The Prepectoral, Hybrid Breast Reconstruction: The Synergy of Lipofilling and Breast Implants

The Influence of Inset and Shaping of Abdominal-Based Free Flap Breast Reconstruction on Patient-Reported Aesthetic Outcome Scores-A Systematic Review

Background: Nowadays, multimodal cancer therapy results in very high survival rates of early-stage breast cancer and microsurgical flap-based breast reconstruction has become safe and reliable, with gradually increasing demand because of its durable and aesthetically pleasing results. This study aimed to explore the impact of different flap shaping and inset techniques on patient-reported outcome measures (PROMs) with regard to the aesthetic result in abdominal flap-based breast reconstruction. Methods: A systematic review was performed screening Pubmed, Cochrane Library and Web of Science for original articles reporting flap inset strategies, concomitantly providing PROMs on the aesthetic result. Results: Of 319 studies identified, six met the inclusion criteria. The studies described different flap rotation options according to the patient's morphology, different inset planes, and avoidance of the monitoring skin paddle, and suggested that a higher flap-to-mastectomy mass ratio was associated with better aesthetic results. In two comparative studies, according to the PROMs (BREAST-Q, Likert scale) and independent observer judgement, both higher patient satisfaction and superior aesthetic results were observed with the newly described techniques. Conclusions: Emphasis on the aesthetic outcome in terms of breast shape and symmetry, providing an individualized approach of flap inset, considering the contralateral breast's shape and volume, results in higher satisfaction scores.

Breast reconstruction after mastectomy

Patients requesting breast reconstruction after mastectomy is an increasing group at plastic- and breast surgery departments in Denmark. This review summarises the present surgical techniques for reconstruction with/without postoperative chemotherapy and/or radiation therapy. These surgical techniques are continuously updated. The most determining factor when selecting a reconstructive technique, is postoperative radiation therapy. Each patient is unique, and an individual assessment is made when planning surgery. The concept of a "babysitter implant" is currently being investigated in Denmark and might be an option for selected patients.

Reply to Comment to: Tuberous Breast Associated with Chest Wall Deformity: A Challenging Planning for Breast Augmentation

Even in cases of noticeable breasts asymmetry, such as in our case, it is advisable to use implants with the same volume and projection, in order to maintain a similar breast footprint and allow a similar aging behavior over time. This can be achieved by reducing the size of the larger breast, thereby addressing the volume discrepancy before the placement of the implants. However, in our case, the skeletal deformities resulted in a significant disparity in the projection of the right and left sides of the chest wall, hindering the use of breast implants with identical projection. Therefore, due to this asymmetrical chest wall deformity, the left prosthesis was placed behind the central and lateral glandular parenchyma, avoiding hyper-projection in the medial part of the breast.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 .

Technical Tips to Reduce Implant Rippling in Staged Pre-pectoral Breast Reconstruction

INTRODUCTION

Pre-pectoral implant-based breast reconstruction (IBR) is becoming increasingly popular, permitting optimal implant positioning on the chest wall, prevention of animation deformity, and reduced patient discomfort. There are, however, concerns related to increased rates of breast implant rippling in pre-pectoral (versus submuscular) IBR, which can prompt a patient to seek revisionary surgery. The aim of this study is to identify factors that can be implemented to reduce implant rippling in the setting of pre-pectoral IBR.

METHODS

A literature review was conducted using the PubMed database to determine the rate of rippling in pre-pectoral IBR. Clinical studies in English were included. Further review was then performed to explore technical strategies associated with reduced rates of rippling in pre-pectoral two-stage breast reconstruction.

RESULTS

Implant rippling has been reported with a rate varying from 0 to 53.8% in 25 studies of pre-pectoral IBR (including both direct-to-implant and two-stage IBR). The majority of studies reviewed did not demonstrate a significant association between BMI and rippling, suggesting that other factors, likely technical and device-related, contribute to the manifestation of implant rippling. Hence, we explored whether specific technical modifications could be implemented that would reduce the risk of rippling in patients undergoing pre-pectoral IBR. Specifically, we highlight the need for close attention to expansion protocol and pocket dimension, expander fill medium and implant characteristics, and the rationale behind adjunctive procedures to reduce implant rippling.

CONCLUSION

Surgical modifications may reduce the incidence of rippling in pre-pectoral breast reconstruction.

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 .

Comparative Analysis of a New Automatic System and Four Existing Techniques for Autologous Fat Grafting

Background

Autologous fat grafting is increasingly used worldwide and is a very attractive technique in many ways. However, treatment duration and postinjection tissue resorption remain problematic elements, which are largely related to the preparation method used. Moreover, few scientific studies objectively compare different fat preparation methods. This study analyzes the efficiency and quality of lipoaspirates prepared with a new filtration/centrifugation system (Adipure) in comparison with several existing techniques.

Methods

Patient lipoaspirates were processed by five different techniques: decantation, centrifugation, Macrofill, Puregraft, and Adipure. Adipose tissue was evaluated in vitro for tissue resorption and oil formation, as well as in vivo after subcutaneous injections in immunodeficient mice. Adipose grafts were collected after 1 month, weighed, and analyzed by histology with a detailed scoring method.

Results

Decanting gives inferior results to all other techniques, in terms of amount of tissue and oil in vitro, or graft weight and histological analysis in vivo. Methods using classical Coleman centrifugation (1200g), or a modified one (400g) associated with washes (Macrofill) produce very similar results, both in vitro and in vivo. Techniques using filtration systems (Puregraft and Adipure) produce less oil overall and have a higher grafting efficiency. The best results regarding grafting efficiency and oil quantity are found with the Adipure device.

Conclusions

A combination of filtration and very low-speed centrifugation potentiates the advantages of these techniques, in terms of graft efficiency. The adipose tissue purification being done in a few minutes, in an automatic way, undoubtedly provides a strong advantage for the use of this new system.

Simultaneous Fat Grafting During Tissue Expander-to-Implant Exchange: A Propensity Score-Matched Analysis

BACKGROUND

Implant-based breast reconstruction (IBBR) is the most common technique for breast reconstruction. The primary resource for correcting deformities, once patients have achieved an adequate volume with two-stage IBBR, is autologous fat grafting. We compared the surgical outcomes of simultaneous fat grafting during TE-to-implant exchange (SFG + TtIE) versus no fat grafting during TE-to-implant exchange (No-FGX).

METHODS

A retrospective review was performed of all consecutive patients undergoing two-stage implant-based breast reconstruction with TE from January 2011 to December 2020. Propensity score matching was implemented to optimize comparability. The control group did not receive fat grafting at the time of TE-to-implant exchange.

RESULTS

After propensity score matching, 196 reconstructions were evaluated, 98 in each group. Reconstructions in the SFG + TtIE received larger implants during exchange in comparison with the No-FGX group (539 ± 135.1-cc versus 495.97 ± 148-cc, p=0.035). The mean volume of fat lipoinjected during TE-to-implant exchange in the SFG + TtIE group was 88.79 ± 41-ml. A higher proportion of reconstructions in the SFG + TtIE group underwent additional fat grafting after exchange versus the No-FGX group (19% versus 9%, p = 0.041). After propensity score matching, only the rate of fat necrosis after exchange was significantly higher in the SFG + TtIE group (10% versus 2%, p = 0.017). The rate of breast cancer recurrence (3% versus 5%, p = 1.00) was comparable between the groups.

CONCLUSION

SFG + TtIE is a safe procedure to improve the envelope of reconstructed breasts during two-stage IBBR. SFG + TtIE does not increase the rate of periprosthetic infection or wound-related complication versus no fat grafting during TE-to-implant exchange, but increases the rate of fat necrosis.

LEVEL OF EVIDENCE III

Therapeutic study. 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.

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.

MRI-Conditional Breast Tissue Expander: First In-Human Multi-Case Assessment of MRI-Related Complications and Image Quality

This study aims to assess potential complications and effects on the magnetic resonance imaging (MRI) image quality of a new MRI-conditional breast tissue expander (Motiva Flora^®) in its first in-human multi-case application. Twenty-four patients with 36 expanders underwent non-contrast breast MRI with T1-weighted, T2-weighted, and diffusion-weighted imaging (DWI) sequences on a 3 T unit before breast tissue expander exchange surgery, being monitored during and after MRI for potential complications. Three board-certified breast radiologists blindly and independently reviewed image quality using a four-level scale ("poor", "sufficient", "good", and "excellent"), with inter-reader reliability being assessed with Kendall's τ_b. The maximum diameters of RFID-related artifacts on T1-weighted and DWI sequences were compared with the Wilcoxon signed-rank test. All 24 examinations were completed without patient-related or device-related complications. The T1-weighted and T2-weighted sequences of all the examinations had "excellent" image quality and a median 11 mm (IQR 9-12 mm) RFID artifact maximum diameter, significantly lower (p < 0.001) than on the DWI images (median 32.5 mm, IQR 28.5-34.5 mm). DWI quality was rated at least "good" in 63% of the examinations, with strong inter-reader reliability (Kendall's τ_b 0.837, 95% CI 0.687-0.952). This first in-human study confirms the MRI-conditional profile of this new expander, which does not affect the image quality of T1-weighted and T2-weighted sequences and moderately affects DWI quality.

Optimizing Acellular Dermal Matrix Integration in Heterologous Breast Reconstructive Surgery: Surgical Tips and Post-Operative Management

Background and Objective: Prepectoral implant placement in breast reconstruction is currently a must-have in the portfolios of breast surgeons. The introduction of new tools and conservative mastectomies is a game changer in this field. The prepectoral plane usually goes hand-in-hand with the ADM wrapping of the implant. It is a cell-free dermal matrix comprising a structurally integrated basement membrane complex and an extracellular matrix. The literature reports that ADMs may be useful, but proper patient selection, surgical placement, and post-operative management are essential to unlock the potential of this tool, as these factors contribute to the proper integration of the matrix with surrounding tissues. Materials and Methods: A total of 245 prepectoral breast reconstructions with prostheses or expanders and ADMs were performed in our institution between 2016 and 2022. A retrospective study was carried out to record patient characteristics, risk factors, surgical procedures, reconstructive processes, and complications. Based on our experience, we developed a meticulous reconstruction protocol in order to optimize surgical practice and lower complication rates. The DTI and two-stage reconstruction were compared. Results: Seroma formation was the most frequent early complication (less than 90 days after surgery) that we observed; however, the majority were drained in outpatient settings and healed rapidly. Secondary healing of wounds, which required a few more weeks of dressing, represented the second most frequent early complication (10.61%). Rippling was the most common late complication, particularly in DTI patients. After comparing the DTI and two-stage reconstruction, no statistically significant increase in complications was found. Conclusions: The weakness of prepectoral breast reconstruction is poor matrix integration, which leads to seroma and other complications. ADM acts like a graft; it requires firm and healthy tissues to set in. In order to do so, there are three key steps to follow: (1) adequate patient selection; (2) preservative and gentle handling of intra-operative technique; and (3) meticulous post-operative management.

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

BACKGROUND

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

OBJECTIVES

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

LEVEL OF EVIDENCE: 4

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

CLINICAL QUESTION/LEVEL OF EVIDENCE

Therapeutic, IV.

Implant vs. autologous tissue-based breast reconstruction: A systematic review and meta-analysis of the studies comparing surgical approaches in 55,455 patients

BACKGROUND

The choice of reconstruction type is of utmost importance in treating breast cancer. There are two major reconstructive pathways in this group of patients: autologous breast reconstruction (ABR) and implant-based breast reconstruction (IBR). The aim of this systematic review and meta-analysis was to assess and compare IBR vs. ABR.

METHODS

A review of studies reporting the differences between the procedures was performed. The MEDLINE/PubMed, ScienceDirect, EMBASE, BIOSIS, SciELO, Scopus, and Web of Science databases were thoroughly searched in September 2021. The data concerning group characteristics, BREAST-Q scores, complication rates, length of stay (LOS), and costs were extracted. The Cochrane risk-of-bias tool was used for randomized studies, while Newcastle-Ottawa Quality Assessment for Cohort Studies was used for other types of research.

RESULTS

Our meta-analysis included 32 studies (n = 55,455). We observed significantly better outcomes following ABR when it comes to esthetic satisfaction (mean difference [MD] -8.51; 95% confidence interval [CI] -10.70, -6.33; p<0.001) and satisfaction with the entire reconstructive treatment (MD -6.56; 95% CI -9.97, -3.14; p<0.001). Both methods appeared to be comparable in terms of safety, while the complication rates varied insignificantly between the groups (odds ratio [OR] 1.06; 95% CI 0.71, 1.59; p = 0.76). ABR seems to be correlated with significantly higher costs (standard mean difference [SMD] -0.69; 95% CI -1.21, -0.17; p = 0.010).

CONCLUSIONS

The results obtained from this evidence-based study will improve the understanding of the different clinical pathways that patients can be assigned to. The study emphasized the advantages and disadvantages of both methods.

Outcomes in Hybrid Breast Reconstruction: A Systematic Review

Background and Objectives: Lipofilling is a commonly performed procedure worldwide for breast augmentation and correction of breast contour deformities. In breast reconstruction, fat grafting has been used as a single reconstructive technique, as well as in combination with other procedures. The aim of the present study is to systematically review available studies in the literature describing the combination of implant-based breast reconstruction and fat grafting, focusing on safety, complications rate, surgical sessions needed to reach a satisfying reconstruction, and patient-reported outcomes. Materials and Methods: We adhered to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) throughout the whole review protocol. A systematic review of the literature up to April 2022 was performed using Medline, Embase, and Cochrane Library databases. Only studies dealing with implant-based breast reconstruction combined with fat grafting were included. Results: We screened 292 articles by title and abstract. Only 48 articles were assessed for full-text eligibility, and among those, 12 studies were eventually selected. We included a total of 753 breast reconstructions in 585 patients undergoing mastectomy or demolitive breast surgeries other than mastectomy (quadrantectomy, segmentectomy, or lumpectomy) due to breast cancer or genetic predisposition to breast cancer. Overall, the number of complications was 60 (7.9%). The mean volume of fat grafting per breast per session ranged from 59 to 313 mL. The mean number of lipofilling sessions per breast ranged from 1.3 to 3.2. Conclusions: Hybrid breast reconstruction shows similar short-term complications to standard implant-based reconstruction but with the potential to significantly decrease the risk of long-term complications. Moreover, patient satisfaction was achieved with a reasonably low number of lipofilling sessions (1.7 on average).

[The Value of Synthetic and Biologic Meshes in Implant-Based Breast Reconstruction]

Implant based breast reconstruction (IBBR) keeps evolving and has been influenced heavily by the use of synthetic and biologic meshes in the last years. In both, subpectoral as well as prepectoral approaches the use of synthetic and biologic meshes has made it possible to place implants precisely according to the breast's footprint and strengthen soft-tissue coverage, particularly in the lower pole of the breast with lower complication rates and better cosmesis. Various mesh options that differ in material, processing, size and cost are currently in clinical use. This review aims to define the role of biologic and synthetic meshes in IBBR regarding the advantages and disadvantages of their use.

Immediate direct-to-implant breast reconstruction: A single center comparison between different procedures

Background

The increased incidence of conservative mastectomy operations (nipple- and skin- sparing) has increased the frequency of immediate breast reconstructions (IBR). In order to guarantee patients the best possible aesthetic outcome, the least chance of complications and moreover, the least postoperative pain, the technique with prepectoral prosthetic pocket was recently reconsidered with the use of ADM. This is the first study using Fortiva® in prepectoral breast reconstruction, and it compares the outcomes of three different patient populations (undergoing retromuscular, prepectoral and prepectoral reconstruction with ADM). The authors suggest that prepectoral breast reconstruction with ADM may bring benefits compared to the current standard technique (retromuscular) as well as compared to the prepectoral reconstruction without ADM.

Methods

Retrospective data analysis of patients who underwent mastectomy followed by immediate breast reconstruction with silicone implants (DTI), performed by a team of breast surgeons and plastic surgeons. Logistic factor regressions were performed in order to investigate the effects of the three different intervention techniques on the incidence of complications. Fisher's exact test was used to analyze the differences in the occurrence of each complication. Mann Whitney test was used to compare the averages of referred pain. A p value &lt;0.05 was considered significant.

Results

A total of 67 patients underwent DTI reconstruction, of which 43 with retromuscular prosthesis, 13 prepectoral and 11 prepectoral with ADM. We found a significantly lower incidence of surgical complications with ADM, exclusively in comparison with retromuscular reconstruction (p = 0.028). It emerges prepectoral reconstruction with ADM involves significantly less visibility of the implant than both the prepectoral surgery without ADM (p = 0.013) and the retromuscular technique (p = 0.029). Finally, postoperative pain referred at twelfth month is significantly less relevant in the group with prepectoral prosthesis and ADM, both in the group with retromuscular (p &lt; 0.001) and prepectoral without ADM (p = 0.001).

Conclusions

This study demonstrates that immediate prepectoral breast reconstruction with ADM is a safe and reliable technique, able to exceed some type of limits imposed by prepectoral reconstruction. Moreover, it provides benefits if compared to the current standard technique. In the future, this technique could also be added to it, after a proper selection of patients in pre- and intraoperative time.

Oncological Safety of Autologous Fat Grafting in Breast Reconstruction: A Meta-analysis Based on Matched Cohort Studies

BACKGROUND

Autologous fat grafting has become a commonly used procedure for breast reconstruction after breast cancer surgical treatment. Nevertheless, oncological considerations remain concerning autologous fat grafting after breast cancer surgery.

OBJECTIVE

This meta-analysis aimed to summarize the current matched cohort studies and provide high-quality evidence-based conclusions on the oncological safety of fat grafting in breast reconstruction.

METHODS

The Preferred Reporting Items for Systematic Reviews and Meta-analysis guidelines were followed. A literature search was performed on August 1, 2021, using PubMed. All relevant matched cohort studies of patients undergoing autologous fat grafting after breast cancer surgery were included. After independently screening the studies and extracting the data, pooled estimates for local and regional recurrence as well as distant metastases were conducted using Review Manager software (RevMan, version 5.3). Outcomes were expressed as odds ratios and 95% confidence intervals.

RESULTS

Seventeen studies involving 7494 patients were included. The observed outcomes indicated that no significant differences existed in the risks of local and regional recurrence or distant metastases between autologous fat grafting and control groups. Also, there was no significant heterogeneity among the studies.

CONCLUSION

This study provided evidence-based conclusions that support the use of autologous fat grafting in breast reconstruction.

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 after Mastectomy, from the Subpectoral to the Prepectoral Approach: An Evidence-Based Change of Mind?

Over the last years, prepectoral implant-based breast reconstruction has undergone a renaissance due to several technical advancements regarding mastectomy techniques and surgical approaches for the placement and soft tissue coverage of silicone implants. Initially abandoned due to the high incidence of complications, such as capsular contraction, implant extrusion, and poor aesthetic outcome, the effective prevention of these types of complications led to the prepectoral technique coming back in style for the ease of implant placement and the conservation of the pectoralis muscle function. Additional advantages such as a decrease of postoperative pain, animation deformity, and operative time contribute to the steady gain in popularity. This review aims to summarize the factors influencing the trend towards prepectoral implant-based breast reconstruction and to discuss the challenges and prospects related to this operative approach.

UK Guidelines for Lipomodelling of the Breast on behalf of Plastic, Reconstructive and Aesthetic Surgery and Association of Breast Surgery Expert Advisory Group

Lipomodelling has become increasingly popular for reconstructive, aesthetic and therapeutic indications. The guidelines summarise available evidence for indications, training, technique, audit and outcomes in lipomodelling and also highlight areas for further research.

Use of the Subfascial Plane for Gender-affirming Breast Augmentation: A Case Series

Transgender women seeking gender-affirming breast augmentation often present with differences in preoperative chest measurements and contours in comparison with cisgender women. These include a more robust pectoralis muscle and limited glandular tissue, raising important considerations in determining the optimal anatomical plane for implantation. Abundant literature has described advantages and drawbacks of the available planes for breast augmentation in cisgender women. Certain drawbacks may be more pronounced for transgender women, given their distinct anatomy. The subfascial plane offers lower complication rates than the subglandular plane when using smooth implants, and avoids implant animation and displacement associated with the subpectoral plane. To our knowledge, existing studies have not yet addressed this discussion in the transfeminine population. The goal of this article is to highlight potential benefits of the subfascial plane for gender-affirming breast augmentation, utilizing a case series of 3 transfeminine patients, and to review the literature on surgical techniques and outcomes in this population.