Artificial Intelligence, Genuine Outcome: Analysis of 72 Consecutive Cases of Subfascial Augmentation Mastopexy With Smooth Round Implants Supported by P4HB Scaffold

BACKGROUND

Ptosis recurrence often leads to unsatisfactory results after mastopexy, even more so when additional stress is provided by implants on compromised native tissue. Poly-4-Hydroxybutyrate(P4HB) scaffold(GalaFLEX) with its favorable safety profile and proven long-term mechanical strength represents a preferred option for soft-tissue support.

OBJECTIVES

Primary endpoint was to assess lower pole stretch from early post operative time up to 3 years.

METHODS

Out of 151 patients operated by the first author from March 2020 to December 2023, a total of 72 with 12-month-mininum follow-up undergoing primary(46) or secondary(26) augmentation mastopexy with subfascial round smooth implants and P4HB scaffold support were included in the study. A 3-D artificial-intelligence (AI) software was used for all measurements. Further analysis included evaluation of ptosis recurrence and all complications.

RESULTS

No recurrent ptosis, bottoming out, implant displacement or capsular contracture were reported during follow up (mean 24.8 months). Lower pole arch's elongation was 8.04% and 9.44% at 1 and 3 years respectively, comparing favorably with previous reports. Statistically significant correlation (p < 0.05) between implant size and lower pole stretch was noted, this being greater for larger implants (>400 cc; p = 0.0011) and primary cases (p = 0.1376). Progressive volume redistribution from upper to lower pole was observed in the first year with substantial stability thereafter.

CONCLUSIONS

This is the largest published series reporting long-term results (up to 45 months) in mastopexy augmentation with GalaFLEX, suggesting its supportive role in lower pole stability even in the setting of concurrent breast augmentation with smooth implants in a subfascial plane.

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.

Experience and Indications for the Use of the P4HB Scaffold (GalaFLEX) in Aesthetic Breast Surgery: A 100-Case Experience

BACKGROUND

The popularity of utilizing mesh in the breast has varied over the years. It is well described, and yet there has been poor uptake of its utilization in aesthetic breast surgery. Poly-4-huydroxybutarate (P4HB; GalaFLEX, Galatea, Lexington, MA) has recently been described as a useful adjunct in supporting poor tissue quality with positive early outcomes and low complication rates.

OBJECTIVES

The authors sought to determine the outcome and range of indications of PH4B in aesthetic breast surgery to document its effectiveness in assisting with long-term outcomes in mastopexy.

METHODS

Firstly, an observational study was undertaken standardizing mastopexy techniques with P4HB included in the procedure. Photographic measurements were taken to determine the extent of lower pole descent and lower pole stretch at 3 months and 1 year postoperative to observe change over time. Secondly, other indications were explored, including the correction of secondary defects such as inferior malposition and symmastia.

RESULTS

The results of the mastopexy study were highly encouraging and comparable with those previously published in the literature, confirming sustained stability of the lower pole over time for mastopexies and implant mastopexies. In addition, the GalaFLEX was successfully employed in correcting many secondary defects.

CONCLUSIONS

P4HB is extremely versatile and easy to utilize and has low complication rates. The results have led to a change in practice, with routine incorporation of GalaFLEX for all routine mastopexies. It has also replaced the utilization of acellular dermal matrices in aesthetic breast surgery.

LEVEL OF EVIDENCE: 4

Synthetic Reabsorbable Mesh (GalaFLEX) as Soft Tissues Adjunct in Breast Augmentation Revision Surgery

BACKGROUND

A significant number of patients with a previous submuscular breast augmentation require a revision surgical procedure during their long-term follow-up period that involves implant pocket change from submuscular to subglandular. Reduced soft tissues thickness represent a major concern that would discourage surgeon to undertake this approach.

OBJECTIVES

The authors sought to determine whether a synthetic resorbable mesh use as supplemental covering device was safe and yielded improved soft tissues thickness and protection against capsular contracture in patients that undergo implant plane shift to subglandular.

METHODS

A retrospective review of 34 patients who underwent revision of a previous breast augmentation involving implant change in a subglandular pocket and upper pole GalaFLEX (Galatea Surgical, Lexington, MA, USA) mesh coverage was conducted. Minor and major complications onset were recorded during short and medium-term follow-up. Patient satisfaction was assessed via an anonymous questionnaire administered 6 months postoperatively.

RESULTS

During our follow-up period that ranged from a minimum of 6 months to a maximum of 28 months we did not report minor or major complications. In particular we did not observe wrinkling/rippling or significant capsular contracture onset. High levels of patients' satisfaction were determined, according to self-reporting questionnaires.

CONCLUSIONS

Initial results of this preliminary report from our case series demonstrate the safety of GalaFLEX as supplemental device in terms of improved soft tissue coverage of the implant for complex revisional cases in breast augmentation.

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

BACKGROUND

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

OBJECTIVES

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

LEVEL OF EVIDENCE: 4

The Use of Anatomic Implants in Aesthetic Breast Surgery

Anatomic implants were introduced in the late 1980s, gaining popularity through the 1990s and beyond. The moratorium on silicone meant that the use of theses devices was less diffuse in the US and has remained so. Fifth-generation devices had improved form stability with more aggressive texturization to enhance soft tissue interaction. The ability to vary height, width and projection independently creates much versatility in their use for complex anatomical situations producing natural results. The impact of BIA-ALCL has had a significant impact on their use.

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 .

The Influence of Effective Analgesia and General Anaesthesia on Patients' Acceptance of Day Case Varicose Vein Surgery

Objective:

To assess the efficacy of locoregional anaesthesia and non-opiate analgesia in controlling pain after varicose vein surgery. To examine patient attitudes to day case surgery for this condition.

Design:

Prospective single patient group study (22 consecutive patients).

Setting:

University College Hospital (Teaching Hospital).

Intervention:

Locoregional and general anaesthesia. Non-opiate analgesia. Surgical treatment for varicose

Main outcome measures:

Patient interview, pain scores, analgesia requirement.

Result:

Post operative Pain was absent in 36% during the first 24 hours. Oral analgesia was given to 36% as inpatients but only 18% after discharge. Before surgery, 95% would have preferred DCS but only 24% at six months. The after-effects of general anaesthesia was the main reason for this change in attitude.

Conclusions:

Patients would like day case surgery for varicose veins but anaesthesia and analgesia must be satisfactory.

The dermal tube: a versatile tool in scar revision

INTRODUCTION AND AIMS

Tethered scars are a common problem that can have functional and aesthetic consequences. Several approaches which use the dermis have been described for tethered scar correction. The objective of this report is to demonstrate the superior aesthetic outcomes achieved through the introduction of a new, simple dermal technique in scar revision surgery.

MATERIALS AND METHODS

From August 2002 through to January 2006, 35 patients were operated on by the senior author for revision of tethered, sunken scars. All scars were considered to demonstrate sunken or depressed characteristics based upon clinical examination and photographic evidence. All patients were operated on by the same surgeon and using the same surgical technique.

KEY RESULTS

All the patients were women (age range 17-64 years), with tethered scars affecting the breast (n=10), lower limb (n=5), upper limb (n=6), chest wall (n=4), laparotomy scars (n=8) and tracheotomy scars (n=2). Scars ranged in length from 4 to 30 cm (mean=12 cm). Follow up ranged from 2 to 24 months (median=16 months). At the 12 month follow up, patients were presented with their pre- and postoperative photos and asked to select the overall improvement in aesthetic appearance achieved as either: 'no improvement', 'improved' or 'marked improvement'. These were then ranked to scores of 0, 1 and 2, respectively (0=no improvement; 1=improved and 2=marked improvement). The responses from the questionnaire showed that the median score was 2 with 100% ranking >or=1. Thirty-two patients (91.4%) scored 2. There were no complications reported and the results at 12 months showed that restoration of volume to the scars had been maintained in all patients. To date, no one has had to undergo further revision and there have been no incidences of re-tethering.

CONCLUSION

The technique is simple to learn by even junior surgeons. Through following four distinct steps consistent and readily reproducible results are achieved.

The differential fascial glide: A technical refinement in abdominoplasty

Body contour surgery is in continuous evolution in an attempt to offer better aesthetic results. With greater understanding of the superficial fascial system of the trunk, various suspension procedures have been devised which use the fascial system as an adjunct to complement traditional abdominoplasty techniques. We present a simple technical refinement to the traditional abdominoplasty which uses the superficial fascial system to tighten the flanks and concomitantly shortens the final scar: the differential fascial glide. In this technique the superficial fascia is dissected as a separate layer from the abdominal flap and suspended in an oblique direction towards the midline whilst the abdominal flap is pulled in a downward and lateral direction, thus creating two opposing vectors of pull. This simple technique results in improved flank contour and a shorter scar in patients undergoing classic abdominoplasty.

Closure of elective skin defects in the leg with a fasciocutaneous V-Y island flap

Skin defects in the leg can be among the most difficult to cover. Split skin grafting of such defects can be complicated by delayed healing and poor cosmesis and this has led to the description of several local flap techniques. Here a technique of V-Y flap closure is described based laterally on a random fascial pedicle. Twenty patients aged from 51 to 85 years had flaps for skin closure after excision of skin tumours, 17 of them in the middle or lower third of the leg. All but one were performed under local anaesthetic, seven as day cases and eight with an overnight stay. No patient was excluded because of medical conditions or skin quality and two patients had significant lymphoedema. A single V-Y flap was used in each case and was found to have much greater mobility than previously described similar flaps. Cosmetic results, and in particular contour preservation, were found to be excellent. There were no complete flap losses but four patients had delayed healing, two related to partial flap necrosis. Four patients had wound infections, one requiring readmission for intravenous antibiotics but no patient had further surgery. The fasciocutaneous V to Y island flap was found to be a very satisfactory method of wound closure in the leg with an acceptable complication rate and excellent cosmetic results.

Fibrolipoma of the median nerve

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