Textured Silicone Breast Implant Use in Primary Augmentation: Core Data Update and Review

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Efficacy of the Modified 5-Item Frailty Index in Predicting Surgical-Site Infections in Patients Undergoing Breast Implant Augmentation: A National Surgical Quality Improvement Project-Based 5-Year Study

Background

The ability to predict breast implant augmentation complications can significantly inform patient management. A frailty measure, such as the modified 5-item frailty index (mFI-5), is becoming an increasingly established risk factor for adverse postoperative outcomes. The authors hypothesized that the mFI-5 is predictive of 30-day postoperative complications in breast augmentation.

Objectives

To investigate if mFI-5 can predict the likelihood and magnitude of 30-day complications resulting from breast augmentations.

Methods

A retrospective review study of the National Surgical Quality Improvement Program database for patients who underwent breast implant augmentation without other concurrent procedures, from 2015 to 2019. Age, BMI, number of major comorbidities, American Society of Anesthesiologists (ASA) classifications, smoking status, mFI-5 score, and modified Charlson comorbidity index score were compared as predictors of all-cause 30-day complications and 30-day surgical-site complications using regression analyses.

Results

Overall, 2478 patients were analyzed, and among them, 53 patients developed complications (2.14%). mFI-5 score significantly predicted surgical-site infection (SSI) complications (odds ratio [OR] = 4.24, P = .026). Frail patients had a higher occurrence of SSIs than nonfrail patients (P = .049). Multivariable analyses showed ASA class predicted 30-day SSI complications (OR = 5.77, P = .027) and mFI-5 approached, but did not reach full significance in predicting overall 30-day complications (OR = 3.14, P = .085).

Conclusions

To date, the impact of frailty on breast implant procedure outcomes has not been studied. Our analysis demonstrates that the mFI-5 is a significant predictor for SSIs in breast implant augmentation surgery and is associated with overall complications. By preoperatively identifying frail patients, the surgical team can better account for postoperative support to minimize the risk of complications.

Level of Evidence 4

Pleural Effusion as a Potential Complication of Foreign Body Reaction to Silicone Breast Implants: A Case Study

Breast augmentation surgery, like any other surgery, has potential complications, including the less common complication of pleural effusion. We present a unique case of a 44-year-old female who developed pleuritic chest pain and shortness of breath 10 days after her breast augmentation surgery, with no prior history of cardiac or autoimmune conditions. The temporal relationship between the surgery and the onset of symptoms suggested a possible direct link to the implants. Imaging showed a small- to moderate-sized left pleural effusion, and pleural fluid analysis revealed findings suggestive of a foreign body reaction (FBR), including evidence of mesothelial and inflammatory cells with a lymphocyte percentage of 44% and monocytes of 30%. The patient received intravenous steroids at a dose of 40 mg every eight hours for three days while hospitalized, followed by a tapered oral dose of steroids upon discharge, for over three weeks. Follow-up imaging studies showed complete resolution of the pleural effusion. The diagnosis of pleural effusion resulting from FBR to silicone gel-filled breast implants involves a clinical history, cytopathological examination, and the exclusion of other potential causes. This case highlights the importance of considering FBR as a potential cause of pleural effusion post-breast augmentation surgery.

Prospective Study of Clinical Outcomes From a Breast Implant Assessment Service

BACKGROUND

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

OBJECTIVES

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

LEVEL OF EVIDENCE: 2

Biomedical Silicones: Leveraging Additive Strategies to Propel Modern Utility

Silicones have a long history of use in biomedical devices, with unique properties stemming from the siloxane (Si-O-Si) backbone that feature a high degree of flexibility and chemical stability. However, surface, rheological, mechanical, and electrical properties of silicones can limit their utility. Successful modification of silicones to address these limitations could lead to superior and new biomedical devices. Toward improving such properties, recent additive strategies have been leveraged to modify biomedical silicones and are highlighted herein.

Effects of substrate topography on the regulation of human fibroblasts and capsule formation via modulating macrophage polarization

The host-material interface is critical in determining the successful integration of medical devices into human tissue. The surface topography can regulate the fibrous capsule formation around implants through macrophage polarization, but the exact mechanism remains unclear. In this study, four types of microgrooves (10 or 50 µm in groove depths and 50 or 200 µm in groove widths) were fabricated on polydimethylsiloxane (PDMS) using lithography. The microgroove surfaces were characterized using the laser scanning confocal microscopy and fourier transform infrared spectroscopy. The effect of surface topography on macrophage phenotypes and conditioned medium (CM) collected from macrophages on human foreskin fibroblast 1 (HFF-1) were investigated. The result revealed that a deeper and narrower microgroove structure means a rougher surface. Macrophages tended to adhere and aggregate on group 50-50 surface (groove depths and widths of 50 µm). THP-1 cell polarized toward both inflammatory M1 and anti-inflammatory M2 macrophages on the surface of each group. Meanwhile, CM from macrophages culture on PDMS differentially up-regulated the proliferation, migration and fibrosis of HFF-1. Among them, the group 50-50 had the strongest promoting effect. In vivo, the inflammatory response and fibrotic capsule around the implants were observed at 1 week and 4 weeks. As time passed, the inflammatory response decreased, while the capsule thickness continued to increase. The rough material surface was more inclined to develop a severe fibrotic encapsulation. In conclusion, this finding further suggested a potential immunomodulatory effect of macrophages in mediating the fibrotic response to implants and facilitated the design of biomaterial interfaces for improving tissue integration.

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.

Comparison of Cromolyn Sodium, Montelukast, and Zafirlukast Prophylaxis for Capsular Contracture

BACKGROUND

Capsular contracture is the most common complication following breast augmentation. Recently, prophylaxis studies aiming to inhibit the release of profibrotic substances to prevent capsular contracture have gained in importance. This study investigated the effects of cromolyn sodium, montelukast, and zafirlukast on capsular contracture in a rat model.

METHODS

Thirty female Wistar albino rats were randomly divided into five groups: control, sham, cromolyn sodium, montelukast, and zafirlukast. Intraperitoneal injections were administered daily to the sham (1 ml per day), cromolyn sodium (10 mg/kg per day), montelukast (10 mg/kg per day), and zafirlukast (1.25 mg/kg per day) groups 1 month before surgery. Miniature breast implants were then placed on the backs of the rats in each group. Injections were continued for the next 3 months. The rats were subsequently killed, and the capsules were harvested and assessed histopathologically. The histopathologic outcomes were acute inflammation status, inflammation severity, synovial metaplasia, foreign body reaction, mast cell count, and capsular thickness.

RESULTS

The cromolyn sodium, montelukast, and zafirlukast groups had less acute inflammation and lower mean inflammation severity scores, foreign body reaction occurrence, mast cell counts, and capsular thickness than the control and sham groups ( p < 0.05). These parameters were better in the cromolyn sodium group than in the montelukast and zafirlukast groups ( p < 0.05).

CONCLUSIONS

Cromolyn sodium appears to inhibit capsular contracture more efficiently than montelukast and zafirlukast. This report may be a pioneer study for the prophylactic use of cromolyn sodium in capsular contracture.

CLINICAL RELEVANCE STATEMENT

The prophylactic administration of cromolyn sodium appears to reduce capsular contracture more efficiently than that of montelukast and zafirlukast. This report might constitute a pioneer study for the prophylactic use of cromolyn sodium in capsular contracture.

Breast Morphological Changes after Transaxillary Dual-Plane Augmentation with Smooth Round Implants: A Prospective Study

BACKGROUND

Breast augmentation is the most performed cosmetic surgery in the world. Although smooth round implants are widely used, the trend in breast morphology change after dual-plane augmentation with such implants remains unclear. In this study, we analyzed the issue with the support of 3D scanning technology, which may help provide an objective basis for the evaluation of postoperative outcomes and the determination of follow-up time points.

METHODS

Patients undergoing dual-plane augmentation with smooth round implants were prospectively included in this study. The variation trend of postoperative breast morphology was analyzed by measuring the specified linear distance, body surface distance, breast projection, nipple position and breast volume at different follow-up time points (1st month, post-1M; 3rd month, post-3M; 6th month, post-6M; 12th month, post-12M).

RESULTS

A total of 18 patients were included in this study. During the postoperative follow-up period, breast height prolonged while interval of the medial border gradually widened. Breast width was maintained without significant alterations from post-1M. The N-MBB lengthened with shortening of the N-LBB, meanwhile the N-IMF was prolonged by 0.6 cm. Breast volume was gradually reduced with the decrease in breast projection. The position of the nipple gradually shifted laterally, superiorly, and posteriorly after surgery. There was no statistically significant difference between the linear distance at post-3M and post-12M, while the surface distance, breast projection, nipple position and breast volume tended to be stable at post-6M.

CONCLUSIONS

After dual-plane augmentation with smooth round implants, the base contour of the breast shifted outwards and downwards, and stabilized after 3 months. The remaining breast morphological parameters reached a relative steady state by post-6M, which could be regarded as the time point for objective evaluation of postoperative effect.

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 .

Patient-Reported Outcomes after Subpectoral Breast Augmentation with Microtextured or Macrotextured Implants Using the BREAST-Q

Background  Breast augmentation with implants is the most commonly performed cosmetic plastic surgery in Brazil and worldwide. The aim of this study was to assess patient satisfaction and quality of life following subpectoral breast augmentation with either microtextured or macrotextured implants, using the BREAST-Q.

Methods  A prospective study was conducted with 40 women with hypomastia undergoing subpectoral breast augmentation. The patients were randomly allocated to two groups to receive either microtextured or macrotextured breast implants. All participants were assessed preoperatively (baseline) and after 2 and 4 months of surgery for quality of life and patient satisfaction with the surgical results, using the BREAST-Q augmentation module, a patient-reported outcome measure.

Results  The patients had a mean age of 28.9 ± 6.45 years. The microtextured ( n  = 20) and macrotextured ( n  = 20) groups were homogeneous for sex, age, education level, marital status, and number of children ( p  > 0.05). Both groups showed significant improvement in satisfaction with breasts ( p  < 0.001), psychosocial well-being ( p  < 0.001), and sexual well-being ( p  < 0.001) at the 2- and 4-month follow-up visits compared with baseline. The observed improvements were associated with high effect size values of 5.09, 3.44, and 3.90, respectively. In contrast, significant decreases from baseline in physical well-being scores ( p  = 0.001) were found 2 and 4 weeks after surgery in both groups.

Conclusion  Subpectoral breast augmentation with either microtextured or macrotextured breast implants improved satisfaction with breasts and quality of life in patients with hypomastia.

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 .

HISTORY OF BREAST IMPLANTS: BACK TO THE FUTURE

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

Safety and Performance of POLYTECH Mesmo Breast Implants: A 5-Year Post-market Surveillance Study on 919 Patients

Background

In 2007, POLYTECH Health & Aesthetics (POLYTECH, Dieburg, Germany) established an ongoing patient survey to improve the post-market surveillance of silicone gel-filled breast implants based on patient-reported outcomes in the context of the pioneering "Implants of Excellence" (IoE) program.

Objectives

To disclose an update on safety and performance outcomes at 5 years for Mesmo breast implants.

Methods

Between January 2014 and October 2019, 919 patients (for a total of 1816 implants) who underwent breast augmentation and reconstruction with Mesmo implants were asked to participate in the IoE program. Data were collected by mean of 1320 questionnaires received. A survival analysis assessed the onset of different complications.

Results

Eight patients (0.9%) experienced capsular contracture Baker grade III or IV with a cumulative rate at 5 years of 1.2% (95% CI = 0.6-2.4). The proportion of revisional surgery was 0.5% with a 5-year rate of 0.6% (95% CI = 0.2-1.5). Additional adverse events such as hematoma, seroma, malposition, open wounds, and other complications were carefully monitored. Questionnaires showed that 93.9% (95% CI = 92.2-95.4) of the patients were satisfied or very satisfied with their aesthetic results with Mesmo implants.

Conclusions

Post-market clinical follow-up revealed that the overall complications rate reported was low. Data demonstrated an excellent safety property on a large cohort of patients. This result allows the rating of Mesmo breast implants as highly competitive and a very safe choice for both surgeons and patients.

Level of Evidence 3

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

Breast Implant-Associated Anaplastic Large Cell Lymphoma With Invasive Chest Wall Masses

BACKGROUND

Breast implant-associated anaplastic large-cell lymphoma (BIA-ALCL) might occur in any patient with a history of textured breast devices, and often presents as a spectrum of disease: from a simple late-onset seroma, to complex advanced locally aggressive disease with chest wall involvement. The combination of medical therapy and surgical implant removal with complete capsulectomy is believed to be curative.

OBJECTIVES

In patients with advanced cases, however, and although generalized recommendations exist, no consensus exists regarding the ideal medical and surgical management of those presenting with invasive disease.

METHODS

This preliminary report describes 2 distinct presentations of rare invasive chest wall BIA-ALCL, both treated successfully, by using a combined medical and surgical multidisciplinary team approach. Subsequently, we discuss considerations and the current literature surrounding the treatment of advanced BIA-ALCL with chest wall and adjacent structure involvement.

RESULTS

All patients necessitated chest wall resection and composite reconstruction due to tumor involvement of the thorax with residual hypermetabolic activity, despite chemotherapeutic pretreatment with different neoadjuvant medical therapies. All healed well after surgery and experienced resolution of symptoms without signs of relapse on regular follow-up.

CONCLUSIONS

In the rare subset of patients presenting with invasive BIA-ALCL, the question persists as to which systemic treatment remains optimal. However, the evidence supports multiple, particularly in combination with surgical extirpation and reconstruction. Here we present 2 proven treatments, both in timing and modalities chosen, as part of the first step to establish a formally accepted treatment paradigm for advanced BIA-ALCL patients with invasive chest wall involvement.

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 .

Implant Fibrosis and the Underappreciated Role of Myofibroblasts in the Foreign Body Reaction

Body implants and implantable medical devices have dramatically improved and prolonged the life of countless patients. However, our body repair mechanisms have evolved to isolate, reject, or destroy any object that is recognized as foreign to the organism and inevitably mounts a foreign body reaction (FBR). Depending on its severity and chronicity, the FBR can impair implant performance or create severe clinical complications that will require surgical removal and/or replacement of the faulty device. The number of review articles discussing the FBR seems to be proportional to the number of different implant materials and clinical applications and one wonders, what else is there to tell? We will here take the position of a fibrosis researcher (which, coincidentally, we are) to elaborate similarities and differences between the FBR, normal wound healing, and chronic healing conditions that result in the development of peri-implant fibrosis. After giving credit to macrophages in the inflammatory phase of the FBR, we will mainly focus on the activation of fibroblastic cells into matrix-producing and highly contractile myofibroblasts. While fibrosis has been discussed to be a consequence of the disturbed and chronic inflammatory milieu in the FBR, direct activation of myofibroblasts at the implant surface is less commonly considered. Thus, we will provide a perspective how physical properties of the implant surface control myofibroblast actions and accumulation of stiff scar tissue. Because formation of scar tissue at the surface and around implant materials is a major reason for device failure and extraction surgeries, providing implant surfaces with myofibroblast-suppressing features is a first step to enhance implant acceptance and functional lifetime. Alternative therapeutic targets are elements of the myofibroblast mechanotransduction and contractile machinery and we will end with a brief overview on such targets that are considered for the treatment of other organ fibroses.

Revision Breast Augmentation

Breast augmentation is consistently one of the most commonly performed aesthetic operations every year. Unfortunately, revision rates following primary augmentation remain as high as 36%. There are several causes for revision breast augmentation; however, the most common and challenging of these include capsular contracture, implant malposition, and ptosis of the aging breast following augmentation. Successful management of these problems requires knowledge on how to best treat the implant and capsule with the corresponding soft tissue simultaneously. While surgical management is important, understanding the pathological causes of these entities during the primary operation can reduce the need for revision. This article utilizes the most up-to-date literature to review the appropriate clinical evaluation and surgical management of these complex cases.

The effect of implant surface on the recurrence rates of capsular contracture following revision breast surgery: Early results from a single surgeon retrospective comparative study

INTRODUCTION

This retrospective comparative study aimed to evaluate the effect of implant surface in two cohorts of consecutive patients who underwent revision surgery following capsular contracture (Baker III-IV) after primary breast augmentation with textured implants.

METHODS

All patients underwent the same surgical procedure (capsulectomy - pocket plane change - implant exchange) and the only difference was that two different types of implants were used during the implant exchange: textured(Group A - biocell) or nanotextured(Group B - silksurface). A comparative analysis was performed using the following parameters: patients' demographics, age, the time between the primary breast augmentation and the revision surgery, the surgical and follow-up outcomes; and the incidence, timing, and capsular contracture recurrence.

RESULTS

Eighty consecutive females were included, Group A(textured): age of 35(19-65) years and time between primary and secondary surgery of 59(6-209) months; and Group B(nanotextured): age of 39(26-58) years and time between primary and secondary surgery of 65(7-218) months. For both groups, at a mean follow-up of 25(21-36) months for Group A(textured), and at a mean follow-up of 24(21-34) months for Group B(nanotextured); capsular contracture reoccurred in 3 cases (7.5%), at 7, 10, and 14 months in Group A and in 3 cases (7,5%), at 9, 10, and 16 months in Group B, post revision surgery. Students' t-test demonstrated no statistically significant differences between the recurrences of the two implant surfaces (p-value>0.05).

CONCLUSION

In capsular contracture revision surgery, the type of implant surface (textured or nanotextured) does not appear to influence recurrence rates. Further studies are required to identify the clinical impact on the implant surface in long-term outcomes of capsular contracture breast surgery.

The State of the Art about Etiopathogenetic Models on Breast Implant Associated-Anaplastic Large Cell Lymphoma (BIA-ALCL): A Narrative Review

Background: Breast-implant-associated anaplastic large cell lymphoma is a rare malignancy linked to texturized breast implants. Although many researchers focus on its etiopathogenesis, this topic is affected by a lack of evidence. Materials and Methods: A literature review about BIA-ALCL was made. Results and conclusions: Although the incidence is reported between 1:355–1:30,000, there is great attention to BIA-ALCL. The incidence is uncertain due to many reasons. It may well be lower, due to inclusion in multiple databases as pointed out by the FDA and undiagnosed cases. The role of chronic inflammation, bacterial contamination, and mechanical forces was discussed. Clarification is needed to understand the mechanisms underlying the progression of alterations and mutations for BIA-ALCL; new molecular analysis and pathogenetic models should be investigated.

Breast Augmentation with Microtextured Anatomical Implants in 653 Women: Indications and Risk of Rotation

BACKGROUND

Anatomical implants provide a wide range of options in terms of implant dimensions for breast augmentation. Nevertheless, many surgeons choose not to use anatomical implants due to the risk of rotation malposition and because their advantages over round implants are not clearly defined.

METHODS

A retrospective review of medical records was performed on all women who underwent breast augmentation or implant exchange with microtextured anatomical implants from 2012 to 2019 in a single private clinic. The authors focused on the outcomes of a subgroup of women with glandular ptosis and nipple placement below the inframammary fold who underwent breast augmentation with anatomical implants. Furthermore, the incidence and risk factors for implant rotation were analyzed.

RESULTS

In total, 653 women underwent primary breast augmentation (n = 529) or implant exchange (n = 124) with anatomical implants. The median follow-up period was 2.7 years (interquartile range, 1.6 to 3.9 years). The incidence of implant rotation was 14 (2.6 percent) in the primary augmentation group and four (3.2 percent) in the implant exchange group. Implant rotation was not associated with type of surgery (p = 0.76), implant projection (p = 0.23), or implant height (p = 0.48). The authors successfully used anatomical implants to elevate the nipple in 92.9 percent of the women with glandular ptosis without using a mastopexy.

CONCLUSIONS

The study results indicate that the rotation risk with microtextured implants is similar to that with macrotextured implants. Furthermore, the authors found that high-projection anatomical implants can be used as an alternative to augmentation-mastopexy in women with glandular ptosis.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Therapeutic, III.

Applying Principles of Breast Revision to Managing Aesthetic Patients with Textured Implants

SUMMARY

Textured breast implants have garnered increased attention recently because of their risk of breast implant-associated anaplastic large cell lymphoma (BIA-ALCL), an uncommon and treatable type of T-cell lymphoma. Treatment involves bilateral en bloc capsulectomy, which is curative in the majority of cases. At present, there is no defined management approach for aesthetic patients asymptomatic for BIA-ALCL requesting the removal of their textured implants, particularly as it relates to the management of the capsule. It is unclear if en bloc capsulectomy is necessary in these patients as it is in patients with BIA-ALCL. In the absence of clear guidance on the management of the capsule in asymptomatic patients, the basic principles of breast revision surgery can be applied to these patients.

Short-term treatment outcomes and safety of two representative brands of the fifth-generation silicone gel-filled breast implants in Korea

It is allegedly reported that the BellaGel^® SmoothFine (HansBiomed Co. Ltd., Seoul, Korea) and Motiva Ergonomix^TM (Establishment Labs Holdings Inc., Alajuela, Costa Rica) are representative brands of a microtextured breast implant in Korea. We compared short-term safety outcomes between them. We evaluated the patients who received breast augmentation using the BellaGel^® SmoothFine (n = 264) or the Motiva Ergonomix™ (n = 76) for aesthetic purposes and those with available medical records. They were followed up during a mean period of 122.11 ± 95.37 (4-477) and 126.80 ± 116.29 (13-534) days in the corresponding order. Early seroma occurred at an incidence of 1.89 and 5.26% following breast augmentation using the BellaGel^® SmoothFine and the Motiva Ergonomix^TM, respectively. This difference reached statistical significance (p < 0.05). Of note, CC occurred at an incidence of 2.27 and 0.00% in the corresponding order. Cumulative incidences of postoperative complications depending on the type of breast implants showed no significant difference; statistical significance was analyzed using the log-rank test (χ² = 1.71, df = 1, p = 0.19). Cumulative survival of the breast implant is shown in Table 3; the Motiva Ergonomix™ showed a longer survival as compared with the BellaGel^® SmoothFine (130.13 ± 13.70 vs. 120.45 ± 5.76 days). In conclusion, we describe short-term treatment outcomes and safety of an implant-based breast augmentation using two representative brands of the fifth-generation silicone gel-filled breast implants in Korean women.

In search for the 'perfect' breast implant: are textured implants still indicated in today's breast augmentation practice?

The popularity of breast augmentation procedure has driven research and debate as to whether any given implant characteristic offers a functional advantage. One such debate exists about the role of surface texturing. In the aftermath of the recent withdrawal of aggressively textured surfaces we would like to summarize the first author's experience of nearly 1500 primary aesthetic breast augmentations with different surfaces and offer our thoughts on this topic. All consecutive primary breast augmentations operated by the first author from January 2010 to June 2019 were included. All patients had silicone implants inserted via inframammary incision. Of all the operated cases, 1029 consecutive female patients had at least 6 months' follow-up (mean 15.1 months). Their mean age was 31.2 years, mean BMI 20.8 kg/m² and mean implant volume was 311 cc. 997(96.9%) patients had dual plane and 32(3.1%) had sub-glandular implant placement. In total 113 patients (11.0%) developed a complication. This represented 15.1% of those with round and 10.0% of anatomical shape (or 10.6% of textured and 14.5% of smooth surface implants). As clinicians, we like patients to receive all the advantages of an implant but not be exposed to any risks. However, in reality, such a 'perfect implant' still does not exist. New literature continues to shed light on this trade-off between an implant's perceived utility and its complications profile. We hope that the search for an alternative technology, with more beneficial surface characteristics and less drawbacks, continues.

Surgical Treatment for Capsular Contracture: A New Paradigm and Algorithm

BACKGROUND

Capsular contracture following breast augmentation is prone to recurrence with conventional surgical therapy. Adding acellular dermal matrix improves results but significantly increases operating time and cost. This study tested a new treatment algorithm that uses acellular dermal matrix selectively to optimize success rates while minimizing its drawbacks.

METHODS

All patients surgically treated by the authors for Baker grade III/IV capsular contracture between 2007 and 2018 were included in this retrospective cohort study. Data were collected on patient, breast augmentation, capsular contracture, and surgical treatment characteristics, in addition to follow-up findings. Treatment success was defined as Baker grade II or better.

RESULTS

One hundred eighty patients underwent 217 surgical treatments for capsular contracture. Conventional treatment was used in 185 cases and acellular dermal matrix in 32. Twenty-six patients were treated for a second occurrence and four were treated for a third. The average follow-up was 2.4 years. Conventional treatment was successful in 72.5 percent of first occurrences, 62.5 percent of second occurrences, and 50.0 percent of third occurrences. Acellular dermal matrix was successful in 96.9 percent of cases. The odds of failure were increased by bilateral capsular contracture (3.9 times) and previous treatment failure (3.5 times). When acellular dermal matrix was used selectively for bilateral capsular contracture or in unilateral cases with a previous treatment failure, the overall treatment success rate improved to 85.6 percent compared with 64.2 percent when this algorithm was not followed (p < 0.001).

CONCLUSION

This study demonstrates that selective acellular dermal matrix use can increase success rate to over 85 percent in the overall treatment of capsular contracture, and to nearly 100 percent in individual cases.

Prospective Study of Saline versus Silicone Gel Implants for Subpectoral Breast Augmentation

Background

Silicone gel implants are regarded as esthetically superior to saline implants, offering a more natural consistency. They are also considered less susceptible to rippling. However, objective measurements and patient-reported outcome studies are lacking. Similarly, minimal data are available quantitating animation deformity.

Methods

A 3-year prospective study was undertaken among 223 women undergoing primary subpectoral breast augmentation using either saline (n = 145) or silicone gel (n = 78) implants. Photographs obtained included frontal views with the patient flexing the pectoral muscles. Images were matched, and vertical differences in nipple position were measured. Breast implants were evaluated using high-resolution ultrasound to detect any ripples or folds at least 3 months after surgery. Outcome surveys were administered. Statistical analysis included the χ² test, point-biserial correlations, and a power analysis.

Results

Respondents reported visible rippling in 18% of women and palpable rippling in 32% of patients, with no significant difference between women treated with saline and silicone gel implants. Ripples were detected on ultrasound scans in 24% of women with saline implants and in 27% of women with silicone gel implants (difference not significant). Ripples were more common in women with lower body mass indices. Fifty percent of patients demonstrated nipple displacement <1 cm on animation. Nipple displacement occurred either up or down with equal frequency and a mean overall nipple displacement of zero.

Conclusions

Saline and silicone breast implants produce similar degrees of rippling, as determined on outcome surveys and ultrasound examination. Animation deformities tend to be minor and well-tolerated.

A Systematic Review of the National Breast Implant Registry for Application in Korea: Can We Predict "Unpredictable" Complications?

Background and Objectives: Since silicone breast implants were introduced to the market several decades ago, the safety of breast implants has remained controversial. Recently, several studies have explored breast implant-associated anaplastic large-cell lymphoma (BIA-ALCL) and breast implant illness (BII). Several countries have developed national breast implant registries to improve the safety and quality of breast implant surgery. We performed a systematic review of the current status of national breast implant registries and propose a pilot form of an appropriate breast implant registry model for Korea. Materials and Methods: The systematic review was conducted in accordance with the “preferred reporting items for systematic reviews and meta-analyses (PRISMA) pro forma”. PubMed and Google Scholar databases were searched to identify all articles containing information on national breast implant registries. We limited the search to articles written in the English language from 2010 to 2020. Articles were reviewed by two independent authors. Results: A total of 63 articles related to national breast implant registries, registry principles and national breast implant registry annual reports were identified. After reviewing the literature, 25 national breast implant registry-related articles were included in the full-text synthesis. Currently, four countries, The Netherlands, Australia, Sweden, and the UK, have breast implant registries with well-formed sources for big data. Overall, similarities in data points were detected for three categories: implant-related complications, operation details, and device information. However, there were differences for each registry in terms of governance, funding, and capture rate. Conclusion: After reviewing other countries’ experiences, tentative datasets for the Korean Breast Implant Registry (K-BIR) were developed. The K-BIR can improve the quality of breast implant surgery in Korea by providing datasets on overall processes and outcome measures with quality indicators and risk adjustment factors. This approach will register characteristics of patients and monitor breast implants, complications, and surgical procedures to improve the outcomes of breast implant surgery in Korea. In addition, it can be used as a track-and-trace system with automated notifications to patients in the event of a product recall or other safety concerns related to a specific type of implant.

Background and Objectives: Since silicone breast implants were introduced to the market several decades ago, the safety of breast implants has remained controversial. Recently, several studies have explored breast implant-associated anaplastic large-cell lymphoma (BIA-ALCL) and breast implant illness (BII). Several countries have developed national breast implant registries to improve the safety and quality of breast implant surgery. We performed a systematic review of the current status of national breast implant registries and propose a pilot form of an appropriate breast implant registry model for Korea. Materials and Methods: The systematic review was conducted in accordance with the “preferred reporting items for systematic reviews and meta-analyses (PRISMA) pro forma”. PubMed and Google Scholar databases were searched to identify all articles containing information on national breast implant registries. We limited the search to articles written in the English language from 2010 to 2020. Articles were reviewed by two independent authors. Results: A total of 63 articles related to national breast implant registries, registry principles and national breast implant registry annual reports were identified. After reviewing the literature, 25 national breast implant registry-related articles were included in the full-text synthesis. Currently, four countries, The Netherlands, Australia, Sweden, and the UK, have breast implant registries with well-formed sources for big data. Overall, similarities in data points were detected for three categories: implant-related complications, operation details, and device information. However, there were differences for each registry in terms of governance, funding, and capture rate. Conclusion: After reviewing other countries’ experiences, tentative datasets for the Korean Breast Implant Registry (K-BIR) were developed. The K-BIR can improve the quality of breast implant surgery in Korea by providing datasets on overall processes and outcome measures with quality indicators and risk adjustment factors. This approach will register characteristics of patients and monitor breast implants, complications, and surgical procedures to improve the outcomes of breast implant surgery in Korea. In addition, it can be used as a track-and-trace system with automated notifications to patients in the event of a product recall or other safety concerns related to a specific type of implant.

Advances and current concepts in reconstructive surgery for breast cancer

In this article, we report on recent advancements in reconstructive care of the breast cancer patient. New developments in sensate breast reconstruction to help address the problem of numbness after mastectomy have emerged and show promise. Methods to restore lymphatic physiologic flow after axillary lymphadenectomy using supermicrosurgical techniques have begun to show benefit by reducing the short-term incidence of breast cancer related lymphedema (BRCL). Breast implant safety has received significant recent attention and we explore the emergence of BIA-ALCL (Breast Implant Associated Anaplastic Large Cell Lymphoma) and its implications for the breast cancer patient and their multidisciplinary care team.

Comparative clinical evaluation of breast augmentation using silicone foam coated implants and textured implants

PURPOSE

To evaluate whether silicone foam implants have a different evolution pattern compared to conventional texture implants.

METHODS

Fifty-eight female patients underwent surgery. They were divided into two groups (silicone foam - Lifesil® - and microtexturized silicone - Lifesil®). The evolution was analyzed in postoperative consultations, with physical examination, photographic documentation and filling in a satisfaction questionnaire, in the postoperative period of one month, four months, one year and then annually, up to a maximum of 3 years of follow-up.

RESULTS

There were no statistically significant differences in presence of rippling, stretch marks, breast ptosis, capsular contracture and quality of scars. There was a higher rate of patients who were very satisfied with the outcome 360 days after surgery in the group receiving silicone foam implants (p = 0.036).

CONCLUSION

In short time, silicone foam envelope implants proved to be as reliable as textured silicone envelope implants, making them an option for augmentation mammoplasty.

Short-term Safety of a Silicone Gel-filled Breast Implant: A Manufacturer-sponsored, Retrospective Study

Currently, 8 different brands of a silicone gel–filled breast implant are commercially available in Korea. But the superiority of short-term safety has not been established.

A 10-Year Follow-Up Experience of 383 Patients with Bilateral Smooth Inflatable Breast Implants Filled with Saline Solution

INTRODUCTION

In light of the concerns regarding the occurrence of anaplastic large-cell lymphoma, seromas, and scar capsules, there appears to be merit in analysis and presentation of the results of our series of inflatable smooth implants filled with saline solution, for which the follow-up was more than 10 years.

PATIENTS AND METHOD

We carried out a retrospective study, including all of the patients who underwent a first breast implant for cosmetic reasons, between 2003 and 2006.

RESULTS

A total of 383 patients with 766 smooth implants filled with saline solution were included in our study. No cases of lymphoma and seroma were diagnosed. Eleven patients exhibited a postoperative hematoma, and four went on to develop a capsule. Twenty-two patients (5.7%) developed a Baker Grade III or IV capsule that required revision surgery. Two patients (0.5%) opted for a bilateral prosthesis replacement due to visual rippling. In total, there were 26 (3.4%) early deflations of prostheses.

DISCUSSION

There is not a statistically significant correlation between the occurrence of hematomas and the formation of a capsule. We found a lower shell rate with smooth-walled versus textured implants. The fact of having a decline of 10 years allows to be exhaustive. As for wrinkling and ripples, their occurrence has not been increased by the use of inflatable retropectoral implants.

CONCLUSION

Smooth inflatable implants filled with saline solution have numerous advantages such as the possibility of a very small approach route and perioperative adaptability of the volume. In light of the lack of indication of anaplastic large-cell lymphoma with smooth implants, they are clearly an attractive alternative to textured implants filled with silicone gel.

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.

Device-Specific Findings of Imprinted-Texture Breast Implants: Characteristics, Risks, and Benefits

BACKGROUND

The relative risks and benefits of various textured breast implants are the focus of considerable discussion. Studies have suggested different risk-benefit profiles for different implant surface topographies.

OBJECTIVES

The study aim was to provide device-specific, quantitative information on Mentor's imprinted Siltex Textured breast implants with respect to textured surface characteristics and ISO 14607 classification, risk of breast implant-associated anaplastic large cell lymphoma (BIA-ALCL), and risk-reduction benefits relative to smooth implants.

METHODS

Surface metrology was performed. Data for smooth and Siltex implants from the prospective MemoryGel Core Study were evaluated by Kaplan-Meier analysis for the most frequently occurring postoperative complications in augmentation and reconstruction leading to subsequent reoperation.

RESULTS

The overall average surface roughness for Siltex MemoryGel and MemoryShape implants was 29.5 and 36.1 µm, respectively. A statistically significantly lower rate of reoperation in patients with Siltex compared with smooth devices over 10 years was observed for both capsular contracture in subglandular primary augmentation patients (4.21% vs 19.84%) and for asymmetry in primary reconstruction patients (3.88% vs 11.1%).

CONCLUSIONS

Surface analysis demonstrated that Siltex implants fall within the ISO 14607 category of "microtexture" breast implants. These devices exhibited a rare risk of BIA-ALCL (0.0012%) based on the most extensive data available. Relative to smooth implants, these Siltex devices provided risk-reduction benefits for the most common reason of reoperation in patients who underwent primary augmentation (capsular contracture) or primary reconstruction (asymmetry) in the Core Study. These findings provide valuable risk-benefit information for surgeons and their patients.

LEVEL OF EVIDENCE: 2

Implant Surface Options and Biofilm Mitigation Strategies

Two important topics in breast augmentation and reconstruction relate to device surface texture and practices to mitigate biofilm contamination of implants. Breast augmentation can be considered a manufacturing process where planning concepts of process engineering and quality can be used to produce great outcomes. This article reviews the options available for surgeons with regards to device surface texture selection and practices to mitigate biofilm contamination of implants at the time of surgery.

Characteristics of adhesion areas between the tissue expander and capsule in implant-based breast reconstruction

Background

The use of anatomic implants has improved the aesthetic results of breast surgery; however, implant malrotation is an uncommon, but serious complication of these procedures. Nevertheless, little research has explored implant adhesion. In this study, we investigated adhesion between the expander and the capsule.

Methods

Seventy-nine cases of immediate breast reconstruction via two-stage implantbased reconstruction performed between September 2016 and November 2017 were evaluated. Mentor CPX4 expanders were used in 14 breasts, and Natrelle expanders in 65. We analyzed areas of adhesion on the surfaces of the tissue expanders when they were exchanged with permanent implants. We investigated whether adhesions occurred on the cephalic, caudal, anterior, and/or posterior surfaces of the expanders.

Results

Total adhesion occurred in 18 cases, non-adhesion in 15 cases, and partial adhesion in 46 cases. Of the non-adhesion cases, 80% (n=12) were with Mentor CPX4 expanders, while 94.4% (n=17) of the total adhesion cases were with Natrelle expanders. Of the partial adhesion cases, 90.7% involved the anterior-cephalic surface. The type of tissue expander showed a statistically significant relationship with the number of attachments in both univariate and multivariate logistic regression analyses (P<0.001) and with total drainage only in the univariate analysis (P=0.015).

Conclusions

We sought to identify the location(s) of adhesion after tissue expander insertion. The texture of the implant was a significant predictor of the success of adhesion, and partial adhesion was common. The anterior-cephalic surface showed the highest adhesion rate. Nevertheless, partial adhesion suffices to prevent unwanted rotation of the expander.

Microtexture and the Cell/Biomaterial Interface: A Systematic Review and Meta-Analysis of Capsular Contracture and Prosthetic Breast Implants

BACKGROUND

The use of textured breast implants over smooth implants has been widely shown to have a lower incidence of capsular contracture. However, the impact of micropatterning techniques on the incidence of postoperative patient morbidity has not been comprehensively investigated.

OBJECTIVES

The authors sought to examine the incidence of capsular contracture, seroma, and implant rippling among the 3 major micropatterning techniques applied in the manufacturing of textured breast implants.

METHODS

Literature searches of PubMed/Medline and Embase between 1995 and 2017 were performed, and 19 studies were selected for analysis. Data from each study were extracted into a form including mean age, study design, population size, mean follow-up, number of capsular contracture cases, number of seroma cases, and number of rippling cases. Meta-analysis was performed separately for studies that included capsular contracture rates for foam textured implants, imprinted textured implants, and salt-loss textured implants.

RESULTS

The pooled rate of capsular contracture rates in primary augmentation patients was 3.80% (95% CI, 2.19-5.40) for imprinted textured implants, 4.90% (95% CI, 3.16-6.64) for foam textured implants, 5.27% (95% CI, 3.22-7.31) for salt-loss textured implants, and 15.56% (95% CI, 13.31-18.16) for smooth implants. The results of each meta-analysis were summarized on a forest plot depicting the distribution of capsular contracture rates from each study.

CONCLUSIONS

Micropatterning of prosthetic implants could drastically reduce postoperative patient morbidity given the advent of recent technologies that allow for more detailed texturing of implant surfaces.

LEVEL OF EVIDENCE: 4

New Evaluation Procedure for Multi-Dimensional Mechanical Strains and Tangent Moduli of Breast Implants: IDEAL IMPLANT® Structured Breast Implant Compared to Silicone Gel Implants

The IDEAL IMPLANT^® Structured Breast Implant is a dual lumen saline-filled implant with capsular contracture and deflation/rupture rates much lower than single-lumen silicone gel-filled implants. To better understand the implant’s mechanical properties and to provide a potential explanation for these eight-year clinical results, a novel approach to compressive load testing was employed. Multi-dimensional strains and tangent moduli, metrics describing the shape stability of the total implant, were derived from the experimental load and platen spacing data. The IDEAL IMPLANT was found to have projection, diametric, and areal strains that were generally less than silicone gel implants, and tangent moduli that were generally greater than silicone gel implants. Despite having a relatively inviscid saline fill, the IDEAL IMPLANT was found to be more shape stable compared to gel implants, which implies potentially less interaction with the capsule wall when the implant is subjected to compressive loads. Under compressive loads, the shape stability of a higher cross-link density, cohesive gel implant was unexpectedly found to be similar to or the same as a gel implant. In localized diametric compression testing, the IDEAL IMPLANT was found to have a palpability similar to a gel implant, but softer than a cohesive gel implant.

Round versus Anatomical Implants in Primary Cosmetic Breast Augmentation: A Meta-Analysis and Systematic Review

BACKGROUND

Choosing implant shape (round or anatomical) is one of the most essential yet controversial decisions in cosmetic breast augmentation. Many surgeons choose implant shape based on personal experience or expert opinion. This is the first systematic review and meta-analysis comparing the aesthetic effect between anatomical and round implants in primary cosmetic breast augmentation.

METHODS

The authors searched the PubMed, MEDLINE, Embase, ScienceDirect, Web of Knowledge, Scopus, and Cochrane Central Register of Controlled Trials databases for studies that compared anatomical and round implants in primary cosmetic breast augmentation. Primary outcomes were postoperative aesthetic effect and correct identification rate of implant shape. Random effects models were used to obtain pooled standardized mean difference and 95 percent confidence intervals.

RESULTS

One randomized comparative and four observational comparative studies met the inclusion criteria. No aesthetic superiority was found in the anatomical implant group with regard to overall appearance (standardized mean difference, 0.06; 95 percent CI, -0.40 to 0.53), naturalness (standardized mean difference, 0.18; 95 percent CI, -1.51 to 1.15), projection, upper pole contour, and lower pole contour. Pooled correct identification rate of implant shape by plastic surgeons was 52 percent (95 percent CI, 0.46 to 0.58).

CONCLUSIONS

Generally, anatomical implants do not seem to have an aesthetic superiority compared to round implants. Plastic surgeons seemed to be unable to accurately differentiate the two implant shapes in vivo. Further studies should focus on identifying the specific indications for the use of anatomical implants.

Clinical Results on Innovation in Breast Implant Design

Breast implants have been shadowed in controversy since their introduction to the market; however, they represent a multi-million dollar industry and play a critical role both for cosmetic augmentation and enhancement and for reconstruction following treatment for cancer. With advancements in technology, breast implants have evolved tremendously over the years. Further, with the cessation of the FDA implemented moratorium on silicone, the use of silicone implants has grown exponentially over the years. Novel designs in the outer shell, breast implant fill particularly the cohesivity of the silicone gel, texturing of the outer shell, and the shape and projection of breast implants have produced a broad array of implants that can be employed by plastic and reconstructive surgeons to maximize outcomes for patients. However, despite the innovations in breast implant design and engineering, it is unclear whether these have had any influence on outcomes and patient satisfaction. The present article aims to provide a comprehensive review of the technological advancements in breast implant technology in optimizing patient outcomes and minimizing complications associated with placement of breast implants for aesthetic as well as reconstructive procedures. The article will provide a synopsis of round versus shaped breast implants, saline versus silicone especially the advent of cohesive silicone gel implants, and the texturing of the outer shell, and how each of these components should be considered when counseling patients and deciding which implants offer the optimal benefits for each individual patient.