The Evolution of Breast Implants

Stiffness and surface topology of silicone implants competitively mediate inflammatory responses of macrophages and foreign body response

Adverse inflammatory responses, dominated by macrophages, that are induced by physical cues of silicone implants can heavily damage the life quality of patients via causing fibrosis and device failure. As stiffness and surface topology affect macrophages at the same time, the competition or partnership among physical cues against the regulation of macrophages is still ambiguous. Herein, a series of PDMS implants with different stiffness at ∼ MPa and surface topology at tens of micrometers were fabricated to investigate the relationship, the regulation rule, and the underlying mechanism of the two physical cues against the inflammatory responses of M1 macrophages. There is a competitive rule: surface topology could suppress the inflammatory responses of M1 macrophages in the soft group but did not have the same effect in the stiff group. Without surface topology, lower stiffness unexpectedly evoked stronger inflammatory responses of M1 macrophages. Implanting experiments also proved that the competitive state against mediating in vivo immune responses and the unexpected inflammatory responses. The reason is that stiffness could strongly up-regulate focal adhesion and activate the MAPK/NF-κB signaling axis to evoke inflammatory responses, which could shield the effect of surface topology. Therefore, for patient healthcare, it is crucial to prioritize stiffness while not surface topology at MPa levels to minimize adverse reactions.

Updates on Breast Reconstruction: Surgical Techniques, Challenges, and Future Directions

The increasing global incidence of breast cancer underscores the significance of breast reconstruction in enhancing patients' quality of life. Breast reconstruction primarily falls into two categories: implant-based techniques and autologous tissue transfers. In this study, we present a comprehensive review of various aspects of implant-based reconstruction, including different types of implants, surgical techniques, and their respective advantages and disadvantages. For autologous breast reconstruction, we classified flaps and optimal harvest sites and provided detailed insights into the characteristics, benefits, and potential complications associated with each flap type. In addition, this review explores the emerging role of fat grafting, which has received increasing attention in recent years. Despite advancements, there remains substantial scope for further improvements in breast reconstruction, emphasizing not only aesthetic outcomes, but also a reduction in complications and postoperative recovery. By offering a comprehensive overview of the historical evolution, current landscape, and future prospects of breast reconstruction, this review aims to provide readers with a comprehensive understanding of breast cancer management strategies.

Advancements in Aesthetic Breast Augmentation: Evaluating the Safety, Efficacy, and Naturalistic Outcomes of Ergonomix2 Implants

BACKGROUND

This pioneering study evaluates the safety, efficacy, and Aesthetic outcomes of Ergonomix2 Motiva Ergonomic Implants in breast augmentation. It aims to assess their capability to offer more natural touch and dynamics, delineate the learning curve for surgical techniques, and examine their safety profile compared to Ergonomix1 implants.

MATERIALS AND METHODS

A prospective cohort study was conducted, comparing 31 patients who received Ergonomix2 implants with a control group of 51 patients with Ergonomix1 implants. Eligible patients were those seeking Aesthetic breast augmentation without prior surgeries or chronic illnesses. Detailed documentation of surgical techniques, implant characteristics, and patient demographics was performed. The study assessed surgical learning curve, implant positioning accuracy, and short-term and early complications. Aesthetic outcomes were evaluated using the BreastQ questionnaire and quantitative elastography.

RESULTS

Patients with Ergonomix2 implants showed significant improvements in Aesthetic outcomes, including breast contour symmetry and natural feel. The learning curve demonstrated a decrease in surgical time and higher implant positioning accuracy. The safety profile was favorable, with a low complication rate and high patient satisfaction levels. Ergonomix2 implants exhibited enhanced softness and pliability, closely mimicking natural breast tissue, as confirmed by elastographic analyzes.

CONCLUSIONS

Ergonomix2 implants represent a significant advancement in Aesthetic breast surgery, offering natural-feeling and dynamically adaptable outcomes. Despite the promising results, the need for specialized surgical techniques and further research on long-term safety and efficacy is emphasized. This study contributes foundational knowledge to the field of ergonomic breast implants and their application in modern plastic surgery.

LEVEL OF EVIDENCE II

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 .

Silicon-containing nanomedicine and biomaterials: materials chemistry, multi-dimensional design, and biomedical application

The invention of silica-based bioactive glass in the late 1960s has sparked significant interest in exploring a wide range of silicon-containing biomaterials from the macroscale to the nanoscale. Over the past few decades, these biomaterials have been extensively explored for their potential in diverse biomedical applications, considering their remarkable bioactivity, excellent biocompatibility, facile surface functionalization, controllable synthesis, etc. However, to expedite the clinical translation and the unexpected utilization of silicon-composed nanomedicine and biomaterials, it is highly desirable to achieve a thorough comprehension of their characteristics and biological effects from an overall perspective. In this review, we provide a comprehensive discussion on the state-of-the-art progress of silicon-composed biomaterials, including their classification, characteristics, fabrication methods, and versatile biomedical applications. Additionally, we highlight the multi-dimensional design of both pure and hybrid silicon-composed nanomedicine and biomaterials and their intrinsic biological effects and interactions with biological systems. Their extensive biomedical applications span from drug delivery and bioimaging to therapeutic interventions and regenerative medicine, showcasing the significance of their rational design and fabrication to meet specific requirements and optimize their theranostic performance. Additionally, we offer insights into the future prospects and potential challenges regarding silicon-composed nanomedicine and biomaterials. By shedding light on these exciting research advances, we aspire to foster further progress in the biomedical field and drive the development of innovative silicon-composed nanomedicine and biomaterials with transformative applications in biomedicine.

The Incidence and Outcomes of Breast Implants Among 1696 Women over more than 50 Years

OBJECTIVE

To investigate the incidence of women with breast implants in 1964-2017 MATERIALS AND METHODS: All women with breast implants in Olmsted County, MN between January 1, 1992 and December 31, 2017 were identified, and a comprehensive review of individual medical records was performed, adding to a previously identified cohort of women with breast implants in 1964-1991. Incidence rates were calculated and were age- and sex-adjusted to the US white female 2010 population.

RESULTS

In 1992-2017, 948 women with breast implants were identified, totaling 1696 Olmsted County, MN women with breast implants in 1964-2017. Overall incidence was 63.3 (95% CI 60.2-66.4) per 100,000 women, but incidence varied significantly over time. Women in 1964-1991 were more likely to have implants for cosmetic reasons and more likely to have silicone implants compared to the 1992-2017 cohort. The overall standardized mortality ratio was 1.17 (95% CI 0.99-1.38) in 1964-1991 and 0.94 (95% CI 0.66-1.29) in 1992-2017. In 1992-2017, breast reconstruction patients had a significantly elevated risk of implant rupture and implant removal versus breast augmentation patients.

CONCLUSION

The incidence of breast implants among women in Olmsted County, MN has varied drastically over the past five decades, with significant changes in the trends for implant type and reason. The findings of this study may provide further insight regarding how risks associated with implants may vary over time.

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 .

Surgical and Patient-Reported Outcomes of 694 Two-Stage Prepectoral versus Subpectoral Breast Reconstructions

BACKGROUND

Opinion regarding the optimal plane for prosthetic device placement in breast reconstruction patients has evolved. The purpose of this study was to assess the differences in complication rates and patient satisfaction between patients who underwent prepectoral and subpectoral implant-based breast reconstruction (IBR).

METHODS

The authors conducted a retrospective cohort study of patients who underwent two-stage IBR at their institution from 2018 to 2019. Surgical and patient-reported outcomes were compared between patients who received a prepectoral versus a subpectoral tissue expander.

RESULTS

A total of 694 reconstructions in 481 patients were identified (83% prepectoral, 17% subpectoral). The mean body mass index was higher in the prepectoral group (27 versus 25 kg/m 2 , P = 0.001), whereas postoperative radiotherapy was more common in the subpectoral group (26% versus 14%, P = 0.001). The overall complication rate was very similar, with 29.3% in the prepectoral and 28.9% in the subpectoral group ( P = 0.887). Rates of individual complications were also similar between the two groups. A multiple-frailty model showed that device location was not associated with overall complications, infection, major complications, or device explantation. Mean scores for Satisfaction with the Breast, Psychosocial Well-Being, and Sexual Well-Being were similar between the two groups. Median time to permanent implant exchange was significantly longer in the subpectoral group (200 versus 150 days, P < 0.001).

CONCLUSION

Prepectoral breast reconstruction results in similar surgical outcomes and patient satisfaction compared with subpectoral IBR.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Therapeutic, III.

Impact of Obesity on Outcomes of Prepectoral vs Subpectoral Implant-Based Breast Reconstruction

BACKGROUND

The impact of obesity on outcomes of prepectoral vs subpectoral implant-based reconstruction (IBR) is not well-established.

OBJECTIVES

The goal of this study was to assess the surgical and patient-reported outcomes of prepectoral vs subpectoral IBR. The authors hypothesized that obese patients would have similar outcomes regardless of device plane.

METHODS

We conducted a retrospective review of obese patients who underwent 2-stage IBR from January 2017 to December 2019. The primary endpoint was the occurrence of any breast-related complication; the secondary endpoint was device explantation.

RESULTS

The authors identified a total of 284 reconstructions (184 prepectoral, 100 subpectoral) in 209 patients. Subpectoral reconstruction demonstrated higher rates of overall complications (50% vs 37%, P = .047) and device explantation (25% vs 12.5%, P = .008) than prepectoral reconstruction. In multivariable regression, subpectoral reconstruction was associated with higher risk of infection (hazard ratio [HR], 1.65; P = .022) and device explantation (HR, 1.97; P = .034). Subgroup analyses demonstrated significantly higher rates of complications and explantation in the subpectoral group in those with a body mass index (BMI) ≥ 35 and BMI ≥40. The authors found no significant differences in mean scores for satisfaction with the breast (41.57 ± 13.19 vs 45.50 ± 11.91, P = .469), psychosocial well-being (39.43 ± 11.23 vs 39.30 ± 12.49, P = .915), and sexual well-being (17.17 ± 7.83 vs 17.0 ± 9.03, P = .931) between subpectoral and prepectoral reconstruction.

CONCLUSIONS

Prepectoral reconstruction was associated with significantly decreased overall complications, infections, and device explantation in obese patients compared with subpectoral reconstruction. Prepectoral reconstruction provides superior outcomes to subpectoral reconstruction with comparable patient-reported outcomes.

LEVEL OF EVIDENCE: 4

Advances on Capsular Contracture-Prevention and Management Strategies: A Narrative Review of the Literature

Capsular contracture (CC) is the most relevant complication of both aesthetic and reconstructive breast implant surgery. For many years, experimental and clinical trials have attempted to analyze CC risk factors, clinical features, and appropriate management strategies. It is commonly accepted that a multifactorial etiology promotes CC development. However, the heterogeneity in patients, implants and surgical techniques make it difficult to suitably compare or analyze specific factors. As a consequence, discordant data are present in literature, and a true systematic review is often limited in its conclusions. Hence, we decided to present a comprehensive review of current theories on prevention and management strategies, rather than a specific "solution" to this complication.

Methods

The PubMed database was searched for literature regarding CC prevention and management strategies. Pertinent articles in English, published before December 1, 2022, were compared with selection criteria and eventually included in this review.

Results

Through the initial search, 97 articles were identified, of which 38 were included in the final study. Several articles explored different medical and surgical preventive and therapeutic strategies, showing numerous controversies on appropriate CC management.

Conclusions

This review provides a clear overview of the complexity of CC. The wide variety of clinical situations in term of patients, implants, and surgical techniques prevent the standardization of CC management strategies. By contrast, a patient-customized approach should be preferred, and different strategies should be considered depending on the specific case. Further research is desirable to better ascertain evidence-based protocols with regard to CC prevention and treatment.

Nagor Impleo Round Silicone Gel Breast Implants: Early Outcome Analysis after 340 Primary Breast Augmentations

For decades, implant-based breast augmentation has been one of the most performed surgical procedures for cosmetic purposes around the world. Hence, novel manufactured implants should be critically investigated to prove them safe and effective. Here, the authors describe the first independently conducted clinical study on Nagor Impleo textured round breast implants. For this retrospective study, outcomes of 340 consecutive female patients undergoing primary cosmetic breast augmentation were analyzed. Demographic and surgical data as well as outcomes and complications were evaluated. Furthermore, a survey concerning effectiveness and aesthetic satisfaction after breast augmentation was examined. All 680 implants were placed in a submuscular plane with incisions at the inframammary fold. The main indications for surgery were hypoplasia and hypoplasia with asymmetry. The mean implant volume was 390 cc and the main type of projection was high profile. The most common complications were hematoma and capsular contracture (0.9 percent, respectively). The overall revision rate for complications was 2.4%. Additionally, almost all patients showed increased quality of life and aesthetic satisfaction after a breast augmentation. Hence, all patients would undergo breast augmentation again with these newly launched devices. Nagor Impleo implants demonstrate a low complication rate and high safety profile. Although high aesthetic satisfaction and quality of life results were achieved, analysis of an even larger series over a longer period of time would be beneficial to evaluate the reliability of this implant.

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 .

The surface topography of silicone breast implants mediates the foreign body response in mice, rabbits and humans

Silicone is widely used in chronic implants and is generally perceived to be safe. However, textured breast implants have been associated with immune-related complications, including malignancies. Here, by examining for up to one year the foreign body response and capsular fibrosis triggered by miniaturized or full-scale clinically approved breast implants with different surface topography (average roughness, 0-90 μm) placed in the mammary fat pads of mice or rabbits, respectively, we show that surface topography mediates immune responses to the implants. We also show that the surface surrounding human breast implants collected during revision surgeries also differentially alters the individual's immune responses to the implant. Moreover, miniaturized implants with an average roughness of 4 μm can largely suppress the foreign body response and fibrosis (but not in T-cell-deficient mice), and that tissue surrounding these implants displayed higher levels of immunosuppressive FOXP3⁺ regulatory T cells. Our findings suggest that, amongst the topographies investigated, implants with an average roughness of 4 μm provoke the least amount of inflammation and foreign body response.

Biofilm Formation on Breast Implant Surfaces by Major Gram-Positive Bacterial Pathogens

BACKGROUND

Bacterial biofilm on surfaces of mammary implants is a predisposing factor for several outcomes. Because Gram-positive bacteria are potential agents of biomaterial-associated infections (BAIs), their abilities to form biofilm on breast implants should be elucidated.

OBJECTIVES

The aim of this study was to evaluate biofilm formation on different mammary prosthesis surfaces by major Gram-positive bacterial pathogens involved in BAIs.

METHODS

We initially evaluated biofilm formation on polystyrene plates with and without fibrinogen or collagen for 1 reference strain and 1 clinical isolate of Enterococcus faecalis, Staphylococcus aureus, Staphylococcus epidermidis, and Streptococcus pyogenes. We also tested the ability of clinical isolates to form biofilm on 4 different implant surfaces: polyurethane foam and smooth, microtextured, and standard textured silicone. Biofilm structure and cell viability were observed by scanning electron microscopy and confocal laser scanning microscopy.

RESULTS

All strains showed strong biofilm formation on polystyrene. After fibrinogen or collagen treatment, biofilm formation varied. With fibrinogen, reference strains of S. aureus and S. pyogenes increased biofilm formation (P < 0.05). Reference strains of all species and the clinical isolate of S. pyogenes increased biofilm formation after collagen treatment (P < 0.05). In general, S. aureus showed higher capacity to produce biofilm. Scanning electron microscopy showed that biofilm attached to all surfaces tested, with the presence of extracellular polymeric substances and voids. Viable cells were more frequent for E. faecalis and S. pyogenes.

CONCLUSIONS

All species produced biofilm on all prosthesis surfaces and under different conditions. Micrographies indicated thicker bacterial biofilm formation on microtextured and/or standard textured silicone by all species, except E. faecalis.

Prepectoral versus subpectoral implant-based breast reconstruction after skin-sparing mastectomy or nipple-sparing mastectomy (OPBC-02/ PREPEC): a pragmatic, multicentre, randomised, superiority trial

INTRODUCTION

The emphasis on aesthetic outcomes and quality of life (QoL) has motivated surgeons to develop skin-sparing or nipple-sparing mastectomy (SSM/ NSM) for breast cancer treatment or prevention. During the same operation, a so-called immediate breast reconstruction is performed. The breast can be reconstructed by positioning of a breast implant above (prepectoral) or below (subpectoral) the pectoralis major muscle or by using the patients' own tissue (autologous reconstruction). The optimal positioning of the implant prepectoral or subpectoral is currently not clear. Subpectoral implant-based breast reconstruction (IBBR) is still standard care in many countries, but prepectoral IBBR is increasingly performed. This heterogeneity in breast reconstruction practice is calling for randomised clinical trials (RCTs) to guide treatment decisions.

METHODS AND ANALYSIS

International, pragmatic, multicentre, randomised, superiority trial. The primary objective of this trial is to test whether prepectoral IBBR provides better QoL with respect to long-term (24 months) physical well-being (chest) compared with subpectoral IBBR for patients undergoing SSM or NSM for prevention or treatment of breast cancer. Secondary objectives will compare prepectoral versus subpectoral IBBR in terms of safety, QoL and patient satisfaction, aesthetic outcomes and burden on patients. Total number of patients to be included: 372 (186 per arm).

ETHICS AND DISSEMINATION

This study will be conducted in compliance with the Declaration of Helsinki. Ethical approval has been obtained for the lead investigator's site by the Ethics Committee 'Ethikkommission Nordwest- und Zentralschweiz' (2020-00256, 26 March 2020). The results of this study will be published in a peer-reviewed medical journal, independent of the results, following the Consolidated Standards of Reporting Trials standards for RCTs and good publication practice. Metadata describing the type, size and content of the datasets will be shared along with the study protocol and case report forms on public repositories adhering to the FAIR (Findability, Accessibility, Interoperability, and Reuse) principles.

TRIAL REGISTRATION NUMBER

NCT04293146.

Breast Implants: A Historical Review With Implications for Diagnosis and Modern Surgical Planning

ABSTRACT

Modern breast surgery was first introduced in the United States in 1962 with the use of silicone gel-filled breast implants. Over the past 6 decades, development of breast implants has been challenged by a variety of influencers including aesthetic appeal in shape, texture, and material; challenges in managing outcomes such as contracture, disease, and rupture; and public perception of risks associated with implants. In 1992, silicone breast prostheses were banned by the US Food and Drug Administration with exception for use in breast reconstruction, congenital deformities, or to replace existing implants.The ban led to heightened concerns about implants and possible disease manifestations. Knowledge of the historical evolution of breast prostheses is useful for understanding the associated risks and outcomes unique to each breast implant era. This article aimed to explore characteristics of breast implants by generation, with implications for diagnosis and assistance to modern surgical planning for novice plastic surgeons.

Implant Fibrosis and the Underappreciated Role of Myofibroblasts in the Foreign Body Reaction

Body implants and implantable medical devices have dramatically improved and prolonged the life of countless patients. However, our body repair mechanisms have evolved to isolate, reject, or destroy any object that is recognized as foreign to the organism and inevitably mounts a foreign body reaction (FBR). Depending on its severity and chronicity, the FBR can impair implant performance or create severe clinical complications that will require surgical removal and/or replacement of the faulty device. The number of review articles discussing the FBR seems to be proportional to the number of different implant materials and clinical applications and one wonders, what else is there to tell? We will here take the position of a fibrosis researcher (which, coincidentally, we are) to elaborate similarities and differences between the FBR, normal wound healing, and chronic healing conditions that result in the development of peri-implant fibrosis. After giving credit to macrophages in the inflammatory phase of the FBR, we will mainly focus on the activation of fibroblastic cells into matrix-producing and highly contractile myofibroblasts. While fibrosis has been discussed to be a consequence of the disturbed and chronic inflammatory milieu in the FBR, direct activation of myofibroblasts at the implant surface is less commonly considered. Thus, we will provide a perspective how physical properties of the implant surface control myofibroblast actions and accumulation of stiff scar tissue. Because formation of scar tissue at the surface and around implant materials is a major reason for device failure and extraction surgeries, providing implant surfaces with myofibroblast-suppressing features is a first step to enhance implant acceptance and functional lifetime. Alternative therapeutic targets are elements of the myofibroblast mechanotransduction and contractile machinery and we will end with a brief overview on such targets that are considered for the treatment of other organ fibroses.

Imaging of the Silicone Implant with a 3D SPACE MR Sequence: The Accuracy for Estimating Implant Volume and Reconstructing Implant Deformation in Breast Surgery

OBJECTIVE

The study is to assess the accuracy and reliability of 3D simulated magnetic resonance imaging with SPACE sequence for estimating implant volume and reconstructing implant deformation, which may assist in the diagnosis of implant complications and making individualized surgical plans for these patients.

METHODS

MRI examinations of ten silicone implants were performed with T2, H₂O-excitation SPACE sequence (T2-spc-H₂O) and silicone-excitation SPACE sequence (T2-spc-Silicone) to find the most accurate method to estimate implant volume by ITK-SNAP. The effect of implant deformation and voxel size of silicone-excitation SPACE sequence on volume measurement was investigated. Thirteen normal patients and ten patients with implant complications (Wuhan Tongji Hospital from March 2017 to May 2019) were enrolled for testing the accuracy and reliability of 3D simulated MRI with silicone-excitation SPACE sequences for volume measurement and reconstructing implant deformation in patients.

RESULTS

The absolute volume differences of T2-spc-Silicone group were significantly less than T2-spc-H₂O and T2 group (6.28 vs. 23.27 vs. 42.19 mL, P < 0.05) in vitro. No significant difference was found between the normality group and the deformation group for estimating the volume of implants. Besides, the voxel size of T2-spc-Silicone from 0.5 × 0.5 × 0.5 mm to 5.0 × 5.0 × 5.0 mm did not significantly affect the accuracy of volume measurement of the implants in deformation state. However, 3D images of the implant became blurred with the voxel size increased. With the voxel size larger than 1.5 × 1.5 × 1.5 mm, the scores of image quality decreased significantly. The number of folds could not be identified accurately with the voxel size larger than 2.0 × 2.0 × 2.0 mm. In normal patients, the measurement errors of T2-spc-Silicone were around 10 mL. In the patients with implant complications, there was no significant difference between measured volume and the actual volume of implants. Moreover, implant deformations were clearly presented by T2-spc-Silicone with the voxel size of 1.0 × 1.0 × 1.0 mm. The results showed excellent intraobserver reliability (ICC = 0.997 > 0.8), and internal consistency ranged from 0.986 to 0.997 (P < 0.001).

CONCLUSIONS

The method to measure implant volume by 3D simulated magnetic resonance imaging with T2-spc-Silicone sequence had possessed desirable accuracy and reliability. The deformation of the implant and the voxel size of the T2-spc-Silicone sequence didn't exhibit a significant effect on the accuracy of the measurement. T2-spc-Silicone with voxel size less than 2.0 × 2.0 × 2.0 mm could be used for 3D reconstruction of the implant deformation. The 1.0 × 1.0 × 1.0 mm was a suitable voxel size to reconstruct implant deformation clearly and quickly.

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 .

Breast Augmentation Surgery: How Do We Do It? Results of a Joint Survey from European Association of Societies of Aesthetic Plastic Surgery

INTRODUCTION

The purpose of this study was to evaluate the current perceptions, preferences, and practice of plastic surgeons in Europe regarding breast implant surgery after the controversy on macrotextured implants and BIA-ALCL and the voluntary recall of all biocell implants.

METHODS

A survey comprising 15 questions about implant selection and postoperative routines associated with breast augmentation was sent to all society members of the EASAPS.

RESULTS

Out of 1473 correspondents, 416 completed the survey with response rate being 28.2%. Countries with less than ten respondents were not included in the analysis. A total of 359 respondents (24.4%) were included in the analysis. Twenty-one respondents (5.8%) had a clinical experience < 5 years, 43 (12%) had 5-10 years' experience, and 295 (82.2%) had > 10 years' experience. Regarding the type of implant, only 6.1% would use a macrotextured implant. Fourteen per cent of surgeons would recommend to change a biocell implant in any case, even without symptoms or problems (rupture, seroma, and capsular contracture), 99.7% would send the capsule for histopathological study (99.7%), 98.9% would perform bilateral implant replacement in case of a unilateral problem of rupture, contracture, or seroma, and 80.8% of respondents considered capsulectomy as a technique for managing capsular contracture degree III/IV.

CONCLUSIONS

The main conclusion is the heterogenicity of answers and practice, due to the lack of guidelines and scientific evidence on breast implants. Although 22 (6.1%) respondents would use a macrotextured implant (either round or anatomic), 71.6% of respondents considered that there is not enough information for removing macrotextured implants from the market and that they should be allowed to be used unrestrictedly or under close surveillance of the regulatory agencies.

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 .

Hot Topics in Breast Surgery

Since the first implant-based breast surgeries were performed nearly 70 years ago, breast augmentation it has changed drastically. As understanding of breast augmentation has advanced, so too have the technologies and techniques used to improve results and minimize the risk of complications in breast implant surgery. This article reviews some of the novel techniques and technologies used today in breast augmentation surgery. How these tools and techniques will withstand the test of time remains to be seen, but they no doubt will add to the fascinating and ever-evolving history of breast augmentation.

Various Properties of Silicone Breast Implant Surfaces and Multimodal Techniques for the Functional Surface Modification

"Silicone breast implants are the most widely used medical devices for breast reconstruction and augmentation, and revision, but even after more than 60 years of use they are associated with multiple continued complications. Using advancement in current technologies, researchers are attempting to create an optimal implant surface for patients. Through these efforts, plastic surgeons and material researchers have made great progress in the field of implant research. Multimodal techniques for the functional modification of implant surfaces will contribute to further the development of ideal biomaterials useful in breast implants.

Does Implant Surface Texture Affect the Risk of Capsular Contracture in Subglandular Breast Augmentation and Breast Augmentation-Mastopexy?

BACKGROUND

Previous studies have reported decreased rates of capsular contracture associated with the use of textured surface breast implants placed in the subglandular plane during breast augmentation. However, since the publication of these studies, our understanding of the pathophysiology of capsular contracture, as well as the surgical techniques utilized to minimize bacterial contamination of the implant, have advanced considerably.

OBJECTIVES

The purpose of this study was to re-evaluate the relation between implant surface texturization and capsular contracture rates for breast implants placed in the subglandular plane during primary breast augmentation.

METHODS

Retrospective chart review was performed of all primary subglandular breast augmentation procedures involving the use of either smooth or textured round silicone gel implants, with or without simultaneous mastopexy. The primary outcome measures included clinically significant capsular contracture (Baker grade III/IV) and revision surgery for capsular contracture.

RESULTS

Between 2010 and 2017, 526 patients underwent primary subglandular breast augmentation with either smooth (n = 212) or textured (n = 314) round silicone gel implants; 248 patients underwent breast augmentation, whereas 278 underwent breast augmentation-mastopexy. Average follow-up was 756 days in the textured group and 461 days in the smooth group. Five cases of capsular contracture were observed in the textured group, and 7 cases of capsular contracture were observed in the smooth group (P = 0.20).

CONCLUSIONS

Smooth surface implants placed in the subglandular plane were not at a significantly increased risk of capsular contracture compared with textured surface implants. We suggest that adherence to a surgical technique focused on minimizing bacterial contamination of the implant is of greater clinical significance than implant surface characteristics when discussing capsular contracture.

LEVEL OF EVIDENCE: 4

Surgeon's preference of subcutaneous tissue resection: most important factor for short-term complications in subcutaneous implant placement after mastectomy-results of a cohort study

Purpose

Little is known about the reason of high short-term complication rates after the subcutaneous placement of breast implants or expanders after mastectomy without biological matrices or synthetic meshes. This study aims to evaluate complications and their risk factors to develop guidelines for decreasing complication rates.

Methods

We included all cases of mastectomy followed by subcutaneous implant or expander placement between 06/2017 and 05/2018 (n = 92). Mean follow-up time was 12 months.

Results

Explantation occurred in 15 cases (16.3%). The surgeon’s preference for moderate vs. radical subcutaneous tissue resection had a significant influence on explantation rates (p = 0.026), impaired wound healing or infection (requiring surgery) (p = 0.029, p = 0.003 respectively) and major complications (p = 0.018).

Multivariate analysis revealed significant influence on complication rates for radical subcutaneous tissue resection (p up to 0.003), higher implant volume (p up to 0.023), higher drain volume during the last 24 h (p = 0.049), higher resection weight (p = 0.035) and incision type (p = 0.011).

Conclusion

Based on the significant risk factors we suggest the following guidelines to decrease complication rates: favoring thicker skin envelopes after surgical preparation, using smaller implants, removing drains based on a low output volume during the last 24 h and no use of periareolar incision with extension medial or lateral. We should consider ADMs for subcutaneous one-stage reconstructions.

The individual surgeon’s preference of subcutaneous tissue resection is of highest relevance for short-term complications—this has to be part of internal team discussions and should be considered in future trials for comparable results.

Device-Specific Findings of Imprinted-Texture Breast Implants: Characteristics, Risks, and Benefits

BACKGROUND

The relative risks and benefits of various textured breast implants are the focus of considerable discussion. Studies have suggested different risk-benefit profiles for different implant surface topographies.

OBJECTIVES

The study aim was to provide device-specific, quantitative information on Mentor's imprinted Siltex Textured breast implants with respect to textured surface characteristics and ISO 14607 classification, risk of breast implant-associated anaplastic large cell lymphoma (BIA-ALCL), and risk-reduction benefits relative to smooth implants.

METHODS

Surface metrology was performed. Data for smooth and Siltex implants from the prospective MemoryGel Core Study were evaluated by Kaplan-Meier analysis for the most frequently occurring postoperative complications in augmentation and reconstruction leading to subsequent reoperation.

RESULTS

The overall average surface roughness for Siltex MemoryGel and MemoryShape implants was 29.5 and 36.1 µm, respectively. A statistically significantly lower rate of reoperation in patients with Siltex compared with smooth devices over 10 years was observed for both capsular contracture in subglandular primary augmentation patients (4.21% vs 19.84%) and for asymmetry in primary reconstruction patients (3.88% vs 11.1%).

CONCLUSIONS

Surface analysis demonstrated that Siltex implants fall within the ISO 14607 category of "microtexture" breast implants. These devices exhibited a rare risk of BIA-ALCL (0.0012%) based on the most extensive data available. Relative to smooth implants, these Siltex devices provided risk-reduction benefits for the most common reason of reoperation in patients who underwent primary augmentation (capsular contracture) or primary reconstruction (asymmetry) in the Core Study. These findings provide valuable risk-benefit information for surgeons and their patients.

LEVEL OF EVIDENCE: 2

A multi-center, retrospective, preliminary observational study to assess the safety of BellaGel® after augmentation mammaplasty

Background

BellaGel® is the only cohesive silicone gel-filled breast implant from a Korean manufacturer, and it was first developed in 2005. It was approved by the CE in 2008, thus becoming the first Asian breast implant available in the EU. We conducted this study to assess the safety of BellaGel® in patients receiving augmentation mammaplasty.

Methods

We evaluated a consecutive series of 239 patients (478 breasts) who received esthetic augmentation mammaplasty using the BellaGel® (round smooth, round textured, round nanotextured, and anatomical textured types of implant) (HansBiomed Co. Ltd., Seoul, Korea) at three clinics in Korea (JW Plastic Surgery Center, BS The Body Plastic Surgery Clinic and Grace Plastic Surgery Clinic) during a period from December 1, 2015 to January 31, 2018.

Results

A total of 239 patients with a mean age of 33.1 ± 8.5 years old were followed up during a mean period of 399.58 ± 232.71 days, where there were no cases of capsular contracture in our clinical series of the patients. Other complications include one case (0.4%) of seroma, three cases (1.3%) of hematoma, and one case (0.4%) of infection. Moreover, there were no significant differences in the cumulative incidences of complications between the four types of the BellaGel® (χ2 = 2.322, df = 3, P = 0.508). Furthermore, the cumulative Kaplan-Meier survival rate was estimated at 0.979 (95% CI 0.961–0.997).

Conclusions

Our results indicate that the BellaGel® is such a safe breast implant that surgeons might consider using it for esthetic augmentation mammaplasty.

Level of evidence: Level III, risk/prognostic study.

Two-stage prepectoral breast reconstruction

The options for prosthetic breast reconstruction have expanded and include prepectoral versus subpectoral location of devices as well as performing these operations in one- or two-stage. Current practice patterns are evolving toward the placement of devices in the prepectoral plane in a single stage. The authors' patient selection criteria and surgical technique were reviewed and organized in a step-by-step format. On and off label techniques for acellular dermal matrix (ADM) assembly were reviewed. A review of surgical outcomes was completed. Two-stage reconstruction confers several advantages such as reducing pressure on the mastectomy skin flaps, optimal implant selection for the second stage and the opportunity to revise the reconstruction, all of which can increase the likelihood of a successful outcome. This manuscript will review the indications, techniques, and outcomes following prepectoral, two-stage prosthetic breast reconstruction.

The Economics of Prepectoral Breast Reconstruction

The world of breast reconstruction over the last several years has seen a dramatic shift in focus to discussion and the application of placing tissue expanders and implants back into the prepectoral space. Although this technique failed during the early advent of breast reconstruction, newer technologies such as advances in fat grafting, improved acellular dermal matrices, better methods of assessing breast flap viability, and enhanced implants appear to have set the stage for the resurgence and positive early results seen with this technique. The main benefits of a switch to prepectoral breast reconstruction clinically appears to be less associated pain, lower incidence of animation deformities, and its associated symptoms as well as presumably better aesthetics. Early data suggest that the results are extremely promising and early adopters have attempted to define the ideal patients for prepectoral breast reconstruction. As with any new operative procedure, an assessment of finances and costs are crucial to its successful implementation. Although current data are minimal, this article attempts to build the fundamentals of an economic model that exhibits and displays potential savings through the use of prepectoral breast reconstruction.

Extensive silicone lymphadenopathy after breast implant insertion mimicking malignant lymphadenopathy

Silicone implants are widely used in aesthetic and reconstructive breast surgery. Silicone lymphadenopathy is a well-known rare complication of implant insertion. Silicone leakage from a rupture or silicone bleeding can accumulate in lymph nodes. Foreign body reactions in the affected lymph nodes may be misdiagnosed as metastasis or malignant lymphadeno pathy upon initial presentation if silicone lymphadenopathy is not considered in the initial diagnosis. We report a case of siliconoma with extensive involvement of multiple lymph nodes mimicking malignant features to emphasize that clinicians should carefully evaluate each patient's medical history and disease status during differential diagnosis.

Comparative Study of Prepectoral and Subpectoral Expander-Based Breast Reconstruction and Clavien IIIb Score Outcomes

Prepectoral breast reconstruction is increasingly popular. This study compares complications between 2 subpectoral and 1 prepectoral breast reconstruction technique.

Intraoperative Comparison of Anatomical versus Round Implants in Breast Augmentation: A Randomized Controlled Trial

BACKGROUND

The purpose of this randomized controlled trial was to determine whether anatomical implants are aesthetically superior to round implants in breast augmentation.

METHODS

Seventy-five patients undergoing primary breast augmentation had a round silicone implant of optimal volume, projection, and diameter placed in one breast and an anatomical silicone device of similar volume and optimal shape placed in the other. After intraoperative photographs were taken, the anatomical device was replaced by a round implant to complete the procedure. A survey designed to measure breast aesthetics was administered to 10 plastic surgeon and 10 lay reviewers for blind evaluation of the 75 cases.

RESULTS

No observable difference in breast aesthetics between anatomical and round implants was reported by plastic surgeons in 43.6 percent or by lay individuals in 29.2 percent of cases. When a difference was perceived, neither plastic surgeons nor lay individuals preferred the anatomical side more often than the round side. Plastic surgeons judged the anatomical side superior in 51.1 percent of cases and the round side superior in 48.9 percent of cases (p = 0.496). Lay individuals judged the anatomical side superior in 46.7 percent of cases and the round side superior in 53.3 percent (p = 0.140). Plastic surgeons identified implant shape correctly in only 26.5 percent of cases.

CONCLUSIONS

This study provides high-level evidence supporting no aesthetic superiority of anatomical over round implants. Given that anatomical implants have important and unique disadvantages, a lack of proven aesthetic superiority argues against their continued use in breast augmentation.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Therapeutic, I.

Shaped versus Round Implants in Breast Reconstruction: A Multi-Institutional Comparison of Surgical and Patient-Reported Outcomes

BACKGROUND

Since the 2012 approval of shaped implants, their use in breast reconstruction has increased in the United States. However, large-scale comparisons of complications and patient-reported outcomes are lacking. The authors endeavored to compare surgical and patient-reported outcomes across implant types.

METHODS

The Mastectomy Reconstruction Outcomes Consortium database was queried for expander/implant reconstructions with at least 1-year postexchange follow-up (mean, 18.5 months). Outcomes of interest included postoperative complications, 1-year revisions, and patient-reported outcomes. Bivariate and mixed-effects regression analyses evaluated the effect of implant type on patient outcomes.

RESULTS

Overall, 822 patients (73.5 percent) received round and 297 patients (26.5 percent) received shaped implants. Patients undergoing unilateral reconstructions with round implants underwent more contralateral symmetry procedures, including augmentations (round, 18.7 percent; shaped, 6.8 percent; p = 0.003) and reductions (round, 32.2 percent; shaped, 20.5 percent; p = 0.019). Shaped implants were associated with higher rates of infection (shaped, 6.1 percent; round, 2.3 percent; p = 0.002), that remained significant after multivariable adjustment. Other complication rates did not differ significantly between cohorts. Round and shaped implants experienced similar 2-year patient-reported outcome scores.

CONCLUSIONS

This prospective, multicenter study is the largest evaluating outcomes of shaped versus round implants in breast reconstruction. Although recipients of round implants demonstrated lower infection rates compared with shaped implants, these patients were more likely to undergo contralateral symmetry procedures. Both implant types yielded comparable patient-reported outcome scores. With appropriate patient selection, both shaped and round implants can provide acceptable outcomes in breast reconstruction.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Therapeutic, III.

Long-term outcomes with the McGhan Style 153 dual-lumen breast implant: Implications for future implant design

BACKGROUND

A variety of saline and silicone implants have been introduced over the years to optimize the shape, aesthetic result and safety profile for use in breast surgery. The McGhan Style 153 dual-lumen silicone implant represented an early generation of anatomically shaped implants later removed from the market due to a high rate of rupture. This study reports long term outcomes and complications, including a revised rupture rate, and discusses potential mechanisms of implant failure and their implications for future implant design.

METHODS

A retrospective review was performed on 79 patients (134 implants). Demographics, operative details, outcomes, and complications were recorded. Rupture rate and location of rupture were included.

RESULTS

The revised implant rupture rate was 36.6% of implants. At least one rupture occurred in 49.4% of patients. Clinical exam was the most common method of detection (55.1% of ruptures). The most common location of rupture was the superior pole (30.6%), followed by a posterior location (24.5%). The capsular contracture rate (Baker grade III/IV) was 51.5%. The total implant removal rate (for rupture, contracture, size change, or asymmetry) was 77.6%. The average time to implant removal was 91.8 months, or 7.5 years (±47.3 months). Average follow up was 120.7 months or 10 years (±49.9 months).

DISCUSSION

The experiences with this anatomic gel implant highlight the importance of shell stability over time, suitable gel cohesiveness to support the asymmetric anatomic shape, avoidance of fold flaws due to wrinkling, and the prevention of distinct stress points on the shell that can result from dual lumen or multi-compartment designs.

LEVEL OF EVIDENCE

Level III, retrospective cohort, therapeutic study.