Breast Implant Surfaces and Their Impact on Current Practices: Where We Are Now and Where Are We Going?

Surgical Management of Textured Breast Implants: Assessing Risk and Analyzing Patient-Reported Outcomes

BACKGROUND

Textured implants have been linked to breast implant-associated anaplastic large-cell lymphoma (BIA-ALCL). Patients who undergo explantation have options for reconstruction, but data on safety and patient-reported outcomes (PROs) are limited. The purpose of this study was to classify complications and PROs in patients opting for surgical management of textured implants.

METHODS

Complication rates and BREAST-Q scores were compared between (1) asymptomatic patients who underwent conversion from textured to smooth implants ( n = 224), (2) symptomatic patients who underwent conversion from textured to smooth implants ( n = 83), (3) patients who underwent explantation without replacement ( n = 44), and (4) patients who underwent replacement with autologous reconstruction ( n = 33). Linear regression examined PROs controlling for clinical and surgical variables.

RESULTS

Overall complication rates in 384 patients (637 implants) differed across groups ( P = 0.034), with the highest rate (25%) in patients who underwent explantation without replacement. These patients were specifically more impacted by minor complications, notably seroma. Capsulectomy extent did not significantly impact complications. Asymptomatic and symptomatic smooth implant patients had improvements in Satisfaction with Breasts ( P < 0.05). Autologous reconstruction patients had significant improvements in Satisfaction with Breasts sustained after 3 months postoperatively ( P < 0.01) and Sexual Well-being sustained after 6-months postoperatively ( P < 0.05). Patients who underwent removal without replacement had lower Physical Well-being of the Chest scores at 1 year or more than the other groups.

CONCLUSIONS

Replacement of textured implants with smooth implants or flaps is safe and is associated with improved satisfaction with breasts and quality of life. The degree of capsulectomy does not appear to impact the incidence of perioperative complications.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Therapeutic, III.

Inferolateral Pectoralis Sling Technique for Augmentation Mastopexy

BACKGROUND

Augmentation mastopexy remains a challenging procedure. The goal is to achieve correction of breast ptosis whilst adding implant volume, and avoid complications of premature waterfall deformity, bottoming out and further revision surgery, particularly when using smooth implants. We aim to describe and evaluate a technique to reduce implant malposition in augmentation mastopexy.

METHODS

This is a technical description and retrospective review of a single surgeons' cases from 2019 to 2022 of all patients who underwent 1 stage subpectoral breast augmentation mastopexy with the inferolateral pectoralis sling.

RESULTS

Over the four year period, 284 patients (568 breasts) underwent augmentation mastopexy with the inferior pectoralis sling. Mean implant size was 360.7cc (range 180-625cc). There were no early complications and 6 (2.1%) patients had late minor complications, with five (1.8%) undergoing revision mastopexy with implant repositioning and 1 (0.4%) undergoing areola scar revision. 20 patients (7%) underwent an implant upsize procedure with the average volume increase being 218.5cc and the average time to upsize 13.6 months (range 6-36 months) CONCLUSIONS: Use of the inferolateral pectoralis muscle sling allows successful one stage augmentation mastopexy with low complication and revision rates.

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 .

Breast Implant-Associated Anaplastic Large Cell Lymphoma: A Case Report about a Male Patient with Pectoral Implants

Introduction

Breast implant-associated anaplastic large cell lymphoma (BIA-ALCL) is still a rare extralymphatic lymphoma. As of March 1, 2023, approximately 1,355 cases of BIA-ALCL have been reported worldwide. However, no such case has yet been described with pectoral implants in male patients. Most patients with BIA-ALCL present with nonspecific implant-associated symptoms such as late-onset seroma, swollen breasts, and deformation of implants.

Case Presentation

Here, we describe BIA-ALCL in a 76-year-old male patient who presented with a late-onset seroma in order to raise awareness for BIA-ALCL also in men after esthetic chest surgery with silicone pectoral implants. The patient had undergone augmentation of the pectoralis muscle with implants for esthetic reasons 9 years before. First cytological specimens showed no malignancy. A repeated cytological assessment after 6 weeks from recurring seroma showed characteristic CD30+ T-cell clones. Surgery with complete bilateral capsulectomy and implant removal was performed. Due to the early-stage ALCL being limited only to the capsule and no evidence of systemic disease, adjuvant systemic treatment was not considered necessary.

Conclusion

Any persisting late-onset seroma also in male patients with pectoral implants should raise suspicion of ALCL as differential diagnosis and should be assessed with cytological examination.

Decision making in breast implant selection for breast reconstruction: A mixed-method study among plastic surgeons

Background

Breast implants and the (dis)advantages of their characteristics (shape, filling, surface, and brand) have been studied extensively. When selecting a specific breast implant, a plastic surgeon makes a trade-off between the various (dis)advantages. However, the factors affecting the choice of their preferred breast implant have not been studied in detail.

Methods

This is a mixed-method study. First, five plastic surgeons were interviewed to identify factors that influence their choice of a breast implant in a reconstructive setting. Second, 42 plastic surgeons were asked to state their preferred implant, weigh the collected factors, and indicate when they would deviate from their preferred implant.

Results

The interviews produced a varied list of factors that influenced the choice of breast implant, including complication rates, marketing, economic, and logistic factors. The results from the survey showed variation in preferred implant and substantial variations in the weighing of these factors. The two most important factors were "study outcomes" and "brand reputation". Ninety percent of the respondents were willing to deviate from their preferred implant, with the patient's preference being the main indication to deviate.

Conclusions

The list of factors that influence the plastic surgeons' choice of a breast implant in a reconstructive setting is extensive and their weighing showed substantial variation. Implant choice was not based solely on scientific evidence. Brand reputation was valued highly, implying that media and marketing may have considerable influence. Therefore, patients must be informed extensively about all aspects of breast implants during shared decision making to obtain true informed consent.

Endoscopically Assisted Correction of Malpositioned Breast Implants Using Absorbable Barbed Sutures

INTRODUCTION

Breast implant malpositioning is the second most common reason for revisional breast surgery. Multiple correction methods are suggested, depending on the malposition, but most of the methods, such as the inframammary fold incision, result in additional scars. We performed transaxillary endoscopic breast implant bottoming out corrections and used V-Loc thread for capsulorrhaphy.

METHODS

Fourteen patients who underwent correction for breast implant bottoming out after transaxillary breast augmentation were included in this study. Transaxillary endoscopic correction was performed using a V-Loc thread.

RESULTS

All the 14 patients were satisfied with the result immediately after surgery. One case of overcorrection and one with implant bottoming out occurred, but did not require additional surgery.

CONCLUSIONS

Transaxillary endoscopic bottoming out correction is a useful technique for those individuals who underwent primary transaxillary incisional breast augmentation. V-Loc thread is useful for endoscopic capsulorrhaphy.

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 .

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

SUMMARY

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

Management of Biofilm with Breast Implant Surgery

LEARNING OBJECTIVES

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

SUMMARY

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

Use of High-Resolution Ultrasound in Characterizing the Surface Topography of a Breast Implant

Background and Objectives: With the emergence of breast implant-associated anaplastic large cell lymphoma (BIA-ALCL), it has become necessary to identify the implant shell type patients have received. Therefore, an immediate, reliable method for identifying a breast implant shell type is essential. Evidence-based research and applying a real-world technique that identifies the surface topographic information of the inserted breast implants, without surgery, has become of paramount importance for breast implant physicians. Methods and Materials: A review of the medical records of 1901 patients who received 3802 breast implants and subsequently received an ultrasound-assisted examination was performed. All patients received not only a breast cancer examination but also a high-resolution ultrasonography (HRUS) assisted examination of the device at a single center between 31 August 2017 and 31 December 2022. Results: Most patients had breast implants within 10 years (77.7%) of the examination. Of the 3802 implants screened, 2034 (53.5%) were identified with macro-textured shell topography in ultrasonography. A macrotextured shell type implant was used in 53.5% of cases and a smooth type in 42.7% of cases. Seventy-three (1.9%) breast implant shell types could not be identified due to ruptures. However, 250 breast implant shell types could be identified despite rupture cases (6.5%). Conclusions: HRUS was found to be a useful and reliable image modality for identifying various surface shell types of breast implants. The shell type information would be helpful to patients who lack information about their breast implants and are concerned about BIA-ALCL.

Breast Implant-Associated Tumors

In addition to anaplastic large T-cell lymphomas (BIA-ALCL), other implant-related tumors have been described for some years. Squamous cell carcinoma (SSC) and B-cell lymphomas occurred in very rare cases. The unexplained pathogenesis as well as the unclear individual risk profile is an ongoing source of uncertainty for patients and physicians. The pathogenesis of the tumors is still largely not understood. While BIA-ALCL occurs more frequently with textured breast implants, other tumors were also observed with smooth implants and at other implant sites. Multiple potential mechanisms are discussed. It is suspected that the etiology of a chronic inflammatory response and subsequently immunostimulation is multifactorial and appears to play a key role in the malignant transformation. Since there are currently no sufficiently valid data for a specific risk assessment, this must be done with caution. This article presents the incidence, pathogenesis, as well as the level of evidence according to the current state of knowledge, and evaluates and discusses the current literature.

EBV-Positive Diffuse Large B-Cell Lymphoma in Association with Polyurethane Textured Breast Implants: Case Report and Literature Overview

OBJECTIVE

Lymphomas associated with breast implants are mostly of the T-cell type which typically present as a late-onset seroma or palpable mass adjacent to the implant. Primary lymphomas of the breast, in the absence of breast implants, are mostly of the B-cell type. However, we present a case of an Epstein-Barr virus-positive diffuse large B-cell lymphoma in a patient with polyurethane textured implants.

CASE

A 75-year-old woman presented with a sudden onset of swelling in her right breast. Her medical history revealed a unilateral mastectomy at the age of 48 for an invasive ductal adenocarcinoma in her left breast. Reconstruction was performed using bilateral McGhan style 150 implants. Nine years later, she was diagnosed with Baker IV capsular contracture and bilateral rupture, as seen on magnetic resonance imaging. A complete capsulectomy with implant change (Polytech, Replicon® SL HP) and mastopexy on the right was performed. Given her history and the sudden onset of swelling, the situation was concerning. Ultrasound showed a large mass in contact with the implant and an effusion around it. After mastectomy with explantation and capsulectomy, she was diagnosed with an Epstein-Barr virus-associated diffuse large B-cell lymphoma (DLBCL) of the capsule in association with textured breast implants.

CONCLUSION

We report the first case of polyurethane textured implant association with the rare entity of EBV+ DLBCL. Our aim is to renew awareness of the clinical significance of late periprosthetic seroma and highlight the need for documenting all cases to advance our understanding of breast implant-associated lymphoma.

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 .

Textured vs. Smooth Breast Implants Using the Jones Criteria-What Is the Currently Available Evidence for BIA-ALCL?: A Systematic Review

Breast-Implant-Associated Anaplastic Large-Cell Lymphoma (BIA-ALCL) is a rare low-incidence type of T-cell non-Hodgkin lymphoma, arising in the capsule around breast implants, and predominantly associated with the use of macro-textured breast implants. The purpose of this study was to use an evidence-based approach to systematically identify clinical studies comparing smooth and textured breast implants in women with regard to the risk of developing BIA-ALCL.

METHODS

A literature search in PubMed in April 2023 and the article reference list of the French National Agency of Medicine and Health Products decision from 2019 were screened for applicable studies. Only clinical studies where the Jones surface classification could be applied (required information: breast implant manufacturer) for comparison of smooth and textured breast implants were considered.

RESULTS

From a total of 224 studies, no articles were included due to the lack of fit to the strict inclusion criteria.

CONCLUSIONS

Based on the scanned and included literature, implant surface types in relation to the incidence of BIA-ALCL were not evaluated in clinical studies and data from evidence-based clinical sources plays a minor to no role in this context. An international database that combines breast implant-related data from (national, opt-out) medical device registries is, therefore, the best available option to obtain relevant long-term breast implant surveillance data on BIA-ALCL.

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

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

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.

The Role of Microorganisms in the Development of Breast Implant-Associated Anaplastic Large Cell Lymphoma

Breast implant-associated anaplastic large cell lymphoma (BIA-ALCL) is a variant of anaplastic large cell lymphoma (ALCL) associated with textured-surface silicone breast implants. Since first being described in 1997, over 1100 cases have been currently reported worldwide. A causal relationship between BIA-ALCL and textured implants has been established in epidemiological studies, but a multifactorial process is likely to be involved in the pathogenesis of BIA-ALCL. However, pathophysiologic mechanisms remain unclear. One of the hypotheses that could explain the link between textured implants and BIA-ALCL consists in the greater tendency of bacterial biofilm in colonizing the surface of textured implants compared to smooth implants, and the resulting chronic inflammation which, in predisposed individuals, may lead to tumorigenesis. This review summarizes the existing evidence on the role of micro-organisms and rough surface implants in the development of BIA-ALCL. It also provides insights into the most updated clinical practice knowledge about BIA-ALCL, from clinical presentation and investigation to treatment and outcomes.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Advances in surface modifications of the silicone breast implant and impact on its biocompatibility and biointegration

Silicone breast implants are commonly used for cosmetic and oncologic surgical indications owing to their inertness and being nontoxic. However, complications including capsular contracture and anaplastic large cell lymphoma have been associated with certain breast implant surfaces over time. Novel implant surfaces and modifications of existing ones can directly impact cell-surface interactions and enhance biocompatibility and integration. The extent of foreign body response induced by breast implants influence implant success and integration into the body. This review highlights recent advances in breast implant surface technologies including modifications of implant surface topography and chemistry and effects on protein adsorption, and cell adhesion. A comprehensive online literature search was performed for relevant articles using the following keywords silicone breast implants, foreign body response, cell adhesion, protein adsorption, and cell-surface interaction. Properties of silicone breast implants impacting cell-material interactions including surface roughness, wettability, and stiffness, are discussed. Recent studies highlighting both silicone implant surface activation strategies and modifications to enhance biocompatibility in order to prevent capsular contracture formation and development of anaplastic large cell lymphoma are presented. Overall, breast implant surface modifications are being extensively investigated in order to improve implant biocompatibility to cater for increased demand for both cosmetic and oncologic surgeries.

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.

Pharmacological Approaches for the Prevention of Breast Implant Capsular Contracture

Capsular contracture is a common complication associated with breast implants following reconstructive or aesthetic surgery in which a tight or constricting scar tissue capsule forms around the implant, often distorting the breast shape and resulting in chronic pain. Capsulectomy (involving full removal of the capsule surrounding the implant) and capsulotomy (where the capsule is released and/or partly removed to create more space for the implant) are the most common surgical procedures used to treat capsular contracture. Various structural modifications of the implant device (including use of textured implants, submuscular placement of the implant, and the use of polyurethane-coated implants) and surgical strategies (including pre-operative skin washing and irrigation of the implant pocket with antibiotics) have been and/or are currently used to help reduce the incidence of capsular contracture. In this article, we review the pharmacological approaches-both commonly practiced in the clinic and experimental-reported in the scientific and clinical literature aimed at either preventing or treating capsular contracture, including (i) pre- and post-operative intravenous administration of drug substances, (ii) systemic (usually oral) administration of drugs before and after surgery, (iii) modification of the implant surface with grafted drug substances, (iv) irrigation of the implant or peri-implant tissue with drugs prior to implantation, and (v) incorporation of drugs into the implant shell or filler prior to surgery followed by drug release in situ after implantation.

High-Throughput Biofilm Assay to Investigate Bacterial Interactions with Surface Topographies

The specific topography of biomaterials plays an important role in their biological interactions with cells and thus the safety of medical implants. Antifouling materials can be engineered with topographic features to repel microbes. Meanwhile, undesired topographies of implants can cause complications such as breast implant-associated anaplastic large cell lymphoma (BIA-ALCL). While the cause of BIA-ALCL is not well understood, it is speculated that textured surfaces are prone to bacterial biofilm formation as a contributing factor. To guide the design of safer biomaterials and implants, quantitative screening approaches are needed to assess bacterial adhesion to different topographic surface features. Here we report the development of a high-throughput microplate biofilm assay for such screening. The assay was used to test a library of polydimethylsiloxane (PDMS) textures composed of varying sizes of recessive features and distances between features including those in the range of breast implant textures. Outliers of patterns prone to bacterial adhesion were further studied using real-time confocal fluorescence microscopy. The results from these analyses revealed that surface area itself is a poor predictor for adhesion, while the size and spacing of topographic features play an important role. This high-throughput biofilm assay can be applied to studying bacteria–material interactions and rational development of materials that inhibit bacterial colonization.

2022 Practice Recommendation Updates From the World Consensus Conference on BIA-ALCL

BACKGROUND

Laboratory and clinical research on breast implant-associated anaplastic large cell lymphoma (BIA-ALCL) is rapidly evolving. Changes in standard of care and insights into best practice were recently presented at the 3rd World Consensus Conference on BIA-ALCL.

OBJECTIVES

The authors sought to provide practice recommendations from a consensus of experts, supplemented with a literature review regarding epidemiology, etiology, pathogenesis, diagnosis, treatment, socio-psychological aspects, and international authority guidance.

METHODS

A literature search of all manuscripts between 1997 and August 2021 for the above areas of BIA-ALCL was conducted with the PubMed database. Manuscripts in different languages, on non-human subjects, and/or discussing conditions separate from BIA-ALCL were excluded. The study was conducted employing the Delphi process, gathering 18 experts panelists and utilizing email-based questionnaires to record the level of agreement with each statement by applying a 5-point Likert Scale. Median response, interquartile range, and comments were employed to accept, reject, or revise each statement.

RESULTS

The literature search initially yielded 764 manuscripts, of which 405 were discarded. From the remaining 359, only 218 were included in the review and utilized to prepare 36 statements subdivided into 5 sections. After 1 round, panelists agreed on all criteria.

CONCLUSIONS

BIA-ALCL is uncommon and still largely underreported. Mandatory implant registries and actions by regulatory authorities are needed to better understand disease epidemiology and address initial lymphomagenesis and progression. Deviation from current diagnosis and treatment protocols can lead to disease recurrence, and research on breast implant risk factors provide insight to etiology.

LEVEL OF EVIDENCE: 4

Breast Implant Illness: Surgical, Autoimmune, and Breast Reconstruction Associations

Breast implant illness refers to a combination of different symptoms related to breast implant surgery, including fatigue, brain fog, and arthralgias. This malaise occurs after cosmetic and reconstructive breast surgeries, although it has not been proven to be a disease. Even recent studies have reported concluding statements of the etiology, diagnosis, and treatment as unclear and widely unknown. Therefore, this review aimed to determine the associations between the manifestations of breast implant illness in surgery and breast reconstruction, as well as the autoimmune responses involved. Complications associated with breast implants include breast pain, capsular contracture, infections, as well as other manifestations specific to breast reconstruction. Moreover, patients with implants may present with new-onset systemic sclerosis, Sjögren’s syndrome, and connective tissue diseases. However, the incidence of capsular contracture has steadily decreased with each generation of implants, particularly since the development of textured implants, as well as with the use of antibiotics and antiseptic pocket irrigation. However, the incidence of anaplastic large cell lymphoma has increased with the use of textured implants. Remarkably, the autoimmune response to these implants remains unclear. Therefore, close follow-up, careful observation of any symptom presentation, and evidence-based treatment decisions are necessary for patients with breast implants.

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

Is It Possible To Differentiate Types Of Breast Implants By Imaging In The Era Of Implant Associated Lymphoma?

Objectives Breast implant-associated anaplastic large-cell lymphoma (BIA-ALCL) has been recognised in the latest years and there is an ongoing extensive research. Although the exact mechanism and cause are still not clear, we now know that the disease is more associated with textured implants. To the best of our knowledge, no previous study investigating the radiological differential of various implants has been conducted. In this essay, we aimed to demonstrate dicriminating in vitro and in vivo imaging features, if any, of variuos types of breast implant devices using mammography, ultrasound, and Magnetic Resonance Imaging (MRI). METHODS Five different implant devices from various manufacturers with different surface materials which are smooth, microtextured, regular macrotextured, lightweight macrotextured, polyurethane coated were involved. In vitro mammography was performed with a digital mammogram (Amulet Innovality, Fuji, Japan) and in vitro and in vivo sonography was performed with Esaote MyLab9 using a 7.5 MHz linear probe. In vitro MRI was performed with 1.5T magnet (Symphony TIM upgrade and Aera, Siemens Healthcare, Erlangen, Germany), with 7 channel breast coil (Sense coil, Innova, Germany). MRI studies included fat sat T2 weighted sequences (T2WS), non-fat sat T2WS and silicone only sequences. Results Each imaging technique had different contributions for dealing with this challenge. Mammography and MRI were limited on identifying the double bands of the capsule. On mammogram, we could only differentiate the lightweight macrotextured implant as the borosilicate microspheres were represented by tiny, round lucencies within the gel. Ultrasound imaging with the proper technique was very helpful for identfying the surface. On in vitro sonogram, the inner capsule (implant shell) was identified as parallel double echogenic bands. Bands of the smooth implant were better delineated compared to the textured implants. The double echogenic bands of the polyurethane coated implant were not even identified separetely. Reverberation artefact caused by the smooth implant was the main discriminating in vivo sonographic feature of smooth implants. On in vitro MRI, we could identify the hyperintense polyurethane coated capsule on fat sat T2WS and non-fat sat T2WS. The tiny hypointense microspheres of the lightweight implant was also identified on the silicone only sequence of the in vitro MRI. Conclusion In this study, we have showed that breast implant material and type may be differed by the help of in vitro and in vivo imaging characteristics on different radiological modalities. These different imaging features could be used for recognising and labelling the implant type, especially macro textured implants which are reported to be more associated with breast implant-associated anaplastic large-cell lymphoma (BIA-ALCL) compared to other types. We believe evaluating these imaging characteristics during daily practice will help radiologists to become aware of the implant type and possible complications or diseases associated with that type.

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 Key of Pocket Dissection in Transaxillary Dual-plane Breast Augmentation: How to Control Inferior Malposition of Smooth Implants

BACKGROUND

Inferior implant malposition after breast augmentation is the second most common reason for revision surgery. This article introduces the new concept of dual-plane pocket formation in transaxillary breast augmentation to prevent inferior implant malposition by preserving the continuity of the superficial layer of the deep pectoralis fascia.

METHODS

Patients who underwent transaxillary endoscopic breast augmentation performed from January 2017 to December 2019 were retrospectively reviewed. With the aid of the endoscope, dissection proceeded. During pectoralis muscle origin detachment, the superficial layer of deep pectoralis fascia was preserved. After making the pocket, silicone gel implants were inserted. A retrospective chart review was done to collect data on postoperative complications.

RESULTS

A total of 251 patients were performed, and the mean follow-up time was 20.6 months. In a total of 28 cases of complications (9.6%), there were 2 cases of reoperations. In a total of three patients (1.2%) of implant malposition, one patient (0.4%) developed mild bilateral bottoming-out deformity.

CONCLUSIONS

Meticulous dissection by endoscopy could avoid the destruction of the superficial layer of the deep pectoralis fascia during pocket dissection and produce an intact fascial system with its own continuity at the inframammary fold (IMF). A well-controlled envelope over the implant and a supporting structure underneath it are important in breast augmentation to prevent inferior implant malposition.

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

BACKGROUND

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

OBJECTIVES

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

LEVEL OF EVIDENCE IV

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

A Preliminary Retrospective Study to Assess the Short-Term Safety of Traditional Smooth or Microtextured Silicone Gel-Filled Breast Implants in Korea

Background and objectives: We conducted this preliminary retrospective study to assess the short-term safety of silicone gel-filled breast implants (SGBIs) that are commercially available in Korean women. Materials and methods :The current retrospective, observational study was conducted in a total of 2612 patients (n = 2612) who underwent augmentation mammaplasty using breast implants at our hospitals between 1 January 2017 and 31 August 2021. Results: Overall, there were a total of 248 cases (9.49%) of postoperative complications; these include 112 cases of early seroma, 52 cases of shape deformation, 32 cases of CC, 12 cases of early hematoma, 12 cases of rupture, 12 cases of infection, 12 cases of stretch deformities with skin excess and 4 cases of rippling. Overall complication-free survival of the breast implant was estimated at 1564.32 ± 75.52 days (95% CI 1416.39–1712.32). Then, the Motiva Ergonomix™ SilkSurface showed the longest survival (1528.00 ± 157.92 days [95% CI 1218.48–1837.56]), followed by the BellaGel® SmoothFine (1458.4 ± 65.76 days [95% CI 1329.56–1587.28]), the Sebbin® Sublimity (1322.00 ± 51.20 days [95% CI 1221.64–1422.32]), the BellaGel® Smooth (1138.72 ± 161.28 days [95% CI 822.6–1454.84), the Mentor® MemoryGel™ Xtra (698.4 ± 52.64 days [95% CI 595.28–801.52]) and the Natrelle® INSPIRA™ (380.00 ± 170.88 days [95% CI 45.04–714.96]) in the decreasing order. On subgroup analysis, both the Motiva ErgonomixTM and Mentor® MemoryGel™ Xtra showed no postoperative complications. However, the BellaGel® SmoothFine, Sebbin® Sublimity and BellaGel® Smooth showed incidences of 8.87%, 4.84% and 1.61%, respectively. A subgroup analysis also showed differences in incidences of postoperative complications between microtextured and smooth breast implants (15.18% vs. 16.67%). Conclusions: In conclusion, our results indicate that diverse types of an SGBI are commercially available and their safety profile varies according to the manufacturer. Plastic surgeons should consider the safety profile of each device in selecting the optimal types of the device for Korean women who are in need of an implant-based augmentation mammaplasty. However, this warrants a single-surgeon, single-center study with long periods of follow-up.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

LEVEL OF EVIDENCE IV

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

Objective Comparison of FDA-Approved Breast Implant Products in the USA: 5-Year Update

BACKGROUND

There are currently four companies offering FDA-approved breast implants: Allergan, Sientra, Mentor, and Ideal Implant. In 2015, our paper "Objective Comparison of Commercially Available Breast Implant Devices" sought to provide a unique conceptual framework to better understand the similarities and differences between FDA-approved breast implant products and tissue expanders. This paper uses the same variables, such as fill material, shape, relative dimensions, and surface coating, to aid understanding of both the surgical trainee and the operating surgeon of what devices each company offers, with a focus on how the market has evolved over the ensuing 5 years.

METHODS

The product catalogs of each FDA-approved company were carefully explored to determine the current available breast implants and tissue expanders. Subsequently, flow charts were created to provide a clear and objective survey of each companies' offerings, highlighting where there are overlap and deficiencies, and where there has been contraction or growth.

RESULTS

Disruptions to the industry, including both technological innovation and the recognition of breast implant-associated anaplastic large cell lymphoma (BIA-ALCL), have caused a significant shift in the details of the available permanent breast implants, breast tissue expanders, sizers, and warranty programs.

CONCLUSION

As it has been in 2015, company jargon and brand names continue to make it challenging to discern the similarities and differences between company devices and programs. This project remained independent of any company's funding, support, or input, making it a uniquely objective and informative survey of the current breast implant market that should assist surgeons in decision-making regarding the breast implant procedures.

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 .

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

BACKGROUND

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

OBJECTIVES

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

LEVEL OF EVIDENCE IV

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

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

BACKGROUND

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

OBJECTIVES

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

LEVEL OF EVIDENCE 4

The surface topography of silicone breast implants mediates the foreign body response in mice, rabbits and humans

Silicone is widely used in chronic implants and is generally perceived to be safe. However, textured breast implants have been associated with immune-related complications, including malignancies. Here, by examining for up to one year the foreign body response and capsular fibrosis triggered by miniaturized or full-scale clinically approved breast implants with different surface topography (average roughness, 0-90 μm) placed in the mammary fat pads of mice or rabbits, respectively, we show that surface topography mediates immune responses to the implants. We also show that the surface surrounding human breast implants collected during revision surgeries also differentially alters the individual's immune responses to the implant. Moreover, miniaturized implants with an average roughness of 4 μm can largely suppress the foreign body response and fibrosis (but not in T-cell-deficient mice), and that tissue surrounding these implants displayed higher levels of immunosuppressive FOXP3⁺ regulatory T cells. Our findings suggest that, amongst the topographies investigated, implants with an average roughness of 4 μm provoke the least amount of inflammation and foreign body response.

Major Complications After Textured Versus Non-textured Breast Implants in Direct-to-Implant Breast Reconstruction: A Propensity Score Analysis

BACKGROUND

While the risks and benefits of smooth versus textured implants for breast reconstruction and primary breast augmentation are thoroughly supported in the literature, few studies have examined the relationship between implant shell texture and complications following direct-to-implant (DTI) breast reconstruction.

OBJECTIVES

The present study examines the relationship between implant shell texture and complications in patients receiving DTI breast reconstruction.

METHODS

Retrospective chart review of patients undergoing DTI breast reconstruction between 2011 and 2018 by a single surgeon was performed. A propensity score matching algorithm was used to eliminate unwanted bias stemming from clinical covariates. Chi-squared and Fisher's exact tests were used to examine the association between implant shell texture and the following major postoperative complications: capsular contracture, hematoma, seroma, necrosis, infection, and implant loss.

RESULTS

A total of 402 unique patients (751 breasts) were included. The majority received smooth implants compared with textured implants (80.3% vs. 19.7%, respectively); 444 breasts were included for comparative analysis after 2:1 propensity score matching (296 smooth implants, 148 textured implants). The only statistically significant difference in outcomes between the two groups was a higher incidence of hematoma in the textured group (2.0% vs 0.0%), Fisher's Exact Test p = 0.04. Additionally, the matched cohort revealed a very low overall rate of capsular contracture (1.0%) for smooth implants.

CONCLUSIONS

Our data demonstrated non-significant differences for most major complication rates or revision surgery rates for smooth versus textured implants after matching. DTI breast reconstruction with smooth implants remains a safe and effective reconstructive option for select patients.

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

Current Concepts in Capsular Contracture: Pathophysiology, Prevention, and Management

Over 400,000 women in the United States alone will have breast implant surgery each year. Although capsular contracture represents the most common complication of breast implant surgery, surgeons continue to debate the precise etiology. General agreement exists concerning the inflammatory origin of capsular fibrosis, but the inciting events triggering the inflammatory cascade appear to be multifactorial, making it difficult to predict why one patient may develop capsular contracture while another will not. Accordingly, researchers have explored many different surgical, biomaterial, and medical therapies to address these multiple factors in an attempt to prevent and treat capsular contracture. In the current paper, we aim to inform the reader on the most up-to-date understanding of the pathophysiology, prevention, and treatment of capsular contracture.

Breast implant-associated EBV-positive diffuse large B-cell lymphoma: Two case reports and literature review

Lymphomas associated with breast implants are mostly of the T-cell type. They are predominantly anaplastic lymphoma kinase-negative anaplastic large cell lymphoma (ALK-negative ALCL) characterized by CD30 positivity universally. Whilst the majority of primary breast lymphomas occurring in the absence of breast implants are of B-cell origin, there are few cases of implant-associated B-cell lymphomas reported to date in the literature, a subset of which are diffuse large B-cell lymphoma (DLBCL). Given the rarity of this entity, we describe two cases of breast implant-associated DLBCL. Both patients developed Epstein-Barr Virus (EBV)-positive large cell lymphoma of B-cell origin confined to the implant capsule with no evidence of systemic lymphoma. Considering the association with EBV, the activated B-cell phenotype and the presumed chronic inflammatory environment associated with the implant capsule, these might represent forms of DLBCL associated with chronic inflammation (DLBCL-CI) or fibrin-associated DLBCL (FA-DLBCL). Treatment included implant removal with total capsulectomy, and for one of the cases adjuvant systemic chemotherapy. Recognizing this rare type of breast implant-associated B-cell lymphoma could improve our understanding of this entity and hence develop appropriate management strategies.

Particulate Debris Released From Breast Implant Surfaces Is Highly Dependent on Implant Type

BACKGROUND

Although breast implants (BIs) have never been safer, factors such as implant debris may influence complications such as chronic inflammation and illness such as ALCL (anaplastic large cell lymphoma). Do different types of BIs produce differential particulate debris?

OBJECTIVES

The aim of this study was to quantify, investigate, and characterize the size, amount, and material type of both loosely bound and adherent surface particles on 5 different surface types of commercial BIs.

METHODS

Surface particles from BIs of 5 surface types (n = 5/group), Biocell, Microcell, Siltex, Smooth, SmoothSilk, and Traditional-Smooth, were: (1) removed by a rinsing procedure and (2) removed with ultrapure adhesive carbon tabs. Particles were characterized (ASTM 1877-16) by scanning electron microscopy and energy-dispersive X-ray chemical analysis.

RESULTS

Particles rinsed from Biocell, Microcell and Siltex were <1 μm in diameter whereas SmoothSilk and Traditional-Smooth surfaces had median sizes >1 μm (range, 0.4-2.7 μm). The total mass of particles rinsed from the surfaces indicated Biocell had >5-fold more particulate compared with all other implants, and >30-fold more than SmoothSilk or Traditional-Smooth implants (>100-fold more for post-rinse adhesion analysis). Energy-dispersive X-ray analysis indicated that the particulate material for Biocell, Microcell, and Siltex was silicone (>50%), whereas particulates from SmoothSilk and Traditional-Smooth implants were predominantly carbon-based polymers, eg, polycarbonate-urethane, consistent with packaging (and were detected on all implant types). Generally, SmoothSilk and Traditional-Smooth implant groups released >10-fold fewer particles than Biocell, Microcell, and Siltex surfaces. Pilot ex vivo tissue analysis supported these findings.

CONCLUSIONS

Particulate debris released from BIs are highly dependent on the type of implant surface and are a likely key determinant of in vivo performance.

LEVEL OF EVIDENCE: 5

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

BACKGROUND

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

OBJECTIVES

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

LEVEL OF EVIDENCE IV

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

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

BACKGROUND

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

OBJECTIVES

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

LEVEL OF EVIDENCE: 4

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.

Transitioning From Conventional Textured to Nanotextured Breast Implants: Our Early Experience and Modifications for Optimal Breast Augmentation Outcomes

BACKGROUND

Nanotextured breast implants were hailed as an innovation that may address capsular contracture and breast implant-associated anaplastic large cell lymphoma and may provide the sweet spot between smooth and conventional textured implants.

OBJECTIVES

This study aimed to evaluate the introduction of nanotextured implants alongside conventional textured implants and to compare early complications.

METHODS

Patients who underwent breast augmentation from the introduction of nanotextured implants in the author's practice with at least 1 year of follow-up were included. They were divided into nanotextured and conventional textured implant groups and then into 3 chronological subgroups. Patient characteristics, implant specifications, operative factors, and complication rates were compared.

RESULTS

A total 415 cases with a mean follow-up of 26.9 months were identified, of which 38.8% utilized nanotextured implants and 61.2% conventional textured implants. Utilization of nanotextured implants increased from 26.9% in period 1 to 54.5% in period 3. Complication rates for the conventional textured group were 0.8% at 1 year and 3.5% on overall follow-up, with mostly capsular contractures; for the nanotextured group, complication rates were 6.8% and 8.7%, respectively, and "bottoming out" was most common. When analyzed across chronological subgroups, complication rates decreased for nanotextured implants by period 3.

CONCLUSIONS

A learning curve and associated complications are expected for early adopters of new implants. In our series, nanotextured implants were associated with higher complication rates at 1 year and on overall follow-up. Modifications in patient selection, intraoperative techniques, and postoperative care reduced complications in the later period.

LEVEL OF EVIDENCE: 4

Breast Augmentation Surgery: How Do We Do It? Results of a Joint Survey from European Association of Societies of Aesthetic Plastic Surgery

INTRODUCTION

The purpose of this study was to evaluate the current perceptions, preferences, and practice of plastic surgeons in Europe regarding breast implant surgery after the controversy on macrotextured implants and BIA-ALCL and the voluntary recall of all biocell implants.

METHODS

A survey comprising 15 questions about implant selection and postoperative routines associated with breast augmentation was sent to all society members of the EASAPS.

RESULTS

Out of 1473 correspondents, 416 completed the survey with response rate being 28.2%. Countries with less than ten respondents were not included in the analysis. A total of 359 respondents (24.4%) were included in the analysis. Twenty-one respondents (5.8%) had a clinical experience < 5 years, 43 (12%) had 5-10 years' experience, and 295 (82.2%) had > 10 years' experience. Regarding the type of implant, only 6.1% would use a macrotextured implant. Fourteen per cent of surgeons would recommend to change a biocell implant in any case, even without symptoms or problems (rupture, seroma, and capsular contracture), 99.7% would send the capsule for histopathological study (99.7%), 98.9% would perform bilateral implant replacement in case of a unilateral problem of rupture, contracture, or seroma, and 80.8% of respondents considered capsulectomy as a technique for managing capsular contracture degree III/IV.

CONCLUSIONS

The main conclusion is the heterogenicity of answers and practice, due to the lack of guidelines and scientific evidence on breast implants. Although 22 (6.1%) respondents would use a macrotextured implant (either round or anatomic), 71.6% of respondents considered that there is not enough information for removing macrotextured implants from the market and that they should be allowed to be used unrestrictedly or under close surveillance of the regulatory agencies.

LEVEL OF EVIDENCE III

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