Aesthetic management of the breast following explantation: evaluation and mastopexy options

[Breast implant removal and simultaneous aesthetic optimization : Possibilities, technical considerations and outcome analysis]

BACKGROUND

Breast augmentation is currently the leading aesthetic surgical procedure worldwide. Thus, there is a high prevalence of women with breast implants demanding serious know-how and expertise concerning long-term complication management. Breast implant carriers can suffer from problems and pathologies making implant removal the best solution. The authors of this article have also been confronted more and more with the unspecified complex of symptoms named breast implant disease (BID), also called breast implant illness (BII). The treatment of choice for BID is implant removal.

OBJECTIVE

Analysis of problems and solutions regarding implant removal. Specific patient analysis according to patients' breast and body configuration. Technical considerations for surgery and preoperative planning. Evaluation of the authors' techniques.

PATIENTS AND METHODS

Evaluation of all patients over a period of 3 years requesting implant removal after esthetic augmentation mammoplasty at the authors' department. All patients were treated according to their specific demands regarding breast shape after implant removal. They either received additional mastopexy, lipofilling or both or simple implant removal without further intervention. Demographic, implant-specific, perioperative and postoperative data have been evaluated for all patients. Additionally, all patients were asked to complete a questionnaire regarding satisfaction and outcome.

RESULTS

We observed a trend for more satisfied patients with less invasive procedures (simple implant removal or simultaneous lipofilling vs. explantation and mastopexy ± lipofilling, 1.8 vs. 2.0 or 2.6, p = 0.198). Patients' average scoring was better if they suffered from an implant rupture (1.55 vs. 2.17, p = 0.053). Overall, a high patient satisfaction has been observed for all procedures.

CONCLUSION

Breast implant carriers can suffer from problems and pathologies making implant removal the best solution. Exactly these patients, consulting their doctor for those problems and questions seem to profit from implant removal. Simultaneous lipofilling and mastopexy of the breast are good options to nevertheless generate an esthetically pleasing result.

Exploring Factors Associated with Implant Removal Satisfaction in Breast Implant Illness Patients: A PRO BREAST-Q Study

Background

Breast implant illness (BII) is a poorly understood heterogeneous disorder treated with implant removal; however, patient-reported symptoms and outcomes after treatment remain unclear.

Methods

A retrospective review of patients undergoing bilateral breast implant removal related to BII by two surgeons at an academic medical center between 2018 and 2022 was conducted. Patients were surveyed using the BREAST-Q Reconstruction model with the American Society for Aesthetic Plastic Surgery BII survey extension. Outcomes were analyzed using multivariable logistic regression, adjusted for patient-associated factors.

Results

Forty-seven patients were surveyed with a response rate of 51% (n = 24). Of the 20 patients who completed the survey, the majority were White (85%), with 45% (n = 9) having a documented history of psychiatric illness. Six (30%) patients had capsular contracture and four (20%) had documented implant rupture. Most implant removal procedures (n = 12, 60%) were not covered by insurance. Fourteen (70%) patients reported a net improvement in their symptoms after implant removal, most commonly chest discomfort, muscle pain, fever, and headaches. Capsular contracture was predictive of reduced psychosocial, sexual, and breast satisfaction scores (P = 0.015). Self-pay was predictive of increased breast satisfaction scores (P = 0.009), but had no impact on symptomatic improvement. A reduced time to implant removal was predictive of fewer residual symptoms (P = 0.032). Psychiatric illness had no significant impact on the outcomes.

Conclusions

In the setting of suspected or diagnosed BII, a reduced time to implant removal may decrease the risk of residual symptoms and improve overall patient satisfaction. In patients with capsular contracture, preoperative counseling should emphasize that implant removal may only improve physical symptoms.

Breast implant reverse surgery: A step-by-step approach

The popularity of breast augmentation has seen a decrease in number in the recent years. Simultaneously, the request for breast implant removal has increased impressively. A total of 77 women undergoing breast implant removal with no exchange were divided into four groups depending on the type of "reverse surgery" following the explantation: simple implant removal, implant removal with lipofilling, implant removal with mastopexy, and implant removal with mastopexy and lipofilling. Following this, an algorithm was created to standardize the ideal "reverse" surgery. After surgery, all the patients were followed for at least 6 months to understand their level of satisfaction regarding the outcome of the surgery. The majority of patients were highly satisfied after explantation. Implant-related issues were found to be the main cause for explantation surgery. Capsulectomy was performed in the minority of cases, as the capsule was found to be an ideal layer for fat grafting. Grouping the patients into 4 categories allowed us to investigate a pattern behind the decision to undergo a certain type of secondary procedure and to create an algorithm with general rules that can be used as a guide for surgeons. The increased demand for this type of surgery underlines a new interesting trend in plastic surgery that, together with Breast Implant-Associated Anaplastic Large Cell Lymphoma advent, will probably have implications on the communication between surgeons and patients and most likely on the choice of choosing different ways of breast volume augmentation.

Imaging Features Following Breast Explant Surgery: A Pictorial Essay

Breast implants can be removed with breast explantation surgery (BES) for various reasons, including patient dissatisfaction, capsular contracture, implant infection or rupture, breast implant-associated anaplastic large cell lymphoma, and a recently emerging phenomenon called breast implant illness. There is very limited data on the imaging appearance after BES. A retrospective chart review was performed for patients with BES findings on imaging reports for the period between October 2016 and October 2021. When assessing BES techniques, a key element is determining whether the implant's fibrous capsule requires removal. The second important question is if the patient requires an additional aesthetic procedure after BES. BES techniques include capsulotomy, and partial, total, or en bloc capsulectomy. Adjunctive aesthetic or reconstructive procedures after BES include fat grafting, mastopexy, augmentation, and reconstruction with flaps. The majority of post-BES breast imaging findings are related to the surgical scar/bed, thereby confirming that the type of explantation surgery is important. Imaging findings after BES include focal and global asymmetries, architectural distortions, calcifications, calcified and non-calcified fat necrosis, masses, hematomas, seromas, capsular calcifications, and silicone granulomas. Most importantly, since these patients have residual breast tissue, paying attention to imaging features that are suspicious for breast cancer is necessary.

Safely Shaping the Breast After Implant Removal and Total Intact Capsulectomy Using the Mammary Imbrication Lift and Fixation Technique

Background

Implant-based breast augmentation is one of the most popular plastic surgery procedures performed worldwide. As the number of patients who have breast implants continues to rise, so does the number of those who request breast implant removal without replacement. There is little in the current scientific literature describing total intact capsulectomy and simultaneous mastopexy procedures.

Objectives

Here, the authors present their current method using the mammary imbrication lift and fixation technique after explant and total capsulectomy.

Methods

Between 2016 and 2021, a total of 64 patients (mean age: 42.95 years; range, 27-78 years) underwent the described mammary imbrication lift and fixation technique with bilateral breast implant removal and total capsulectomy.

Results

Mean follow-up was 6.5 months (range, 1-36 months). Postoperative complications included minor cellulitis in 1 patient (1.6%), late onset hematoma with infection in 1 patient (1.6%), fat necrosis and pulmonary embolism in 1 patient with prior history of thromboembolic events (1.6%), and breast scar irregularity in 4 patients (6.2%) who required subsequent minor scar revision or steroid injections. Two patients (1.6%) underwent revision surgery with bilateral breast fat grafting to improve shape and add volume.

Conclusions

The mammary imbrication lift and fixation technique described here can safely and simultaneously be performed with a total intact capsulectomy and explant procedure. This technique avoids wide undermining, intentionally opening the capsule, performing subtotal capsulectomy, and preserving blood supply to the breast tissue and nipple with low complication rates.

Level of Evidence 3

Clinical recommendations for diagnosis and treatment according to current updated knowledge on BIA-ALCL

Shared strategies and correct information are essential to guide physicians in the management of such an uncommon disease as Breast Implant-Associated Anaplastic Large Cell Lymphoma (BIA-ALCL). A systematic review of the literature was performed to collect the most relevant evidence on BIA-ALCL reported cases. A panel of multidisciplinary experts discussed the scientific evidence on BIA-ALCL, and updated consensus recommendations were developed through the Delphi process. The lastest reported Italian incidence of BIA-ALCL is 3.5 per 100.000 implanted patients (95% CI, 1.36 to 5.78), and the disease counts over 1216 cases worldwide as of June 2022. The most common presentation symptom is a late onset seroma followed by a palpable breast mass. In the event of a suspicious case, ultrasound-guided fine-needle aspiration should be the first step in evaluation, followed by cytologic and immunohistochemical examination. In patients with confirmed diagnosis of BIA-ALCL confined to the capsule, the en-bloc capsulectomy should be performed, followed by immediate autologous reconstruction, while delayed reconstruction applies for disseminate disease or radically unresectable tumor. Nevertheless, a multidisciplinary team approach is essential for the correct management of this pathology.

Incidence and Preoperative Risk Factors for Major Complications After Capsulectomy: Analysis of 3048 Patients

BACKGROUND

Although there are many indications for periprosthetic breast capsulectomy, heightened public attention surrounding breast implant illness has resulted in increased rates of capsulectomy.

OBJECTIVES

This study aimed to identify the incidence of major complications and risk factors associated with capsulectomy.

METHODS

From an examination of a prospectively enrolled cosmetic surgery insurance database, CosmetAssure (Birmingham, AL), patients undergoing capsulectomy between January 2, 2017 and July 31, 2019 were identified. Outcomes measured included the occurrence of and risk factors for major complication(s) necessitating an emergency department visit, hospitalization, or reoperation within 45 postoperative days.

RESULTS

Among 76,128 patients evaluated, 3048 (4.0%) underwent capsulectomy. There was a significant increase in number of capsulectomies following January 6, 2019 (2.7/day vs 5.2/day, P < 0.05). Capsulectomy patients were more likely to have any complication and specifically hematoma than those undergoing breast implant removal or replacement without capsulectomy (2.8% vs 1.9% and 1.6% vs 0.9%, respectively, P < 0.05). Eighty-four (2.8%) developed at least 1 complication. The most common complications included hematoma (1.6%) followed by infection (0.5%). American Society of Anesthesiologists Class III/IV was an independent risk factor for any complication and BMI ≥30 kg/m2 and office-based surgical suites were risk factors for infection.

CONCLUSIONS

A growing number of capsulectomies are being performed. The most common major complication is hematoma. Patients undergoing capsulectomy experience a higher complication rate than those undergoing breast implant removal or replacement without capsulectomy. Patients should be counseled regarding the potential for major complications.

LEVEL OF EVIDENCE: 2

The ECLiPSE Procedure as an Alternative to Mastopexy following Implant Removal

With the rise in number of breast implant removals for a variety of indications, strategies to improve aesthetic outcomes, while minimizing scars and operating time, will prove to be of benefit. We present here a novel periareolar sickle skin excision as a good option for women with mild to moderate ptosis and central loss of breast volume following implant removal/capsulectomy.

Management of Symptomatic Patients with Textured Implants

SUMMARY

Proper management of symptomatic textured implant patients is critical to identify and treat associated oncologic disease. Textured surface breast implants were first introduced more than 50 years ago in an effort to decrease high rates of capsular contracture and implant malposition observed with first-generation smooth surface breast implants. Textured implants were dominant over smooth devices in the United States in the late 1990s, but they fell out of favor for newer-generation smooth implants, while texture remained the dominant selling implants worldwide until recently. A class I device recall by the US Food and Drug Administration in 2019 precipitated a removal of the highest selling implant worldwide, Allergan Biocell, due to a disproportionately increased risk of breast implant-associated anaplastic large cell lymphoma (BIA-ALCL). Operative strategies, such as bacterial control at the time of textured implant insertion, have not been credibly shown to affect or prevent the future development of BIA-ALCL. BIA-ALCL patients require complete surgical excision of their disease, whereas textured implant patients who are otherwise asymptomatic do not require surgical removal. For suspicious cases, diagnostic testing with CD30 immunohistochemistry should be performed before any surgical intervention. Capsules are evaluated with 12 strategic regional biopsies in a standardized approach. If surgeons are revising or exchanging textured implants, they may reasonably consider a total capsulectomy, though this is not advocated by the Food and Drug Administration or national societies, and has not been shown to mitigate future risk of BIA-ALCL. The purpose of this article is to review data on and outcomes for textured surface implants, disease-associated risk, and the management strategy for revisionary surgery and device surveillance.

Adjunctive Procedures and Informed Consent with Breast Implant Explantation

BACKGROUND

The use of injectable or implantable materials or devices in the breast for augmentation or reconstruction has a history of innovation and controversy. Staying current in the field of breast implant management today means understanding not just the published literature but also its absence. Cutting edge breast implant treatment also means awareness of patient and media-driven interests and requests.

METHODS

Adjuvant treatments to optimize physical and psychological well-being with breast implant explantation, without replacement, will be addressed through literature review and analysis.

RESULTS

The body of literature demonstrates evidence of variable, and sometimes contradictory, methods to address adjunctive management of systemic concerns, the capsule, soft tissue of the native breast/chest, and treatment timing related to explantation. Few approaches are supported by very strong evidence. Many treatment methodologies are defensible. Any current attempts at optimizing management in patients undergoing explantation will be somewhat impaired by the ongoing nebulousness of related issues, such as breast implant illness. It seems clear, therefore, that plastic surgeons must fulfill their duty as caregivers to provide explantation surgery, either to attempt to improve physical health, mental well-being, or simply to respect patients' wishes. A well-informed surgeon will likely employ a variety of approaches, adapted to the unique patient presentations at hand.

CONCLUSION

It is expected that consultations, incisions, tissue rearrangements, surgical timing, and treatment indications will continue to vary as scientific investigation strives to understand and to optimize treatment of patients experiencing difficulty with breast implants.

Modified anterior intercostal artery perforator flap (AICAP) for autologous breast volume restoration after explantation

Explantation of breast implants has become increasingly common. This study aimed to analyze breast auto-augmentation following implant explantation (using a laterally designed anterior intercostal artery perforator [AICAP] flap) in patients who did not need new implants and required volume preservation. Twenty-four patients (48 breasts) aged 31-67 years (mean, 52.4 years) with body mass index (BMI) between 24.43 and 29.34 (mean, 27.32) kg/m2 underwent this procedure. All patients had implant-related problems, such as recurrent capsular contracture (n=11), seroma (n=2), animation deformity (n=3), rupture-induced bleeding (n=5), and breast implant disease (n=3). Sizes of implants removed ranged from 215 to 355 ml. The mean flap size was 23.9 cm × 7.5 cm, and the average flap thickness was 2.3 cm (range, 2.0-3.2 cm). Flap survival was clinically examined postoperatively by ultrasonography. Pre- and postoperative final breast volumes were compared by direct patient observation and independent photograph observation by three plastic surgeons according to a 4-point scale (bad=1, regular=2, good=3, and excellent=4) and the brassiere size. All flaps were completely viable after harvesting. No postoperative signs of fat necrosis were observed, and independent plastic surgeon evaluation revealed good and excellent results in all cases. Patient satisfaction evaluated by BREAST-Q data was >90%. This new design, AICAP flap (with a lateral thoracic extension), can be safely used for breast volume restitution after breast implant explantation with high patient satisfaction. This flap exhibited reasonable potential of providing additional volume in patients who undergo implant explantation and require the preservation of similar volume.

Simultaneous Mastopexy Explantation With a Vertical Bipedicle and Novel Open Pattern Marking Technique

There are limited studies in the plastic surgery literature that detail technical considerations in simultaneous breast implant removal and mastopexy procedures. These procedures are difficult, with significant potential for complications and poor cosmesis. The current plastic surgery literature describes a limited number of techniques that address these concerns, virtually all of which are variants of superior or superior medial pedicle vertical pattern mastopexy. This paper details a safe technique for simultaneous explantation and mastopexy with a novel open marking pattern and vertical bipedicle, which can restore breast cosmesis following implant removal. The study will briefly retrospectively review the results of a consecutive series of 86 patients who underwent this procedure from November 2018 to November 2019, with no incidence of partial or total nipple-areola complex necrosis. Thus, the technique is safe and allows the flexibility for intraoperative adjustments that are necessary for these procedures. A future study will conduct a more in-depth analysis of the results.

Breast implant illness: a topic in review

Recently, the term breast implant illness has become popularized in social media to describe a constellation of symptoms which have been attributed to a patient's breast implants. These symptoms include fatigue, chest pain, hair loss, headaches, chills, photosensitivity, rash, and chronic pain amongst others. While physicians aim to treat these physical symptoms, currently the evidence supports the safety of silicone breast implants. This article entitled "Breast implant illness: a topic in review" presents an up-to-date review focusing on the safety of silicone breast implants. Patients retain the right to decide to keep or remove their breast implants and for those who choose to pursue explantation, they should be advised to seek the care of a board-certified plastic surgeon. As a scientific community is our duty to continue to conduct well-designed scientific studies to gain more insight into the safety of breast implants as it related to cancer detection, autoimmune disease, and other health concerns to improve patient safety, awareness, and education. This review article aims to delineate both the content and timing of all research and evidence as it pertains to the newly coined phrase "breast implant illness". The authors of this study support that currently there have not been any concrete or evidence-based studies which support the formation of a new syndrome "silicone implant illness".

Surgical Management of the Explant Patient: An Update on Options for Breast Contouring and Volume Restoration

BACKGROUND

Breast implant removal is becoming a common procedure in light of the current events and controversies with silicone breast implants. The authors believe strongly in informing patients about the indications and options regarding both explantation and the management of the secondary breast deformity.

METHODS

Relevant literature regarding the management of the explant patient was reviewed and organized to provide an update on prior publications addressing the explant patient population.

RESULTS

Surgical management options after implant removal include breast contouring and volume restoration. Fat augmentation has been used in both aesthetic and reconstructive breast surgery.

CONCLUSIONS

The authors review the surgical management for explantation, breast contouring, and autologous fat grafting for volume restoration. In the explant patient, autologous fat grafting serves as a reliable option for volume restoration.

Combined Breast Implant Explantation and Multilevel Mastopexy Technique

Patients dissatisfied with their breast implants are faced with 2 options: secondary augmentation or removal of the implants. Simple removal of breast implants often leads to wide, deflated, and laterally displaced breasts which are notoriously difficult to reconstruct. We present a surgical technique that was specifically developed to recreate the breast mound using the wide laterally displaced breast tissue left after breast implant removal.

Mastopexy and Mastopexy-Augmentation

Mastopexy and mastopexy-augmentation are aesthetic breast surgeries that seek to create youthful, beautiful appearing breasts. Age, hormonal changes, or weight loss can lead to alterations that require addressing the skin envelope and breast parenchyma. Many surgical approaches have been described including periareolar, vertical, and Wise pattern techniques, but most modern mastopexies include manipulation of the breast parenchyma to improve the longevity of breast ptosis correction. Mesh support of the ptotic breast is an extension of this paradigm shift and seeks to restore the lost strength of the support structures of the breast. Despite initial controversy, single stage mastopexy-augmentation has been demonstrated to be a safe option for appropriately selected and informed patients who desire both correction of shape and volume. Revisions may still be necessary based on patient and surgeon goals for correction. Evolving technologies will likely continue to enhance the ability of aesthetic plastic surgeons to provide pleasing, durable correction of breast ptosis.

Preoperative Saline Implant Deflation in Revisional Aesthetic Breast Surgery

BACKGROUND

Preoperative saline deflation is a clinically useful intervention in revisional breast surgery. It allows suspensory ligament recovery, reveals true glandular volume, and simplifies mastopexy markings. Presently unknown are the volumetric changes that occur after deflation.

OBJECTIVES

The authors report the three-dimensional (3D) changes that occur with preoperative deflation prior to revisional breast surgery.

METHODS

We reviewed available charts of revisional breast surgery patients who underwent preliminary saline implant deflation. Our protocol is deflation 4 weeks prior to revision. Three weeks following deflation, the patient is evaluated to finalize the operative plan, including the need for implants, mastopexy, and adjunctive procedures. A subset underwent 3D imaging to quantify the volumetric changes over the 3-week deflation period.

RESULTS

Between 2002 and 2014, 55 patients underwent saline implant deflation prior to 57 revisional surgeries. Seventeen were revised without implants and 40 with implants. The 3D subset of 10 patients showed a mean 15.2% volume increase and 0.18 cm notch-to-nipple distance decrease over the 3 weeks following deflation and prior to definitive surgical correction.

CONCLUSIONS

Breast volume increases and the notch-to-nipple distance decreases during the 3-week interval prior to reoperation. This "elastic breast recoil" occurs after the mass effect of the implant is removed, resulting in recovery of stretched suspensory ligaments and gland reexpansion. We believe 4 weeks is optimal for gland normalization. Ideal candidates include patients requiring secondary mastopexy without implants, implant downsizing in the same pocket, and secondary augmentation mastopexy. Preoperative saline deflation and 3D analyses are useful for preoperative planning in reoperative breast surgery.

Mastopexy and reduction mammoplasty pedicles and skin resection patterns

SUMMARY

Mastopexy and reduction mammoplasty share techniques of pedicle formation and skin excision patterns, with the main difference being the amount of breast tissue resected. Various types of excision patterns and orientation of pedicles were developed throughout the years, each with flares of popularity at different times. This article reviews the multiple techniques of pedicle orientation and skin excision patterns separately and gives the advantages and disadvantages of each.

A clinical study of late seroma in breast implantation surgery

BACKGROUND

The use of mammary implants may lead to a variety of early and delayed complications. The most common delayed complications are capsular contracture and implant failure. Late seroma has seldom been reported. In a long-term prospective observational study, cases of late seroma were assessed and recorded.

METHODS

Between March 2005 and November 2009, suspected cases of late seroma in patients who had undergone breast augmentation or reconstruction with textured implants were evaluated clinically and with instrumental analyses. An ultrasound-guided needle aspiration of the fluid was performed.

RESULTS

In this study, 13 cases of late seroma (8 augmentations and 5 reconstructions) were observed. The overall incidence of this complication was 1.68%. Chemical analyses confirmed the diagnosis of seroma, which recurred in all the patients within days of evacuation. For 12 patients, a reoperation was performed, during which the implant was removed, a total capsulectomy was performed, and in cases of subglandular breast augmentation, the implant pocket was changed to a submuscular placement before a new prosthesis was inserted. One patient underwent a second ultrasound-guided needle aspiration. No seroma recurrence was observed in any of the patients during the follow-up period.

CONCLUSION

In case of unexpected breast enlargement after prosthesis implantation, the physician should first rule out infection, then investigate possible friction irritation from either a fold in the device or rubbing of a textured implant. According to the authors' experience and another report, this complication occurs in 1% to 2% of cases. The inclusion of this complication in the informed consent form should be considered. Long-term studies designed to investigate the underlying causes of late seroma are warranted for the prevention and treatment of this complication.

An exploration of patient decision-making for autologous breast reconstructive surgery following a mastectomy

OBJECTIVE

The aim of this study was to examine patients' experiences of the decision to undergo breast reconstructive surgery following mastectomy.

METHOD

21 Women, who had undergone reconstruction, took part in a semi-structured qualitative interview, which examined the participants' experience of the decision-making process. The recorded interviews were transcribed verbatim and analyzed using "framework analysis".

RESULTS

Women who underwent immediate reconstruction spoke of the convenience of undergoing only one operation with regards to juggling work and childcare arrangements. For women who underwent delayed reconstructive surgery the reasons centre on dissatisfaction with wearing prosthesis. Others spoke of no choice, as immediate reconstruction was not offered as an option. However both groups did report similar influential factors and received and used similar informational content and informational sources in order to make their decision.

CONCLUSION

The study outlines the different motivations for undergoing immediate or delayed breast reconstruction and highlights that there is not always a choice offered to patients.

PRACTICE IMPLICATIONS

Future patients who are considering breast reconstruction should be provided with the relevant information to make a well informed decision and may benefit from different methods of information delivery that could include decision aids such as informational booklets, photographs, and videos.

Successfully exploiting two opposing forces: a rational explanation for the "interlocking suture"

BACKGROUND

Issues of poor circumareolar scars and asymmetry or malposition of the nipple-areola complex (NAC) are frequently associated with those breast reduction or pexy techniques that rely on an ample excision of skin around the areola, either alone or associated with a vertical scar in a circumvertical approach. To prevent such problems, in 2007 Hammond et al. introduced the "interlocking suture." The objective of this study was to demonstrate the true ability of this suture to reduce the common complications of periareolar surgery simply by managing the existing contrast between NAC centripetal and outer breast tegument centrifugal forces.

METHODS

By using finite element method (FEM) software, the NAC traditional interrupted stitches were compared with both round-block and interlocking sutures, and the skin strain in all three procedures was qualified.

RESULTS

The contribution of circuitous stitches in the interlocking suture leads to a more advantageous distribution of forces. FEM analysis shows that the interlocking suture reduces skin stress on peripheral breast teguments by 14% compared to the round-block suture and by 15% compared to the traditional (radial) suture. When evaluating the areolar edge, the interlocking suture leads to a reduction in skin stress of 9.9% compared with traditional interrupted stitches.

CONCLUSIONS

The efficient, long-lasting results of the interlocking suture are directly due to its unique design, which effectively reduces the tension between the NAC and breast tegument edges in periareolar surgery, thus improving the quality of the scar.

Secondary mastopexy in the augmented patient: a recipe for disaster

BACKGROUND

Augmentation mammaplasty is popular procedure, but one that is associated with a relatively high rate of revisionary surgery. Over time, the augmented breast frequently becomes ptotic and patients may return requesting mastopexy. Experience has shown that secondary mastopexy in the augmented breast is fraught with potential complications, including fat necrosis, skin flap loss, and nipple ischemia.

METHODS

Factors that contribute to increased morbidity when mastopexy is performed in the previously augmented breast are analyzed; the surgical options available for correcting ptosis in these cases are systematically reviewed.

RESULTS

The long-term presence of implants typically results in changes in breast anatomy and physiology, including parenchymal atrophy, tissue thinning, and diminished skin blood supply. These factors greatly increase the surgical risks of secondary mastopexy.

CONCLUSIONS

When planning and executing mastopexy in the previously augmented patient, the plastic surgeon must carefully consider the potential adverse effect of implants on the blood supply to the breast. With thoughtful planning and cautious operative technique, good results can be achieved in most cases, and the risk of serious complications can be minimized.

Mastopexy Preferences: A Survey of Board-Certified Plastic Surgeons

BACKGROUND

The purpose of this survey was to assess the current trends in mastopexy techniques and to compare satisfaction rates and complications associated with different techniques.

METHODS

In September of 2002, a mastopexy survey was sent to 1500 members of the American Society for Aesthetic Plastic Surgery; 487 complete responses were received, for a response rate of 32.5 percent. Questions elicited categorical answers, and the data were evaluated using the chi-square test and the comparison of two proportions.

RESULTS

The inverted-T incision technique is the most popular. Satisfaction was reported to be highest with the short scar periareolar inferior pedicle reduction (or SPAIR) and Hall-Findlay techniques. Physician satisfaction was lowest with the periareolar technique. The three most common complications for all techniques were suture spitting, excess scarring, and bottoming out. The periareolar group had a greater frequency of revision (p = 0.002). The inverted-T group had a greater frequency of bottoming out (p = 0.043). The short scar group had a greater frequency of asymmetry (p = 0.008).

CONCLUSIONS

The traditional inverted-T technique is the most popular, but the newer short scar techniques have become more popular in the last 5 years. The inverted-T incision continues to be associated with bottoming out and excess scarring. The periareolar technique has the greatest need for revision and the lowest physician satisfaction, despite its application to a greater volume of mastopexies per year.

A long-term study of outcomes, complications, and patient satisfaction with breast implants

BACKGROUND

Breast implants have been used worldwide for more than 40 years. Despite extensive clinical experience, there is continued concern about the safety of these devices. The purpose of this study was to compare the efficacy, complication rates, frequency of reoperation, and degree of patient satisfaction with different types of implants.

METHODS

This is a consecutive, population-based study consisting of all patients receiving implants at a multidisciplinary breast center between 1979 and 2004 (25 years). A prospective implant database was constructed and maintained in Excel, and statistical analysis was performed using SAS 8.2. Various outcomes, including infections, hematomas, undesirable waviness, capsular contracture, deflation, rupture, reoperation, and patient satisfaction, were monitored.

RESULTS

Data were collected on 3495 implants in 1529 women. The longer implants were in place, the greater the cumulative risk of developing contracture; hematoma significantly increased the risk of contracture; smooth and textured implants had similar contracture rates; polyurethane foam-covered implants had a reduced risk of contracture persisting for at least 10 years after implantation. There was a relatively high rate of reoperation and a relatively short interval between primary surgery and reoperation; the most common indication for reoperation was capsular contracture. Implant recipients expressed a high overall level of satisfaction.

CONCLUSIONS

Breast implants are associated with a significant rate of local complications and reoperation. There are marked differences in outcomes as a function of implant surface type and surgical indication. Despite relatively frequent complications and reoperations, implant recipients are largely satisfied.

Planning elective operations on patients who smoke: survey of North American plastic surgeons

Patient smoking status affects many aspects of plastic surgery, including patient selection, counseling, management, and outcomes. No specific recommendations for performing elective procedures on patients who smoke are available. The goal of this study was to determine the current practice standards and attitudes toward this often controversial topic. In September of 2000, 1600 members of the American Society for Aesthetic Plastic Surgery were sent questionnaires, 955 of which were returned. Questions elicited categorical answers, either dichotomous or multiple choice. Data were evaluated using logistic regression and the chi-square and binomial tests. Our results show that 60 percent (p < 0.01) of plastic surgeons routinely perform a less than optimal procedure on their patients who smoke. The survey measured willingness to perform various operative procedures on patients who smoke and types of smoking cessation aids offered. Of those physicians who require patients to quit smoking before surgery, only 16.7 percent (p < 0.01) would perform a nicotine test if they suspected noncompliance. Interestingly, 28.6 percent (p < 0.01) of the physicians responding admit to a smoking history, whereas only 1.5 percent (p < 0.01) continue to smoke, compared with the national smoking rate of almost 25 percent. Physicians who are previous smokers are less likely to offer smoking cessation aids than those who have never smoked, and the proportion not offering aids increases as the amount of previous smoking increases (p = 0.02). This study shows that a wide range of opinions exists on which elective surgical procedures should be performed on patients who smoke. Furthermore, the physician's prior smoking history influences this decision. No clear consensus exists on how best to treat patients who smoke who request elective surgeries. Although surgeons would prefer to operate on nonsmokers, they are faced with a significant population of patients who use tobacco. No clear consensus exists on how best to treat these individuals. Advancements in wound healing research and smoking cessation aids will provide more insight into this treatment dilemma.

A prospective analysis of patients undergoing silicone breast implant explantation

Despite the lack of a scientifically proven link between silicone implants and disease, many women have chosen to have their implants removed out of concern for their health. Unfortunately, there are few studies in the literature that have investigated the outcome of explanations, and there are no prospective analyses of the effect explantation has on a patient's general health. The goal of this study was to use a prospective database to determine whether there were any preoperative parameters that could be used to predict which patients would be improved following removal of silicone breast implants and to provide a quantifiable measure of that improvement. A total of 38 patients with silicone breast implants underwent operative removal of their breast implants by faculty at the University of Texas Southwestern Medical Center. They were given questionnaires regarding several personal and medical parameters to be completed preoperatively, at 6 weeks postoperatively, and at 6 months postoperatively. In addition, their physicians completed preoperative and postoperative evaluations of the patient's general health status. A control group of 38 patients was established; they were matched with the experimental group with regard to age and other initial parameters. Their responses to questionnaires were then grouped according to standard subscales to evaluate physical functioning, physical role, bodily pain, general health, vitality, social functioning, emotional role, mental health, appearance evaluation, appearance orientation, illness orientation, and body area satisfaction. When compared with the control group, we found that patients who had undergone explantation showed a temporary decrease in musculoskeletal symptoms and bodily pain, as well as an increase in vitality, mental health, and body area satisfaction. Of the experimental group, those who initially indicated a higher number of musculoskeletal symptoms and a higher appearance evaluation were more likely to indicate a significant improvement in general health since explantation.

Factors predictive of quality of life after silicone-implant explanation

'Medical records of 180 patients who underwent silicone gel-filled breast implant explanation were retrospectively reviewed. The goal of this study was to determine if any patient variable(s) had predictive value for positive quality of life after explanation. The medical complaints, symptoms, and established diagnoses were considered equally and were referred to as self-reported medical problems. The study revealed that no single problem or pairing of problems was associated with or predictive of outcome. The results show, however, that the number of medical problems was significantly predictive of patient perception of quality of life. A total of 50 explanation patients completed quality-of-life surveys. Specifically, those patients who reported five or fewer medical problems that predated explantation were significantly more likely to perceive an increased quality of life after surgery than those who reported nine or more medical problems (p < 0.04). In conclusion, it is difficult to correlate subjective patient symptoms with postoperative improvements in quality of life after explantation.