Current Risk Estimate of Breast Implant-Associated Anaplastic Large Cell Lymphoma in Textured Breast Implants

A Histological Assessment Tool for Breast Implant Capsules Validated in 480 Patients with and Without Capsular Contracture

BACKGROUND

Understanding the impact of breast implants on the histological response in the surrounding fibrous capsule is important; however, consensus is lacking on how to analyze implant capsules histologically. We aimed to develop a standardized histological assessment tool to be used in research potentially improving diagnostic accuracy and treatment strategies for capsular contracture.

METHODS

Biopsies of breast implant capsules from 480 patients who had undergone breast augmentation or reconstruction were collected and stained with hematoxylin and eosin. Initially, biopsies from 100 patients were analyzed to select histological parameters demonstrating the highest relevance and reproducibility. Then, biopsies from the remaining 380 patients were used to determine intra- and interobserver agreements of two blinded observers and agreement with a pathologist. Finally, we tested the association between the parameters and capsular contracture.

RESULTS

The histological assessment tool included ten parameters assessing the inflammatory, fibrotic, and foreign-body reaction to breast implants, each graded on two-, three-, or four-point scales. Intra- and interobserver agreements were almost perfect (0.83 and 0.80), and agreement with the pathologist was substantial (0.67). Four parameters were significantly correlated with capsular contracture, namely chronic inflammation with lymphocyte infiltration (p < 0.01), thickness of the collagen layer (p < 0.0001), fiber organization (p < 0.01), and calcification (p < 0.001).

CONCLUSIONS

This is the first validated histological assessment tool for breast implant capsules. The validated tool not only advances our understanding of capsular contracture but also sets a new standard for histological evaluation in breast implant research and clinical diagnostics.

NO LEVEL ASSIGNED

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Undifferentiated Pleomorphic Sarcoma Mimicking Breast Implant-Associated Anaplastic Large Cell Lymphoma

Breast implant augmentation is a low-risk procedure with few life-threatening complications, most commonly rupture or leakage and contraction of the capsule. Breast implant-associated (BIA) malignancies are rare. Anaplastic large cell lymphoma (ALCL) is the most well-known neoplastic condition associated with breast augmentation. Carcinomas arising in association with implants have been reported but are rarer than ALCL. BIA-mesenchymal tumors are extremely rare and most are locally aggressive fibromatosis. To date, only eight cases of BIA sarcomas have been reported. Herein, we describe a case of silicone BIA-undifferentiated pleomorphic sarcoma (UPS) that was initially mistaken for ALCL because of a significant clinical and radiological overlap in presentation and imaging. Here, we present the morphological and molecular features of this rare neoplasm. We reviewed the existing literature related to BIA sarcomas to highlight the importance of considering this diagnosis in cases of recurrent ALCL-negative BIA effusions.

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

BACKGROUND

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

OBJECTIVES

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

LEVEL OF EVIDENCE: 3

An Update on Implant-Associated Malignancies and Their Biocompatibility

Implanted medical devices are widely used across various medical specialties for numerous applications, ranging from cardiovascular supports to orthopedic prostheses and cosmetic enhancements. However, recent observations have raised concerns about the potential of these implants to induce malignancies in the tissues surrounding them. There have been several case reports documenting the occurrence of cancers adjacent to these devices, prompting a closer examination of their safety. This review delves into the epidemiology, clinical presentations, pathological findings, and hypothesized mechanisms of carcinogenesis related to implanted devices. It also explores how the surgical domain and the intrinsic properties and biocompatibility of the implants might influence the development of these rare but serious malignancies. Understanding these associations is crucial for assessing the risks associated with the use of medical implants, and for developing strategies to mitigate potential adverse outcomes.

Silicone implant surface microtopography modulates inflammation and tissue repair in capsular fibrosis

Excessive fibrous capsule formation around silicone mammary implants (SMI) involves immune reactions to silicone. Capsular fibrosis, a common SMI complication linked to host responses, worsens with specific implant topographies. Our study with 10 patients investigated intra- and inter-individually, reduced surface roughness effects on disease progression, wound responses, chronic inflammation, and capsular composition. The results illuminate the significant impact of surface roughness on acute inflammatory responses, fibrinogen accumulation, and the subsequent fibrotic cascade. The reduction of surface roughness to an average roughness of 4 μm emerges as a promising approach for mitigating detrimental immune reactions, promoting healthy wound healing, and curbing excessive fibrosis. The identified proteins adhering to rougher surfaces shed light on potential mediators of pro-inflammatory and pro-fibrotic processes, further emphasizing the need for meticulous consideration of surface design. The composition of the implant capsule and the discovery of intracapsular HSP60 expression highlight the intricate web of stress responses and immune activation that can impact long-term tissue outcomes.

Textured versus Smooth Tissue Expanders: A Comparison of Complications in 3526 Breast Reconstructions

BACKGROUND

Increased understanding of breast implant-associated anaplastic large-cell lymphoma has led to a shift away from textured breast devices. A few small studies have compared the complication rates of textured and smooth tissue expanders (TEs). The aim of this study was to compare complication profiles in patients undergoing two-stage postmastectomy breast reconstruction with either textured or smooth TEs.

METHODS

The authors performed a retrospective review of female patients who underwent immediate breast reconstruction with textured or smooth TEs from 2018 to 2020 at their institution. Rates of seroma, infection/cellulitis, malposition/rotation, exposure, and TE loss were analyzed in the overall cohort and subgroups undergoing prepectoral and subpectoral TE placement. A propensity score-matched analysis was used to decrease the effects of confounders comparing textured and smooth TEs.

RESULTS

The authors analyzed 3526 TEs (1456 textured and 2070 smooth). More frequent use of acellular dermal matrix, SPY angiography, and prepectoral TE placement was noted in the smooth TE cohort ( P < 0.001). Univariate analysis suggested higher rates of infection/cellulitis, malposition/rotation, and exposure in smooth TEs (all P < 0.01). Rates of TE loss did not differ. After propensity matching, no differences were noted in infection or TE loss. Prepectoral smooth expanders had increased rates of malposition/rotation.

CONCLUSIONS

TE surface type did not affect rates of TE loss, although increased rates of expander malposition were noted in the smooth prepectoral cohort. Further research is needed to examine breast implant-associated anaplastic large-cell lymphoma risk with temporary textured TE exposure to improve decision-making.

CLINICAL QUESTION/LEVEL OF EVIDENCW

Therapeutic, III.

Smooth vs Textured Expanders: Patient Factors and Anatomic Plane Are Greater Factors in Determining First-Stage Breast Reconstruction Outcomes

BACKGROUND

Textured implants and expanders are associated with an increased risk of breast implant-associated anaplastic large cell lymphoma (BIA-ALCL). As a result, plastic surgeons are utilizing smooth expanders, but many perceive these produce undesirable outcomes including infection, seroma, and lateral displacement.

OBJECTIVES

The aim of this study was to compare clinical outcomes of smooth and textured expanders.

METHODS

Breast reconstruction patients from January 2018 to May 2021 were retrospectively reviewed. Included patients underwent placement of tissue expanders at the time of mastectomy. Primary outcomes included postoperative seroma, infection, malposition, days to final reconstruction, explantation, and the need for capsulorrhaphy.

RESULTS

In total, 233 patients were reviewed, of whom 167 met both inclusion and exclusion criteria. There was no statistically significant difference in poor outcomes comparing smooth and textured expanders. Days to final reconstruction was lower with smooth expanders per breast (P = .0424). The subpectoral group was associated with an increased likelihood of undergoing capsulorrhaphy (P = .004). Prepectoral placement was associated with more seromas (P = .0176) and infections (P = .0245). Demographic factors included older age as a protective factor for undergoing capsulorrhaphy (odds ratio [OR] = 0.962, P = .038), obesity increased the risk of infection (OR = 5.683, P = .0279) and malposition (OR = 6.208, P = .0222), and radiation was associated with malposition (OR = 3.408, P = .0246).

CONCLUSIONS

There was no significant difference in poor outcomes between smooth and textured expanders. Patient demographics and anatomical plane placement had greater effects on infection, seroma, and the need for capsulorrhaphy compared with tissue expander texturing.

LEVEL OF EVIDENCE: 3

Smooth versus Textured Tissue Expanders: Comparison of Outcomes and Complications in 536 Implants

Background  Increasing concerns regarding the safety of textured surface implants have resulted in surgeons transitioning from textured tissue expanders (TEs) to smooth TEs. Given this change has only recently occurred, this study evaluated outcomes between smooth and textured TEs. Methods  Women who underwent two-stage breast reconstruction using TEs from 2013 to 2022 were included. TE-specific variables, perioperative information, pain scores, and complications were collected. Chi-squared, t -test, and linear regression analyses were performed. Results  A total of 320 patients received a total of 384 textured and 152 smooth TEs. Note that 216 patients received bilateral reconstruction. TEs were removed in 9 cases. No significant differences existed between groups regarding comorbidities. Smooth TEs had a higher proportion of prepectoral placement ( p  < 0.001). Smooth TEs had less fills (3 ± 1 vs. 4 ± 2, p  < 0.001), shorter expansion periods (60 ± 44 vs. 90 ± 77 days, p  < 0.001), smaller expander fill volumes (390 ± 168 vs. 478 ± 177 mL, p  < 0.001), and shorter time to exchange (80 ± 43 vs. 104 ± 39 days, p  < 0.001). Complication rates between textured and smooth TEs were comparable. Smooth TE had a greater proportion of TE replacements ( p  = 0.030). On regression analysis, pain scores were more closely associated with age ( p  = 0.018) and TE texture ( p  = 0.046). Additional procedures at time of TE exchange ( p  < 0.001) and textured TE ( p  = 0.017) led to longer operative times. Conclusion  As many surgeons have transitioned away from textured implants, our study shows that smooth TEs have similar outcomes to the textured alternatives.

Epidemiology of Breast Implant-Associated Anaplastic Large Cell Lymphoma in the United States: A Systematic Review

BACKGROUND

Although textured implants represent fewer than 10% of implants used in the United States, the country reports the highest incidence of breast implant-associated anaplastic large cell lymphoma (BIA-ALCL).

OBJECTIVES

The aim of this study was to perform a systematic literature review on US-based epidemiology to update knowledge on BIA-ALCL in the United States.

METHODS

Publications on US BIA-ALCL epidemiology were searched between September 2022 and March 2023 on MEDLINE (National Institutes of Health; Bethesda, MD), Embase (Elsevier, Amsterdam, the Netherlands), Web of Science (Clarivate, London, UK), and SCOPUS (Elsevier, Amsterdam, the Netherlands). The US numerator was obtained by averaging the FDA MAUDE database and the PSF PROFILE registry, while the denominator was estimated from chest X-rays, and included female transgender individuals. Prevalence and risk were assessed accordingly, but the incidence rate (IR) could not be updated due to the lack of available follow-up data.

RESULTS

Out of 987 identified manuscripts, 10 were included. The US prevalence of BIA-ALCL in the literature ranged from 1:300 to 1:500,000 and the IR from 4.5 per 10,000 to 31.1 per 100 million persons per year. A mean value of 453.5 BIA-ALCL cases was calculated. From a denominator of 4,264,618 individuals, which includes all breast implant surfaces, we calculated 414,521 individuals with textured implants, indicating a textured prevalence of 109.4 cases per 100,000 individuals and a risk of 1:913.

CONCLUSIONS

BIA-ALCL IR, prevalence, and risk has increased when calculated exclusively for patients with textured devices. Although US macrotextured implants were recalled by the FDA, these findings may influence the surveillance of existing patients and the use of macrotextured implants in other parts of the world where they remain widespread.

LEVEL OF EVIDENCE: 4

Implant replacement and anaplastic large cell lymphoma associated with breast implants: a quantitative analysis

Introduction

Breast implant-associated anaplastic large-cell lymphoma (BIA-ALCL) is a rare form of non-Hodgkin T-cell lymphoma associated with breast reconstruction post-mastectomy or cosmetic-additive mammoplasty. The increasing use of implants for cosmetic purposes is expected to lead to an increase in BIA-ALCL cases. This study investigated the main characteristics of the disease and the factors predicting BIA-ALCL onset in patients with and without an implant replacement.

Methods

A quantitative analysis was performed by two independent researchers on cases extracted from 52 primary studies (case report, case series, and systematic review) published until April 2022 and searched in PubMed, Scopus, and Google-Scholar databases using "Breast-Implant" AND/OR "Associated" AND/OR "Anaplastic-Large-Cell-Lymphoma". The statistical significance was verified by Student's t-test for continuous variables, while Fisher's exact test was applied for qualitative variables. Cox model with time-dependent covariates was used to estimate BIA-ALCL's onset time. The Kaplan-Meier model allowed the estimation of the probability of survival after therapy according to breast implant exposure time.

Results

Overall, 232 patients with BIA-ALCL were extracted. The mean age at diagnosis was 55 years old, with a mean time to disease onset from the first implant of 10.3 years. The hazard of developing BIA-ALCL in a shorter time resulted significantly higher for patients not having an implant replacement (hazard ratio = 0.03; 95%CI: 0.005-0.19; p-value < 0.01). Patients with implant replacement were significantly older than patients without previous replacement at diagnosis, having a median time to diagnosis since the first implant of 13 years (7 years in patients without replacement); anyway, the median time to BIA-ALCL occurrence since the last implantation was equal to 5 years.

Discussion

Our findings suggest that, in BIA-ALCL patients, the implant substitution and/or capsulectomy may delay the disease's onset. However, the risk of reoccurrence in an earlier time should be considered in these patients. Moreover, the time to BIA-ALCL onset slightly increased with age. Selection bias, lack of awareness, misdiagnosis, and limited data availability could be identified as limits of our study. An implant replacement should be considered according to a risk stratification approach to delay the BIA-ALCL occurrence in asymptomatic patients, although a stricter follow-up after the implant substitution should be recommended.

Systematic Review Registration

https://www.crd.york.ac.uk/PROSPERO, identifier: CRD42023446726.

BIA-ALCL Epidemiology in an Aesthetic Breast Surgery Cohort of 1501 Patients

BACKGROUND

Epidemiologic studies on breast implant-associated anaplastic large cell lymphoma (BIA-ALCL) currently estimate the risk between 1:300 and 1:30,000, assessed mainly in large breast reconstruction populations.

OBJECTIVES

The aim of the study was to assess BIA-ALCL epidemiology in a cohort of patients who have received textured implants for cosmetic indications.

METHODS

In a prospective cohort observational study, 1501 patients who received a cosmetic breast augmentation between 2006 and 2016 were monitored, recording any implant-related complications, including BIA-ALCL. Cross-checking of clinical, pathology, and external records data identified cases. Prevalence, implant-specific prevalence (I-SP), incidence rate (IR), event-free time (EFT), and the Kaplan-Meier survival estimate were calculated.

RESULTS

All but 2 patients received macrotextured or microtextured devices bilaterally. Mean follow-up was 3.2 years (1 months to 16.4 years). Five BIA-ALCL cases were investigated. Prevalence was 1:300 patients; I-SP was 6.9 cases/1000 individuals/Allergan BIOCELL devices and 1.3 cases/1000 individuals/Mentor Siltex devices; and IR was 1.07 cases/1000 females/year. Mean (SD) EFT was 9.2 years.

CONCLUSIONS

When using a denominator based on a cohort of cosmetic patients, BIA-ALCL occurrence is higher than previously reported, particularly with macrotextured devices. Given the similar IRs in reconstructive and cosmetic cohorts, their even distribution could be consequent to underreporting due to poorer follow-up and lower awareness in the latter group. The genetic predisposition in the oncologic cohort reasonably affects the early onset more than the IR. The importance of accurate follow-up is confirmed. Stratification risks analysis can guide surgeons during patient counseling regarding the decision for prophylactic explantation.

LEVEL OF EVIDENCE: 4

Oncological Outcomes After Multidisciplinary Management of Breast Implant-Associated Anaplastic Large Cell Lymphoma (BIA-ALCL)

INTRODUCTION

Breast implant-associated anaplastic large cell lymphoma (BIA-ALCL) is an uncommon type of non-Hodgkin lymphoma, associated with breast implant capsules. Despite improvements in our understanding of BIA-ALCL, communicating the prognosis to patients remains challenging due to limited long-term follow-up data. This has important implications for decision-making, including recommendations for subsequent reconstructive procedures. The aim of this study was to assess the longer-term oncological outcomes of patients receiving multidisciplinary treatment for BIA-ALCL.

METHODS

This was a retrospective cohort study of BIA-ALCL patients treated at a tertiary referral unit. The data are presented using simple descriptive statistics.

RESULTS

Between 2015 and 2022, 18 BIA-ALCL patients were treated at our institution. The median age at diagnosis was 48.5 (IQR 41-55) years. Ten patients developed BIA-ALCL after cosmetic breast augmentation, and 8 after breast reconstruction following mastectomy for cancer. All patients had a history of textured implant insertion. The median time from first implant surgery to diagnosis was 8.5 (IQR 7-12) years. All patients underwent en-bloc total capsulectomy with implant removal, and 2 received systemic therapy. Fifteen patients had Stage I (IA-IC) disease, 2 had Stage IIA and 1 Stage III BIA-ALCL, based on the TNM classification system. At a median follow-up of 45 (IQR 15-71) months, there were no episodes of local or systemic relapse or death.

CONCLUSIONS

Surgical management for BIA-ALCL is sufficient in early-stage disease, and associated with excellent oncological outcomes. This information is reassuring for patients when discussing recurrence risk.

Prevalence of women with breast implants in Sweden: a study based on the population-based mammography screening programme

BACKGROUND

Knowledge about the prevalence of women with breast implants is paramount in calculations of risks and in estimations of effects on screening and breast cancer treatment. Most of the estimations of prevalence made to date are rough and often based on sales data. The main aim of this study was to  calculate the prevalence of breast implants in Swedish women. The secondary aim was to investigate if it is feasible to establish the occurrence of breast implants with the help of the public mammography screening programme, in a country with a publicly funded welfare-type healthcare system and with a clear documentation of screening.

METHODS

Information on implants was prospectively collected from all screening attendants from 1st of February 2022 to 1st of August 2022 based on a question from the radiographer to the woman and later verified on the mammogram.

RESULTS

During the study period 4,639 women were screened, of which 182 had implants (3.9%). The  frequency varies between 1.6 and 6.4% in different age groups.

CONCLUSION

The prevalence of breast implants in Swedish women is estimated to be around 4%. The population-based mammography screening programme in countries with a publicly funded welfare-type healthcare system and a clear documentation of mammography screening attendance, seems to be a feasible way to establish the prevalence of breast implants in the population. The large number of women with breast implants warrants further studies regarding the best diagnostic and treatment alternatives for this group. Pre-registration: ClinicalTrials.Gov identifier NCT05222100.

The evaluation of the delayed swollen breast in patients with a history of breast implants

Breast implants, whether placed for reconstructive or cosmetic purposes, are rarely lifetime devices. Rupture, resulting from compromised implant shell integrity, and capsular contracture caused by constriction of the specialized scar tissue that normally forms around breast implants, have long been recognized, and remain the leading causes of implant failure. It is apparent, however, that women with breast implants may also experience delayed breast swelling due to a range of etiologic factors. While a majority of delayed seromas associated with breast implants have a benign etiology, this presentation cannot be ignored without an adequate workup as malignancies such as breast implant associated anaplastic large cell lymphoma (BIA-ALCL), breast implant associated diffuse large B-cell lymphoma (BIA-DLBCL), and breast implant associated squamous cell carcinoma (BIA-SCC) can have a similar clinical presentation. Since these malignancies occur with sufficient frequency, and with sometimes lethal consequences, their existence must be recognized, and an appropriate diagnostic approach implemented. A multidisciplinary team that involves a plastic surgeon, radiologist, pathologist, and, as required, surgical and medical oncologists can expedite judicious care. Herein we review and further characterize conditions that can lead to delayed swelling around breast implants.

BIA-ALCL in patients with genetic predisposition for breast cancer: our experience and a review of the literature

Breast implant-associated anaplastic large cell lymphoma (BIA-ALCL) is an emerging non-Hodgkin's lymphoma that occurs exclusively in patients with breast implants. The estimated risk of developing BIA-ALCL from exposure to breast implants is largely based on approximations about patients at risk. There is a growing body of evidence regarding the presence of specific germline mutations in patients developing BIA-ALCL, rising interest regarding possible markers of genetic predisposition to this type of lymphoma. The present paper focuses attention on BIA-ALCL in women with a genetic predisposition for breast cancer. We report our experience at the European Institute of Oncology, Milan, Italy, describing a case of BIA-ALCL in a BRCA1 mutation carrier who developed BIA-ALCL 5 years after implant-based post mastectomy reconstruction. She was treated successfully with an en-bloc capsulectomy. Additionally, we review the available literature on inherited genetic factors predisposing to the development of BIA-ALCL. In patients with genetic predisposition to breast cancer (mainly TP53 and BRCA1/2 germline mutations), BIA-ALCL prevalence seems to be higher and time to onset appears to be shorter in comparison to the general population. These high-risk patients are already included in close follow-up programs allowing the diagnosis of early-stage BIA-ALCL. For this reason, we do not believe that a different approach should be followed for postoperative surveillance.

Practice Trends in the Management of Asymptomatic Breast Reconstruction Patients with Textured Implants: A Survey Analysis

Despite the increasing prevalence of breast implant associated anaplastic large cell lymphoma, there remains a paucity of literature guiding management of asymptomatic patients with textured breast implants. This risk can be anxiety provoking in breast reconstruction patients given their history of cancer or increased future risk. The purpose of this study is to evaluate current practice trends when managing the concerned asymptomatic patient following textured implant-based breast reconstruction.

Methods

An electronic survey was distributed to members of the American Society of Plastic Surgeons, regarding management of asymptomatic breast reconstruction patients with textured devices. Anonymous responses were collected, and statistical analysis was performed.

Results

A total of 304 responses were received. Of respondents, 237 (92%) have managed asymptomatic patients with textured devices. Historically, the overwhelming majority (89%) used textured devices; however, only 25% report current use. Regarding management of asymptomatic breast reconstruction patients, 87% recommend conservative management, while 13% recommend surgical management. When surgery is performed, 16.3% of respondents elected for implant exchange, 33.8% recommended implant exchange with partial capsulectomy, and 49.8% elected for implant exchange with total capsulectomy. Evaluation of practice patterns based on demographics demonstrated statistically significant differences in current use of textured devices and management of acellular dermal matrix.

Conclusions

Despite decreased current use, there is a significant population of asymptomatic breast reconstruction patients with a history of textured devices concerned for risk of breast implant associated anaplastic large cell lymphoma. This survey demonstrates ongoing variability in surgeon recommendations regarding conservative and surgical management of these patients and the need for continued development of evidence-based guidelines.

Breast reconstruction: Review of current autologous and implant-based techniques and long-term oncologic outcome

Implant-based reconstruction is the most common method of breast reconstruction. Autologous breast reconstruction is an indispensable option for breast reconstruction demanding keen microsurgical skills and robust anatomical understanding. The reconstructive choice is made by the patient after a discussion with the plastic surgeon covering all the available options. Advantages and disadvantages of each technique along with long-term oncologic outcome are reviewed.

A Comparison of Smooth and Microtextured Breast Implants in Breast Augmentation: A Retrospective Study

Background  The number of cosmetic and reconstructive surgeries that use breast implants is increasing in Korea. Recently, it has been reported that breast implant-associated anaplastic large-cell lymphoma is related to textured breast implants, and interest in classification according to the texture of breast implants is increasing. However, there is currently no clear and unified classification. In particular, the definition of “microtextured” is highly varied. In this study, we retrospectively investigated and analyzed the clinical outcomes of smooth and microtextured breast implants.

Methods  A retrospective chart review of all patients who underwent breast augmentation surgery with smooth and microtextured silicone gel implants between January 2016 and July 2020 was performed. We retrospectively analyzed implant manufacturer, age, body mass index (BMI), smoking status, incision location, implant size, follow-up period, complications, and reoperation rate.

Results  A total of 266 patients underwent breast augmentation surgery, of which 181 used smooth silicone gel implants and 85 used microtextured silicone gel implants. Age, BMI, smoking status, implant size, and follow-up period were not significantly different between the two groups. Similarly, complications and reoperation rates were not significantly different between the two groups.

Conclusion  It is important to provide information regarding the clinical risks and benefits of breast implants to surgeons and patients through a clear and unified classification according to the texture of the breast implant.

Breast Implant-Associated Anaplastic Large Cell Lymphoma

Pathologic staging including assessment of margins is essential for the proper management of patients with breast implant-associated anaplastic large-cell lymphoma (BIA-ALCL). As most patients present with effusion, cytologic examination with immunohistochemistry and/or flow cytometry immunophenotyping are essential for diagnosis. Upon a diagnosis of BIA-ALCL, en bloc resection is recommended. When a tumor mass is not identified, a systematic approach to fixation and sampling of the capsule, followed by pathologic staging and assessment of margins, is essential. Cure is likely when lymphoma is contained within the en bloc resection and margins are negative. Incomplete resection or positive margins require a multidisciplinary team assessment for adjuvant therapy.

First Case Report of Breast Implant Associated-Anaplastic Large Cell Lymphoma from India: Are We Ready?

Breast implant associated-anaplastic large cell lymphoma (BIA-ALCL) has become a hot topic in recent plastic surgery and oncology forum. Its cases have been on the rise since its first emergence more than two decades ago. This condition is less known and management guidelines are still evolving. BIA-ALCL was seen recently with a classical presentation in one of our patients, who underwent immediate reconstruction with a macro-textured silicone implant following breast cancer surgery. We want to add the first case report from India to the global information database. There are still unanswered questions in its management, and we wish to highlight the same to make way for further research. With the rise in aesthetic and reconstructive implant surgeries, the knowledge of BIA-ALCL must expand among oncologists, radiologists, and pathologists for early identification and treatment for better patient outcomes.

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

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

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

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

Breast 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.

Identifying Public Perceptions, Attitudes, and Concerns about Breast Implants and Their Complications: A National Survey

BACKGROUND

Aesthetic and reconstructive implant-based breast operations are among the most common plastic surgery procedures. This study assessed the baseline knowledge of common breast implant-associated complications, and their influence on consideration of breast implants among adult laywomen within the United States.

METHODS

Five hundred women were recruited through Amazon's Mechanical Turk. Respondents self-reported demographics and experience with breast implants. Questions were asked addressing respondents' understanding of complications and concerns regarding breast implants.

RESULTS

Of the authors' cohort (average age, 37.8 ± 11.7 years), 12.0% had received breast implants, 72.8% knew someone with implants, and nearly 50% would consider receiving implants in the future. As many as 82.2% reported at least one concern influencing their consideration of implants: safety (75.2%), cost (70.0%), unnatural shape (43.3%), and feel (45.2%). Respondents not considering implants were significantly concerned by foreign body implantation ( P < 0.001). Almost 75% believed that implants last longer than 10 years. Following education about risks of capsular contracture and implant rupture, one-third of respondents considering implants and half of those unsure were "less likely" to receive implants. The majority were unchanged in their likelihood after learning about infection (74.4%) and implant migration (69.2%). Respondents with a history of implants were significantly less likely to believe there is strong evidence supporting the aforementioned complications ( P < 0.001).

CONCLUSIONS

The rising awareness surrounding breast implant safety has the potential to significantly impact perceptions and receptivity. This study identifies public perceptions of common breast implant-associated complications and primary long-term concerns, highlighting the importance of education on postoperative complications in informed consent and surgical decision-making.

Silicone Breast Implant Surface Texture Impacts Gene Expression in Periprosthetic Fibrous Capsules

BACKGROUND

Silicone breast implants with smooth outer shells are associated with higher rates of capsular contracture, whereas textured implants have been linked to the development of breast implant-associated anaplastic large cell lymphoma. By assessing the gene expression profile of fibrous capsules formed in response to smooth and textured implants, insight into the development of breast implant-associated abnormalities can be gained.

METHODS

Miniature smooth or textured silicone implants were surgically inserted into female rats ( n = 10) and harvested for the surrounding capsules at postoperative week 6. RNA sequencing and quantitative polymerase chain reaction were performed to identify genes differentially expressed between smooth and textured capsules. For clinical correlation, the expression of candidate genes was assayed in implant capsules harvested from human patients with and without capsular contracture.

RESULTS

Of 18,555 differentially expressed transcripts identified, three candidate genes were selected: matrix metalloproteinase-3 ( MMP3 ), troponin-T3 ( TNNT3 ), and neuregulin-1 ( NRG1 ). In textured capsules, relative gene expression and immunostaining of MMP3 and TNNT3 was up-regulated, whereas NRG1 was down-regulated compared to smooth capsules [mean relative fold change, 8.79 ( P = 0.0059), 4.81 ( P = 0.0056), and 0.40 ( P < 0.0001), respectively]. Immunostaining of human specimens with capsular contracture revealed similar gene expression patterns to those of animal-derived smooth capsules.

CONCLUSIONS

An expression pattern of low MMP3 /low TNNT3 /high NRG1 is specifically associated with smooth implant capsules and human implant capsules with capsular contracture. The authors' clinically relevant breast implant rat model provides a strong foundation to further explore the molecular genetics of implant texture and its effect on breast implant-associated abnormalities.

CLINICAL RELEVANCE STATEMENT

The authors have demonstrated that there are distinct gene expression profiles in response to smooth versus textured breast implants. Since surface texture may be linked to implant-related pathology, further molecular analysis of periprosthetic capsules may yield strategies to mitigate implant-related complications.

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

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

BIA-ALCL Epidemiological Findings From a Retrospective Study of 248 Cases Extracted from Relevant Case Reports and Series: A Systematic Review

BACKGROUND

The epidemiologic picture of Breast Implant Associated-Anaplastic Large Cell Lymphoma (BIA-ALCL) is unclear, with no high-level evidence, as only case reports and series are available.

OBJECTIVES

We aimed at updating the BIA-ALCL epidemiology by using all available data through a systematic review of scientific literature.

METHODS

A search on PubMed, Scopus, and Web of Science was conducted between October 2021 and April 2022. Out of the 2,799 available records, we selected 114 pertinent articles, featuring 248 BIA-ALCL cases which were retrospectively analyzed by means of descriptive statistics, incidence rate (IR), Kaplan-Meier survival curves and Pearson correlation coefficient.

RESULTS

United States, Netherlands, Italy, and Australia were the most reporting countries. Mean age at 1st implantation was 42y, and 53y at diagnosis. Aesthetic indication was 52% and reconstructive 48%, macrotextured surface was linked to 73.8% of cases and seroma to 83%. Total follow-up was 492 months, mean Event Free Time (EFT) to BIA-ALCL development was 129 months. IR was 96 new cases/1.000 women per year after first implantation, and directly correlated to number of replacements. EFT was directly correlated to number of replacements, implant rupture and capsule contracture, while inversely associated to patients' age at first implantation and to BRACA1/2 and TP53 mutations.

CONCLUSIONS

Macrotextured implants use in older patients and in BRCA1/2 and TP53 mutated should be reconsidered, being associated to earlier disease onset. Implant replacement of asymptomatic, risk-stratified patients, can be indicated due to its protective role against BIA-ALCL, reducing IR rate and risk, while increasing the EFT.

Prepectoral Breast Reconstruction without Acellular Dermal Matrix: Have We Come Full Circle?

Breast reconstruction is an integral part of breast cancer treatment [...].

Breast Implant-Associated Anaplastic Large-Cell Lymphoma: Updated Systematic Review and Analysis of Treatment Strategies

BACKGROUND

Although guidelines have been published on treatment of breast implant-associated anaplastic large-cell lymphoma (BIA-ALCL), there has been no comprehensive analysis of BIA-ALCL treatment variation based on the available literature. The authors sought to assess current treatment strategies of BIA-ALCL relative to current guidelines.

METHODS

Database searches were conducted in June of 2020. Included articles were case reports and case series with patient-level data. Collected variables included clinicopathologic features, implant characteristics, diagnostic tests, ALCL characteristics, treatment, and details of follow-up and outcome. Treatment data from before and after 2017 were compared with National Cancer Center Network guidelines.

RESULTS

A total of 89 publications were included and 178 cases of BIA-ALCL were identified. Most patients presented with seroma ( n = 114, 70.4 percent), followed by a mass ( n = 14, 8.6 percent), or both ( n = 23, 14.2 percent). Treatment included en bloc capsulectomy of the affected implant in 122 out of 126 cases with treatment details provided (96.8 percent). Radiation therapy was given in 38 cases (30.2 percent) and chemotherapy was given in 71 cases (56.3 percent). Practitioners used less chemotherapy for local disease after treatment guideline publication in 2017 ( p < 0.001), whereas treatment for advanced disease remained unchanged ( p = 0.3). There were 10 recurrences and eight fatalities attributable to BIA-ALCL, which were associated with advanced presentation (29 versus 2.1 percent; OR, 19.4; 95 percent CI, 3.9 to 96.3; p < 0.001).

CONCLUSIONS

BIA-ALCL remains a morbid but treatable condition. Current guidelines focus treatment for local disease and reduce nonsurgical interventions with radiation or chemotherapy. Patients presenting with advanced BIA-ALCL experience higher rates of recurrence and mortality.

Current Understanding of Breast Implant-Associated Anaplastic Large Cell Lymphoma

Every year, breast implants are inserted worldwide for reconstructive or aesthetic reasons. Breast implant-associated anaplastic large cell lymphoma (BIA-ALCL) is a rather uncommon type of T cell lymphoma that is positive for the CD30 biomarker. Despite being far more common than other primary breast lymphomas, BIA-ALCL has a very low incidence. Textured types of implants have been linked to almost all cases. The majority of patients have a favorable prognosis after the removal of implants and capsules. Nevertheless, the chance of a fatal outcome is higher with capsular invasion and tumor bulk. Although the exact cause of BIA-ALCL is unknown, it has been suggested that persistent infections or toxins related to the implants may play a role. Therefore, physicians must be aware of breast implants' rare but potentially significant side effects. Before surgery, patients with verified instances should be directed to a breast medical oncologist or lymphoma specialist for oncologic assessment. Total en-bloc capsulectomy, a surgical procedure that removes the implant and the surrounding capsule, is usually adequate. In other cases, a late diagnosis necessitates more invasive surgery and systemic therapies, which, while typically effective, have been linked to poor outcomes and even fatalities. Since it is a recently described entity and the "denominator" (i.e., the total number of breast implant procedures) is unknown, it is challenging to determine the risk of development. In this review, we hope to emphasize the elements of etiology, demography, clinical features, and current treatment approaches for BIA-ALCL. In doing so, we hope to increase the medical professional's knowledge of the recognition and treatment of BIA-ALCL.

Breast Implant-Associated Anaplastic Large Cell Lymphoma (BIA-ALCL) in a young transgender woman: A case report

Introduction

Breast Implant-Associated Anaplastic Large Cell Lymphoma (BIA-ALCL) is a rare T-cell lymphoma occurring after breast implant procedures. As gender confirmation therapy (GCT) in male-to-female transgender (FT), up to 60–70 % of patients require breast augmentation and are at risk for BIA-ALCL. Hence, we report the youngest BIA-ALCL case in the Italian population and the first early-stage BIA-ALCL occurred in FT patients.

Case presentation

A 27-years-old FT was admitted to outpatients' clinics due to swollen left breast. The patient underwent GCT with a macrotextured implant four years before. Clinical examination revealed swollen left breast. Ultrasound and magnetic resonance imaging confirmed left breast periprosthetic effusion. Positron emission tomography-computed tomography scan did not reveal any focal pathological uptake. Fine needle aspiration cytology confirmed BIA-ALCL suspect. The patient underwent bilateral en bloc breast implant removal and periprosthetic capsulectomy. Due to the early stage, adjuvant chemotherapy was omitted. Postoperative follow-up was unremarkable.

Clinical discussion

BIA-ALCL is a rare, emergent clinical concern after breast implant surgery. GCT leads to improved body satisfaction and quality of life in FT individuals. As for non-trans patients undergoing breast reconstruction or breast augmentation, this clinical case once again demonstrates that FT patients undergoing breast implant surgery are at risk of BIA-ALCL.

Conclusion

Physicians should promote awareness among patients' GCT and tailored postoperative follow-up.

•

Breast implants are associated with BIA-ALCL, a rare t-cell cell lymphoma.

•

Cold seroma several years after breast implant surgery is the most common symptom.

•

Up to 70 % of male-to-female transgender patients require breast augmentation.

•

Clinicians should be aware of BIA-ALCL after breast implants in male-to-female transgender.

Breast Cancer Recurrence after Smooth vs. Textured Implant-Based Breast Reconstruction: A Matched Cohort Study

BACKGROUND

An increasing number of reports on breast implant-associated anaplastic large cell lymphoma have recently raised concerns about the potential influence of breast implants on carcinogenicity, particularly implants with a textured surface. We compared the recurrence outcomes between smooth and textured implant reconstructions for breast cancer.

METHODS

All patients who underwent immediate direct-to-implant (DTI)-based breast reconstruction for primary breast cancer between January 2010 and December 2016 were reviewed. A total of 590 patients were included. After propensity score 1:2 matching, 138 patients were included in the smooth implant group and 276 patients in the textured implant group. Locoregional recurrence-free survival (LRRFS), disease-free survival (DFS), and distant metastasis-free survival (DMFS) rates were compared between the groups.

RESULTS

After matching, the median follow-up periods were 62 months and 66 months for the smooth and textured groups, respectively. We observed no significant differences between the smooth and textured implant groups in terms of locoregional recurrence (10.9% vs. 11.6%; P = 0.827), distant metastasis (3.6% vs. 4.0%; P = 0.547), or first recurrence (12.3% vs. 13.4%; P = 0.757) rates. No significant differences were observed between the groups in five-year LRRFS (89.5% vs. 89.4%; P = 0.840), DFS (87.7% vs. 88.1%; P = 0.794), or DMFS (98.8% vs. 96.8%; P = 0.741) rates.

CONCLUSIONS

No significant differences were observed between the smooth and textured implant groups in this matched cohort analysis of recurrence outcomes in patients with primary breast cancer who underwent immediate DTI reconstruction. Further larger-scale investigations are necessary to validate our results.

Two Independent Capsules Surrounding a Single Textured Implant in Ehlers-Danlos Syndrome

Textured breast implants are associated with prolonged inflammation leading to increased risk for complications such as the development of anaplastic large cell lymphoma. The underlying molecular mechanisms that drive increased inflammation toward textured implants (compared with smooth implants) remain poorly understood. Here, we present the first known case of a patient with Ehlers-Danlos syndrome (EDS) who developed two independent fibrotic capsules around a single textured silicone implant. The patient was found to have one internal capsule tightly adherent to the implant and a second external capsule that was attached to the surrounding tissue. We observed that the internal implant-adherent capsule was composed of a highly aligned and dense collagen network, completely atypical for EDS and indicative of a high mechanical stress environment. In contrast, the external nonadherent capsule, which primarily interacted with the smooth surface of the internal capsule, displayed disorganized collagen fibers with no discernible alignment, classic for EDS. Remarkably, we found that the internal capsule displayed high activation of monocyte chemoattractant protein-1, a mechanoresponsive inflammatory mediator that was not elevated in the disorganized external capsule. Taken together, these findings demonstrate that the tight adhesion between the textured implant surface and the internal capsule creates a high mechanical stress environment, which is responsible for the increased local inflammation observed in the internal capsule. This unique case demonstrates that mechanical stress is able to override genetic defects locally in collagen organization and directly connects the textured surface of implants to prolonged inflammation.

Conversion of Breast Implants into Natural Breast Reconstruction: Evaluating Lipofilled Mini Dorsi Flap

Background:

Autologous reconstruction techniques can provide a long-lasting natural breast reconstruction for patients. This study aimed to further investigate outcomes in the conversion of breast implant reconstruction into a lipofilled mini dorsi flap, focusing on reviewing its techniques, efficiency, and final results.

Methods:

Over 3 years, we performed a number of breast implant replacements via the lipofilled mini dorsi flap technique. The artificial implants were replaced to a deepithelized flap. The efficiency and tolerance of the technique were evaluated by the whole surgical team, and the achieved results were also analyzed by the patients in terms of postoperative pain, functional impact, and the softness of the reconstructed breast by comparing their prior condition to the lipofilled mini dorsi flap condition at least 9 months after operation.

Results:

Forty-seven consecutive operations were prospectively studied. The mean ± standard deviation volume of the removed implants was 348.66 ± 86.54 mL. The mean volume of fat injected was 284.13 ± 62.94 mL. The procedure’s average duration was 108.93 ± 17.65 minutes. The surgical team evaluated the results as very satisfactory in 32 cases (68.1%), satisfactory in 15 cases (31.9%), and moderately satisfactory or unsatisfactory in zero cases (0.0%). Eighteen patients (38.3%) evaluated their reconstruction as very good, while 20 patients (42.6%) considered their reconstruction as good, four (8.5%) as average, and zero (0.0%) as insufficient.

Conclusion:

According to our experience, the lipofilled mini dorsi flap is a simple, less invasive, and quick procedure to convert breast implants into natural breast reconstruction.

"Oncologic Safety of Staged Pre-Pectoral Implant Reconstruction Following Nipple-Sparing Mastectomy: a Mean 9-Year Follow-Up."

BACKGROUND

Prepectoral reconstruction following nipple-sparing mastectomy has recently gained popularity as an alternative to total or partial submuscular reconstruction. In the absence of long-term follow-up, concerns have been raised over the oncologic safety of using mastectomy flaps that preserve the entire thickness of the subcutaneous fat and its circulation. In this article we present our average 9-year oncologic follow-up of patients who underwent nipple-sparing mastectomy and 2-stage prepectoral implant reconstruction without acellular dermal matrix.

METHODS

In this retrospective study, a group of previously reported 151 consecutive breast cancer patients [246 breasts, (160 therapeutic, 86 preventative)] who underwent nipple-sparing mastectomy and staged prepectoral implant reconstruction between 2005 and 2015 were followed up for an average of 109 months (range, 14 to 192 months). Tumor related data, oncologic markers, staging, neoadjuvant/adjuvant therapy, and radiation therapy were evaluated to determine local recurrence, overall survival, and disease-free survival rates.

RESULTS

Local recurrence rate in 151 patients was 2.6 percent. Eleven patients (7.3 percent) died from metastatic disease and 3 patients from unrelated causes. The average 109-month overall survival rate was 92.9 percent and disease-free survival rate was 87.8 percent. Over the same period nine patients (6 percent) were alive with distant disease.

CONCLUSION

Our 9-year two-stage prepectoral reconstruction study of nipple-sparing mastectomy shows that the procedure is oncologically safe, having comparable recurrence, overall survival, and disease-free survival rates as total mastectomy.

A South African Breast Implant-Associated Anaplastic Large Cell Lymphoma: Clinical Presentation and Six-Year Follow-Up

Breast augmentation is the most common surgical procedure for women globally, with 1,795,551 cases performed in 2019. Breast implant-associated anaplastic large cell lymphoma (BIA-ALCL) is highly uncommon, with 733 reported cases as of January 2020. In South Africa, there are less than 4000 breast augmentation surgeries annually. This case presents the first case report documentation of a South African woman diagnosed with BIA-ALCL. The patient was a 61-year-old woman who consulted the Breast Care Centre of Excellence in Johannesburg in 2015. She had a prior history of bilateral augmentation mammoplasty with subsequent implant exchange. The patient presented with periprosthetic fluid with a mass-like enhancement on the left breast. Aspiration of the mass-like fluid was positive for CD45, CD30, and CD68 and negative for CD20 and ALK-1, indicative of BIA-ALCL. Surgical treatment included bilateral explantation, complete capsulectomies, and bilateral mastopexy. Macroscopic examination of the left breast capsulectomy demonstrated fibrous connective tissue. The histological examination of the tumor showed extensive areas of broad coagulative necrosis with foamy histiocytes. Immunohistochemistry examination of this tumor showed CD3-, CD20-, and ALK-1-negative and CD30- and CD68-positive stains. PCR analysis for T-cell clonality showed monoclonal T-cell expansion. These findings confirm the presence of BIA-ALCL. The patient recovered well after surgery and did not require adjuvant therapy. A patient with a confirmed diagnosis of BIA-ALCL was successfully treated with explantation and complete capsulectomy. She was followed up regularly for six years, and the patient remains well and in remission.

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

BACKGROUND

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

OBJECTIVES

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

LEVEL OF EVIDENCE: 4

A Single Center's Clinical Experience With Ergonomix Breast Implants

BACKGROUND

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

OBJECTIVES

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

LEVEL OF EVIDENCE: 4

Comprehensive Evaluation of the Current Knowledge on Breast Implant Associated-Anaplastic Large Cell Lymphoma

Breast implant-associated anaplastic large cell lymphoma (BIA-ALCL) is a recently spotlighted T-cell origin non-Hodgkin's lymphoma with an increasing incidence of over 800 cases and 33 deaths reported worldwide. Development of BIA-ALCL is likely a complex process involving many factors, such as the textured implant surface, bacterial biofilm growth, immune response, and patient genetics. As the incidence of BIA-ALCL is expected to increase, it is important for all surgeons and physicians to be aware of this disease entity and acquire thorough knowledge of current evidence-based guidelines and recommendations. Early detection, accurate diagnosis, and appropriate treatment are the foundations of current care.

The Inferior-Based Dermoglandular Flap with Partial Subpectoral Implant Transposition and Revision Mastopexy for Subglandular Breast Augmentation Complications

BACKGROUND

Revision augmentation-mastopexy is a complex procedure that aims to correct the complications of a previous surgery. The purpose of this study was to evaluate the reliability of the inferior-based dermoglandular flap with partial subpectoral implant coverage to correct implant- and tissue-related complications associated with primary subglandular breast augmentation and its influence on improving outcomes.

METHODS

This was a retrospective study in which a total of 53 patients (106 breasts) underwent revision augmentation-mastopexy using the double coverage technique for an implant with an inferior-based dermoglandular flap and superior-based pectoralis major muscle (biplane) as the first layer and a nipple-areolar flap with breast pillars as the second layer. This technique provides a suspensory reconstruction that acts as hammock to minimize the pressure on the inframammary fold and maintain position integrity.

RESULTS

The follow-up period ranged from 2.3 to 4 years (mean 3.6 years), and the recorded complications were minor wound dehiscence less than 1 cm² at the "T" junction in three breasts (2.83 %) and mild hypertrophic scarring in five breasts (4.72%).

CONCLUSION

The use of an inferior-based dermoglandular flap with partial subpectoral biplane implant reinforcement allows autologous support and double coverage to decrease the incidence of implant- and tissue-related complications, especially pseudoptosis, lower pole widening, capsular contracture, rippling, and implant visibility. It achieves enhanced upper pole fullness, medial cleavage, projection, and breast volume.

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 .

Tissue Expander-associated T Cells: Relevance to Breast Implant-associated Anaplastic Large-cell Lymphoma

The generation of breast implant–associated anaplastic large-cell lymphoma (BIA-ALCL) is closely associated with textured implants. The phenotype of BIA-ALCL cells is well examined, but its cell of origin remains unknown. Here we investigate what types of T cells are recruited and differentiated in the surrounding capsules and tissues as a consequence of continuous contact with a textured surface.

Polydioxanone Internal Support Matrix: A Rationale for Prophylactic Internal Bra Support in Breast Augmentation

Background

Textured breast implants have been used in aesthetic breast surgery to decrease the rates of implant malposition. A recent analysis of a large-volume single-surgeon experience found statistically similar rates of malposition in smooth vs micro-textured breast implants.

Objectives

Prophylactic use of a polydioxanone (PDO) internal support matrix in breast augmentation was hypothesized to prevent scar malposition and increase pocket control.

Methods

In total, 200 patients received silicone gel primary augmentations performed by a single surgeon from January 2018 to December 2020; 84 patients received smooth implants alone; 49 patients received micro-textured implants; and 67 patients received smooth implants plus PDO internal support matrix. All surgeries were performed in the dual plane using an inframammary incision. Implant-related complications and scar malposition were recorded and compared.

Results

No significant difference in implant-related complication rates was found between shell types (3.57% for smooth devices alone and 2.04% for textured devices [P = 0.62; 95% CI −0.06 to 0.01]). There were zero complications in the smooth plus mesh study arm. A comparison of scar malposition rates between the smooth alone and textured groups revealed no significant difference (15.4% for smooth devices and 8.16% for textured devices [P = 0.23; 95% CI −0.12 to 0.01]). The smooth implant group with the prophylactic placement of PDO mesh had the lowest scar malposition rate of 4.48%, a significant difference compared with the smooth devices alone (P = 0.03; 95% CI −0.21 to −0.01).

Conclusions

Micro-textured devices show a trend toward decreased scar malposition, although not significant. Prophylactic use of PDO internal support matrix in silicone gel breast augmentation is safe and has the lowest incidence of scar malposition.

Level of Evidence: 3

A Rationale for Micro-textured Breast Implant Augmentation

Background

Textured breast implants have been used in aesthetic breast surgery to decrease rates of malposition and capsular contracture. Recent concerns regarding breast implant-associated anaplastic large cell lymphoma (BIA-ALCL)’s link to textured devices have prompted many physicians to re-evaluate their use.

Objectives

The authors aimed to create an algorithm for when to use smooth versus micro-textured breast implants and provide their rationale for when micro-textured implants may be more beneficial.

Methods

133 patients received primary augmentations performed by a single surgeon from January 2018–December 2020. 84 patients received smooth implants and 49 patients received micro-textured implants. All surgeries were performed in the dual-plane using an inframammary incision. Implant-related complications and scar malposition were recorded and compared between groups.

Results

No significant difference in the prevalence of implant-related complications was found (3.57% for smooth devices and 2.04% for micro-textured devices [P-value 0.621257, 95% CI -0.06100–0.007467]). There were no cases of BIA-ALCL. Comparison of scar malposition rates between the smooth and micro-textured groups also revealed no statistically significant difference (15.4% for smooth devices and 8.16% for micro-textured devices [P-value 0.226156, 95% CI -0.1200–0.007467]). Patients in the micro-textured group proportionately had more anatomical risk factors for malposition.

Conclusions

Micro-textured breast implants continue to be a safe and effective choice for patients. Micro-textured implants show a trend towards decreased scar malposition, although not statistically significant. Patients at high risk for malposition with micro-textured breast implants give similar results to patients at average risk for malposition with smooth implants.

Breast Implant Capsule-Associated Squamous Cell Carcinoma: Report of 2 Patients

Breast implant augmentation is a low-risk procedure with few life-threatening complications. Capsular contracture and rupture/leakage of the implant are the most common complications encountered. Malignant breast implant augmentation-associated lesions are rare, with anaplastic large cell lymphoma being the most common. Squamous cell carcinomas associated with breast implant augmentation are exceedingly rare, with only eight patients reported. Breast implant capsule-associated squamous cell carcinoma occurs in patients with long standing breast implant augmentations (>11 years). We report two additional patients with breast implant capsule-associated squamous cell carcinoma. Review of the literature reveals that invasion beyond the breast implant capsule into the adjacent tissue by the squamous cell carcinoma appears to have negative prognostic implications, and possibly warrants close clinical follow-up.