Objective Comparison of Commercially Available Breast Implant Devices

A Propensity Score-Matched Comparison of Perioperative Outcomes in Prepectoral Smooth Versus Textured Tissue Expander Breast Reconstruction

INTRODUCTION

Textured tissue expanders (TEs) had previously gained popularity due to minimizing expander migration, rotation, and capsule migration. Recent studies, though, have revealed increased risk of anaplastic large-cell lymphoma associated with certain macrotextured implants, prompting surgeons at our institution to switch to smooth TEs; evaluation is thus required for specific viability and similarity of outcomes of smooth TEs. Our study aims to evaluate perioperative complications in prepectoral placement of smooth versus textured TEs.

METHODS

Our retrospective study evaluated perioperative outcomes of patients who underwent bilateral prepectoral TE placement, with either smooth or textured TE, at an academic institution between 2017 and 2021 performed by 2 reconstructive surgeons. The perioperative period was defined as the interval between expander placement until conversion to flap/implant or removal of TE due to complications. Our primary outcomes included hematoma, seroma, wounds, infection, unspecified redness, total number of complications, and returns to operating room secondary to complications. Secondary outcomes included time to drain removal, total number of expansions, hospital length of stay, length of time until the next breast reconstruction procedure, next breast reconstruction procedure, and number of expansions.

RESULTS

Two hundred twenty-two patients were evaluated in our study (141 textured, 81 smooth). After propensity matching (71 textured, 71 smooth), our univariate logistic regression showed no significant difference in perioperative complications between smooth and textured expanders (17.1% vs 21.1%; P = 0.396) or complications that required a return to the operating room (10.0% vs 9.2%; P = 0.809). No significant differences were noted for hematoma, seroma, infections, unspecified redness, or wounds between both groups. A significant difference was noted in days to drain out (18.57 ± 8.17 vs 20.13 ± 0.07, P = 0.001) and type of the next breast reconstruction procedure (P < 0.001). Our multivariate regression showed that breast surgeon, hypertension, smoking status, and mastectomy weight were significant for increased risk for complications.

CONCLUSION

Our study demonstrates similar rates and effectiveness of smooth versus textured TE when used for prepectoral placement, making smooth TEs a safe and valuable alternative for breast reconstruction because of their decreased risk of anaplastic large-cell lymphoma compared with textured TEs.

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

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

What are the likely causes of Breast Implant Associated Anaplastic Large Cell Lymphoma (BIA-ALCL)?

Breast implant-associated anaplastic large cell lymphoma (BIA-ALCL) is a CD30-positive, anaplastic lymphoma kinase-negative T-cell lymphoma. Where implant history is known, all confirmed cases to date have occurred in patients with exposure to textured implants. The etiopathogenesis of BIA-ALCL is likely to be multifactorial, with current evidence-based theories recognising the combination of chronic infection in setting of textured implants, gram-negative biofilm formation, chronic inflammation, host genetics (e.g. JAK/STAT, p53) and time in tumorigenesis. Proposed triggers for the development of malignancy are mechanical friction, silicone implant shell particulates, silicone leachables and bacteria. Of these, the bacterial hypothesis has received significant attention, supported by a plausible biological model. In this model, bacteria form an adherent biofilm in the favourable environment of the textured implant surface, producing a bacterial load that elicits a chronic inflammatory response. Bacterial antigens, primarily of gram-negative origin, may trigger innate immunity and induce T-cell proliferation with subsequent malignant transformation in genetically susceptible individuals. Future research, investigating BIA-ALCL genetic mutations and immunological modulation with Gram-negative biofilm in BIA-ALCL models is warranted to establish a unifying theory for the aetiology of BIA-ALCL.

Trends in Breast Augmentation Research: A Bibliometric Analysis

BACKGROUND

Breast augmentation is one of the most demanded procedures in plastic surgery and one of the most commonly performed by plastic surgeons. However, a bibliometric analysis of breast augmentation has not been published in recent years. The current study aimed to use a bibliometric analysis to conduct a qualitative and quantitative evaluation of breast augmentation research and provide the research trends and hotspots in this field.

METHODS

Publications on breast augmentation research were extracted from the Web of Science core collection database. VOSviewer 1.6.18 was used to assess co-authorship, co-occurrence, citation of countries, institutions, authors, and journals, as well as hotspot keywords.

RESULTS

On February 8, 2022, 4637 records of breast augmentation research published from 1985 to 2021 were collected. The bulk of the retrieved studies were original research articles (n = 2235, 48.20%). A total of 1053 (22.71%) papers were open access. The annual publication output increased annually. The USA was the driving force in this field and had a strong academic reputation. The top-contributing institution was the University of Texas MD Anderson Cancer Center (2.37%, with 110 publications). Plastic and reconstructive surgery (998 publications, 21.52%) published the most research in this field and was also the most frequently co-cited journal (22,351 citations, total link strength (TLS): 409,301). Clemens MW (68 publications, 1.47%) was the most prolific author, and Spear SL (1456 citations, TLS: 27,231) was the most frequently co-cited author. The research hotspots included the following four aspects: safety and effectiveness of breast implants, implant-based breast reconstruction, breast cancer incidence after breast implantation, and breast implant-associated anaplastic large-cell lymphoma (BIA-ALCL). The research trends were BIA-ALCL, implant-based breast reconstruction, BREAST-Q, acellular dermal matrix, capsular contracture, and autologous fat grafting.

CONCLUSION

The present study provides a panoramic view of breast augmentation research in plastic and reconstructive surgery. This novel comprehensive bibliometric analysis can help researchers and nonresearchers alike to rapidly identify the potential partners, research hotspots, and research trends within their areas of interest.

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 .

Objective Comparison of FDA-Approved Breast Implant Products in the USA: 5-Year Update

BACKGROUND

There are currently four companies offering FDA-approved breast implants: Allergan, Sientra, Mentor, and Ideal Implant. In 2015, our paper "Objective Comparison of Commercially Available Breast Implant Devices" sought to provide a unique conceptual framework to better understand the similarities and differences between FDA-approved breast implant products and tissue expanders. This paper uses the same variables, such as fill material, shape, relative dimensions, and surface coating, to aid understanding of both the surgical trainee and the operating surgeon of what devices each company offers, with a focus on how the market has evolved over the ensuing 5 years.

METHODS

The product catalogs of each FDA-approved company were carefully explored to determine the current available breast implants and tissue expanders. Subsequently, flow charts were created to provide a clear and objective survey of each companies' offerings, highlighting where there are overlap and deficiencies, and where there has been contraction or growth.

RESULTS

Disruptions to the industry, including both technological innovation and the recognition of breast implant-associated anaplastic large cell lymphoma (BIA-ALCL), have caused a significant shift in the details of the available permanent breast implants, breast tissue expanders, sizers, and warranty programs.

CONCLUSION

As it has been in 2015, company jargon and brand names continue to make it challenging to discern the similarities and differences between company devices and programs. This project remained independent of any company's funding, support, or input, making it a uniquely objective and informative survey of the current breast implant market that should assist surgeons in decision-making regarding the breast implant procedures.

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 .

Breast Implant-Associated Anaplastic Large Cell Lymphoma With Invasive Chest Wall Masses

BACKGROUND

Breast implant-associated anaplastic large-cell lymphoma (BIA-ALCL) might occur in any patient with a history of textured breast devices, and often presents as a spectrum of disease: from a simple late-onset seroma, to complex advanced locally aggressive disease with chest wall involvement. The combination of medical therapy and surgical implant removal with complete capsulectomy is believed to be curative.

OBJECTIVES

In patients with advanced cases, however, and although generalized recommendations exist, no consensus exists regarding the ideal medical and surgical management of those presenting with invasive disease.

METHODS

This preliminary report describes 2 distinct presentations of rare invasive chest wall BIA-ALCL, both treated successfully, by using a combined medical and surgical multidisciplinary team approach. Subsequently, we discuss considerations and the current literature surrounding the treatment of advanced BIA-ALCL with chest wall and adjacent structure involvement.

RESULTS

All patients necessitated chest wall resection and composite reconstruction due to tumor involvement of the thorax with residual hypermetabolic activity, despite chemotherapeutic pretreatment with different neoadjuvant medical therapies. All healed well after surgery and experienced resolution of symptoms without signs of relapse on regular follow-up.

CONCLUSIONS

In the rare subset of patients presenting with invasive BIA-ALCL, the question persists as to which systemic treatment remains optimal. However, the evidence supports multiple, particularly in combination with surgical extirpation and reconstruction. Here we present 2 proven treatments, both in timing and modalities chosen, as part of the first step to establish a formally accepted treatment paradigm for advanced BIA-ALCL patients with invasive chest wall involvement.

Judging an Expander by Its Cover: A Propensity-Matched Analysis of the Impact of Tissue Expander Surface Texture on First-Stage Breast Reconstruction Outcomes

BACKGROUND

There is increased scrutiny of texturing on implants and a paucity of data looking at texturing on expanders. Because of the difficulty in controlling potential confounders with these comparative studies, the authors performed propensity matching between smooth and textured tissue expander cohorts to provide definitive insight into the impact of expander texture on breast reconstruction outcomes.

METHODS

A single-surgeon experience with immediate two-stage breast reconstruction was reviewed for 90-day postoperative complications after mastectomy and expander placement. Variables extracted included demographics, comorbidities, tissue expander texturing, mastectomy type, infection, seroma, skin flap necrosis, dehiscence, explantation, and overall complication rates. Subjects were 1:1 propensity matched using the nearest neighbor matching algorithm with caliper (maximum propensity score difference) of 0.2, and chi-square test was performed for statistical analysis.

RESULTS

After 1:1 propensity matching, 282 reconstructed breasts were analyzed (141 textured versus 141 smooth expanders). Textured expanders had higher minor infection rates than smooth expanders (5.0 percent versus 0 percent; p = 0.024). Smooth expanders had higher seroma rates than textured expanders (5.0 percent versus 0.7 percent; p = 0.031). Smooth expanders also had longer drain retention (20.4 days versus 16.8 days; p = 0.001). There was no difference in other complications, including major infection, explantation, or any complication, between textured and smooth expanders.

CONCLUSIONS

Textured expanders are associated with increased minor infection risk, whereas smooth expanders are associated with increased seroma formation. However, these differing complication profiles coalesce to equal explantation rates.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Therapeutic, III.

Examining the Post-operative Well-Being of Women Who Underwent Mammoplasty: A Cross-Sectional Study

Background: Mammoplasty is the most common surgery used for breast augmentation (aesthetic plastic) and breast reconstruction (disease-related plastic) in women who have been diagnosed with and surgically treated for regional breast cancer with modified radical mastectomy. This study aims to examine the long-term effects of mammoplasty on the psychological well-being of women. Methods: Participants were 44 women aged 30-50 years (mean = 40.4 ± 5.9). They were divided into two groups based on the purpose of the breast surgery they underwent [augmentation surgery (AS) vs. reconstruction surgery (RS)] and the time that had elapsed since their surgery (≤3 vs. >3 years). Results: Our findings suggest that women who underwent AS reported a decline in their psychological well-being over time. The women who had undergone AS ≤3 and >3 years did not show any differences in emotional functioning, with the exception of the BREAST-Q scores on the satisfaction with breasts subscale. We examined the impact of mammoplasty on the satisfaction levels and well-being of women who had undergone RS (after MRM). They were less satisfied with their breasts than those who belonged to the AS group, confirming our hypothesis. However, this was true only among those who had undergone surgery ≤3 years earlier. Conclusions: In conclusion, our findings underscore the need to provide psychological support to those who have undergone breast AS and RS. Additionally, this study implies the need for personalized psychological interventions to improve the emotional adaptation process and enhance women's mental well-being.

Advances and current concepts in reconstructive surgery for breast cancer

In this article, we report on recent advancements in reconstructive care of the breast cancer patient. New developments in sensate breast reconstruction to help address the problem of numbness after mastectomy have emerged and show promise. Methods to restore lymphatic physiologic flow after axillary lymphadenectomy using supermicrosurgical techniques have begun to show benefit by reducing the short-term incidence of breast cancer related lymphedema (BRCL). Breast implant safety has received significant recent attention and we explore the emergence of BIA-ALCL (Breast Implant Associated Anaplastic Large Cell Lymphoma) and its implications for the breast cancer patient and their multidisciplinary care team.

Short-term Safety of a Silicone Gel-filled Breast Implant: A Manufacturer-sponsored, Retrospective Study

Currently, 8 different brands of a silicone gel–filled breast implant are commercially available in Korea. But the superiority of short-term safety has not been established.

Mastopexy Autoaugmentation by Using Vertical and Triangular Flaps of Mammary Parenchyma Through a Vertical Ice Cream Cone-Shaped Approach

BACKGROUND

Mastopexy autoaugmentation by using an extended vertical flap and two transverse triangular flaps of mammary parenchyma was performed through an adjustable vertical ice cream cone-shaped approach.

METHOD

A vertical rectangular flap with the length of the inferior pole and thickness of the mammary parenchyma was supported at the inframammary fold. Dissection of the vertical flap was extended underneath the areola until the projection of its upper limit, adding 4-5 cm to the length of the vertical flap. A triangular flap supported on its lower half with 4-6 cm long and thickness of the vertical pillar was dissected on both vertical pillars. Patients were followed up for 2 years.

RESULTS

The vertical rectangular flap filled the upper pole and central breast. The triangular flaps apart from filling the lower pole increased the mammary cone projection. The medial rotation advancement of the triangular flaps created a transverse support girdle at the lower pole, maintaining the vertical flap into position. In addition, fixation of the vertical flap along its entire length avoided long-term down-displacement of the breast. A keel resection of mammary parenchyma was performed in the larger breast in mild or moderate asymmetries.

CONCLUSION

Mastopexy autoaugmentation through an adjustable vertical approach using vertical and triangular flaps of mammary parenchyma filled the upper pole and central breast and reshape the lower pole, recovering the breast contour. It provided long-term stabilization of the mammary cone without a breast implant or fat transfer.

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 .

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

BACKGROUND

With breast implant-associated anaplastic large cell lymphoma (BIA-ALCL) now accepted as a unique (iatrogenic) subtype of ALCL directly associated with textured breast implants, we are now at a point where a sound epidemiologic profile and risk estimate are required. The aim of this article is to provide a comprehensive and up-to-date global review of the available epidemiologic data and literature relating to the incidence, risk, and prevalence of BIA-ALCL.

METHODS

All current literature relating to the epidemiology of BIA-ALCL was reviewed. Barriers relating to sound epidemiologic study were identified, and trends relating to geographical distribution, prevalence of breast implants, and implant characteristics were analyzed.

RESULTS

Significant barriers exist to the accurate estimate of both the number of women with implants (denominator) and the number of cases of BIA-ALCL (numerator), including poor registries, underreporting, lack of awareness, cosmetic tourism, and fear of litigation. The incidence and risk of BIA-ALCL have increased dramatically from initial reports of 1 per million to current estimates of 1/2,832, and is largely dependant on the "population" (implant type and characteristics) examined and increased awareness of the disease.

CONCLUSIONS

Although many barriers stand in the way of calculating accurate estimates of the incidence and risk of developing BIA-ALCL, steady progress, international registries, and collegiality between research teams are for the first time allowing early estimates. Most striking is the exponential rise in incidence over the last decade, which can largely be explained by the increasingly specific implant subtypes examined-driven by our understanding of the pathologic mechanism of the disease. High-textured high-surface area implants (grade 4 surface) carry the highest risk of BIA-ALCL (1/2,832).

Clinical Results on Innovation in Breast Implant Design

Breast implants have been shadowed in controversy since their introduction to the market; however, they represent a multi-million dollar industry and play a critical role both for cosmetic augmentation and enhancement and for reconstruction following treatment for cancer. With advancements in technology, breast implants have evolved tremendously over the years. Further, with the cessation of the FDA implemented moratorium on silicone, the use of silicone implants has grown exponentially over the years. Novel designs in the outer shell, breast implant fill particularly the cohesivity of the silicone gel, texturing of the outer shell, and the shape and projection of breast implants have produced a broad array of implants that can be employed by plastic and reconstructive surgeons to maximize outcomes for patients. However, despite the innovations in breast implant design and engineering, it is unclear whether these have had any influence on outcomes and patient satisfaction. The present article aims to provide a comprehensive review of the technological advancements in breast implant technology in optimizing patient outcomes and minimizing complications associated with placement of breast implants for aesthetic as well as reconstructive procedures. The article will provide a synopsis of round versus shaped breast implants, saline versus silicone especially the advent of cohesive silicone gel implants, and the texturing of the outer shell, and how each of these components should be considered when counseling patients and deciding which implants offer the optimal benefits for each individual patient.

The A, B and C's of Silicone Breast Implants: Anaplastic Large Cell Lymphoma, Biofilm and Capsular Contracture

Breast implantation either for cosmetic or reconstructive e purposes is one of the most common procedures performed in plastic surgery. Biofilm infection is hypothesised to be involved in the development of both capsular contracture and anaplastic large cell lymphoma (ALCL). Capsular contracture is one of the principal reasons for breast revision surgery and is characterised by the tightening and hardening of the capsule surrounding the implant, and ALCL is an indolent lymphoma found only in women with textured implants. We describe the types of breast implants available with regard to their surface characteristics of surface area and roughness and how this might contribute to capsular contracture and/or biofilm formation. The pathogenesis of capsular contracture is thought to be due to biofilm formation on the implant, which results in on-going inflammation. We describe the current research into breast implant associated ALCL and how implant properties may affect its pathogenesis, with ALCL only occurring in women with textured implants.

The Diagon/Gel Implant: A Preliminary Report of 894 Cases

The breast has always been perceived as the emblem of femininity. Desire of having an ideal breast form has been of interest for a long time.

METHODS

This preliminary article is a retrospective analysis of 894 cases of breast augmentation with Diagon/Gel breast implants covered with a micropolyurethane foam (Microthane). The surgical technique employed is a modified dual plane, which enables us to use a new anatomical implant to move the glandular parenchyma into a higher position.

RESULTS

The study extended from January 2010 to September 2015, during which no breast implant developed Baker grade III or IV capsular contracture (CC) and only a few adverse events occurred. Patients reported to be highly satisfied with the final outcome, which was very natural both in the form and movement.

CONCLUSIONS

The new concept of Diagon/Gel represents the next step in the evolutionary progress of breast implants and allows the surgeon to perform not only a breast augmentation but also parenchymal elevation, which otherwise would have required a mastopexy, and we have called it breast enhancement.