Breast Implant Imaging Surveillance among U.S. Plastic Surgeons: U.S. Food and Drug Administration Recommendations versus Clinical Reality

Current State of Evidence-Based Long-Term Monitoring Protocols for Breast Plastic Surgery Patients

BACKGROUND

Recommendations for breast surveillance following breast plastic surgery are frequently changing. Establishing guidelines for long-term monitoring protocols may help identify treatable conditions and prevent untoward sequelae. We sought to evaluate the current state of evidence-based long-term monitoring protocols for patients following breast augmentation, reduction, and breast reconstruction.

METHODS

Official guidelines from various American societies and international societies were analyzed for alignment in evidence-based recommendations regarding breast surveillance.

RESULTS

The most recent US FDA update recommends magnetic resonance imaging or ultrasound starting 5-6 years after surgery and every 2-3 years thereafter. Discrepancies exist among professional societies: the American Society of Plastic Surgeons (ASPS) aligns with the FDA, while the American Society of Breast Surgeons and American College of Radiology (ACR) find no role for imaging for asymptomatic cases. Ultrasound is first-line for any implant concerns, with MRI if necessary. European societies oppose routine breast implant imaging. Breast reduction patients lack unique screening protocols; monitoring aligns with age and cancer risk factors. Following mastectomy and breast reconstruction, most organizations advocate for annual clinical examinations, with more frequent examinations initially. Evidence suggests that physical examination is sufficient to detect local cancer recurrence, with imaging only indicated if there is concern for recurrence. No surveillance imaging is recommended by the American Society of Clinical Oncology, National Comprehensive Cancer Network, or ASPS; however, ACR recommends mammography for autologous reconstruction only.

CONCLUSION

Multispecialty and regulatory body alignment may promote provider and patient adherence. Ongoing studies of long-term outcomes are needed to strengthen the level of evidence for monitoring guidelines.

Breast Implant Rupture Surveillance Practices among Plastic Surgeons in Publicly Funded Healthcare Systems

BACKGROUND

The United States Food and Drug Administration (FDA) recommends silicone breast implant rupture surveillance using MRI or ultrasound beginning at 5-6 years post-insertion and every 2-3 years thereafter. No surveillance guidelines exist in Canada or the UK. This study aims to identify surveillance practices and perceived barriers to surveillance among plastic surgeons in Canada and the UK and compare surgeon practices between public and private sectors.

METHODS

All active members of the Canadian Society of Plastic Surgeons (CSPS) and British Association of Plastic, Reconstructive and Aesthetic Surgeons (BAPRAS) with an interest in breast surgery were surveyed. Surgeon demographics, screening practices and perceived barriers to screening were analyzed. Fisher's exact test was used to detect significant associations.

RESULTS

The survey response rate was 16%. Most surgeons (68%, n=58/85) were familiar with FDA guidelines; however, only 2.4% (n=2/85) followed them. Surgeons in private practice screened significantly more than surgeons in the public sector [45% (n=13/29) vs 13% (n=7/56), p<0.002]. Among surgeons, ultrasound and high-definition ultrasound were the most common screening modalities and a perceived lack of clinical necessity followed by a perceived lack of satisfactory evidence qualifying these guidelines was the most reported barrier to screening.

CONCLUSION

Despite awareness of FDA guidelines, compliance among surgeons surveyed remains low, reportedly due to a perceived lack of necessity or evidence base. Most public sector surgeons opt not to screen and do not recommend surveillance, even without barriers. While governing bodies should consider current practices to shape guidelines, increasing surgeons' awareness on their evidentiary foundation and potential consequences of silent ruptures is imperative.

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.

Evaluating silicone breast implant rupture with photon-counting CT and volumetric silicone maps

We present a case of an 81-year-old woman who presented to the emergency department with bleeding from a right breast wound. The patient had prior imaging suggestive of bilateral silicone implant rupture and a history of low tolerance for MRI scans. Ultrasound imaging in the emergency setting showed findings in the right breast suggestive of a fistula with free silicone and hematoma. A subsequent photon-counting CT scan with custom silicone-specific segmentation allowed differentiation of silicone from hematoma, provided anatomic assessment and location of the fistula, and revealed bilateral silicone-induced lymphadenopathy.

Breast Implant Imaging Surveillance Practice: Survey of Breast Imaging Radiologists in the Society of Breast Imaging

OBJECTIVE

The objectives of this Society of Breast Imaging (SBI)-member survey study were to assess the current imaging patterns for evaluation of symptomatic and asymptomatic breast implant integrity, including modalities used and imaging intervals.

METHODS

A 12-question survey assessing the frequency of imaging modalities used to evaluate implant integrity, approximate number of breast implant integrity studies requested per month, intervals of integrity studies, and referring provider and radiology practice characteristics was distributed to members of the SBI.

RESULTS

The survey response rate was 7.6% (143/1890). Of responding radiologists, 54.2% (77/142) were in private, 29.6% (42/142) in academic, and 16.2% (23/142) in hybrid practice. Among respondents, the most common initial examination for evaluating implant integrity was MRI without contrast at 53.1% (76/143), followed by handheld US at 46.9% (67/143). Of respondents using US, 67.4% (91/135) also evaluated the breast tissue for abnormalities. Among respondents, 34.1% (46/135) reported being very confident or confident in US for diagnosing implant rupture. There was a range of reported intervals for performing implant integrity studies: 39.1% (43/110) every 2-3 years, 26.4% (29/110) every 4-5 years, 15.5% (17/110) every 6-10 years, and 19.1% (21/110) every 10 years.

CONCLUSION

For assessment of implant integrity, the majority of respondents (53.2%, 76/143) reported MRI as initial imaging test. US is less costly, but the minority of respondents (34.1%, 46/135) had confidence in US performance. Also, the minority of respondents (39.1%, 43/110) performed implant integrity evaluations every 2-3 years per the FDA recommendations for asymptomatic surveillance.

Evaluating Chatbot Efficacy for Answering Frequently Asked Questions in Plastic Surgery: A ChatGPT Case Study Focused on Breast Augmentation

BACKGROUND

The integration of artificial intelligence (AI) and machine learning (ML) technologies into healthcare is transforming patient-practitioner interaction and could offer an additional platform for patient education and support.

OBJECTIVES

This study investigated whether ChatGPT-4 could provide safe and up-to-date medical information about breast augmentation that is comparable to other patient information sources.

METHODS

ChatGPT-4 was asked to generate 6 commonly asked questions regarding breast augmentation and respond to them. Its responses were qualitatively evaluated by a panel of specialist plastic and reconstructive surgeons and reconciled with a literature search of 2 large medical databases for accuracy, informativeness, and accessibility.

RESULTS

ChatGPT-4 provided well-structured, grammatically accurate, and comprehensive responses to the questions posed; however, it was limited in providing personalized advice and sometimes generated inappropriate or outdated references. ChatGPT consistently encouraged engagement with a specialist for specific information.

CONCLUSIONS

Although ChatGPT-4 showed promise as an adjunct tool in patient education regarding breast augmentation, there are areas requiring improvement. Additional advancements and software engineering are needed to enhance the reliability and applicability of AI-driven chatbots in patient education and support systems.

Ideal Implant Structured Breast Implants: Core Study Results through 10 Years

BACKGROUND

The Ideal Implant structured breast implant uses different technology than unstructured saline or silicone gel implants, making it a third type of implant. U.S. Food and Drug Administration (FDA) and Health Canada granted approval in November of 2014. This saline-filled implant has an internal structure consisting of a series of nested shells that support the upper pole when upright and control movement of the saline to provide a natural feel. Because women can look in the mirror to know their implants are intact, they have peace of mind. In contrast, most women are concerned about silicone gel implant ruptures, which are silent and require FDA-recommended magnetic resonance imaging or ultrasound scans for detection.

METHODS

This U.S. trial enrolled 502 women: 399 for primary and 103 for revision augmentation. Investigators were 45 American Board of Plastic Surgery-certified plastic surgeons at 35 sites. Of the 502 women enrolled, 426 (84.9%) completed 10-year follow-up visits, a higher percentage than all other FDA breast implant trials.

RESULTS

Through 10 years of follow-up, surgeon satisfaction was 94.8% for primary and 87.4% for revision augmentation; and patient satisfaction was 92.7% for primary and 82.3% for revision augmentation. Cumulative Kaplan-Meier risk rates for two major adverse events were lower than in the silicone gel implant trials: Baker class III and IV capsular contracture was 6.6% for primary and 11.5% for revision augmentation; and rupture/deflation was 3.7% for primary and 4.7% for revision augmentation.

CONCLUSION

Ten-year results from 426 women show the Ideal Implant has high patient and surgeon satisfaction, a low rate of capsular contracture, and a low rate of rupture/deflation.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Therapeutic, IV.

Magnetic Resonance Imaging Surveillance Study of Silicone Implant-based Breast Reconstruction: A Retrospective Observational Study

This study aimed to evaluate the results of magnetic resonance imaging (MRI) surveillance of implant-based breast reconstruction in patients with breast cancer.

Methods

This retrospective observational study analyzed patients who underwent implant-based breast reconstruction and MRI surveillance by a single surgeon from March 2011 to December 2018, in a single center. All patients were informed about the recommendation of the Food and Drug Administration for MRI surveillance, and they choose to undergo MRI 3 years after surgery.

Results

The compliance rate for MRI surveillance was 56.5% (169/299). MRI surveillance was performed at a mean of 45.8 (4.04 years) ± 11.5 months after surgery. One patient (0.6%) showed an abnormal finding of an intracapsular rupture of the silicone implant.

Conclusions

MRI surveillance for implant rupture in implant-based breast reconstruction showed a low incidence of silent implant rupture (0.6%), whereas the compliance of MRI was relatively high (56.5%). These results raise questions about whether taking an MRI in 3-4 years is suitable for imaging surveillance of breast silicone implants. Screening recommendations should be more evidence-based, and more studies are needed to prevent unnecessary screening and patient burden.

Assessment, Complications, and Surveillance of Breast Implants: Making Sense of 2022 FDA Breast Implant Guidance

As more information about the potential risks and complications related to breast implants has become available, the United States Food and Drug Administration (FDA) has responded by implementing changes to improve patient education, recalling certain devices and updating the recommendations for screening for silicone implant rupture. In addition to staying up-to-date with FDA actions and guidance, radiologists need to maintain awareness about the types of implants they may see, breast reconstruction techniques including the use of acellular dermal matrix, and the multimodality imaging of implants and their complications. Radiologists should also be familiar with some key differences between the updated FDA guidelines for implant screening and the imaging recommendations from the American College of Radiology Appropriateness Criteria. The addition of US as an acceptable screening exam for silicone implant rupture by the FDA is one of the most notable changes that has potentially significant implications.

Comprehensive Care of Women With Genetic Predisposition to Breast and Ovarian Cancer

Women at risk for hereditary breast and ovarian cancer syndromes are frequently seen in primary care and gynecology clinics. They present with a distinctive set of clinical and emotional needs that revolve around complex risk management discussions and decision making. The care of these women calls for the creation of individualized care plans that facilitate adjustment to the mental and physical changes associated with their choices. This article provides an update on comprehensive evidence-driven care of women with hereditary breast and ovarian cancer. The aim of this review is to aid clinicians in identifying those at risk for hereditary cancer syndromes and provide practical advice on patient-centered medical and surgical risk management. Topics of discussion include enhanced surveillance, preventive medications, risk-reducing mastectomy and reconstruction, risk-reducing bilateral salpingo-oophorectomy, fertility, sexuality, and menopausal management, with attention to the importance of psychological support. High-risk patients may benefit from a multidisciplinary team that provides realistic expectations with consistent messaging. The primary care provider must be aware of the special needs of these patients and the consequences of their risk management interventions.

What 736 Plastic Surgeons Think about Explantation and Capsulectomy: A Global Opinion Poll

BACKGROUND

Breast implant illness, although not classified as a disease entity, has recently gained significant attention globally. The purpose of this study was to assess the status of explantation practices, discuss plastic surgeon's attitude toward requests for explantation and capsulectomy, and evaluate surgical management when accepting these challenges.

METHODS

Twenty closed-ended multiple choice questions were formulated to an opinion poll. The anonymous opinion poll was distributed to members of American Society for Aesthetic Plastic Surgery and presidents of plastic surgery societies on all continents.

RESULTS

A total of 736 plastic surgeons responded to the opinion poll. Although geographic variation was noted, a majority of 69.8 percent stated that explantation surgery had increased in their practice compared to the previous year. Requests for explantation without capsulectomy met with high acceptance rates among surgeons, regardless of whether patients were asymptomatic or not. Patients who also requested capsulectomy received less enthusiastic replies depending on the type of practice, years in practice, implant position, and type of capsulectomy (en bloc, total, or partial). When fat grafting was indicated, 68.7 percent stated that simultaneous lipofilling is limited when capsulectomy is performed, yet 44.5 percent stated that they would remove thin normal capsules in a symptomatic patient even when simultaneous fat grafting is requested by the patient.

CONCLUSION

The opinion poll supports the hypothesis that demand for explantation and capsulectomy increased globally among symptomatic and asymptomatic patients; that attitudes toward simultaneous capsulectomy are divided; and that management may differ according to geographic location, experience, and type of practice.

Applications of Ultrasound in the Postoperative Period: A Review

Background Recent advances in ultrasound technology have further increased its potential for routine use by plastic and reconstructive surgeons.

Methods An extensive literature review was performed to determine the most common applications of ultrasound in the postoperative care of plastic and reconstructive surgery patients.

Results In contrast with other available imaging modalities, ultrasound is cost-effective, rapid to obtain, eliminates the need for ionizing radiation or intravenous contrast, and has virtually no contraindications. In addition to its diagnostic capabilities, ultrasound can also be used to facilitate treatment of common postoperative concerns conveniently at the bedside or in an office setting.

Conclusion This article presents a review of the current applications of ultrasound imaging in the postoperative care of plastic and reconstructive surgery patients, including free flap monitoring following microsurgery, diagnosis and treatment of hematoma and seroma, including those associated with BIA-ALCL, and breast implant surveillance.

Safety and Effectiveness of Silicone Gel-Filled Breast Implants in Primary Augmentation Patients

Background

Results from the MemoryGel Breast Implants Core Clinical Study suggest these devices are safe and effective at 10 years after implantation. Although clinical trials are essential for measuring the safety and effectiveness of a device, real-world evidence can supplement clinical trials by providing information on outcomes observed in diverse clinical settings for a more heterogeneous population, without fixed treatment patterns, and without continuous patient monitoring, such that follow-up is more representative of normal clinical practice.

Objectives

The aim of this study was to measure real-world outcomes, including safety and effectiveness, in patients who underwent primary breast augmentation with smooth MemoryGel implants.

Methods

This was a case series looking at patients, age 22 years and older, who underwent primary breast augmentation at a single site between December 2006 and December 2016 and who had a minimum of 2 years of follow-up. Descriptive statistics were used to summarize baseline characteristics and outcomes. Kaplan-Meier models were used to estimate safety outcomes for capsular contracture (Baker grade III/IV), infection, and rupture.

Results

A total of 50/777 (6.4%) patients reported a complication, with an average time to complication of 3.9 years (range, 19 days-11.8 years) postprocedure. Kaplan-Meier estimates of the 10-year cumulative incidence of capsular contracture (Baker grade III/IV), infection, and rupture were 4.7%, 0.1%, and 1.6%, respectively.

Conclusions

Analyses of a large population from a single site provide further support for the long-term safety and effectiveness of MemoryGel breast implants in a primary augmentation cohort.

Level of Evidence: 4

The Value of Ultrasound in the Evaluation of the Integrity of Silicone Breast Implants

Background and Objective: Breast implant surgery for cosmetic purposes is the most popular plastic surgery and it has been performed for over 100 years. Rupture of silicone gel-filled breast implants usually is asymptomatic and is one of the more dangerous complications due to free silicone migration. The aim of our study was to evaluate the diagnostic value of ultrasound (US) in the evaluation of the integrity of silicone breast implants and identify the main sign of intact and ruptured breast implants. Patients and Methods: In this retrospective study, the medical documentation of women who underwent breast implant surgery and US checkups at Tautrimas Aštrauskas Clinic in Kaunas, Lithuania, during 2015–2020 was analyzed. The patients were divided into two groups: patients with intact and ruptured breast implants. The accuracy, sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) as well as the signs of implant integrity of US examination were evaluated. Results: In this study, 76 women with bilateral breast implants (n = 152) were reviewed. On a US examination, ruptured implants were found in 41.1% (n = 61) of the cases; of them, 78.7% (n = 48) of the cases had ≥2 US signs of a ruptured implant, and in all these cases, implant rupture was confirmed at surgery. Overall, one US sign of a ruptured implant was found in 21.3% (n = 13) of the cases. Of them, inhomogeneous content in all cases (n = 3) was found in the intact implant group, and an abnormal implant shell was documented more often in the ruptured implant group, not intact one (n = 9, 90% vs. n = 1, 10%). US had a diagnostic accuracy of 94.7%, sensitivity of 98.3%, specificity of 89.2%, PPV of 93.4%, and NPV of 97.1% in the evaluation of implant integrity. Conclusions: Our results show that US is a very reliable alternative in evaluating breast implant integrity and could be the investigation of choice for implant rupture, while MRI could be advocated only in inconclusive cases. Uneven implant shell was found to be the most important US sign of breast implant rupture. Based on the findings, we recommend performing US examination after breast augmentation surgery with silicone gel-filled implants annually.

Breast Implants Follow-up: Results of a Cross-Sectional Study on Patients Submitted to MRI Breast Examinations

INTRODUCTION

Breast implants follow-up with any type of examination is often neglected; this may cause an error or delay in the diagnosis of complications prosthesis-related such as BIA-ALCL. This study aims to better understand adequate follow-up criteria.

METHOD

All female patients undergoing aesthetic breast augmentation and breast MRI in its follow-up conducted from April 2006 to December 2019 were included in this study. The variables analyzed were age, breast implant surgery date, time with the implant, reason for the examination, and the final examination report. A logistic regression analysis was conducted to search for the predictors of positive findings in MRI. A Cox Regression analysis and cumulative risk curves, controlled by age, was performed to investigate the relationship between time with implants and the risk of positive findings in MRI.

RESULTS

The patients submitted to MRI had complaints in 29.6% of cases, with pain being the most common, 13.9% of cases. In logistic regression analysis, time with the implant was associated with a higher risk of positive findings in univariate analysis (OR = 1.07, p = 0.036), but not in multivariate analysis. Both pain and breast form changes were independent predictors for positive findings in MRI, OR = 2.79, p = 0.04, and OR = 16.98, p < 0.001, respectively. The cumulative risk of positive findings in MRI increased considerably only after 10 years of implantation.

CONCLUSIONS

Time with breast implants may be associated with a higher risk of changes in breast MRI examinations, although this relationship was not significant in multivariate logistic regression analysis. The cumulative risk for positive findings seems to increase considerably only after 10 years of implantation. This study draws attention to the paramount importance of follow-up with a clinical breast examination. Despite time with implants or patients' age, both pain and breast form changes were the most important predictors for MRI alterations.

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 .

Understanding Silicone Breast Implant-Associated Complications for Radiologists

미용적 성형 및 유방암 수술 후 재건의 목적으로 사용되는 실리콘 보형물의 사용이 국내외에서 크게 증가함에 따라 진료 영역에서 실리콘 보형물 삽입술을 받은 환자들을 어렵지 않게 접하게 되었다. 기존에 알려져 있던 보형물의 파열이나 구축과 같은 합병증 외에 최근에는 유방 보형물 연관 역형성 대세포 림프종과 같은 악성 종양과의 연관성도 보고되면서 보형물 관련한 영상 검사가 증가하고 있다. 이러한 상황에서 영상의학과 의사들은 보형물 삽입술을 받은 환자에 대해 어떤 검사가 필요하고 어떤 영상 소견이 보형물 관련 합병증을 시사하는지에 관한 충분한 지식을 갖추고 있어야 할 것이다. 본 종설에서는 영상의학과 의사들이 알아야 하는 실리콘 보형물의 다양한 합병증과 이들의 영상 소견에 대해 다루고자 한다.