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

Comparison of POLYTECH MESMO and Motiva Ergonomix Breast Implants With Focus on Displacement Issues: A Single Surgeon's Experience with 329 Patients

BACKGROUND

Nanotextured breast implants (classified as smooth implants by the latest ISO 14607:2018) have been described as possibly reducing major textured implant-related complications such as capsular contracture and breast implant-associated anaplastic large cell lymphoma. On the other hand, microtextured breast implants benefit from an optimal safety profile based on a much larger body of literature.

OBJECTIVES

The aim of this study was to directly compare the incidence of complications between Motiva Ergonomix (Establishment Labs Holdings, Inc., Alajuela, Costa Rica) and POLYTECH MESMO (POLYTECH Health & Aesthetics GmbH, Dieburg, Germany) breast implants, especially regarding the displacement issues that might arise after breast augmentation.

METHODS

Consecutive patients who previously underwent surgery by the same physician for placement of Motiva Ergonomix and POLYTECH MESMO implants were included in this study. They were divided into 2 groups according to the type of implant. The onset of complications was assessed through survival analysis.

RESULTS

Data were collected from 329 patients, 185 (56.2%) with POLYTECH MESMO and 144 (43.8%) with Motiva Ergonomix implants. The median follow-up was 8 months for both groups. Of the 42 women (12.8%) who experienced at least one complication, 26 belonged to the Motiva Ergonomix subgroup (P = .013). The most represented complications during this period resulted from displacement issues, with a clear prevalence of bottoming out in the Motiva Ergonomix cohort: 15 cases vs 0 cases in the POLYTECH MESMO cohort (P < .001). For 7 patients, a reoperation was required, more frequently for patients with Motiva Ergonomix implants (4.2% vs 0.5%; P = .046).

CONCLUSIONS

POLYTECH MESMO devices provided a more favorable outcome. Motiva Ergonomix devices revealed a concerning incidence of displacement issues during the first postsurgery years, with no advantage over other major complications.

LEVEL OF EVIDENCE: 3

Conceptualizing Scaffold Guided Breast Tissue Regeneration in a Preclinical Large Animal Model

Scaffold-guided breast tissue regeneration (SGBTR) can transform both reconstructive and cosmetic breast surgery. Implant-based surgery is the most common method. However, there are inherent limitations, as it involves replacement of tissue rather than regeneration. Regenerating autologous soft tissue has the potential to provide a more like-for-like reconstruction with minimal morbidity. Our SGBTR approach regenerates soft tissue by implanting additively manufactured bioresorbable scaffolds filled with autologous fat graft. A pre-clinical large animal study was conducted by implanting 100 mL breast scaffolds (n = 55) made from medical-grade polycaprolactone into 11 minipigs for 12 months. Various treatment groups were investigated where immediate or delayed autologous fat graft, as well as platelet rich plasma, were added to the scaffolds. Computed tomography and magnetic resonance imaging were performed on explanted scaffolds to determine the volume and distribution of the regenerated tissue. Histological analysis was performed to confirm the tissue type. At 12 months, we were able to regenerate and sustain a mean soft tissue volume of 60.9 ± 4.5 mL (95% CI) across all treatment groups. There was no evidence of capsule formation. There were no immediate or long-term post-operative complications. In conclusion, we were able to regenerate clinically relevant soft tissue volumes utilizing SGBTR in a pre-clinical large animal model.

The Spectrum of Non-neoplastic Changes Associated With Breast Implants: Histopathology, Imaging, and Clinical Significance

Breast implant-associated anaplastic large cell lymphoma has been recognized as a distinct entity in the World Health Organization classification of hematolymphoid neoplasms. These neoplasms are causally related to textured implants that were used worldwide until recently. Consequently, there is an increased demand for processing periprosthetic capsules, adding new challenges for surgeons, clinicians, and pathologists. In the literature, the focus has been on breast implant-associated anaplastic large cell lymphoma; however, benign complications related to the placement of breast implants occur in up to 20% to 30% of patients. Imaging studies are helpful in assessing patients with breast implants for evidence of implant rupture, changes in tissues surrounding the implants, or regional lymphadenopathy related to breast implants, but pathologic examination is often required. In this review, we couple our experience with a review of the literature to describe a range of benign lesions associated with breast implants that can be associated with different clinical presentations or pathogenesis and that may require different diagnostic approaches. We illustrate the spectrum of the most common of these benign disorders, highlighting their clinical, imaging, gross, and microscopic features. Finally, we propose a systematic approach for the diagnosis and handling of breast implant specimens in general.

Polyurethane Implants in Revisional Breast Augmentation: A Prospective 5-Year Study

BACKGROUND

Revisional surgery for aesthetic breast augmentation remains a challenging procedure. Polyurethane (PU) implants have been found to avoid capsular contracture recurrence as well as to prevent implant displacement by bio-integrating with the pocket.

OBJECTIVES

Our study aimed to assess the use of PU implants in breast revisional surgery and to provide an algorithm.

METHODS

Over a 5-year period, a prospective study was conducted involving consecutive patients undergoing implant revision. Patient demographics, previous breast procedures, and specific surgical details were documented. Postoperative outcomes were followed up.

RESULTS

Out of 92 patients (184 breasts), 78 (156 breasts) were included in the analysis. The average age was 47.5, with a BMI of 22.3 and a mean follow-up of 5 years. A majority (63%) represented secondary revisional cases, while 37% were tertiary cases. Implant size averaged 296 cc, with 53% placed in retropectoral position and 47% prepectoral. Significantly more implants in secondary cases were changed from prepectoral to retropectoral (P = .005), and in tertiary changed from retropectoral to prepectoral (P = .002). Complete capsulectomy was performed in 61.5% and partial in 25.6%. Additional lipofilling was performed in 32%, and concurrent mastopexy in 40%. Revisional surgery in our series had a 1.9% acute complication rate, 4.5% longer-term reoperation rate for corrections, 0.6% implant exchange rate, and no recurrent capsular contracture.

CONCLUSIONS

This is the first study to provide data on outcomes of revisional breast augmentation surgery with PU implants. It shows that polyurethane implants offer consistent stability and have low rates of recurrent capsular contracture in revisional surgery.

LEVEL OF EVIDENCE: 3

Outcomes of Implant Exchange and Latissimus Dorsi Flap Replacement After Breast Implant Complications

BACKGROUND

Immediate action is required to address some complications of implant-based reconstruction after mastectomy to prevent reconstruction failure. Implant exchange may be simple but poses the risk of further complications while autologous flap reconstruction seems more complex but may pose less subsequent risk. Which of these is preferable remains unclear.

METHODS

We reviewed thirty-two female breast cancer patients who had serious complications with their breast implants after post-mastectomy reconstruction. Latissimus dorsi flap (LDF) patients underwent explantation and immediate reconstruction with an LDF, while implant exchange (IE) patients underwent immediate implant removal and exchange with an expander followed by delayed reconstruction with silicon or immediately with a smaller size silicone implant.

RESULTS

LDF patients underwent a single operation with an average duration of care of 31 days compared to an average 1.8 procedures (p= 0.005) with an average duration of care of 129.9 days (p < 0.001) among IE patients. Seven IE (50%) had serious complications that required subsequent revision while no LDF patients required additional procedures. Patient overall satisfaction and esthetics results were also superior in the LDF group at six months.

CONCLUSION

In patients who want to reconstructively rescue and salvage their severely infected or exposed breast implant, the LDF offers an entirely autologous solution. LDF reconstruction in this setting allows patients to avoid an extended duration of care, reduces their risk of complications, and preserves the reconstructive process.

LEVEL OF EVIDENCE III

The journal asks authors to assign a level of evidence to each article. For a complete description of Evidence-Based Medicine ratings, see the Table of Contents or the online Instructions for Authors at www.springer.com/00266 .

Breast Conserving Therapy for Patients With Prior Cosmetic Implant-Based Breast Augmentation: Outcomes and Comparison Against a Matched Cohort

INTRODUCTION

Controversy exists regarding potential increased toxic effects in patients with cosmetic implant-based augmentation (CIBA) who receive radiation therapy. We evaluated acute and chronic toxic effects associated with radiation therapy in women with prior CIBA treated with whole-breast irradiation (WBI) as part of breast conserving therapy (BCT) and compared these results against a cohort of patients without prior breast augmentation who received similar therapy.

METHODS

A retrospective review was performed to identify patients with a prior history of CIBA who subsequently underwent BCT with WBI. The control group consisted of consecutively treated patients without prior CIBA who also underwent BCT with WBI. Analyses included a comparison of baseline and treatment-associated factors between the augmentation and control groups, evaluation of toxic effects between both groups, and multivariable analysis of factors associated with the receipt of additional surgery following radiation.

RESULTS

Thirty-six patients with prior CIBA and 135 consecutively treated patients without CIBA were identified. Patients with prior CIBA were treated from 2006 through 2019, and patients without CIBA were treated from 2016 through 2019, though treatment characteristics and median follow-up time were similar between the two groups. Patients with prior CIBA were significantly less likely to experience acute moist desquamation (0% vs. 18%; P = .005). There were otherwise no statistically significant differences in acute (≤ 6 months) or chronic (> 6 months) toxic effects between the two groups. Rates of excellent/good chronic cosmetic outcome were 89% for the CIBA group and 97% in the control group (P = .094). On multivariable analysis, patients without prior CIBA (OR = 0.04; CI = 0.01-0.13; P < .001) and patients treated with moderately hypofractionated irradiation (OR = 0.08; CI = 0.02-0.23; P < .001) were significantly less likely to undergo additional surgery following receipt of WBI. Two patients experienced implant loss following radiation therapy.

CONCLUSIONS

WBI as part of BCT in patients with prior implant-based breast augmentation appears safe and is associated with favorable cosmetic outcomes. There was an increased need for additional surgery in patients with prior CIBA, but rates of acute and chronic toxic effects appeared similar to those in nonaugmented patients.

Bilateral Hematoma Following Air Travel after Breast Augmentation: A Cautionary Tale and Literature Review

In this study, we report a rare incidence of bilateral hematoma following air travel in a patient who had recently undergone breast augmentation surgery. The case underscores the potential risks associated with flying shortly after such procedures. Through a literature review, we aimed to explore the incidence rates and highlight the need for further research in this area. This case report aims to raise awareness among healthcare professionals and patients about the need for cautious post-surgical travel planning to mitigate the risk of similar complications.

Systematic Review of Capsular Contracture Management following Breast Augmentation: An Update

BACKGROUND

Capsular contracture is one of the most frequent indications for revision following breast augmentation. Management goals focus on restoring breast aesthetics and minimizing subsequent recurrence of capsular contracture. As new data emerge, close review of the data are merited to build evidence-based clinical guidelines to inform surgical practice and management of capsular contracture.

METHODS

A systematic review of the MEDLINE, Embase, and Cochrane Database of Systematic Reviews databases was conducted to characterize the surgical management of capsular contracture in revision breast augmentations. The primary endpoint was capsular contracture recurrence rate.

RESULTS

The review was conducted in November of 2021. Primary search revealed 14,163 results. Initial screening by title left 1223 articles. Abstract review left 90 articles for full-text review, of which 34 were ultimately included and were all observational in nature.

CONCLUSIONS

Capsular contracture management remains an important topic, with limited high-level evidence for establishing clear evidence-based treatment guidelines. Although more evidence is required to assess the effects of capsulectomy, implant exchange, and plane change, these appear to be useful mechanisms for reducing recurrent capsular contracture. There is more evidence regarding the use of acellular dermal matrix, although this still requires long-term follow-up studies. New developments regarding textured implants limit the revision breast augmentation surgeon to smooth devices.

Biocompatibility of polyurethane-coated breast implants: A histological comparison of implant capsules

BACKGROUND

Biocompatibility describes the influence of materials on their biological environment. Implant material in the human body can cause a foreign body reaction and the formation of a capsule around the foreign material. Since capsular formation is the most frequent issue after breast-implant insertion, knowledge and awareness of biocompatibility is crucial, especially since worldwide, breast augmentation continues to be the most popular plastic surgery, with over 1.6 million procedures performed in 2020, according to surveys by the International Society of Aesthetic Plastic Surgery (ISAPS).

MATERIAL AND METHODS

This study includes 80 capsular samples of female patients who underwent revision surgery after breast-implant insertion at the University Hospital Regensburg. Capsules of breast implants with different surface structures (smooth, textured and polyurethane-coated) and shapes (round-shaped, anatomically-shaped) were analyzed histologically after hematoxylin-eosin-staining in respect to capsular thickness and layer formation.

RESULTS

Capsular thickness and layering showed a statistically significant difference between polyurethane-coated and smooth as well as polyurethane-coated and textured implants. Capsules around polyurethane-coated implants presented greater thickness. However, the difference between smooth and textured implants was not statistically significant. Furthermore, the shape of the implants also indicated a statistically significant difference in capsular thickness. Implants of anatomical shape resulted in a thinner capsule than round-shaped breast-implants.

CONCLUSION

In conclusion, this study demonstrated a thicker capsule around polyurethane-coated breast implants and no difference in capsular thickness between smooth and textured breast implants. Anatomically shaped breast-implants presented a thinner capsule than round shaped breast-implants.

Practice Profile of Practicing Plastic Surgeons: A 20-year Review of Plastic Surgery Statistics

Background

Evaluation of practice patterns by American Board of Plastic Surgery (ABPS) diplomates allows for a greater understanding as to how the field is progressing. Understanding evolving procedural trends can give insight into plastic surgeons' subspecialty focus and influence resident training to prepare them for future practice.

Methods

American Society of Plastic Surgeons member only projections for aesthetic and reconstructive procedures were reviewed from 1999 to 2018 in 5-year increments to identify shifts in frequency between the beginning (1999-2003) and end (2014-2018) of the timeframe. Tracer utilization for all four ABPS modules were also examined between 2014 and 2018. Descriptive statistics were performed to identify significant changes (P < 0.05) in subspecialty focus and procedure trends.

Results

Annual procedure incidence between 2014 and 2018 was compared with that between 1999 and 2003. The annual number of procedures more than doubled from 3,244,084 to 6,628,082. Among reconstructive procedures, there was a statistically significant increase in the number of breast reconstruction, breast implant removal, and maxillofacial surgery procedures, and a statistically significant decrease in the number of procedures focused on reconstruction of birth defects, burn injuries, and hand anomalies. In aesthetic surgery, significant increases were seen in the number of augmentation mammoplasty, abdominoplasty, and mastopexy procedures, with significant decreases in the number of blepharoplasty and rhinoplasty procedures.

Conclusions

Understanding the changing practice patterns of ABPS diplomates is essential to define the direction that our specialty is taking over time, and to guide program directors in plastic surgery on areas of focus for appropriate training of plastic surgeons.

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

OBJECTIVE

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

RESULTS

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

CONCLUSION

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

LEVEL OF EVIDENCE III

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

Implant-Based Breast Reconstruction: Impact of Body Mass Index on Postoperative Complications and Aesthetic Results: A 5-Year, Single-Center Study

BACKGROUND

Increasing adoption of implant-based breast reconstruction (IBR) has raised expectations regarding postoperative outcomes and aesthetic results. BMI has been extensively explored as a predictor of complications. This study is the first to examine complication rates in underweight subjects, and compares these rates among underweight, normal weight, overweight, and obese patients.

OBJECTIVES

The aim of this study was to investigate the influence of BMI on postoperative complications and aesthetic results in IBR following mastectomy.

METHODS

Retrospective analysis encompassed patients undergoing mastectomy with subsequent IBR, performed by a collaborative team of breast and plastic surgeons. Demographics, treatment specifics, and outcomes were evaluated by univariate and multivariate regression models. Significance was determined at P < .05.

RESULTS

In total, 1046 IBRs were performed in 921 patients, of whom 63 had a BMI <18.5 kg/m2, 572 were normal weight, 215 were overweight, and 71 were obese. Significantly higher complication rates were observed in both obese and overweight patients compared with normal-weight patients (P < .001). Each unit increase in BMI correlated to 7% increased odds of overall complications and 13% increased odds of reconstructive failure. Underweight individuals had higher capsular contracture rates than normal-weight patients, 14.3% vs 3.65%, respectively (P = .001). In addition, aesthetic complications rates in underweight patients were higher than in normal-weight patients, 36.4% vs 25.7%, respectively (P < .05).

CONCLUSIONS

This study confirmed BMI to be a strong predictor of postoperative complications and aesthetic outcomes, and demonstrates that low BMI has a significant impact on the incidence of capsular contracture and aesthetic complications.

LEVEL OF EVIDENCE: 3

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

INTRODUCTION

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Capsular Contracture Rate in Augmentation Mammoplasty With Motiva Breast Implant Insertion: A Single-Center Experience in Korea

BACKGROUND

Capsular contracture is the most common complication following breast implant surgery, and the implant shell characteristics are important in preventing this complication.

OBJECTIVES

The aim of this study was to evaluate the capsular contracture rate for SmoothSilk Motiva implants (Establishment Labs Holdings Inc., New York, NY) in females who underwent primary and revisional breast augmentation over a 3-year period.

METHODS

A total of 1324 cases that took place from 2017 to 2020 were retrospectively analyzed, with 1027 being primary surgeries and 297 being revisional surgeries.

RESULTS

In the 1324 cases of augmentation mammoplasty with SmoothSilk Motiva implants, the overall capsular contracture rate was 1.8% (n = 24). The capsular contracture rate in the 1027 primary surgery cases was 1.07% (n = 11), and the capsular contracture rate in the 297 revisional surgery cases was significantly different at 4.39% (n = 13, P = .0001). More specifically, the capsular contracture rate in 182 revisional surgery for cases without capsular contracture was 1.12% (n = 2), and it showed no statistically significant difference from the rate in primary surgery cases (P = .965). However, the rate in 115 revisional surgery for cases with capsular contracture was 9.57% (n = 11), and it showed a statistically significant difference from the rate in primary surgery cases (P = .000) and the rate in revisional surgery for cases without capsular contracture (P = .001).

CONCLUSIONS

Augmentation mammoplasty with SmoothSilk Motiva implants demonstrated a lower rate of capsular contracture than traditional smooth or textured implants. Revisional surgery for cases without capsular contracture showed a similar rate of capsular contracture to primary surgery cases, but the rates were higher in revisional surgery for cases with capsular contracture.

LEVEL OF EVIDENCE: 4

Single-Institution Early Experience With a New, Smooth, Opaque, and Round Breast Implant Over a 2-Year Period

Background

The ideal breast implant does not exist and the choice of implant for breast augmentation is largely based on what surgeons think will be best for their patients.

Objectives

To evaluate the preliminary results of a new, smooth, round, and opaque breast implant (PERLE, GC Aesthetics; Dublin, Ireland) from a single-center UK aesthetic practice.

Methods

Retrospective cohort study of all patients undergoing breast implant surgery with PERLE at the authors' center between January 2021 and December 2022. Outcomes data such as rates of capsular contracture, infection, revision surgery, and synchronous mastopexy were analyzed.

Results

Of the 385 patients identified, 374 (97.1%) had PERLE implants placed by 3 surgeons for primary (n = 290) and secondary breast augmentation (n = 21), and augmentation-mastopexy (n = 63). Capsular contracture occurred in no cases, infection in 1 (0.2%), and revision surgery in 21 patients (5%). The incision used was always submammary, unless a synchronous mastopexy was performed; implants were placed in the subglandular/subfascial plane in the majority of cases (85.3%), and the rest were dual plane (14.7%). Eight revisions were performed in patients undergoing breast augmentation (due to implant displacement in 6 patients, and hematoma and infection in 1 patient each). Fourteen revisions were performed in those undergoing augmentation-mastopexy. The average follow-up time was 18 months.

Conclusions

The authors' early, single-center experience with PERLE implants suggests a safety profile and overall complication rate that is comparable with other modern implants. They will continue to monitor the safety and effectiveness of PERLE and discuss the reasons and evolution in the choice of breast implant.

Level of Evidence 4

Complication Rates in Therapeutic Versus Prophylactic Bilateral Mastectomies: Insights From a National Database

BACKGROUND

The "Jolie effect" and other media focus on prophylactic treatments have resulted in unilateral breast cancer patients increasingly undergoing contralateral prophylactic mastectomy. Little is known, however, regarding outcomes following therapeutic versus prophylactic mastectomy. In this study, we compared complication rates of unilateral breast cancer patients undergoing contralateral prophylactic mastectomy (BM-TP) to patients undergoing bilateral prophylactic mastectomy (BM-P).

METHODS

The BM-TP and BM-P patients from 2015 to 2019 were identified in Optum Clinformatics DataMart. Six-month outcomes were assessed and included wound complications, infection, hematoma/seroma, breast pain, fat necrosis, flap failure, implant failure/removal, other flap/implant complications, and other complications. Multivariable regression models adjusted for age, residence, insurance, race, and Charlson Comorbidity Index score.

RESULTS

Of 9319 women, 7114 (76.3%) underwent BM-TP, and 2205 (23.7%) underwent BM-P. In multivariable analysis, BM-TP had higher odds of overall complications (adjusted odds ratio [aOR], 1.35; P < 0.0001), but no difference was observed among patients who had autologous ( P = 0.1448) or no breast reconstruction ( P = 0.1530). Higher odds of overall complications persisted even after controlling for radiation therapy (aOR, 1.25; P = 0.0048) and chemotherapy (aOR, 1.28; P = 0.0047), but not after controlling for lymph node surgery ( P = 0.7765).

CONCLUSION

The BM-TP (vs BM-P) patients face higher odds of overall complications but without any difference in certain reconstructive modalities or after controlling for lymph node surgery.

An Antifibrotic Breast Implant Surface Coating Significantly Reduces Periprosthetic Capsule Formation

BACKGROUND

The body responds to prosthetic materials with an inflammatory foreign body response and deposition of a fibrous capsule, which may be deleterious to the function of the device and cause significant discomfort for the patient. Capsular contracture (CC) is the most common complication of aesthetic and reconstructive breast surgery. The source of significant patient morbidity, it can result in pain, suboptimal aesthetic outcomes, implant failure, and increased costs. The underlying mechanism remains unknown. Treatment is limited to reoperation and capsule excision, but recurrence rates remain high. In this study, the authors altered the surface chemistry of silicone implants with a proprietary anti-inflammatory coating to reduce capsule formation.

METHODS

Silicone implants were coated with Met-Z2-Y12, a biocompatible, anti-inflammatory surface modification. Uncoated and Met-Z2-Y12-coated implants were implanted in C57BL/6 mice. After 21, 90, or 180 days, periprosthetic tissue was removed for histologic analysis.

RESULTS

The authors compared mean capsule thickness at three time points. At 21, 90, and 180 days, there was a statistically significant reduction in capsule thickness of Met-Z2-Y12-coated implants compared with uncoated implants ( P < 0.05).

CONCLUSIONS

Coating the surface of silicone implants with Met-Z2-Y12 significantly reduced acute and chronic capsule formation in a mouse model for implant-based breast augmentation and reconstruction. As capsule formation obligatorily precedes CC, these results suggest contracture itself may be significantly attenuated. Furthermore, as periprosthetic capsule formation is a complication without anatomical boundaries, this chemistry may have additional applications beyond breast implants, to a myriad of other implantable medical devices.

CLINICAL RELEVANCE STATEMENT

Coating of the silicone implant surface with Met-Z2-Y12 alters the periprosthetic capsule architecture and significantly reduces capsule thickness for at least 6 months postoperatively in a murine model. This is a promising step forward in the development of a therapy to prevent capsular contracture.

Histologic and Immunohistochemical Evaluation of Human Breast Capsules Formed around Five Different Expander Surfaces

BACKGROUND

Polyurethane (PU) coating and implant texturization were designed to reduce the incidence of capsular contracture (CC), even if the link between surface type and CC remains unclear. To date, the etiopathogenetic aspects have not been fully clarified. The aim of this study was to evaluate capsules formed around five different breast expanders.

METHODS

Thirty patients were divided into randomized groups implanted with five different expanders: smooth, coated with PU foam (poly), with a low-microtextured, high-microtextured, and macrotextured surface (L-micro, H-micro, macro). Specimens of the capsules were removed at implant reconstruction and evaluated for morphology and immunohistochemistry expression of α-smooth muscle actin (α-SMA), collagen type I and III, CD68, CD34, and CD3. Remodeling Combined Index was also evaluated.

RESULTS

Expression of α-SMA was significantly increased in smooth capsules versus poly, low-microtextured, and high-microtextured groups ( P = 0.007; P = 0.010; P = 0.028), whereas the prevalence of collagen type I in smooth capsules and collagen type III in poly capsules identified a stable versus an unstable tissue. Remodeling Combined Index and α-SMA showed an inverted correlation. CD68 and CD34 cellular expression increased significantly in poly capsules with respect to smooth ( P < 0.001; P < 0.001) and macrotextured groups ( P < 0.001; P < 0.001). CD3 showed no significant difference among the groups.

CONCLUSION

In this human study, the authors observed that increased tissue remodeling and reduced myofibroblast activation, along with the inflammatory infiltration and neoangiogenesis, especially in the poly and low-microtextured groups, might promote the formation of an unstable and less fibrotic capsule, lowering the risk of CC.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Therapeutic, III.

Stem Cell-Enriched Hybrid Breast Reconstruction Reduces Risk for Capsular Contracture in a Hybrid Breast Model

BACKGROUND

Hybrid breast reconstruction (HBR) combines silicone implants with fat grafting to improve implant coverage, treating local tissue deficiencies and leading to a more natural breast appearance. Recent data also indicated less capsular contracture after HBR. The authors developed a novel technique and animal model of cell-assisted (CA) HBR to illuminate its effects on capsular contracture.

METHODS

Animals received silicone implants in a dorsal submuscular pocket. Although animals of the HBR group received fat grafting around the implant without stem cell enrichment, rats of the CA-HBR1 and the CA-HBR2 groups received stem cell-enriched fat grafting with 2 × 10 6 and 4 × 10 6 adipose-derived stem cells immediately after implant insertion. On day 60, animals underwent sonography and elastography imaging and were euthanized, and outcome analysis was performed by means of histology, immunohistochemistry, chemical collagen quantification, and gene expression analysis.

RESULTS

With this novel technique, long-term survival of adipose-derived stem cells within the implant pocket was demonstrated after 60 days after implant insertion. CA-HBR led to significantly reduced thickness and collagen density of capsular contractures. In addition, CA-HBR resulted in reduced fibrotic responses with less occurrence of collagen type I and transforming growth factor-β in capsule tissue. Moreover, the addition of stem cells suppressed fibrotic and inflammatory responses on a genetic level with significant underexpression of collagen type I and transforming growth factor-β1.

CONCLUSIONS

With this new technique and animal model, the authors observed a preventive effect on capsular contracture substantiating the basis of clinical outcomes of HBR. The authors propose that the addition of stem cells to HBR might booster its beneficial results.

CLINICAL RELEVANCE STATEMENT

Stem cell-enriched fat grafting around silicone implants may reduce the risk for capsular contracture after silicone breast implantation. While fat grafting alone already shows beneficial effects, the addition of stem cells to the fat graft can potentiate this effect.

Surgical Management of Breast Amyloidosis

Amyloidosis is characterized by extracellular deposition of insoluble misfolded beta-pleated proteins. Amyloid disease involving the breast is rare and there is a paucity of literature guiding surgical management in caring for these patients. In this article we review medical and surgical management with an emphasis on post mastectomy breast reconstruction. We propose an algorithm for breast reconstructive options based on unique considerations in this patient population. An institutional database at the Medical College of Wisconsin was used to identify patients diagnosed with breast amyloidosis from 2011 to 2021. We utilized the electronic medical record to present patient demographics, diagnostic and treatment data regarding the medical and surgical management of these patients. Five women were identified with a median age of 70 years and a median follow up of 19 months (range, 9-80 months). All patients were diagnosed with light chain (AL) type of amyloidosis. Systemic amyloidosis was identified in 3 patients and localized disease was identified in 2 patients. Concurrent breast malignancy was identified in 2 patients who underwent skin-sparing mastectomies followed by breast reconstruction with both prosthetic and autologous techniques. Both prosthetic and autologous reconstructive techniques are safe in patients with amyloidosis, however careful consideration and preoperative work-up are warranted to avoid complications in this vulnerable population. Further studies are warranted to improve surgical outcomes in patients with amyloidosis involving the breast.

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

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

Methods

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

Results

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

Conclusions

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

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

Hybrid Microsurgical Breast Reconstruction:: HyFIL® & HyPAD™ Techniques

There are numerous indications for hybrid breast reconstruction, with the most common being patients who have inadequate donor site volume to achieve the desired breast volume. This article reviews all aspects of hybrid breast reconstruction, including preoperative and assessment, operative technique and considerations, and postoperative management.

Study of the Effect of Different Breast Implant Surfaces on Capsule Formation and Host Inflammatory Response in an Animal Model

BACKGROUND

Breast implants are biomaterials eliciting a physiological and mandatory foreign body response.

OBJECTIVES

The authors designed an animal study to investigate the impact of different implant surfaces on the formation of the periprosthetic capsule, the inflammatory response, and the cellular composition.

METHODS

The authors implanted 1 scaled-down version of breast implants by different manufactures on 70 female Sprague Dawley rats. Animals were divided into 5 groups of 14 animals. Group A received a smooth implant (Ra ≈ 0.5 µm) according to the ISO 14607-2018 classification, Group B a smooth implant (Ra ≈ 3.2 µm), Group C a smooth implant (Ra ≈ 5 µm), Group D a macrotextured implant (Ra ≈ 62 µm), and Group E a macrotextured implant (Ra ≈ 75 µm). At 60 days, all animals received a magnetic resonance imaging (MRI), and 35 animals were killed and their capsules sent for histology (capsule thickness, inflammatory infiltrate) and immunohistochemistry analysis (cellular characterization). The remaining animals repeated the MRI at 120 days and were killed following the same protocol.

RESULTS

MRI showed a thinner capsule in the smooth implants (Groups A-C) at 60 days (P < .001) but not at 120 days (P = .039), confirmed with histology both at 60 days (P = .005) and 120 days (P < .001). Smooth implants (Groups A-C) presented a mild inflammatory response at 60 days that was maintained at 120 days and a high M2-Macrophage concentration (anti-inflammatory).

CONCLUSIONS

Our study confirms that smooth implants form a thinner capsule, inferior inflammatory infiltrate, and a cellular composition that indicates a mild host inflammatory response. A new host inflammatory response classification is elaborated classifying breast implants into mild, moderate, and high.

Enhanced Recovery After Surgery Protocol Allows Safe Same-Day Discharge in Expander Based and Oncoplastic Breast Reconstruction

PURPOSE

Data after enhanced recovery after surgery (ERAS) with same-day discharge in breast reconstruction is limited. This study evaluates early postoperative outcomes after same-day discharge in tissue-expander immediate breast reconstruction (TE-IBR) and oncoplastic breast reconstruction.

METHODS

A single-institution retrospective review of TE-IBR patients from 2017 to 2022 and oncoplastic breast reconstruction patients from 2014 to 2022 was performed. Patients were divided by procedure and recovery pathway: group 1 (TE-IBR, overnight admission), group 2 (TE-IBR, ERAS), group 3 (oncoplastic, overnight admission), and group 4 (oncoplastic, ERAS). Groups 1 and 2 were subdivided by implant location: groups 1a (prepectoral) and 1b (subpectoral), and groups 2a (prepectoral) and 2b (subpectoral). Demographics, comorbidities, complications, and reoperations were analyzed.

RESULTS

A total of 160 TE-IBR patients (group 1, 91; group 2, 69) and 60 oncoplastic breast reconstruction patients (group 3, 8; group 4, 52) were included. Of the 160 TE-IBR patients, 73 underwent prepectoral reconstruction (group 1a, 25; group 2a, 48), and 87 underwent subpectoral reconstruction (group 1b, 66; group 2b, 21). There were no differences in demographics and comorbidities between groups 1 and 2. Group 3 had a higher average body mass index than group 4 (37.6 vs 32.2, P = 0.022). There was no significant difference between groups 1a and 2a or between groups 1b and 2b in rates of for rates of infection, hematoma, skin necrosis, wound dehiscence, fat necrosis, implant loss, or reoperations. Group 3 and group 4 showed no significant difference in any complications or in reoperations. Notably, no patients in same-day discharge groups required unplanned hospital admission.

CONCLUSIONS

Many surgical subspecialities have successfully adopted ERAS protocols into their patient care and have shown both its safety and feasibility. Our research shows that same-day discharge in both TE-IBR and oncoplastic breast reconstruction does not increase risk for major complications or reoperations.

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

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

Methods

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

Results

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

Conclusions

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

Prospective Study of Clinical Outcomes From a Breast Implant Assessment Service

BACKGROUND

Breast augmentation remains the commonest cosmetic surgical procedure worldwide, in spite of recent regulatory action.

OBJECTIVES

The aim of this study was to evaluate women with breast implants attending a breast implant assessment clinic and to capture clinical and implant data in women presenting to the service.

METHODS

Patients were enrolled prospectively between January 2018 and December 2021. Clinical, implant, and practitioner data were recorded. Patients reported satisfaction on size, shape, and overall outcome as well as the presence or pain. Radiological evaluation, where indicated, was performed and data were included on these findings.

RESULTS

A total of 603 patients were assessed. Their mean age was 42.7 years and mean age at implantation was 29.1 years. The most common complications were capsular contracture followed by pain, waterfall deformity, and double bubble, with rupture/contracture rates increasing after the 10-year mark. The risk of double bubble was significantly lower if patients were operated on by certified practitioners (odds ratio = 0.49, P = 0.011). There was almost universally poor awareness of the risks of breast implants in patients presenting for evaluation.

CONCLUSIONS

This study has shown benefit in a breast implant assessment clinic to gather information on adverse events and patient-reported outcomes following breast implant surgery. Having appropriately trained and certified practitioners perform cosmetic augmentation significantly lowers the risk of implant malposition and deformity. Any adverse event occurring within 5 years of initial surgery should be flagged as a mandatory reportable clinical indicator and trigger further investigation.

LEVEL OF EVIDENCE: 2

Is It All about Surface Topography? An Intra-Individual Clinical Outcome Analysis of Two Different Implant Surfaces in Breast Reconstruction

The most common long-term complication of silicone breast implants (SMI) remains capsular fibrosis. The etiology of this exaggerated implant encapsulation is multifactorial but primarily induced by the host response towards the foreign material silicone. Identified risk factors include specific implant topographies. Of note, breast implant-associated anaplastic large cell lymphoma (BIA-ALCL) has only been observed in response to textured surface implants. We hypothesize that reduction of SMI surface roughness causes less host response and, hence, better cosmetic outcomes with fewer complications for the patient. A total of 7 patients received the routinely used CPX^®4 breast expander (~60 µM Ra) and the novel SmoothSilk^® (~4 µM Ra), fixed prepectoral with a titanized mesh pocket and randomized to the left or right breast after bilateral prophylactic NSME (nipple-sparing mastectomy). We aimed to compare the postoperative outcome regarding capsule thickness, seroma formation, rippling, implant dislocation as well as comfortability and practicability. Our analysis shows that surface roughness is an influential parameter in controlling fibrotic implant encapsulation. Compared intra-individually for the first time in patients, our data confirm an improved biocompatibility with minor capsule formation around SmoothSilk^® implants with an average shell roughness of 4 µM and in addition an amplification of host response by titanized implant pockets.

Breast augmentation under local anesthesia with intercostal blocks and light sedation

INTRODUCTION

This study of breast augmentations performed under local anesthesia with intercostal blocks and light sedation describes the outcomes and evaluates benefits and complications.

METHOD

From December 2005 until August 2019, 335 women consecutively underwent bilateral breast augmentation procedures. The anesthetic protocol consisted of an initial intravenous bolus of 1 mg midazolam and 0.25 mg alfentanil preoperatively. In 2017, this was changed to 2-4 mg midazolam intramuscularly, 1 mg midazolam intravenously, and 2.5 µg sufentanil intravenously. Intercostal blocks were injected at the midaxillary line into the intercostal spaces two to seven. The operating field was infiltrated with tumescent local anesthesia. Retrospective data extraction from patients' medical charts was done, registering demographics, dosage of anesthesia, surgical characteristics, complications, and reoperation rates.

RESULTS

Two hundred and eighty-one women underwent primary augmentation and 54 had implant replacement. The most common complications included suboptimal cosmetic results, asymmetry, and healing-related problems. The overall rate of reoperation was 16.1% within an average follow-up period of 2 years, ranging from 0 to 12.5 years. The majority of the reoperations were due to cosmetic reasons. The change in anesthetic regime was associated with a significantly (p < 0.0001) decreased need for supplementary medication with no increased risk of complications.

CONCLUSION

Breast augmentations in local anesthesia with intercostal blocks and light sedation can be performed safely and can serve as an alternative to procedures in general anesthesia.

Nanotechnology: A revolutionary approach to prevent breast cancer recurrence

Breast cancer is the most prevalent malignancy in women worldwide and one of the deadliest after lung cancer. Currently, standard treatment approaches for breast cancers are surgery accompanied by chemotherapy or radiotherapy. Cancer local recurrence after mastectomy is commonly considered as being a poor prognostic predictor. There have been advancements in the procedures utilized for breast reconstruction following mastectomy, much as there have been advancements in the early diagnosis and treatment of breast cancer. For the last decade, developing nanotechnology applications for cancer therapies has had much focus. The benefits granted by nanotechnologies via enhancing biological processes and promoting better biomaterial compatibility, as well as generating functionalized tissues, transpire exciting possibilities. Modified nanomedicine may introduce tremendous improvements to the fields of breast cancer recurrence through implants. It can modify the surfaces of implants to optimize tissue growth, thus minimizing inflammation and unsatisfactory results. Here we discuss new nanotechnology advancements and incorporate them into breast reconstruction surgeries following mastectomy or lumpectomy. In addtion, we repurpose old technologies, like growth factor therapies using nanotechnology for more efficient delivery.

Oncoplastic Augmentation Mastopexy in Breast Conservation Therapy: Retrospective Study and Postoperative Complications

BACKGROUND

Oncoplastic techniques, in conjunction with lumpectomy and adjuvant radiotherapy, have been demonstrated to achieve good aesthetic results and cancer outcomes in the treatment of patients with macromastia or significant ptosis. This study evaluated a series of patients undergoing breast conservation with concomitant oncoplastic-augmentation-mastopexy and a contralateral augmentation-mastopexy.

METHODS

Patients undergoing lumpectomy for breast conservation were identified via a retrospective chart review. Inclusion criteria included patients with ptosis and preexisting breast implants or insufficient breast volume undergoing oncoplastic implant placement/exchange and mastopexy. Demographic characteristics, operative details, and complications were assessed.

RESULTS

Thirty-four consecutive patients (64 breasts, 4 unilateral procedures) were included in the study. Average age was 51.4 years, average body mass index was 27, and 38.2% were smokers/former smokers. The average operative time was 2.5 hours. Furthermore, 38.2% of patients received chemotherapy, and 82.4% of patients received breast adjuvant radiotherapy. The average length of follow-up was 11.7 months. In the sample that received radiation, the capsular contracture rate was 25%, with a 7.1% contracture revision rate. For the entire group, a total of 8 patients (23.5%) underwent revisions for either positive margins (8.8%), capsular contracture (8.8%), implant loss (2.9%), or cosmetic concerns (2.9%). One patient developed a pulmonary embolism.

CONCLUSIONS

Oncoplastic-augmentation-mastopexy is a safe technique with acceptable complication rates. This technique is best used for breast cancer patients with breast ptosis and a paucity of breast volume or preexisting implants who wish to pursue breast-conserving therapy. The revision rates are acceptable compared with single-stage cosmetic augmentation procedures as well as other oncoplastic techniques described in the literature, but patients must be clearly counseled on contracture risk.

Breast Reconstruction: Economic Impact Swiss Health Insurance System

BACKGROUND

Considering present concerns about healthcare costs and the lack of evidence and published articles on breast reconstruction costs in Switzerland, we retrospectively investigated charges to the Swiss healthcare system for different breast reconstruction procedures at the Centre Hospitalier Universitaire Vaudois.

METHODS

We selected all hospitalized patients at the University Hospital who underwent a "total" delayed breast reconstruction from January 2012 to December 2015. Analysis included 72 women who underwent autologous or implant-based reconstructions. Three main breast reconstruction techniques were included: Deep Inferior Epigastric Perforator (n = 46) autologous flap reconstruction, Tissue Expander followed by Implant (n = 12) and pedicled Latissimus Dorsi (n = 12) flap with or without tissue expander and implant (n = 7). For all different groups, the global costs of reconstruction and total number of required operations were statistically compared.

RESULTS

Global costs for Deep Inferior Epigastric Perforator reconstruction were 29,728 ± 1892 CHF (avg ± Std. Error of Mean), while Tissue Expander reconstruction showed a significantly higher global cost, reaching an average of 44,313 ± 5553 CHF (avg ± Std. Error of Mean). LD showed a similar cost, compared to the Deep Inferior Epigastric Perforator reconstruction (29,813 ± 3637 CHF), increasing when including an implant (37,688 ± 4840 CHF). No significant differences in the number of interventions were detected.

CONCLUSION

These data show that autologous breast reconstruction (DIEP) delivers the best cost ratio, with lower overall costs. Implant-based reconstructions showed a greater likelihood of complications and re-intervention, globally creating superior costs when compared to autologous reconstructions.

Preventing Soft Tissue Complications in Secondary Aesthetic Breast Surgery Using Indocyanin Green Angiography

BACKGROUND

Secondary cosmetic breast surgery after primary augmentation with implant can be associated with an increased risk of adverse events. Partial/complete nipple areolar complex (NAC) necrosis is particularly feared. In this preliminary study, the authors propose the use of Indocyanine Green (ICG) angiography in order to assess the blood supply of breast tissue after implant removal.

OBJECTIVES

The main objective is to prevent skin and gland necrosis in revision breast surgery.

METHODS

We performed a retrospective comparative analysis of 33 patients undergoing secondary breast surgery between 2018 and 2021 by a single surgeon (M.S.). Breast tissue perfusion was assessed in 16 patients by intraoperative ICG-angiography at the end of implant removal and possible capsulectomy. Non-stained/non-fluorescent areas were judged to be low perfusion areas and were excised with short scar mastopexy.

RESULTS

In the ICG-angiography group, 7 patients (44%) showed an area of poor perfusion along the inferior pole, all of these patients underwent subglandular breast augmentation. Resection of the poor perfusion areas allowed an uneventful postoperative course. In the non ICG-angiography group (17 patients), 5 patients experienced vertical scar dehiscence/necrosis. We found a statistically significant association between non-ICG angiography group and vertical scar dehiscence/necrosis, and also between vertical scar dehiscence/necrosis and subglandular implant placement (P-value = 0.04).

CONCLUSIONS

Safer secondary surgery can be offered to patients undergoing secondary aesthetic breast procedures, especially when the first augmentation surgery is unknown e.g. implant plane, type of pedicle used, the implant is large and subglandular, and capsulectomy is performed.

Case Report: Improved surgical treatment for breast capsular contracture by the punctiform-incision approach through the nipple

Capsular contracture is one of the most common complications of breast implants, which often leads to secondary surgery. Patients with unconspicuous breast contracture do not need treatment, while for those with severe symptoms, a capsule revision surgery is of great necessity, including a total periprosthetic capsulectomy and replacement with a new implant. However, if the capsular contracture happens in the submuscular space, it will be very difficult to release it completely, and it may lead to more complications such as damage to surrounding tissue. The new method of pouch can create a new subpectoral plane for the insertion of a new implant instead of a total capsulectomy, but this method is unsuitable for patients who have little breast tissue or thin skin. To solve this thorny clinical problem, we invented a double-headed separating instrument and came up with a novel operation method to release the capsular contracture, which opened from the nipple by the punctiform-incision approach and caused only a mild and undetectable trauma. This operation went off without a hitch, and the postoperative breast shape was good, and the breast felt and moved naturally. In addition, there were no significant complications throughout the one-year follow-up period. This case was an excellent demonstration of the novel breast capsular contracture release surgery using our optimized double-headed capsule contracture separator.

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

Rare reports linking textured breast implants to anaplastic large-cell lymphoma have generated controversies regarding their relative advantage over smooth implants. To evaluate trends in implant use in Israel, we sent a seven-item questionnaire to all active board-certified breast plastic surgeons in the country. About half responded. Approximately 60% of responders reported a moderate-to-considerable decrease in both the relative number of augmentation mammoplasty procedures and the use of implants during mastopexies in the last year. Nearly 40% had switched from textured to smooth implants to some extent. More than 40% still used textured implants for aesthetic procedures, and reconstructive procedures. Surgeons with more experience demonstrated a greater preference for smooth implants. The uncertainty regarding the safety of textured breast implants has led to a partial transition to the use of smoother implants and, importantly, to a general reduction in all breast-implant-based procedures.

Abdullah A, Alkhalidi H, Alrehaili M. Early onset of capsular contracture after breast augmentation with implant: report of two cases & review of literature

Capsular contracture (CC) is a local complication caused by an inflammatory reaction that leads to fibrosis. CC commonly occurs after one year of surgery. Hence, there has been no previously reported early onset of CC. Therefore, we report two unusual cases of early onset of post-breast reconstruction capsular contracture.

The Application of Anatomy Combined With Ultrasound Knife in Transaxillary Endoscopic Biplane Breast Augmentation

Objective

We aim to clarify the vascular and nerve anatomy of the breast and combine it with an ultrasound knife to use in transaxillary endoscopic biplane breast augmentation.

Methods

This study is a retrospective review of patients undergoing transaxillary endoscopic biplane breast augmentation between October and October 2021. Related variables were collected using a standardized data collection template. The detailed process of the transaxillary endoscopic biplane breast augmentation under anatomy instruction is carefully described in this study, and the postoperative effect was closely observed.

Results

Sixty-three female patients underwent transaxillary endoscopic biplane breast augmentation. The average implants volume counted 242.46 ± 31.34 cc, and the average operation time was 155.92 ± 22.34 min. Patients were followed up for a mean of 13.67 months (range, 3-27 months), and most of the patients achieved good postoperative results and no severe complications and were satisfied with both appearance and function.

Conclusions

The application of anatomy combined with an ultrasound knife in transaxillary endoscopic biplane breast augmentation is a promising way to achieve good breast shapes with high patient satisfaction and is worthy of clinical promotion and application.

A Single Center's Clinical Experience With Ergonomix Breast Implants

BACKGROUND

This retrospective study reports on the early experience of a private surgical center with Motiva Ergonomix SilkSurface breast implants.

OBJECTIVES

The aim of this study was to examine the incidence of complications and satisfaction levels in women who received primary and revision breast augmentation or augmentation-mastopexy with Ergonomix SilkSurface breast implants.

METHODS

A total of 356 consecutive patients received Ergonomix SilkSurface breast implants between April 2014 and October 2018 by 3 different surgeons and were followed-up for a minimum of 12 months. Complications were assessed by measuring the rate of rupture, capsular contracture, malposition, late seroma, double capsule, reoperation, symmastia, ptosis, extrusion, and infection. Satisfaction with aesthetic results was assessed on a Likert scale by both surgeon and patient.

RESULTS

Only 6 major complications were observed in these 356 patients (712 implants): 1 unilateral implant ptosis ("bottoming out") at 12 months (0.14%) and 2 capsular contractures (0.28%), 1 at 14 months and 1 at 2 years. At all time points, 98% of the patients were "extremely satisfied or very satisfied" with the aesthetic results, and the surgeons categorized the outcomes as "very important or important improvement" in 96% of the cases.

CONCLUSIONS

Motiva Ergonomix SilkSurface devices provided high patient satisfaction up to more than 5 years postoperatively with very few complications. These data are consistent with other reports in the literature. The observed favorable outcomes might be attributed, at least in part, to the bioengineered "cell-friendly" surface of these implants.

LEVEL OF EVIDENCE: 4

An Online Calculator for Estimating Breast Implant Volume from Imaging

Breast implant surgery remains one of the most common surgical procedures performed in the United States. Implant exchange can be complicated by unavailability of medical records or implant identification cards. Using chest imaging of 154 breast implants, an algorithm for estimating breast implant volume was generated. Based on four simple measurements and patient body mass index, a free, online calculator was created with a mean error of volume estimate of less than 1 cm3 and a SD of 44 cm3. In instances where a surgeon does not have implant records available but has chest imaging, this online tool can be used to obtain a relatively accurate estimate of implant volume.

The Value of Capsule Thickness on Breast Ultrasound as an Indicator of the Severity of Capsular Contracture and Its Correlation with the Baker Classification

BACKGROUND

We conducted this study to explore the value of the capsule thickness as an indicator of the severity of capsular contracture (CC) alternatively to the Baker classification system in patients who were treated with an implant-based augmentation mammaplasty.

METHODS

A total of 117 eligible patients (202 breasts) were included in the current study. We measured the capsule thickness using ultrasound and histologic examination in association with the Baker grades I, II, III and IV. Then, we analysed agreement of the capsule thickness between the two methods using an intra-correlation coefficient (ICC 2,1) with 95% confidence intervals (CIs). The CC of Baker grades II, III and IV (105 breasts), for which the capsule thickness could be measured using US, served as Model 1. Moreover, Model 1 including the CC of Baker grades I (97 breasts) served as Model 2.

RESULTS

The capsule thickness was measured as 0.58 ± 0.11 (0.4-0.8) mm, 1.07 ± 0.16 (0.8-1.31) mm and 1.89 ± 0.55 (1-4.1) mm on ultrasound in association with Baker grades II, III and IV, respectively. In addition, it was also measured as 0.28 ± 0.07 (0.09-0.41) mm, 0.58 ± 0.08 (0.42-0.75) mm, 1.06 ± 0.14 (0.79-1.34) mm and 2.13 ± 1.14 (1.38-6.98) mm on histologic examination in association with Baker grades I, II, III and IV, respectively. In Model 1 and 2, the ICC was calculated as 0.942 (95%CI 0.914-0.961) and 0.955 (95%CI 0.940-0.966), respectively. The cut-off values between the Baker grades I-II, II-III and III-IV were calculated as 0. mm, 0.8 mm and 1.2 mm, respectively.

CONCLUSIONS

In conclusion, the capsule thickness might be used as an indicator of the severity of CC alternatively to the Baker classification system. But further studies 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 the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Implant Malposition in Prepectoral Breast Reconstruction: Experience with Natrelle® Cohesive Implants over 6.5 Years

Implant malposition has been reported to be a common reason for revision surgery after implant-based breast reconstruction (IBR). With the recent increase in the use of smooth implants due to concerns for breast implant-associated anaplastic large-cell lymphoma with textured implants, we compared and reported the rates of malposition in prepectoral IBR and identified risk factors. A retrospective review of patients who underwent prepectoral IBR with Natrelle® (Allergan, Inc., Irvine, CA) implants at our institution between January 2014 and May 2020 was performed. Clinical characteristics, implant types, and the rate of malposition, defined as implant flipping or rotation, were recorded. Univariate and multivariable time-to-event analyses using the Cox proportional-hazards model were performed to identify predictors of malposition. Three hundred seventy-five patients (660 breasts) were included. Four hundred forty-one (66.8%) breasts had smooth round implants whereas 219 (33.2%) had textured anatomical devices. Malposition requiring either a manual correction or surgical intervention occurred in 26 (5.9%) smooth round implants versus 3 (1.4%) textured anatomical. Multivariable analysis showed that having a smooth round implant (aHR: 7.19, 95% CI: [2.04 - 25.4]) and an increase in implant volume (aHR: 1.003, 95% CI: [1.001 - 1.006]) were associated with having a malposition requiring intervention. Among smooth round implants; INSPIRA® Cohesive implants were more likely to result in a malposition requiring intervention (p<0.0001) compared to other smooth round implants. Overall, malposition requiring intervention occurred in 5.9% of smooth round implants and 1.4% of textured anatomical implants. Statistical analysis demonstrates that smooth round implants and an increase in implant volume both are associated with a malposition requiring intervention.

In Vivo and In Vitro Fibroblasts' Behavior and Capsular Formation in Correlation with Smooth and Textured Silicone Surfaces

BACKGROUND

As the most principal complication following breast augmentation with silicone breast implants, capsular contracture is greatly influenced by surface texture. However, there have long been widespread debates on the function of smooth or textured surface implants in reducing capsular contracture.

MATERIALS AND METHODS

Three commercially available silicone breast implants with smooth and textured surfaces were subjected to surface characterization, and in vitro and in vivo assessments were then implemented to investigate the effect of these different surfaces on the biological behaviors of fibroblasts and capsular formation in rat models.

RESULTS

Surface characterization demonstrated that all three samples were hydrophobic with distinct roughness values. Comparing the interactions of fibroblasts or tissues with different surfaces, we observed that as surface roughness increased, the adhesion and cell spreading of fibroblasts, the level of echogenicity, the density of collagen and α-SMA-positive immunoreactivity decreased, while the proliferation of fibroblasts and capsule thickness increased.

CONCLUSIONS

Our findings elucidated that the effect of silicone implant surface texture on fibroblasts' behaviors and capsular formation was associated with variations in surface roughness, and the number of myofibroblasts may have a more significant influence on the process of contracture than capsule thickness in the early stage of capsular formation. These results highlight that targeting myofibroblasts may be wielded in the prevention and treatment strategies of capsular contracture clinically.

LEVEL OF EVIDENCE V

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

The Effect of Biological Scaffold (Biodesign) in Postmastectomy Direct-to-Implant Breast Reconstruction: A 5-Year Single-Institution Experience

BACKGROUND

Direct-to-implant (DTI) breast reconstruction is one of the immediate implant-based breast reconstruction methods. If the amount of soft tissue (eg, muscle or fascia) is insufficient to completely cover the implant, biological scaffold or acellular dermal matrix can be safely used for implant coverage. In this study, we used an acellular porcine small intestinal submucosa (SIS) mesh (Biodesign; Cook Medical Inc, Bloomington, IN) for DTI reconstruction to explore the impact of its use on breast reconstruction results.

METHODS

We retrospectively assessed cases involving DTI reconstruction at Taipei Veterans General Hospital from 2015 to 2019. Women, 18 years or older, who underwent immediate DTI reconstruction after mastectomy were included in the study. Mastectomy may have been performed because of therapeutic or prophylactic reasons. Patients who did and did not use SIS mesh for reconstruction were studied separately, and the 2 groups were compared in terms of clinical outcomes and complications. The validated, self-administered BREAST-Q Reconstruction Module version 2.0 survey was used to evaluate health-related quality of life and satisfaction among patients who underwent breast reconstruction.

RESULTS

A total of 30 DTI breast reconstructions were enrolled. The mean age was 49.2 years, and the mean body mass index was 22.3 kg/m2. The mean postoperative follow-up duration was 17.1 months. Nipple-sparing mastectomy was performed for 26 cases (86.7%), and DTI breast reconstructions using SIS mesh for implant coverage were done in 14 cases (46.7%). The overall complication rate was 53.3% in 30 reconstructions, with nipple complications being the most common complication. The non-SIS and SIS-using groups had a similar overall complication rate postoperatively. As for the quality-of-life assessment, the SIS group obtained a higher score on BREAST-Q than those for whom SIS was not used.

CONCLUSIONS

Porcine SIS mesh might be a safe and effective alternative to biological scaffolds in immediate 1-stage implant-based breast reconstruction to improve the quality of life after surgery.

Smooth versus Textured Implants and Their Association with the Frequency of Capsular Contracture in Primary Breast Augmentation

BACKGROUND

Capsular contracture is the most frequent complication of breast implant augmentation. Although studies indicate that textured implants have a low incidence of contracture, they have been associated with anaplastic cell lymphoma, which influences the choice of surface. This study estimated and compared the annual capsular contracture rate of both smooth and textured implants in primary breast implants.

METHODS

Two hundred fifty-three patients (506 implants) were evaluated from January of 2017 to July of 2019; 42.2 percent of the implants were smooth and 57.8 percent were textured. The inframammary approach was used in the subfascial (55.3 percent) and submuscular (44.7 percent) pockets. The primary outcome was the appearance of capsular contracture (Baker grade II, III, and IV) within the first postoperative year.

RESULTS

Smooth implants had a higher capsular contracture rate at 1 year postoperatively compared with textured implants, although with borderline statistical significance (p = 0.06). Smooth surface breast implants in the subfascial plane had a 4-fold higher risk of contracture than those with a textured surface in the same plane (OR, 4.4; 95 percent confidence interval, 1.6 to 12.4). However, when placed in the submuscular plane, both textures had a similar contracture risk. The rate of contracture was similar after 2 years postoperatively (p = 0.21).

CONCLUSIONS

Using the inframammary approach and a standardized technique, there were no significant differences in the incidence of capsular contracture between the smooth and textured implants. In the subfascial plane, the contracture rate with smooth implants was higher than with textured implants. However, in the submuscular plane, there was no difference between the surfaces.

CLINICAL QUESTION/LEVEL OF EVIDENCW

Therapeutic, III.

Implants and Breast Pocket Irrigation: Outcomes of Antibiotic, Antiseptic, and Saline Irrigation

BACKGROUND

Breast implant-associated infection and capsular contracture are challenging complications that can result in poor outcomes following implant-based breast surgery. Antimicrobial irrigation of the breast pocket or implant is a widely accepted strategy to prevent these complications, but the literature lacks an evidence-based consensus on the optimal irrigation solution.

OBJECTIVES

The objective of this systematic review was to compare clinical outcomes, specifically capsular contracture, infection, and reoperation rates, associated with the use of antibiotic, antiseptic, and saline irrigation.

METHODS

A systematic review was performed in March 2020 based on the following search terms: "breast implant," "irrigation," "antibiotic," "bacitracin," "antiseptic," "povidone iodine," "betadine," "low concentration chlorhexidine," and "hypochlorous acid." Capsular contracture, infection, and reoperation rates were compared by analysis of forest plots.

RESULTS

Out of the 104 articles screened, 14 met the inclusion criteria. There was no significant difference in capsular contracture rates between antibiotic and povidone-iodine irrigation, although the data comparing these 2 groups were limited and confounded by the concurrent use of steroids. Antibiotic irrigation showed a significantly lower rate of capsular contracture compared with saline irrigation and a lower rate of capsular contracture and reoperation compared with no irrigation at all. Povidone-iodine was associated with lower rates of capsular contracture and reoperation compared with saline irrigation but there were no data on infection rates specific to povidone-iodine irrigation.

CONCLUSIONS

Our study supports the use of antibiotics or povidone-iodine for breast implant irrigation. Further research is required to better determine which of these 2 irrigation types is superior.

LEVEL OF EVIDENCE: 4

Trends in Breast Augmentation Research: A Bibliometric Analysis

BACKGROUND

Breast augmentation is one of the most demanded procedures in plastic surgery and one of the most commonly performed by plastic surgeons. However, a bibliometric analysis of breast augmentation has not been published in recent years. The current study aimed to use a bibliometric analysis to conduct a qualitative and quantitative evaluation of breast augmentation research and provide the research trends and hotspots in this field.

METHODS

Publications on breast augmentation research were extracted from the Web of Science core collection database. VOSviewer 1.6.18 was used to assess co-authorship, co-occurrence, citation of countries, institutions, authors, and journals, as well as hotspot keywords.

RESULTS

On February 8, 2022, 4637 records of breast augmentation research published from 1985 to 2021 were collected. The bulk of the retrieved studies were original research articles (n = 2235, 48.20%). A total of 1053 (22.71%) papers were open access. The annual publication output increased annually. The USA was the driving force in this field and had a strong academic reputation. The top-contributing institution was the University of Texas MD Anderson Cancer Center (2.37%, with 110 publications). Plastic and reconstructive surgery (998 publications, 21.52%) published the most research in this field and was also the most frequently co-cited journal (22,351 citations, total link strength (TLS): 409,301). Clemens MW (68 publications, 1.47%) was the most prolific author, and Spear SL (1456 citations, TLS: 27,231) was the most frequently co-cited author. The research hotspots included the following four aspects: safety and effectiveness of breast implants, implant-based breast reconstruction, breast cancer incidence after breast implantation, and breast implant-associated anaplastic large-cell lymphoma (BIA-ALCL). The research trends were BIA-ALCL, implant-based breast reconstruction, BREAST-Q, acellular dermal matrix, capsular contracture, and autologous fat grafting.

CONCLUSION

The present study provides a panoramic view of breast augmentation research in plastic and reconstructive surgery. This novel comprehensive bibliometric analysis can help researchers and nonresearchers alike to rapidly identify the potential partners, research hotspots, and research trends within their areas of interest.

LEVEL OF EVIDENCE III

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