (GAS) options are available to address gender dysphoria in the male-to-female (MtF) population, including facial and chest feminization, body contouring,  and genital surgery. While hormone replacement therapy may result in some degree of breast development, it is often insufficient to effectively result in an adequate female-like breast contour. The creation of a female chest is generally the first surgical step in the transition. The primary aim of this manuscript is to describe the surgical technique with ergonomix round prostheses used at our high-volume GAS center and to point out how anatomical differences between trans-female and cis-female patients impact surgery. Furthermore, we provide an overview of the demographic data and postoperative outcomes.

Reoperative Transaxillary Approach Algorithm: Extending the Surgical Alternatives for Secondary Breast Augmentation in the Era of Scarless Surgery

BACKGROUND

Although the transaxillary approach (TAA) is useful in primary breast augmentation (BA) surgery, drawbacks of this technique include the need to correct complications arising from reuse of the axillary incision.

OBJECTIVES

The purpose of this study was to assess the outcomes of secondary BA procedures performed via the TAA in a cohort of patients operated on by a single surgeon and to provide an algorithm for reoperative TAA technique selection.

METHODS

Sixty-two patients (122 breasts) underwent secondary TAA BA, which was indicated for capsular contracture (CC) in 35 patients (56.4%). Periods for analysis included less than 10 days, 1, 3, 6, and 12 months, and then at 2-year intervals postprocedure.

RESULTS

Forty-three patients (69.3%) had a previous premuscular (PM) pocket; in 35 (81.3%) of these patients the new pocket was kept in the same position. Nineteen patients (30.7%) had a previous submuscular pocket, and 15 patients (78.9%) had the new pocket transferred to the PM plane. Ten cases of complications were observed in 8 patients (16.1%), Baker grade II/III CC in 3 (4.8%), and axillary banding in 2 (3.2%), during a mean follow-up of 72 months (range, 6-170 months). Fifty-nine patients (95.1%) were either very satisfied or satisfied with their aesthetic result.

CONCLUSIONS

Recent progress in surgical techniques has led to significant improvements in aesthetic outcomes following BA. The TAA can play a useful role in secondary BA cases and our results show this procedure to be useful, with acceptable complication rates, and the added bonus of avoiding additional scarring on the breast.

LEVEL OF EVIDENCE: 4

Hybrid Breast Augmentation: A Reliable Formula for Preoperative Assessment of Fat Graft Volume Based on Implant Volume and Projection

BACKGROUND

Autogenous fat grafting (AFG) is an established technique used as an adjunct to breast augmentation (BA) to redesign breast shape. Surgeons often use experience and intuition to estimate AFG volume, which can result in incorrect assessment of donor areas and unnecessary fat removal.

OBJECTIVES

This aim of this study was to develop a method based on a mathematical formula, which utilizes implant volume and projection to predict AFG volume.

METHODS

Thirty patients (60 breasts) underwent primary hybrid BA. A software package (SketchUp) was used to simulate 3-dimensional AFG and implant volumes, which in turn were used to develop an equation for estimating AFG volume according to 3 different implant projections. The results for each group were compared, via Pearson's correlation coefficient, with the results of the clinical series.

RESULTS

All patients received Motiva Ergonomix SmoothSilk/SilkSurface implants, ranging in volume from 175 to 355 cc (mean, 265 cc), as well as an average AFG volume of 79.2 cc/breast (range, 50-110 cc). Twenty-nine patients (96.6%) were either very satisfied or satisfied during a mean follow-up of 18 months (range, 6-28 months). A high correlation was observed between the AFG performed in the cohort and predictions obtained from the formula (r = 0.938, P < 0.001).

CONCLUSIONS

The AFG volume in hybrid BA procedures can be estimated utilizing measurements based on implant volume/projection. This low-cost method can be applied to guide surgical decision-making in patients who are candidates for BA.

LEVEL OF EVIDENCE: 4

SMS-Split Muscle Support: A Reproducible Approach for Breast Implant Stabilization

BACKGROUND

Recent concerns regarding the association between macrotextured breast implants and anaplastic large cell lymphoma (ALCL) have led to renewed interest in the use of devices with less texturing. Smooth implants appear to have a decreased risk of ALCL; however, low implant adherence has led to questions about implant stabilization and bottoming-out. The senior author has used a split muscle support (SMS) technique to help support the implant infero-laterally in over 380 breast augmentations and augmentation-mastopexy using smooth implants, with a low complication and reoperation rate.

METHODS

A retrospective chart review of 387 consecutive breast augmentation and augmentation-mastopexy patients operated on by the senior author over 24 months was performed. The SMS technique was classified in three grades according to amount of implant support by the pectoralis major muscle.

RESULTS

Patients were followed for an average of 13 months. Major complications occurred in seven (1.9%) patients, of which five (1.4%) were considered implant-related. There were one case of implant rotation and three cases of malposition during the transition from microtexture to nanotexture implants and one case of capsular contracture in a previously irradiated breast. Three post-massive weight loss patients required reoperation for further skin adjustment, and one patient requested upsizing of her implants at 3 months.

CONCLUSIONS

The SMS technique is easily reproducible, adjustable intraoperatively according to patient characteristics, and helps stabilize breast implants. With increasing patient awareness regarding ALCL, the association of smooth implants along with the varying degrees of implant support afforded by SMS can help achieve a low complication and reoperation rate.

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.

Usefulness of Radio Frequency Identification Device in Diagnosing Rotation of Motiva SmoothSilk Implants after Augmentation Mammoplasty

Breast implant displacement has been described as a significant risk following augmentation mammoplasty. Magnetic resonance imaging (MRI) is considered the method of choice for diagnosing implant complications, but it has its limits in assessing correct implant position and displacement. Motiva SmoothSilk/SilkSurface^® Implants (MSS) are the first to incorporate a radio frequency identification device (RFID), which produces an imaging artifact in MRI sequences. Given the frequency of breast augmentation procedures and the recent US Food and Drug Administration prospective trial involving SS with RFID, further analysis of implant stability and diagnostic imaging methods to evaluate implant positioning is necessary. The objective of this study was to assess the use of MRI with this new RFID-containing implant as a new tool to assess correct implant positioning. The authors performed this technique in 5 patients (10 implants) undergoing primary breast augmentation or revision surgery with MSS implants (255-385 cc, mean = 325 cc). The average area and volume of the artifact were 15.7 cm² and 31.75 cm³, respectively. All cases presented satisfactory results, with 1 case of implant displacement. Our clinical and radiological outcome demonstrated that RFID technology is a useful tool for correct visualization of the implant position and diagnosis of complications such as slight displacements or rotation. To our knowledge, this is the first RFID breast implant that has been objectively evaluated for MRI issues.