Public Perceptions on Breast Implant–Associated Anaplastic Large Cell Lymphoma

Breast Implant-Associated Anaplastic Large Cell Lymphoma Awareness: An Analysis of the Responses to an Institutional Campaign and Global Recall

BACKGROUND

We performed an assessment of patient response rates and clinical outcomes to the global recall for textured breast implants and to our institution's letters informing them of their risk of breast implant-associated anaplastic large cell lymphoma (BIA-ALCL).

METHODS

A retrospective review of patients who had textured implants placed at our institution was completed. Outcome measures included patient response rates to either the global recall or our institution's letters, rate of textured implant removal, and type of subsequent revision surgery.

RESULTS

A total of 1176 patients with textured implants were reviewed for this study. In total, 374 patients (31.8%) reached out to discuss their risk of BIA-ALCL, and 297 (25.3%) eventually presented to the clinic. One hundred twenty eight patients (34.2%) responded after the letter but before the US Food and Drug Administration (FDA) ban of macrotextured BIOCELL implants, 186 (49.7%) after the FDA ban, and 48 (12.8%) after the manufacturer's multichannel campaign. One hundred eighteen patients with textured implants (11.6%) proceeded with surgery. Most underwent exchange with smooth implants (76 patients [64.4%]) after textured implant removal.

CONCLUSIONS

A significant portion of patients (31.8%) responded to our letters, the FDA ban, and the manufacturer's campaign. Despite the low incidence of BIA-ALCL and the ongoing recommendation for observation in the setting of no symptoms, 11.6% of our patients still elected to proceed with implant removal. Exchange to smooth implants was the most popular surgical option at 64.4%.

Cost communication in cosmetic and reconstructive breast surgery: Public perceptions in the United States

BACKGROUND

There is a need to better understand the financial toxicity of surgery on patients. Recent data demonstrated that plastic surgeons seldom discuss out-of-pocket costs with patients. Not much is known regarding the public perceptions of out-of-pocket cost communication in reconstructive and cosmetic breast surgery.

METHODS

A cross-sectional survey was administered to adult women in the United States from November 2021 to December 2021 using Amazon Mechanical Turk. Perceptions regarding cost communication in plastic surgery were gathered. Incomplete responses were excluded. Multivariable models were used to identify predictors of responses.

RESULTS

There were 512 complete responses. Respondents had a mean age of 37.4 years. The majority strongly agreed or agreed that plastic surgeons should discuss out-of-pocket costs with patients undergoing implant-based breast reconstruction (85%), plastic surgeons should know the impact of surgery on patients' financial well-being (78%), and discussing costs was the most important aspect of the appointment (70%). Respondents who were unsure of their insurance status had lower odds of strongly agreeing or agreeing that surgeons should discuss out-of-pocket costs for autologous reconstruction (OR 0.12, CI 0.02-0.58, p = 0.01) and cosmetic breast augmentation (OR 0.14, CI 0.03-0.65, p = 0.01). Privately insured respondents had greater odds of strongly agreeing or agreeing to both, respectively (OR 2.21, CI 1.32-3.82, p < 0.01; OR 1.94, CI 1.17-3.31, p = 0.01) CONCLUSION: Many laywomen support the cost communication in plastic surgery and believe that plastic surgeons should know the impact of surgery on the patients' financial well-being, with variability among the sociodemographic groups. Plastic surgeons should strongly consider discussing costs with patients undergoing breast surgery.

Safely Shaping the Breast After Implant Removal and Total Intact Capsulectomy Using the Mammary Imbrication Lift and Fixation Technique

Background

Implant-based breast augmentation is one of the most popular plastic surgery procedures performed worldwide. As the number of patients who have breast implants continues to rise, so does the number of those who request breast implant removal without replacement. There is little in the current scientific literature describing total intact capsulectomy and simultaneous mastopexy procedures.

Objectives

Here, the authors present their current method using the mammary imbrication lift and fixation technique after explant and total capsulectomy.

Methods

Between 2016 and 2021, a total of 64 patients (mean age: 42.95 years; range, 27-78 years) underwent the described mammary imbrication lift and fixation technique with bilateral breast implant removal and total capsulectomy.

Results

Mean follow-up was 6.5 months (range, 1-36 months). Postoperative complications included minor cellulitis in 1 patient (1.6%), late onset hematoma with infection in 1 patient (1.6%), fat necrosis and pulmonary embolism in 1 patient with prior history of thromboembolic events (1.6%), and breast scar irregularity in 4 patients (6.2%) who required subsequent minor scar revision or steroid injections. Two patients (1.6%) underwent revision surgery with bilateral breast fat grafting to improve shape and add volume.

Conclusions

The mammary imbrication lift and fixation technique described here can safely and simultaneously be performed with a total intact capsulectomy and explant procedure. This technique avoids wide undermining, intentionally opening the capsule, performing subtotal capsulectomy, and preserving blood supply to the breast tissue and nipple with low complication rates.

Level of Evidence 3

Patient Decision-Making for Management of Style 410 Anatomical Implants in Breast Reconstruction

BACKGROUND

In July of 2019, the U.S. Food and Drug Administration (FDA) recalled the Allergan Natrelle 410 Highly Cohesive Anatomically Shaped Silicone-Filled Textured Breast Implants because of a heightened risk of developing breast implant-associated anaplastic large cell lymphoma (BIA-ALCL). The objective of this study was to describe patient decision-making in management of preexisting 410 textured implants.

METHODS

A single-institution retrospective chart review was conducted to determine all patients who received 410 anatomical implants from two surgeons. Patients who received these implants were contacted in July to September of 2019 regarding the FDA recall and asked to schedule a consultation to discuss explant/exchange versus surveillance. Outcomes analyzed included decision of surveillance versus explantation and subsequent reconstructive operations.

RESULTS

Eighty-nine patients had received 410 implants from 2013 to 2017. Of the 147 breasts that were reconstructed, 58.5% were oncologic mastectomies and 41.5% were prophylactic. The majority of patients (71.9%) cited BIA-ALCL as the predominant influencing factor in their decision for management. Other factors included appearance, implant concerns unrelated to BIA-ALCL, and other medical conditions. Twenty patients (22.5%) underwent explantation of the Style 410 implants. The remaining 77.5% of patients elected for monitored surveillance. There was a significant association between a history of breast cancer and explantation of the Style 410 implants ( P = 0.0335).

CONCLUSIONS

The majority of patients with Style 410 textured implants elected to undergo surveillance for BIA-ALCL. When deciding to explant or exchange the Style 410 implants, plastic surgeons should work in conjunction with their patients to carefully outline management options.

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.

Breast Implant-Associated Anaplastic Large Cell Lymphoma (BIA-ALCL): Are You Covered?

BACKGROUND

Breast implant-associated anaplastic large cell lymphoma (BIA-ALCL) is a locally aggressive T-cell lymphoma that can develop following breast implantation. In 2017, and updated in 2019, the National Comprehensive Cancer Network (NCCN) recommended total capsulectomy with implant removal as definitive therapy.

OBJECTIVES

The aim of this study was to evaluate the US insurance coverage for the management of BIA-ALCL and compare it to the NCCN recommendations.

METHODS

A cross-sectional analysis of US insurance policies for coverage of BIA-ALCL treatment was conducted. Insurance companies were selected based on their market share and state enrollment. Medical necessity criteria were abstracted from the publicly available policies.

RESULTS

Of the 101 companies assessed, only 30 (30%) had a policy for the management of BIA-ALCL. Of those policies, all (n = 30, 100%) provided coverage of the implant removal of the breast diagnosed with BIA-ALCL. For the contralateral breast implant, 20 policies (67%) covered their removal, but significantly fewer did so if the implant was placed for cosmetic reasons vs medically necessary (n = 13 vs n = 20, 43% vs 67%; P = 0.0026). Twenty-one policies (70%) covered an implant reinsertion, but fewer would do so if the implant was cosmetic rather than medically necessary (n = 5, 17% vs 70%; P < 0.0001).

CONCLUSIONS

There was notable intercompany variation in the coverage of BIA-ALCL treatment, some of which is unnecessarily based on whether the original reason for the breast implant was cosmetic or medically necessary. This variability may significantly reduce access to definitive treatment in patients with a BIA-ALCL diagnosis.

The impact of Allergan implant-related issues on patients with breast implants for reconstruction

Background In August 2019, the Ministry of Food and Drug Safety and the Korean Society of Plastic and Reconstructive Surgeons confirmed the first case report of breast implant-associated anaplastic large cell lymphoma (BIA-ALCL) in Korea and provided recommendations. This study was conducted to evaluate the impact of the first case report of BIA-ALCL on patients and whether the impact could be mitigated through expert recommendations.Methods A retrospective chart review was performed of patients who underwent implant-based breast reconstruction using Biocell textured breast implants at Soonchunhyang University Hospital. After the first case report of BIA-ALCL and informing the patients via text messages, the pattern of outpatient visits and the proportion and indications of outpatient office visitors who received reoperations were analyzed.Results After the first BIA-ALCL case report in Korea, 12 patients underwent reoperations due to other complications identified incidentally, while only three patients underwent prophylactic surgery. Among the patients who underwent reoperation after the Allergan issues, 76.7% received implant exchange. There was no significant difference in the proportion of reoperation types before and after the Allergan issues and the transmission of text messages (P=0.700).Conclusions Despite the major issues, outpatients were managed successfully according to our recommendations. The study found a low rate of regular outpatient visits; however, our efforts increased this rate. Therefore, methods for appropriate information delivery are needed for outpatient visits, as well as a system for regular monitoring. As experts, plastic surgeons should provide responsible leadership in this situation to relieve patients’ concerns.

Consumer Awareness and Comfort with Resident-run Cosmetic Clinics: A Crowdsourcing Study

Background:

Resident cosmetic clinics (RCCs) are the training modality of choice among both residents and faculty and are a mainstay at most residency programs.^1–4 Despite this, knowledge of RCCs among plastic surgery consumers remains untested. We hypothesize that the public would be aware of and receptive to RCCs.

Methods:

Participants with prior cosmetic procedures or interest in future cosmetic procedures were recruited using Amazon Mechanical Turk and asked to complete a survey in September 2020. First, prior awareness of RCCs was assessed. After a brief description of RCCs, perceptions of safety and preferences for care were assessed.

Results:

After screening for quality, 815 responses were included. Forty-five percent of consumers were aware of RCCs. Seventy-six percent of consumers believed that RCCs were just as safe as attending clinics and 65% were comfortable receiving care from fourth-year residents or higher. Belief in RCC safety was associated with 4.8 times higher odds of feeling comfortable receiving care at an RCC [95% confidence interval (3.3–7.1), P < 0.001]. When given a hypothetical choice between residents and attendings in two scenarios, 46% of consumers chose residents for abdominoplasty and 60% chose residents for Botox injections. Belief in RCC safety was associated with choosing a resident or being indifferent in both scenarios.

Conclusions:

Consumer preference regarding RCCs has largely been untested. This study shows that belief in RCC safety influences consumers’ perceived comfort with receiving care at an RCC. This knowledge can help guide RCC practice and maximize learning opportunities for surgeons-in-training.