Tailor-Made Mastopexy Plus Implant, A Safe Journey Toward Breast Reshaping and Augmentation

BACKGROUND

Augmentation/mastopexy represents one of the most complex procedures in the setting of cosmetic surgery, and there is still an ongoing debate about the most suitable approach to undertake to avoid major complications and deliver the desired result. The present study aims to offer a further contribute to the topic by presenting our personal experience with an implant-guided tailor-made mastopexy technique to manage moderate breast ptosis and hypotrophy.

METHODS

A retrospective analysis of our database was carried out, and a total of 194 women who underwent a tailor-made resection pattern mastopexy plus implant from November 2016 to December 2021 were enrolled. All patients included in the study presented breast hypoplasia and ptosis classified as Regnault grade II. At the first-year follow-up visit, patients received an anonymous written questionnaire that addressed their self-perception of cosmetic results and overall satisfaction.

RESULTS

The technique presented in the study showed a favorable safety profile with a total complication rate accounting for an 8.2% and an overall reoperation rate as low as 4.6%. Major concerns including wound dehiscence, implant exposure, and nipple necrosis are not reported. Patients' self-reported outcomes revealed high satisfaction rates and stable results in the long-term follow-up.

CONCLUSIONS

The described approach ensures proper reshaping together with the desired increased breast volume minimizing the chance of implant exposure due to wound dehiscence or any sort of tissue necrosis from devascularized skin edges. The surgical procedure described herein is safe and reliable.

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 .

Twelve Years and over 2400 Implants Later: Augmentation Mammoplasty Risk Factors Based on a Single Plastic Surgeon's Experience

Background

Breast augmentation is one of the most commonly performed aesthetic surgery procedures. Yet, few reports in the literature analyze individual surgeon experiences with a unified surgical method on a large group of patients. This study aimed to analyze a single surgeon's complications rate and experience with the Akademikliniken augmentation mammaplasty method from the beginning of his career.

Methods

A retrospective outcome analysis of all patients (n = 1646) who underwent breast augmentation between 2009 and 2021 performed by a single surgeon was conducted. Complications and reoperation rates were evaluated. In addition, correlations with the patient and implant characteristics and insertion-method-related risk factors were analyzed.

Results

In total, 1212 female patients (mean age, 31.47 years) were analyzed. The minimal follow-up for every patient was 6 months (mean follow-up, 18.35 months). The total complication rate was 7.1%, and the most common complication (2.64%) was capsular contracture (Baker scale III/IV). Implant insertion with a funnel significantly lowered the overall risk of complications (P = 0.009). Statistical analysis indicates that the single independent risk factors for primary breast augmentation are patient age younger than 27 years, initial breast size B and C, and tobacco smoking.

Conclusions

This study indicated that capsular contracture and implant rotation are the most common complications of analyzed primary augmentation mammoplasty. It also identifies various risk and protection factors, such as funnel usage, which should be considered by the surgeon when performing this type of procedure.

Devil's Advocate: Evidence-Based Recommendation for "One Breast-One Insertion Funnel" Policy

BACKGROUND

Rates of capsular contracture have reduced significantly since the use of insertion funnels to place breast implants became routine. However, due to financial constraints, the same funnel is usually used for implantation of both sides.

OBJECTIVES

The aim of this study was to determine whether the risk of capsular contracture is higher for the second breast when the same insertion funnel is used for both breasts.

METHODS

The authors collected a sample of the insertion funnel tip immediately after removing the funnel from its sterile packaging and another tip sample after the funnel had been used to insert the first implant. These samples were sent for microbiological culture evaluations. Capsular contracture rates in the first implanted breast vs the second implanted breast were then retrospectively analyzed.

RESULTS

All samples taken from the funnel before the first implantation showed no bacterial growth. All 10 samples taken from the funnel after the first implantation showed organism growth (8 were positive for Staphylococcus epidermidis and 2 for Cutibacterium acnes). Retrospective analysis of the results revealed that the overall capsular contracture rate had reduced after the authors began to use insertion funnels. However, this complication was still more common on the second implanted breast.

CONCLUSIONS

Surgeons should consider the use of separate insertion funnels for each breast. This might help to slightly reduce the incidence of capsular contracture.See the abstract translated into Hindi, Portuguese, Korean, German, Italian, Arabic, and Chinese (Simplified and Traditional) online here: https://doi.org/10.1093/asj/sjad288.

LEVEL OF EVIDENCE: 4

Evaluation of Different Breast Implant Shapes in the Same Patient: Is There Really a Difference between Round and Anatomical Implants?

Background

The choice of the right implant shape is one of the most frequent debates in cosmetic breast augmentation. In current literature, the question of whether there is a difference in the appearance of different implant shapes is still an argument of highly controversial discussion. The aim of the present work was, therefore, to analyze whether any difference exists in terms of aesthetic outcome between round and anatomical implants, and if they can be distinguished from each other in a like for like swap, making sure the evaluation was made in exactly similar conditions.

Methods

Fourteen consecutive patients who underwent aesthetic breast augmentations received primarily an implant of a given volume, projection, and shape (round or anatomical) and then decided to undergo implant replacement to a different shape but maintaining the same volume and projection. At 12-months follow-up, standardized photographs were taken, blinded and randomized. They were evaluated by 10 plastic surgeons and 10 nurses.

Results

All 20 observers could distinguish between round and anatomical shape in all 14 cases (100%), which was highly significant (P < 0.0001) for each observer.

Conclusions

The present data indicate that there is a clear difference between anatomical and round-shaped implants in terms of aesthetic appearance, when a comparison is properly performed. With the use of both round and anatomical implant shapes, aesthetically appealing results can be achieved in cosmetic breast augmentation. The right implant choice must be made, based on patients' anatomy and desires.

Silicone Migration From Breast Implants: A Case of Ocular Siliconoma and Literature Review

BACKGROUND

Breast augmentation with implants is one of the most popular cosmetic surgery operations performed worldwide. Complications of breast implants are well recognized, and include capsular contracture, implant rupture, and infrequently distant migration of silicone, resulting in siliconoma. Distant migration of silicone can present many years after implantation with a wide variety of signs and symptoms.

OBJECTIVES

The aim of this study was to describe the authors' experience of orbital silicone migration and to review the literature describing documented cases of distant silicon migration from breast implants, both ocular and nonocular.

METHODS

In January 2022, a case of breast implant augmentation presented with silicone migration into the right orbit. This rare case was monitored and diagnosed with ocular muscle palsy and diplopia. Here, the authors present the patient's presenting complaint, symptomatology, working investigations, and outcomes. A comprehensive report of all available cases of distant silicone migration is presented along with their associated complications and more specifically ocular silicone migration.

RESULTS

Systemic migration of silicone from breast implants to the orbital region is extremely rare: a total of 4 previous cases of ocular silicone migration from breast implants have been described previously; the authors describe the fifth case herein.

CONCLUSIONS

Silicone implant rupture can present with a wide variety of clinical symptoms that may mimic different clinical pathologies. In every patient with a history of breast augmentation with silicone implants, the possibility of silicone migration should be always taken into consideration during the differential diagnosis process.

LEVEL OF EVIDENCE: 5

Breast Augmentation in the Digital Era: The Power of Social Media in a Surgeon's New Practice

BACKGROUND

Opening a new practice is always challenging, and one of the main problems is how to engage patients. Most of them use social media to gather information about surgery and surgeons.

OBJECTIVES

The aim was to evaluate social media's impact on a new practice, compared with a long-standing practice run by the same surgeon. Furthermore, changes in patients' and surgeons' perspectives regarding social media in recent years were studied.

METHODS

In the 2 aforementioned practices, a questionnaire was administered to patients seen in consultation for primary breast augmentation regarding their interaction with social media before booking the visit. Another questionnaire was administered to 152 surgeons to assess their perceptions of social media.

RESULTS

Two hundred forty-seven patients in Italy and 129 in Sweden answered the questionnaire. In the first year of the Italian practice, 97.2% of patients booked a consultation with the surgeon thanks to social media; after 3 years, the percentage dropped to 68.02%. Comparing Italian and Swedish patients, 68.02% vs 28.68%, respectively, booked a consultation with the surgeon specifically thanks to social media, 91.09% vs 79.84% did research about the surgeon before booking a consultation, and 36.03% vs 10.08% contacted the surgeon before booking an appointment. One hundred fifty-two surgeons from 24 different countries answered the questionnaire, and 77.9% opined that social media positively affected their practice.

CONCLUSIONS

Social media is fundamental in patient-surgeon interaction and can strongly influence patient inflow, especially at the beginning of a new practice. Surgeons should be capable of using these tools to engage patients, bearing in mind the important role of these media in patients' education.

It Is Time to Resolve the Dilemma and Move Away From Using Drains in Primary Breast Augmentation

Background

Breast augmentation is one of the most commonly performed aesthetic surgical procedures, yet there has been no consensus on the use of drains. While some surgeons believe in using them due to fear of complications or because they were taught in a conventional manner, the authors present their experience of performing breast surgery without the use of drains.

Objectives

To study whether performing breast augmentation without the use of drains is safe.

Methods

Anthropometric details and complications of all the consecutive primary breast augmentation patients performed by a single surgeon from 2009 to 2022 were collected and analyzed. In none of these patients, drains were used.

Results

A total of 429 (21%) patients were lost to follow-up and only those 1617 patients with a minimum follow-up of 6 months were included in this study. The mean age of the study group was 29.8 years with a mean BMI of 24.68. Mean follow-up was 16.24 months. Hematoma occurred in 15 patients (0.92%), seroma in 12 (0.74%), explantation due to infection in 3 patients (0.18%), and capsular contracture in 44 patients (2.72%). All these complications were in the lower range of complications of breast augmentation reported in the literature.

Conclusions

Unwarranted use of drains in breast augmentation should be avoided as it does not seemingly prevent the complications of breast augmentation surgery. Instead, it may increase the chances of infection, pain, and discomfort, and prolong the antibiotic coverage, and hence put an additional overall financial burden on the patient.

Level of Evidence 4

Patient and Clinician Reported Outcomes of the Inframammary Incision "Short Scar Technique" in Primary Breast Augmentation

Background

Breast augmentation is a common aesthetic surgery procedure and surgeons are constantly trying to develop techniques that help improve patients' outcome. One of the most important aspects is achieving a favorable scar. The "traditional" breast augmentation scar is in the inframammary fold (IMF), whereas trans-axillary and trans-umbilical approaches have been described as an attempt to move the "location" of the scar and make it less noticeable. Nonetheless, relatively little attention has been paid to improving the IMF scar, which remains the most commonly used scar for silicone implants.

Objectives

The authors have previously described a technique that uses an insertion sleeve and custom-made retractors to allow implant insertion through a shorter IMF scar. However, at the time, the authors did not evaluate the quality of the scar and patient satisfaction. In this manuscript, the authors describe patient and clinician-reported outcomes for this short scar technique.

Methods

All consecutive female patients, undergoing primary aesthetic breast augmentation with symmetric implants were included in this review.

Results

Three different scar-assessment scales demonstrated good results at 1-year postop, as well as the good correlation between patient-reported and clinician-observed scores. BREAST-Q subscale for overall satisfaction also demonstrated good overall patient satisfaction.

Conclusions

Besides providing an added aesthetic value to the result of breast augmentation, a shorter scar may also appeal to patients who are concerned about the size and quality of postoperative scars and like to search for "before and after" pictures prior to scheduling consultations.

Level of Evidence 4

The Search for the Ideal Female Breast: A Nationally Representative United-States-Census Study

INTRODUCTION

Many studies have started to search for the perfect aesthetic breast in order to create a pars-pro-toto for reconstruction, but especially for aesthetic surgery. To date, no representative study with anatomically accurate models was performed.

METHODS

In an online based United-States-census-representative survey with 1049 participants, questions regarding the preferred breast were asked utilizing lifelike morphed 3D-generated female models for the first time. Attributes such as breast pole ratio, areola size, breast direction and projection were asked.

RESULTS

The results show that, contrary to what has been claimed in previous studies, an upper-pole-to-lower-pole ratio of 55:45 is preferred by both female and male participants. When it comes to breast size, on the other hand, there are clear gender-specific differences. While women opted for a cup size around B, the men preferred larger cup sizes. Moreover, the smallest depicted areola size of 30 mm was favored among all groups in the survey.

DISCUSSION

Most publications used rather detrimental models for their surveys. We therefore opted for computer-generated 3D models and varied their naturalness. This enabled us to ensure a more aesthetic and accurate illustration and thus obtained more comparable and reliable results paired with the representation of the US-population. Taken together this study unveiled unexpected insights into the population favored breast attributes that might change operative planning in breast surgery.

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 http://www.springer.com/00266 .

The impact of parity in primary breast augmentation: A clinical and cost-effective case control study

INTRODUCTION

Breast augmentation is one of the most commonly performed aesthetic procedures in women. Despite the structural changes which occur during pregnancy and lactation have been extensively studied, there is no clarity in terms of the time required for the parenchymal angiogenic changes to regress or if these neovessels are preserved even years after the last lactating period. This study investigated whether these post-pregnancy structural changes on the breasts may influence the surgical efficiency, affect the rates of complications and have an impact on cost-effectiveness in primary breast augmentation.

METHODS

This study encompasses a retrospective review of all patients who underwent implant-based bilateral primary breast augmentation, through inframammary fold (IMF) incision under general anaesthetic, by a single surgeon. The age, height, weight and parity (nulliparous or multiparous status), characteristics of implants used and clinical outcomes after a minimum of 6-month post-operative follow-up were recorded. A further prospective comparative trial investigated the effects of parity in the surgical efficiency and cost-effectiveness in primary breast augmentation. The surgical efficiency (total operative time) and the immediate complications of 85 consecutive cohort of patients were recorded by an independent observer. Statistical correlation investigated the relevance of parity as predictors of surgical efficiency and cost-effectiveness.

RESULTS

A total of 894 patients were included with a minimum of 6-month follow-up following implants-based primary breast augmentation. There were 445 (49.8%) nulliparous and 449 (50.2%) patients had at least one child at the time of surgery. The average parity index was calculated to be 1.05. The average body mass index (BMI) was 20.8 kg/m² (15.9-30.8). The mean implant volume used was 314 ml. Fifteen percent (n = 134) presented with post-operative complications, with an average follow-up period of 12.8 (6-116) months. The differences between parity and incidence of complications were not statistically significant (p = 0.82). Surgical efficiency parameters from 85 women (54 multiparous and 31 nulliparous) demonstrated total operative time difference; 35 ± 6.3 min for multiparous and 30.2 ± 5 min for nulliparous. There was a clinical average difference of 4.8 min, with a maximum difference of 16.1 min. These statistically significant difference account for an average increase of 13.7% in the operating time in multiparous versus nulliparous (p-value=0.0004, 95% CI = 2.2-7.4 min).

CONCLUSION

Primary breast augmentation in parous women faces parenchymal and vascular histological breast tissue transformations which may not fully revert to the pre-pregnant state. These changes encountered during pocket dissection seem to have an impact on the operating time, cost-effectiveness and can therefore affect negatively surgical efficiency. Nevertheless, when surgical technique is based on sharp, precise dissection and proactive haemostasis, parity does not show to have an impact on the rates of complications, despite longer operation times.

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

Background

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

Objectives

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

Methods

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

Results

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

Conclusions

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

Level of Evidence 3

Quantitative Analysis of Nipple to Inframammary Fold Distance Variation in Tuberous Breast Augmentation: Is there a Progressive Lower Pole Expansion?

INTRODUCTION

In patients with short nipple to inframammary fold (N-IMF) distance, as in tuberous breast, the cohesivity and gel distribution of shaped implants work as a controlled tissue expander, progressively adapting the tissues to the implant's shape. This phenomenon translates into a gradual increase of the N-IMF distance over time, but the true extent to which this occurs has not been quantified to date. This study aims to quantify the postoperative variation of the N-IMF distance in tuberous breast treated with shaped cohesive silicone breast implants.

METHODS

We did a retrospective review of a prospective maintained database of all consecutive patients with bilateral Groulleau I and II tuberous breasts who underwent primary breast augmentation between April 2017 and May 2018 at our institution. To quantify the lower mammary pole's morphological changes, we evaluated the N-IMF distance under maximal stretch as an endpoint. We recorded this value at time 0 (preoperative), immediate post-op (equivalent to the distance planned preoperatively) and at month 1, month 6 and 1-year post-op. Then we calculated the average N-IMF distance variation of our sample of patients with a 99% interval of confidence for each breast obtained. Comparisons were performed using the Sign test and the Mann-Whitney U test.

RESULTS

The average implant weight was 353g (range 290-450; SD ±46.147). Of the 54 breasts analyzed, the immediate post-op N-IMF distance was on average 2.43 cm longer than the preop IMF with a 99% confidence interval between 2.01 and 2.86 and SD of ±1.22. The mean difference between the preop N-IMF distance and after 1, 6 and 12 months was respectively 2.78 cm (SD,1.56) (99% CI, 2.24-3.34), 3.08 cm (SD, 1.57) (99% CI, 2.53-3.64), and 3.36 (1.55) (99% CI, 2.82-3.91) Comparing immediate postoperative nipple to inframammary fold distance (N-IMF) to the 1, 6 and 12 months N-IMF values, an average of 4.23% (CI 1.3-7.16), 7.74% (CI 4.25-11.23) and 10.84% (CI 7.21-14.49) of skin length, was gained respectively. According to implants' weight, subgroup analysis showed that implants > 400 g were associated with significantly higher N-IMF distance increase (p <0.05) compared to implants < 400 g.

CONCLUSIONS

Our findings suggest that a significant progressive postoperative increase in N-IMF distance should be expected in all cases of tuberous breast augmentation with anatomical implants over a 1 year period. This aspect may have an important implication on the IMF incision and the new fold position preoperative planning. LEVEL OF EVIDENCE IV.

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

INTRODUCTION

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

METHODS

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

RESULTS

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

CONCLUSION

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

The Dual Vascular Pedicle: A Novel Method to Approach Challenging Cases in Single-Stage Mastopexy/Augmentation

BACKGROUND

Age, pregnancy and weight change can affect the shape of the female breast. Various mastopexy/augmentation techniques have been described to address these changes which work well in primary and uncomplicated cases. However, there is a distinctive category of high-risk patients which includes post-bariatric, active smokers, those with poor skin quality, wanting larger implants or undergoing secondary surgery. The complications reported in this group of patients are as high as 32%.

MATERIALS AND METHODS

We describe a new technique of one-stage mastopexy/augmentation, using a wide dermo-glandular pedicle, and our early results with 51 consecutive patients.

RESULTS

Fifty-one patients were operated between January 2016 and September 2018, with a mean age of 40.0 years. Ten patients were smokers, eight were post-massive weight loss, six had previous mastopexy. At a mean follow-up of 22 months, only two patients had a unilateral bottoming out. There were no incidents of hematoma, seroma, capsular contracture or major tissue-related complications.

CONCLUSION

Plastic surgery has been described as a struggle between beauty and blood supply. We have performed a one-stage mastopexy/augmentation using a wide and thick dermo-glandular glandular pedicle to maximize the blood supply in a range of challenging patients with promising results.

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 .

Controllable Factors to Reduce the Rate of Complications in Primary Breast Augmentation: A Review of the Literature

BACKGROUND

Aesthetic augmentation mammoplasties are one of the most demanded procedures performed in the aesthetic surgical sector. Because of the high epidemiological impact, the evaluation of measures to reduce the risk of complications is highly needed. The goal of this review is to evaluate the current literature for successful actions to reduce the risk of complications in aesthetic breast augmentation.

METHODS

We searched Medline-listed journals for "complications primary breast augmentation" and defined surgeon-dependent and patient-dependent factors within those.

RESULTS

Most of the strategies to reduce the risk of any complication are based on meticulous hygienic precautions and adequate training of the surgeon. The current literature suggests complications such as capsular contracture, infection and BIA-ALCL are closely linked with bacterial contamination and therefore can be avoided with different hygienic measures.

LEVEL OF EVIDENCE III

This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

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

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

The Evolution of Patients' and Surgeons' Perspectives Towards the Role of the Internet and Social Media in Breast Augmentation Over 5 Years

BACKGROUND

The influence of the internet and social media (SoMe) in the decision-making of patients is recognized. Plastic surgeons are aware of this trend but are entangled between ethics, professionalism, and business acumen.

OBJECTIVES

In this study, the authors presented the evolution of perspectives of patients and surgeons recruited through a private clinic over 5 years.

METHODS

A questionnaire was administered to patients consulting for primary breast augmentation in 2014, 2017, and 2019. Plastic surgeons who worked at or visited the Akademikliniken in 2014, 2017, and 2019 completed a separate questionnaire.

RESULTS

In total, 1646 patient responses were collected. Patients who started their information gathering with the internet increased from 68.0% to 72.9%, and 94.1% of patients looked for information about aesthetic surgery on the internet before their consultation. Patients who read about aesthetic surgery on SoMe increased 29.1%. Of 462 surgeons recruited, 62% opined that the majority of patients had gathered information online before consultation. Fewer surgeons in 2019 thought that the internet and SoMe led to better information (down from 61.7% to 35.2%). An increase from 38.3% to 65.3% of surgeons attributed it to unrealistic expectations. However, only 9.7% of surgeons would support removal of plastic surgery material from SoMe compared with 21.9% in 2014.

CONCLUSIONS

The increased utilization and influence of the internet and SoMe on patients and surgeons is rapid. Aesthetic plastic surgeons must equip themselves to cope with the risks and capitalize on the opportunity for patient engagement and public education.

Transitioning From Conventional Textured to Nanotextured Breast Implants: Our Early Experience and Modifications for Optimal Breast Augmentation Outcomes

BACKGROUND

Nanotextured breast implants were hailed as an innovation that may address capsular contracture and breast implant-associated anaplastic large cell lymphoma and may provide the sweet spot between smooth and conventional textured implants.

OBJECTIVES

This study aimed to evaluate the introduction of nanotextured implants alongside conventional textured implants and to compare early complications.

METHODS

Patients who underwent breast augmentation from the introduction of nanotextured implants in the author's practice with at least 1 year of follow-up were included. They were divided into nanotextured and conventional textured implant groups and then into 3 chronological subgroups. Patient characteristics, implant specifications, operative factors, and complication rates were compared.

RESULTS

A total 415 cases with a mean follow-up of 26.9 months were identified, of which 38.8% utilized nanotextured implants and 61.2% conventional textured implants. Utilization of nanotextured implants increased from 26.9% in period 1 to 54.5% in period 3. Complication rates for the conventional textured group were 0.8% at 1 year and 3.5% on overall follow-up, with mostly capsular contractures; for the nanotextured group, complication rates were 6.8% and 8.7%, respectively, and "bottoming out" was most common. When analyzed across chronological subgroups, complication rates decreased for nanotextured implants by period 3.

CONCLUSIONS

A learning curve and associated complications are expected for early adopters of new implants. In our series, nanotextured implants were associated with higher complication rates at 1 year and on overall follow-up. Modifications in patient selection, intraoperative techniques, and postoperative care reduced complications in the later period.

LEVEL OF EVIDENCE: 4

Implant Insertion Time and Incision Length in Breast Augmentation Surgery with the Keller Funnel: Results from a Comparative Study

BACKGROUND

The Keller funnel is an easy-to-use mechanical device that aids breast implant insertion. This study analyzed implant insertion time and incision length using the Keller funnel versus conventional manual insertion.

METHODS

This was an analysis of two cohorts of adult patients undergoing primary breast augmentation with anatomical implants at a single center. In the 'insertion time cohort' (N = 20), implants were inserted with a Keller funnel on one side and manually on the other; follow-up lasted 4 years. In the 'incision length cohort,' both implants were inserted with a Keller funnel (N = 50) or manually (N = 50), with follow-up lasting 12 months.

RESULTS

In the insertion time cohort, mean total insertion time (from implant sterile-package opening to final positioning in the pocket) was 35 s (range 13-76 s) with the Keller funnel and 25 s (range 13-43 s) using manual insertion (p = 0.07); the mean time needed to push the implant through the incision was 6 s (range 3-10 s) with the Keller funnel and 16 s (range 13-40 s) with manual insertion (p = 0.04). In the incision length cohort, mean incision length was shorter with the Keller funnel versus manual insertion (35.5 ± 2.1 mm vs. 46.2 ± 3.2 mm; p < 0.001). There were no differences in complications based on insertion method.

CONCLUSION

The Keller funnel was associated with decreased incision length and reduced time to push the implant through the incision. This brings potential clinical advantages in minimizing scarring and reducing contamination of the device.

LEVEL OF EVIDENCE III

This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Patients' and Surgeons' Perceptions of Social Media's Role in the Decision Making for Primary Aesthetic Breast Augmentation

BACKGROUND

Social media (SoMe) has evolved to be a platform that patients use to seek information prior to an operation, share perioperative and postoperative journey, provide feedback, offer and receive support. While there have been studies looking at the evolution and usage of SoMe either by patients or by surgeons, there is no information that compares its usefulness for both the groups.

OBJECTIVES

The aim of this study was to compare the views held by patients and surgeons, towards social media and other internet resources, in relation to one commonly performed operation.

METHODS

A questionnaire was presented to 648 consecutive patients who attended our clinic for consultation for primary breast augmentation from September 2016 to March 2017. A separate "surgeons' questionnaire" was answered by a group of 138 plastic surgeons who were either practicing in branches of our clinic, had previously done fellowship with us, or were visiting the clinic.

RESULTS

All 138 surgeons and 648 patients responded to the questionnaire. A total of 91.4% of patients said that they had searched online and 61.4% had searched in specific online groups for information on breast augmentation. A total of 88.9% of patients had specifically looked for clinical photographs and 73.4% had specifically searched for unfavorable reviews of the surgeon. In comparison, 72.5% of surgeons thought that over three quarters of patients gather information on the internet while only 20.3% thought that over three quarters of patients use social media for their information. A total of 52.5% of surgeons have noticed that social media affected their consultations.

CONCLUSIONS

With the evolution of the internet and related technologies, the role of social media continues to increase. While patients use social media to help make their decisions, it is not the only deciding factor. Surgeons appear to underestimate the patients' use of these technologies. There is concern in each group about the amount of inaccurate information on the social media. This underlines the importance of providing factual, evidence-based information to the patients.

Inhibitory Effect of Retinoids on the Generation of Procoagulant Activity by Blood Mononuclear Phagocytes

Retinoids are known to modulate several functions of mononuclear phagocytes. We have studied the effect of retinyl acetate (RAc) and retinoic acid (RA) on the production of procoagulant activity (PCA) by human peripheral blood mononuclear cells stimulated with endotoxin (1 εg/ml, 4 or 20 h at 37°C). Both compounds caused a dose-dependent reduction in the expression of cell-associated PCA (from 86 to <10% of control in the range of concentration comprised between 0.1 and 100 εM). This effect was also observed when the cells were exposed to retinoids for 10 min and washed before challenge with endotoxin, indicating that it is rapid and irreversible. In contrast, incubation of RAc or RA for 3 h at 37° C with cells that have been already stimulated with endotoxin (20 h at 37° C) remained without influence on cell PCA. The inhibitory action of retinoids was also observed when monocyte-enriched (>85%) preparations or highly purified monocyte-derived macrophages (>99%) were used instead of whole mononuclear cells. BW755C, an inhibitor of cyclo-oxygenase and lipoxygenase, reversed the inhibitory effect of retinoids, whereas acetylsalycilic acid, an inhibitor of cyclo-oxygenase, was inactive, suggesting the involvement of a lipoxygenase product. The inhibition of monocyte/macrophage PCA production and the subsequent reduction of cell potential for fibrin deposition might represent one of the mechanisms whereby retinoids exert their antiinflammatory and immunomodulatory activities.

Unbalanced Coagulation-Fibrinolysis Potential during L-Asparaginase Therapy in Children with Acute Lymphoblastic Leukaemia

Treatment of acute lymphoblastic leukaemia (ALL) with L-asparaginase (L-asp) may be associated with thrombotic complications, but the pathogenetic mechanisms of thrombus formation and persistence remain unclear. We studied the procoagulant activity (PCA) of peripheral blood mononuclear cells and some components of the plasma fibrinolytic system in L0 children with ALL undergoing remission induction therapy which includes L-asp. Mononuclear cells obtained 14 days after starting L-asp treatment generated significantly higher amounts of PCA (identified as tissue factor) than cells isolated before the first dose of L-asp and 7 days after the cessation of L-asp administration (p <0.01). Augmented PCA coincided with an increase in the plasma D-dimer. The plasma levels of type 1- plasminogen activator inhibitor were found signiticantly elevated during L-asp therapy (p <0.05), whereas plasminogen levels were markedly decreased (p <0.05). These findings suggest that, during the course of L-asp treatment, the coagulation-fibrinolysis balance is shifted towards promotion of fibrin formation and deposition. Although it remains to be conclusively established whether Lasp per se or the concurrent administration of multiple chemotherapeutic agents is responsible for these changes, the latter could contribute to the thrombotic complications associated with remission induction therapy for ALL.

Increased Mononuclear Cell Tissue Factor and Type-2 Plasminogen Activator Inhibitor and Reduced Plasma Fibrinolytic Capacity in Children with Lymphoma

Blood clotting activation and fibrin deposition are common findings in lymphoma patients. We evaluated the capacity of peripheral blood mononuclear cells to produce procoagulant activity (PCA) and plasminogen activator inhibitor (PAI) in 12 children with newly diagnosed lymphoma (8 non-Hodgkin’s, 4 Hodgkin’s) and in 12 matched healthy donors. In the same subjects we also measured plasma antigen levels of tissue-type PA (t-PA), urokinase-type PA (u-PA), PAI-1, PAI-2, and D-dimer. PCA generated by mononuclear cells after incubation for 20 h at 37° C was significantly higher in patients than in controls (p = 0.027). In all samples it was identified as tissue factor by functional criteria (dependence on factor VII). Moreover, culture medium obtained from patients’ mononuclear cells after incubation for 20 h at 37° C contained significantly higher amounts of PAI activity and PAI-2 antigen than control samples (p <0.001). Plasma PAI-1 and t-PA antigens were significantly augmented in patients (p <0.005), the mean increase of PAI-I being about 5 times higher than that of t-PA. Plasma levels of D-dimer wete markedly increased in the patients’ group (p <0.001), whereas u-PA and PAI-2 antigens did not differ from controls. It is suggested that monocytes from lymphoma patients are endowed with functional abnormalities leading to the simultaneous expression of tissue factor and antifibrinolytic activity. These abnormalities, coupled with a reduced plasma fibrinolytic potential, could play an important pathogenetic role in blood clotting activation and fibrin deposition associated with lymphoma.

Do Not Fear an Implant's Shape: A Single Surgeon's Experience of Over 1200 Round and Shaped Textured Implants in Primary Breast Augmentation

BACKGROUND

Breast implants can be characterized by their fill material, surface texture, or shape. Whereas long-term good quality studies have provided evidence for the fill material and texture, there is still little consensus for choosing the shape of an implant. Surveys indicate that many surgeons choose only one implant shape, for reasons that may not always agree with outcomes from long-term studies.

OBJECTIVES

We reviewed the first author's experience over the last six years with both round and anatomical implants, compared the rate of complications with either implant shape, and discussed the importance of keeping an open mind about using both implant shapes for primary breast augmentation.

METHODS

A review of all consecutive primary breast augmentation patients by the first author over a six-year time period who had a minimum follow up of 6 months after surgery.

RESULTS

Six-hundred and forty-eight female patients had 1296 silicone breast implants inserted over the six-year period. Mean age at surgery was 30.5 years and mean BMI was 20.6 kg/m2. All implants were textured, 134 (in 67 patients, 10.3%) were round in shape with mean volume of 338 cc (range, 220-560 cc), while 1162 implants (in 581 patients, 89.7%) were anatomical shaped with a mean volume of 309 cc (range, 140-615 cc). Among these patients, 11.9% (n = 8) with round implants and 9.0% (n = 52) of those with anatomical implants developed complications postoperatively.

CONCLUSIONS

A single, ideal implant that is suitable for every primary breast augmentation does not exist. The optimum choice of implant shape in any given situation should take into account the patient's physical characteristics, available implant types, patient's desires, and the surgeon's experience. Together with round implants, anatomical devices ought to be considered as one of the tools in the surgeon's toolbox. By choosing to ignore them a priori means that the surgeon will only have access to half of his armamentarium and will therefore be able to offer a limited set of options to his patients.

LEVEL OF EVIDENCE 4

Aesthetic Training for Plastic Surgeons: Are Residents Getting Enough?

Plastic Surgery is one of the most competitive specialties in the field of medicine. However, this specialty has a unique particularity: the difficulties in Aesthetic Surgery training within the residency program. Despite the fact that the full title of the specialty is Plastic, Reconstructive, and Aesthetic Surgery and that Aesthetic Surgery is a part of the examination syllabus, the actual training in the specific area is limited. One of the solutions to this problem is Fellowships. The first author describes his personal experience with Aesthetic training and how it enhanced his knowledge in the area as well as the status of Fellowships in various training programs.

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.

Implementation of an Integrated Biodimensional Method of Breast Augmentation with Anatomic, Highly Cohesive Silicone Gel Implants: Short-Term Results With the First 620 Consecutive Cases

BACKGROUND

The previously described Akademikliniken (AK) method is a comprehensive approach to breast augmentation with form stable implants that has been shown to afford favorable outcomes when applied by experienced surgeons.

OBJECTIVES

To evaluate outcomes of a surgeon newly adopting this method at the beginning of his career.

METHODS

A retrospective review of patients undergoing dual plane subpectoral augmentation with Style 410 implants between April 2009 and December 2014 was undertaken. The review was performed one year after the last operation. The first author (P.M.) performed all operations. Complications and reoperation rates were analyzed and correlated with patient and implant characteristics using the chi-square or Fisher's exact test, as appropriate.

RESULTS

A total of 620 consecutive patients met the inclusion criteria with a mean follow up of 8 months (range, 1 week-60 months). Complications occurred in 14.8% of the patients: request for larger size (3.3%), rotation (3%), and Baker III/IV capsular contracture (2.2%) were the most common ones. Low implant projection was a statistically significant risk factor (P < 0.05) for the most common complication - request for a larger size. The overall reoperation rate was 8.7%. The most common indication for reoperation was request for larger size (2.2%) followed by rotation (2.2%) and capsular contracture (2%).

CONCLUSIONS

Breast augmentation with form stable anatomical implants requires a considerably different process. By implementing a systematic approach such as the AK method, novices in this terrain can expect to achieve reasonable outcomes.

LEVEL OF EVIDENCE

4.

Autologous Collagen Matrix (ACM): Lower Pole Support With a Supero-Anterior Capsular Flap in Secondary Subpectoral Breast Augmentation

Background

Secondary aesthetic breast surgery is a complex and challenging scenario. It requires the surgeon to identify contributing factors, provide patient education, make a further management plan, and optimize the conditions for a favorable result. Various techniques have been described in literature but the rate of reoperation is still high. The first author has been using a supero-anterior capsular flap with a neopectoral subcapsular pocket and an implant change in these cases.

Objectives

To review the patient characteristics, indications, and early results of using part of the existing implant capsule for secondary subpectoral breast augmentations.

Methods

All patients who underwent secondary breast augmentation, over a period of 2 years by the first author (P.M.), using the supero-anterior capsular flap technique were included. The technique involves dissection of a new subpectoral pocket and uses the existing implant capsule as an internal brassiere.

Results

A total of 36 patients were operated by this technique. Of these, 17 patients had developed a complication while 19 patients wanted a change in size only. At a mean follow up of 10.2 months, there was no bottoming out, double bubble, or capsular contracture.

Conclusions

This reliable technique provides stable results as shown by low rate of complications with the existing follow up.

Level of Evidence 4

Role of Macrotextured Shaped Extra Full Projection Cohesive Gel Implants in Primary Aesthetic Breast Augmentation

Background

Extra full projection implants are used in a select group of aesthetic breast surgery patients. Their use is selective enough that they have not been included in long term manufacturer studies and the indications for their use have attracted much debate. Only a handful of studies have reported the outcomes from implantation of these devices.

Objectives

We review our experience of using extra full projection anatomically shaped macrotextured silicone gel implants discussing our rationale, indications, and results.

Methods

All patients undergoing primary aesthetic breast surgery with extra full projection anatomical implants by the first author (P.M.) over a seven-year period (January 2009 to December 2015) were included.

Results

Three hundred and ten female patients had 620 macrotextured extra full projection anatomically shaped cohesive silicone gel breast implants of mean volume 338 cc (range, 195-615 cc) placed over the seven-year period. All of them had at least a 6-months follow up. There were 39 complications (12.6%) at an average follow up of 12.3 months, including implant malposition/rotation (5.4%), capsular contracture (2.6%), and bottoming out (1.6%). A total of 41 patients (13.2%) were reoperated, of which 30 (9.7%) were due to a complication and 11 (3.5%) because of patient choice. Most of the complications were in the initial part of the case series.

Conclusions

The outcomes following the use of extra full projection implants in a carefully selected group of patients are comparable in the short term to those reported for other shaped implants and complications appear to decrease with experience.

Level of Evidence

4.

The influence of social media and easily accessible online information on the aesthetic plastic surgery practice: literature review and our own experience

INTRODUCTION

Patients interested in aesthetic plastic surgery procedures increasingly seek advice on social media and rely on easily accessible online information. The investigatory goal was to determine the impact of this phenomenon on the everyday aesthetic plastic surgery practice.

METHODS AND PATIENTS

Five hundred consecutive patients completed a questionnaire prior to their consultation with a plastic surgeon at our clinic. A questionnaire was also completed by 128 plastic surgeons practising in 19 different countries. A literature review was performed.

RESULTS

Almost all patients (95%) used the internet to collect information prior to consultation, for 68% of them it being their first search method. Social media were used by 46% of patients and 40% of these were strongly influenced when choosing a specific doctor. The majority of plastic surgeons (85%) thought the information found on social media could lead to unrealistic expectations. However, 45% of plastic surgeons believed that their consultations became easier after the advent of social media, 29% found them more difficult. A literature review showed a high percentage of poor quality internet websites regarding plastic surgery and an increase in use of social media among plastic surgeons.

CONCLUSION

The internet and social media play an important and growing role in plastic surgery. This results in more informed patients but may create unrealistic expectations. Even if the internet provides ample information, it cannot replace the face-to-face consultation, which always should remain a detailed process, covering both risks and limitations of alternative procedures. Available literature on how social media influences the medical practice is still scarce and further research is needed.

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.

Customized planning of augmentation mammaplasty with silicon implants using three-dimensional optical body scans and biomechanical modeling of soft tissue outcome

The aesthetic results of augmentation mammaplasty are essentially determined by the size and the shape of the implant as well as its position on the chest. To achieve successful aesthetic results, customized surgery planning based on a reliable visual concept of the prospective surgery outcome and quantitative methods for assessment of three-dimensional (3D) breast shape could be of considerable additional value. This report evaluates a novel method for customized planning and quantitative optimization of breast augmentation based on 3D optical body scanning of the patient's breast and computational modeling of soft tissue mechanics. This method allows a 3D photo-realistic appearance of postsurgery breasts to be simulated for different surgical scenarios. It also allows the result of a virtual simulation to be implemented using measurements derived from a computationally predicted breast model. A series of clinical studies are presented that demonstrate the feasibility and accuracy of the proposed approach for customized 3D planning of breast augmentation, including direct comparison between simulated and postsurgery results. Our experimental results show that for 89% of the breast surface, the average difference between the simulated and postsurgery breast models amounts to less than 1 mm. The presented method for customized planning of augmentation mammaplasty enables realistic prediction and quantitative optimization of postsurgery breast appearance. Based on individual 3D data and physical modeling, the described approach enables more accurate and reliable predictions of surgery outcomes than conventionally used photos of prior patients, drawings, or ad hoc data manipulation. Moreover, it provides precise quantitative data for bridging the gap between virtual simulation and real surgery.

Study of the correlation between microfauna and the macrostructure of activated sludge and the efficiency of biological wastewater treatment plants

Assessment of protozoan populations is an important tool in evaluating the efficiency of activated sludge in the treatment of wastewater. In this process, protozoa play a significant role by grazing on dispersed bacteria, supporting a healthy food web in activated sludge artificial ecosystems. The objective of this study was to verify how the success of the purification process in activated sludge plants, mainly in terms of TSS, BOD, and COD, is related to ciliate protozoa communities and the presence of filamentous bacteria. Samples were collected from five water treatment plants in the Puglia region, in the period May 2007 - April 2008. Microfauna and filamentous bacteria were identified and quantified, and the sludge biotic index calculated. The data show a correlation between the biological components of activated sludge and traditional chemical parameters. Our results indicate that biological analyses represent a valid alternative to traditional chemical testing in assessing the performance of activated sludge systems.

Helicobacter pylori neutrophil-activating protein stimulates tissue factor and plasminogen activator inhibitor-2 production by human blood mononuclear cells

Helicobacter pylori neutrophil-activating protein (HP-NAP) is a virulence factor that activates phagocytic NADPH-oxidase. The effect of HP-NAP on the production of tissue factor (TF), plasminogen activator inhibitor-2 (PAI-2), and urokinase-type plasminogen activator (u-PA) by human blood mononuclear cells (MNC) was evaluated by using functional and immunological assays and mRNA analysis. HP-NAP induced time- and dose-dependent increases in TF and PAI-2, with a maximal effect at 300 nmol/L (>15-fold increase in antigens). No changes in u-PA were observed. When whole bacteria were used, an H. pylori mutant lacking HP-NAP was significantly less active than the wild-type strain. MNC from a patient with chronic granulomatous disease behaved as do normal cells, which indicates that HP-NAP effects can occur independently of NADPH-oxidase. HP-NAP, by inducing the coordinate expression of cell procoagulant and antifibrinolytic activities, might favor fibrin deposition and contribute to the inflammatory reaction of gastric mucosa elicited by H. pylori.

Nicotine effects on polymorphonuclear cell apoptosis and lipopolysaccharide-induced monocyte functions. A possible role in periodontal disease?

Apoptosis provides a mechanism for clearance of unwanted cells in a variety of situations in which programmed or physiological cell death occurs; but the premature death of defensive cells could promote infection, inflammation and concomitant disease. We detected high values of apoptosis in polymorphonuclear cells (PMN) elicited from crevicular sulci of smokers affected by adult periodontitis. To learn more about the effects of nicotine on the periodontal environment, we studied its ability to modulate the apoptosis of two phagocytic lines, PMN and mononuclear cells, which are continuously recruited from gingival vessels to prevent or control plaque extension. Brief exposure of PMN to nicotine concentrations ranging from 0.01 to 0.3% shortened, in a dose-dependent relationship, the lag culture time required to observe at fluorescent microscopy the morphological traces of apoptosis. These observations were confirmed by specific tools of apoptosis: DNA fragmentation on gel electrophoresis and expression of the apoptosis-signaling receptor Fas/Apo-1. The apoptotic effect excited by nicotine on these first line defensive cells may be an important feature of the pathogenesis of periodontal disease. As for mononuclear leukocytes, nicotine was unable to induce apoptotic modifications on cells observed up to 72 h culture time, but the drug inhibited IL-1beta release and procoagulant activity (PCA) expression. The conflicting role played by these lipopolysaccharide (LPS)-induced monocyte functions in the inflammatory process is a further intrigue in the mechanism by which nicotine compromises the oral health.

Retinoic acid stimulates plasminogen activator inhibitor 2 production by blood mononuclear cells and inhibits urokinase-induced extracellular proteolysis

Retinoids have been shown to modulate several functions of mononuclear phagocytes. We investigated the in vitro effect of all-trans-retinoic acid (ATRA) on the production of two major fibrinolytic components, urokinase-type plasminogen activator (u-PA) and PA inhibitor 2 (PAI-2), by human blood mononuclear cells (MNC). ATRA caused a dose-dependent (range 0.01-10 microM) accumulation of PAI-2 antigen and activity into the cell culture medium, with a maximal increase (about 5-fold over control) at a concentration of 1-10 microM. Similarly, a dose-dependent increase in PAI-2 antigen was observed in cell extracts upon ATRA stimulation. Northern blot analysis showed a parallel increase in the amount of PAI-2 mRNA in ATRA-treated cells. Time-course experiments with 1 microM ATRA showed enhanced PAI-2 mRNA expression as early as 2 h, reaching a maximum at 4-6 h and then declining at 18-24 h, and a time-dependent increase in PAI-2 antigen in the cell culture medium. At variance with PAI-2, u-PA was not influenced by the drug. To establish whether ATRA-induced changes influenced the fibrinolytic process, we evaluated the effect of MNC stimulated with ATRA on u-PA-induced degradation of diluted plasma clots. ATRA-treated cells markedly inhibited clot lysis induced by low concentrations of u-PA. The effect was due to enhanced extracellular PAI-2 accumulation since it was observed with conditioned medium from ATRA-treated cells; it was abolished by the addition of neutralizing anti-PAI-2 antibodies and was negligible when single-chain t-PA was used instead of u-PA. Since monocyte/macrophage-mediated, plasminogen-dependent extracellular proteolysis has been proposed as an important mechanism of tissue damage in several inflammatory states, our findings might contribute to better explain the anti-inflammatory properties of retinoids.

Effect of Helicobacter pylori lipopolysaccharide (LPS) and LPS derivatives on the production of tissue factor and plasminogen activator inhibitor type 2 by human blood mononuclear cells

Different Helicobacter pylori lipopolysaccharides (LPSs) and LPS-derivatives were studied for their ability to induce the production of procoagulant activity (PCA) and plasminogen activator inhibitor type 2 (PAI-2) by human blood mononuclear leukocytes. Smooth (S)- and rough (R)-form LPSs caused a similar increase in cell-associated PCA (tissue factor) and PAI-2 antigen release. Both effects were potentiated by fetal bovine serum via a CD14-mediated mechanism. The potency of H. pylori LPSs was approximately 1000-fold lower than that of Salmonella typhimurium LPSs. When H. pylori LPS derivatives (dephosphorylated R-LPS, S-lipid A, and R-lipid A) were used, PCA and PAI-2 production were markedly reduced. R-lipid A was approximately 4-fold less efficient than S-lipid A. These findings suggest that the induction of monocyte tissue factor and PAI-2 by H. pylori LPS is influenced by the lipid A structure and modulated by the core oligosaccharide and that phosphate groups present in both regions may play an important role.

Cultured human mesangial cells produce both type 1 and type 2 plasminogen activator inhibitors

Cultured human mesangial cells (HMC) derived from normal kidneys have been shown to synthesize tissue-type plasminogen activator (t-PA) and excess amounts of PA inhibitor type 1 (PAI-1). Conflicting results have been obtained concerning the production of urokinase-type PA (u-PA) and efforts to show PA inhibitor 2 (PAI-2) met with failure. We evaluated the fibrinolytic profile of cultured HMC lines obtained from 12 patients with renal carcinoma and one cadaveric kidney donor. Subconfluent cells (third passage) were incubated overnight in serum-free medium. t-PA, u-PA, PAI-1 and PAI-2 antigens were assayed by ELISA methods and PA and PAI activities by amidolytic methods both in conditioned medium (CM) and cell extracts (CE). Besides PAI-1, PAI-2 antigen was detected in all but one HMC lines. At variance with the former, which was largely released in the culture medium, PAI-2 was mainly cell-associated. t-PA antigen was found in all but two cell lines while u-PA antigen was detected in relatively high concentrations in 8 cell lines. PA activity, identified as u-PA by functional and immunological criteria, was measured in CM of six of the eight u-PA producing cell lines, whereas PAI activity was undetectable or very low in CM of all cell lines, suggesting that PAI-1 was largely inactive. Functional assays of cell extracts demonstrated the presence of PA activity, again identified as u-PA, only in samples (five lines) containing u-PA antigen in excess over PAI-2. PAI activity was found instead in the extracts in which the inhibitor was higher than the activator (six lines) and was identified as PAI-2, as it inhibited u-PA but not single-chain t-PA and was neutralized by a polyclonal anti-PAI-2 antibody. The heterogeneous fibrinolytic pattern of HMC lines was confirmed by mRNA analysis of three representative lines. Results were similar when HMC lines at passage five were used, except that the u-PA content was significantly reduced both in CM and CE. These findings indicate that the fibrinolytic profile of cultured HMC is more complex than previously reported. The production of large amounts of PAI-2 may represent an additional control mechanism of proteinase activity.

Blood and tissue fibrinolytic profiles in patients with colorectal carcinoma

In patients with colorectal cancer, profound alterations of the plasminogen activator system have been described at the tumor level, but conflicting results have been obtained for fibrinolytic parameters in plasma. Components of the fibrinolytic system, including tissue-type and urokinase-type plasminogen activators and their inhibitors type 1 and 2, were measured in tissue and/or plasma from 41 patients with colorectal cancer and in 40 controls. Procoagulant activity of freshly isolated mononuclear cells (basal activity) and the procoagulant activity and fibrinolytic proteins produced by the cells after incubation for 18 h without exogenous stimulation were also evaluated. Malignant tissue extracts had significantly higher levels of urokinase-type plasminogen activator and plasminogen activator inhibitor-1, but lower levels of tissue-type plasminogen activator than normal mucosa. Plasminogen activator inhibitor-1 alone was higher in advanced (Dukes' stages C + D) than limited (B) tumors. Plasminogen activator inhibitor-2 was not different in malignant tissue and normal mucosa. Plasma levels of plasminogen activator inhibitor-1 antigen were significantly increased in cancer patients compared with controls, but there were no differences in tissue-type and urokinase-type plasminogen activator, in plasminogen activator inhibitor-2, and D-dimer levels. Intra-patient analysis revealed no significant correlation between tumor and plasma levels of plasminogen activators or type 1 inhibitor. Tissue-type plasminogen activator, but not the urokinase type or inhibitor type 1, was higher in venous than in arterial blood collected at the tumor site during surgery. Basal procoagulant activity of mononuclear cells and the procoagulant activity and inhibitor type-2 produced by the cells after short-term culture were comparable in patients and controls. These findings indicate that, at least in our patients with colorectal cancer, the profound changes occurring at tumor level are barely detectable in the blood. Thus, the clinical relevance of plasma fibrinolytic parameters, especially urokinase-type plasminogen activator antigen, as tumor markers in colorectal cancer remains to be established.

Increased mononuclear cell tissue factor and type-2 plasminogen activator inhibitor and reduced plasma fibrinolytic capacity in children with lymphoma

Blood clotting activation and fibrin deposition are common findings in lymphoma patients. We evaluated the capacity of peripheral blood mononuclear cells to produce procoagulant activity (PCA) and plasminogen activator inhibitor (PAI) in 12 children with newly diagnosed lymphoma (8 non-Hodgkin's, 4 Hodgkin's) and in 12 matched healthy donors. In the same subjects we also measured plasma antigen levels of tissue-type PA (t-PA), urokinase-type PA (u-PA), PAI-1, PAI-2, and D-dimer. PCA generated by mononuclear cells after incubation for 20 h at 37 degrees C was significantly higher in patients than in controls (p = 0.027). In all samples it was identified as tissue factor by functional criteria (dependence on factor VII). Moreover, culture medium obtained from patients' mononuclear cells after incubation for 20 h at 37 degrees C contained significantly higher amounts of PAI activity and PAI-2 antigen than control samples (p < 0.001). Plasma PAI-1 and t-PA antigens were significantly augmented in patients (p < 0.005), the mean increase of PAI-I being about 5 times higher than that of t-PA. Plasma levels of D-dimer were markedly increased in the patient's group (p < 0.001), whereas u-PA and PAI-2 antigens did not differ from controls. It is suggested that monocytes from lymphoma patients are endowed with functional abnormalities leading to the simultaneous expression of tissue factor and antifibrinolytic activity. These abnormalities, coupled with a reduced plasma fibrinolytic potential, could play an important pathogenetic role in blood clotting activation and fibrin deposition associated with lymphoma.

Enhanced endothelial tissue factor but normal thrombomodulin in endotoxin-treated rabbits

Exposure of cultured endothelial cells to bacterial endotoxin induces an enhancement of cell procoagulant activity (PCA) and a simultaneous reduction of thrombomodulin activity (TM). We evaluated the effect of endotoxin on the expression of both endothelial PCA and TM in vivo, in rabbits. Animals were given a single i.v. injection of endotoxin (E. coli 0111:B4 LPS, W, 10-200 micrograms/kg); the thoracic aorta was harvested after 2 or 4 hours and placed in an ad hoc device to expose the endothelial surface only. Endotoxin treatment resulted in a dose-dependent increase of endothelial PCA (p < 0.001, at 100 micrograms/kg or more), which was totally dependent on factor VII and thus identified as tissue factor. In contrast, endothelial TM activity, as measured by the rate of thrombin-induced protein C activation, was similar in control and endotoxemic rabbits, even when the animals were given two injections (50 micrograms/kg, 24 h apart), or a continuous infusion (40 micrograms/kg/h during 4 hours) of endotoxin. To explore the effect of endotoxin on TM activity at the microcirculation level, we measured the extent of protein C activation in vivo, induced by a continuous infusion of low doses of thrombin (1 NIH U/kg/min for 60 min). Again, endotoxin administration was not associated with significant changes in TM-dependent protein C activation, as assessed by the anticoagulant activity present in a barium citrate plasma eluate obtained at the end of thrombin infusion. Although reduction of TM during persistent endotoxemia cannot be definitively excluded, our data support a major role of endothelial PCA in LPS-induced coagulative changes.

Reduction of tumor-associated fibrinolytic-activity by antimetastatic dosages of 2 ru(ii)-dmso complexes in mice bearing lewis lung-carcinoma

Some Ru(II)-DMSO complexes have antimetastatic properties in experimental tumors. Since plasminogen activators are thought to play an important role in the expression of cancer cell metastatic capacity, we evaluated the effect of two Ru(II)-DMSO complexes on the fibrinolytic activity of Lewis lung carcinoma. Tumor-bearing mice were given daily, for 14 days, an i.p. injection of antimetastatic dosages of cis-RuCl2(DMSO)4 (700 mg/kg/die) or trans-RUCl2(DMSO)4 (37 mg/kg/die), or vehicle. Tumor extracts obtained on day 15 from treatment groups had significantly lower (plasminogen-dependent) fibrinolytic activity than extracts from control animals (p<0.001). Urokinase inhibitor activity in tumor extracts did not differ among groups and did not correlate with plasminogen activator activity, Fibrin autography of control tumor extracts revealed the presence of a main fibrinolytic band co-migrating with urinary plasminogen activator (urokinase-type) and of minor bands with a higher molecular weight. In samples from animals treated with either Ru(II)-DMSO complex the most striking finding was a reduction of the band corresponding to free urokinase. These findings suggest that ruthenium complexes decrease the fibrinolytic activity of tumor cells by reducing urokinase production rather than by enhancing inhibitor production. Treatment of tumor-bearing mice with cis-RuCl2(DMSO)4 at a dosage equimolar to the trans isomer, neither reduced metastasis formation nor decreased plasminogen activator activity of tumor extracts. The depression of tumor-associated proteolytic activity could contribute to the antimetastatic properties of ruthenium complexes.