Capsulectomy, Implant Exchange, and Placement of Acellular Dermal Matrix Is Effective in Treating Capsular Contracture in Breast Augmentation Patients

Capsular Contracture After Breast Augmentation: Our Approach to Prevent Reoccurrence with Combined Total Capsulectomy and Implantation of Motiva Ergonomix® Implants

BACKGROUND

Breast augmentation is the second most common aesthetic surgery worldwide. Capsular contracture, a prevalent complication which affects up to 30% of patients post-surgery, often leads to further necessary surgeries.

OBJECTIVES

This study investigates the effectiveness of total capsulectomy combined with Motiva Ergonomix® implant replacement in resolving capsular contracture and minimizing recurrence rates.

METHODS

We conducted a retrospective study of 1067 patients and enrolled 51 women with capsular contracture post-breast augmentation. Patients were treated between 2014 and 2023 in a single center by three surgeons. Capsular contracture severity was graded using Baker's classification. Surgical interventions included total capsulectomy and implant replacement, using various incision techniques and changes in implant anatomical planes. Patients were followed up for a minimum of 12 months to a maximum of 9 years.

RESULTS

A total of 51 patients with grade III or IV capsular contracture underwent revisional surgery, involving the implantation of 102 Motiva Ergonomix® prostheses; 77 explanted implants resulted intact, 15 exhibited silicone bleeding, and 10 showed ruptured. Capsular contracture recurrence was observed in only 1.96% of cases during the follow-up period.

CONCLUSIONS

The combination of total capsulectomy and implantation of Motiva Ergonomix® implants significantly reduces the recurrence rate of capsular contracture. Despite the study's limitations, including its single-center design and a small sample size, our results suggest that this approach is a viable and effective solution to manage this common complication in breast augmentation patients. Further multicentric studies are recommended to validate these results.

LEVEL OF EVIDENCE V

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

A Comparison of Ovine-Reinforced Hybrid Mesh (OviTex PRS) With Porcine Acellular Dermal Matrix (STRATTICE) in the Treatment of Advanced Breast Implant Capsular Contracture

Background

Tissue reinforcement techniques with porcine acellular dermal matrices (ADMs) have been widely adopted as standard care in treating capsular contracture. However, the application of alternative xenograft or mesh materials has not been widely studied.

Objectives

To examine the efficacy of OviTex PRS Reinforced Tissue Matrix (Resorbable) (TELA Bio, Malvern, PA), a hybrid ovine-reinforced mesh, in comparison with STRATTICE Reconstructive Tissue Matrix (Allergan, Irvine, CA), in patients with advanced capsular contracture.

Methods

A retrospective review was conducted on patients who underwent breast revision surgery for Baker Grade III or IV capsular contracture. Patient data were reviewed for outcomes, complications, cost, and postoperative incidence of recurrent capsular contracture after treatment with each specific mesh.

Results

Fifty-nine of 89 breasts (66.3%) were treated with OviTex and 30 (33.7%) were treated with STRATTICE. All patients experienced a reduction in Baker grades. In patients treated with OviTex, 96.6% (n = 57) of breasts had a postoperative Baker Grade I with the remaining 3.4% (n = 2) breasts presenting with a Baker Grade II. In comparison, 73.3% (n = 22), 23.3% (n = 7), and 3.3% (n = 1) of the STRATTICE cohort presented with Baker Grades I, II, and III, respectively. This demonstrated a statistically significant improvement in Baker grade capsular contracture in the OviTex cohort (P < .05) compared with STRATTICE. Average cost was $27.37/cm2 for STRATTICE compared with $22.28/cm2 for OviTex PRS.

Conclusions

OviTex may be successfully utilized to treat capsular contracture. Patient outcomes may be superior to STRATTICE in recurrent capsular contracture, particularly when a previous ADM had been utilized. Cost data show improved savings with the use of OviTex compared with STRATTICE.

Level of Evidence 3

National trends in revision procedures in post-mastectomy breast reconstruction: Autologous vs implant-based approaches

BACKGROUND

Breast reconstruction involves collaborative decision-making between patients and surgeons, but the need for multiple revisions after the initial reconstructive surgery process can burden patients and the healthcare system. This study explored how the type of breast reconstruction (autologous [ABR], immediate implant-based reconstruction [IBR], or two-stage IBR) impacts postreconstruction revision rates.

METHOD

Using MarketScan Databases, a retrospective database study (2007-2021) was conducted, identifying revision procedures through Current Procedural Terminology codes. Statistical analysis with linear models, adjusted for patient characteristics and surgical factors, used a significance threshold of p < 0.05.

RESULTS

Among 58,264 patients, 6.2% of ABR patients, 3.8% of immediate IBR patients, and 3.6% of two-stage IBR patients underwent future revisions. IBR had a 51% lower incidence rate of revision operations than ABR (incidence rate ratio = 0.49, p < 0.001). Within IBR, there was no significant difference in the number of operations between immediate IBR (0.06 ± 0.32) and two-stage IBR (0.05 ± 0.32, p = 0.95). Immediate IBR demonstrated 12% (OR = 0.88, p = 0.0022) and 70% (OR = 0.30, p < 0.001) lower odds of requiring breast revision and fat grafting compared to ABR, respectively. Two-stage reconstruction had 66 % lower odds of requiring only fat grafting than ABR (OR = 0.34, p < 0.001).

CONCLUSION

ABR necessitated a higher number of total revision procedures after completion of the initial reconstruction. These findings will better equip providers and patients to counsel patients in understanding their reconstructive journey, planning their reconstructions and timing, and provide more accurate estimates of the number of procedures that will be required to reach their aesthetic goals and final outcome.

Symptom Improvement After Explantation With No Capsulectomy for Systemic Symptoms Associated With Breast Implants

BACKGROUND

Systemic symptoms associated with breast implants (SSBI) is a term used to describe a group of patients who attribute a variety of symptoms to their implants. Previous studies have shown symptom improvement after implant removal in these patients irrespective of whether part or all the implant capsule has been removed.

OBJECTIVES

The aim of this study was to evaluate implant removal with no capsule removed in symptomatic and control subjects.

METHODS

Eligible study subjects were sequentially enrolled at 5 investigator sites. The SSBI Cohort included patients with systemic symptoms they attributed to their implants who requested explantation. The Non-SSBI Cohort included subjects without systemic symptoms attributed to their implants who requested explantation with or without replacement. All subjects agreed to undergo explantation without removal of any capsule.

RESULTS

Systemic symptom improvement was noted in SSBI subjects without removal of the implant capsule, comparable to the results of our previously published study. SSBI patients showed a 74% reduction in self-reported symptoms at 6 months with no capsulectomy which was not statistically different from partial or total capsulectomies (P = .23).

CONCLUSIONS

Explantation with or without capsulectomy provides symptom improvement in patients with systemic symptoms they associate with their implants.

LEVEL OF EVIDENCE: 3

A feasibility study assessing quantitative indocyanine green angiographic predictors of reconstructive complications following nipple-sparing mastectomy

Introduction

Immediate post-mastectomy breast reconstruction offers benefits; however, complications can compromise outcomes. Intraoperative indocyanine green fluorescence angiography (ICGFA) may mitigate perfusion-related complications (PRC); however, its interpretation remains subjective. Here, we examine and develop methods for ICGFA quantification, including machine learning (ML) algorithms for predicting complications.

Methods

ICGFA video recordings of flap perfusion from a previous study of patients undergoing nipple-sparing mastectomy (NSM) with either immediate or staged immediate (delayed by a week due to perfusion insufficiency) reconstructions were analysed. Fluorescence intensity time series data were extracted, and perfusion parameters were interrogated for overall/regional associations with postoperative PRC. A naïve Bayes ML model was subsequently trained on a balanced data subset to predict PRC from the extracted meta-data.

Results

The analysable video dataset of 157 ICGFA featured females (average age 48 years) having oncological/risk-reducing NSM with either immediate (n=90) or staged immediate (n=26) reconstruction. For those delayed, peak brightness at initial ICGFA was lower (p<0.001) and significantly improved (both quicker-onset and brighter p=0.001) one week later. The overall PRC rate in reconstructed patients (n=116) was 11.2%, with such patients demonstrating significantly dimmer (overall, p=0.018, centrally, p=0.03, and medially, p=0.04) and slower-onset (p=0.039) fluorescent peaks with shallower slopes (p=0.012) than uncomplicated patients with ICGFA. Importantly, such relevant parameters were converted into a whole field of view heatmap potentially suitable for intraoperative display. ML predicted PRC with 84.6% sensitivity and 76.9% specificity.

Conclusion

Whole breast quantitative ICGFA assessment reveals statistical associations with PRC that are potentially exploitable via ML.

Acellular dermal matrix in breast augmentation surgery: A systematic review

Background

The use of acellular dermal matrix (ADM) in breast reconstruction was described for the first time in 2000s. Recently, ADMs have been used not only in reconstructive surgery but also in cosmetic breast surgery for both primary and revision indications. Therefore, the matrices represent an important support to recent surgical techniques for breast augmentation in treatment or prevention of complications. Conversely, ADMs can affect operative times, costs, and additional complications related to their placement. A review of the literature was carried out to evaluate the efficacy, safety, and indication for the use of these matrices in cosmetic breast surgery.

Methods

A literature review was conducted including manuscripts published up to April 2023 on breast augmentation using ADM. PubMed and MEDLINE were the databases used for research. The keywords used were "Breast augmentation" and "Acellular Dermal Matrix." Non-English language articles have been excluded.

Results

The initial search for "breast augmentation" yielded 7900 results, which were further reviewed for "Acellular Dermal Matrices" in breast augmentation, selecting 74 articles. Following further screening, 12 articles were included in the review. A total of 787 patients were treated with breast augmentation and ADM placement. The main indication was capsular contracture (60%).

Conclusions

The current evidence from the published scientific literature, albeit limited, suggests the indication for the use of ADM in revision surgery, to support the prosthetic pocket, to minimize the risk of capsular contracture and its recurrence.

Revision Breast Reconstruction With Biologic or Synthetic Mesh: An Analysis of Postoperative Capsular Contracture Rates

Background

Both biologic and synthetic mesh have been found to reduce the risk of capsular contracture, yet there is limited data assessing the use of these scaffold materials in revision breast reconstruction.

Objectives

This investigation sought to assess the ability of either biologic or synthetic mesh to prevent capsular contracture in the revision breast reconstruction population.

Methods

A retrospective chart review was conducted of implant-based revision reconstructions performed by the senior author between 2008 and 2023. Patient demographics and outcomes were assessed, including the incidence of Baker Grade III or IV capsular contractures. Results were compared between biologic and synthetic mesh groups using univariate and multivariate analysis.

Results

Ninety-five breasts underwent revision reconstruction with 90 (94.7%) for correction of malposition, 4 (4.2%) for size change, and 1 (1.1%) for revision after additional oncologic breast surgery. Of these breasts, 26 (27.4%) used biologic mesh and 69 (72.6%) used synthetic mesh. Capsular contracture occurred in 1 (3.8%) biologic mesh breast and 4 (5.8%) synthetic mesh breasts. There was no significant difference in the incidence of capsular contracture between the 2 groups (P = 1.000). None of the recorded demographics were risk factors for capsular contracture, including the use of biologic or synthetic mesh (P = .801).

Conclusions

Both biologic and synthetic mesh are successful at preventing capsular contracture in patients undergoing implant-based revision reconstruction. This adds to the growing evidence that both scaffold materials can be used in complex revision breast reconstruction to aid in preventing capsular contracture.

Level of Evidence 4

Review: Implant-Based Breast Reconstruction After Mastectomy for Breast Cancer: A Meta-analysis of Randomized Controlled Trials and Prospective Studies Comparing Use of Acellular Dermal Matrix (ADM) Versus Without ADM

BACKGROUND

Breast cancer is the world's most prevalent cancer, and many breast cancer patients undergo mastectomy as the choice of treatment, often with post-mastectomy breast reconstruction. Acellular dermal matrix (ADM) use has become a method to improve outcomes of reconstruction for these patients. We aimed to compare postoperative complications and patient-reported outcomes, which are still poorly characterized, between groups utilizing acellular dermal matrix during reconstruction and those without.

MATERIALS AND METHODS

We searched electronic databases from inception to 16 June 2022 for randomized controlled trials and prospective cohort studies comparing the outcomes of patients who have and have not received acellular dermal matrix in implant-based breast reconstruction. The results were quantitatively combined and analyzed using random-effects models.

RESULTS

A total of nine studies were included, representing 3161 breasts. There was no significant difference in postoperative outcomes, such as seroma formation (p = 0.51), hematomas (p = 0.20), infections (p = 0.21), wound dehiscence (p = 0.09), reoperations (p = 0.70), implant loss (p = 0.27), or skin necrosis (p = 0.21). Only two of the studies included evaluated patient-reported outcomes between the use and non-use of ADM in implant-based breast reconstruction using BREAST-Q questionnaire, as well as self-reported pain. There was no reported significant difference in BREAST-Q or pain scores.

CONCLUSIONS

This meta-analysis shows comparable short- and long-term outcomes between ADM and non-ADM breast reconstruction, suggesting that the use of ADM may not be necessary in all cases given their additional cost. However, there is a paucity of data for patient-reported outcomes, and further research is required to determine whether ADM use affects patient-reported outcomes.

Systematic Review of Capsular Contracture Management following Breast Augmentation: An Update

BACKGROUND

Capsular contracture is one of the most frequent indications for revision following breast augmentation. Management goals focus on restoring breast aesthetics and minimizing subsequent recurrence of capsular contracture. As new data emerge, close review of the data are merited to build evidence-based clinical guidelines to inform surgical practice and management of capsular contracture.

METHODS

A systematic review of the MEDLINE, Embase, and Cochrane Database of Systematic Reviews databases was conducted to characterize the surgical management of capsular contracture in revision breast augmentations. The primary endpoint was capsular contracture recurrence rate.

RESULTS

The review was conducted in November of 2021. Primary search revealed 14,163 results. Initial screening by title left 1223 articles. Abstract review left 90 articles for full-text review, of which 34 were ultimately included and were all observational in nature.

CONCLUSIONS

Capsular contracture management remains an important topic, with limited high-level evidence for establishing clear evidence-based treatment guidelines. Although more evidence is required to assess the effects of capsulectomy, implant exchange, and plane change, these appear to be useful mechanisms for reducing recurrent capsular contracture. There is more evidence regarding the use of acellular dermal matrix, although this still requires long-term follow-up studies. New developments regarding textured implants limit the revision breast augmentation surgeon to smooth devices.

Efficacy of Acellular Dermal Matrix Type in Treatment of Capsular Contracture in Breast Augmentation: A Systematic Review and Meta-Analysis

BACKGROUND

Capsular contracture is a known complication of breast augmentation and is among the top reasons for revisional breast augmentation procedures. The use of acellular dermal matrix (ADM) has been shown to reduce the rate of capsular contracture in breast reconstruction and augmentation, theorizing that it acts as a protective barrier between the implant capsule and inflammatory process responsible for capsular contracture. The role of ADM in treatment of capsular contracture has been investigated in numerous studies, with a variety of ADMs.

OBJECTIVES

The aim of this study was to perform a systematic review of existing literature on the use of ADM for treatment of capsular contracture in aesthetic breast augmentation patients to investigate differences in efficacy of ADM types.

METHODS

The PubMed, Embase, and CINAHL databases were systematically reviewed for articles pertaining to capsular contracture, acellular dermal matrices, and breast augmentation. Number of patients, type of ADM, Baker grade, follow-up time, complication rate, and capsular contracture rate were recorded from identified articles. Data was pooled from studies to calculate a capsular contracture rate for each ADM type, with a chi-squared test performed for analysis. Identified studies with a comparative group were included in a meta-analysis utilizing risk ratio (RR) to assess the efficacy of ADM.

RESULTS

Nine articles including ADM for treatment of capsular contracture in breast augmentation met criteria for inclusion, with a total of 481 breasts. Strattice was the most commonly utilized ADM (n = 391), followed by AlloDerm (n = 57). There was a statistically significant difference in efficacy of ADM among the studied ADM types (P < .001). AlloDerm, FlexHD, and DermaMatrix had the lowest capsular contracture rates (0%). NeoForm and SurgiMend had the highest capsular contracture rates (each 25%, but with n = 4 and n = 8, respectively). Strattice had a capsular contracture rate of 1.53% in the pooled data, and meta-analysis showed that Strattice reduced the risk of capsular contracture (RR 0.14 [95% CI 0.06, 0.31]) compared with conventional treatment.

CONCLUSIONS

Acellular dermal matrices appear to be effective at treating capsular contracture after breast augmentation while maintaining a low complication rate. Overall capsular contracture rates are low with the use of ADM. There is a statistically significant difference in efficacy among ADM types. Meta-analysis shows that Strattice is effective at reducing the risk of capsular contracture in breast augmentation patients when compared to conventional treatment. Future research, especially in the form of randomized controlled trials, is needed to further investigate the efficacy of various ADMs in the treatment of capsular contracture.

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.

Peer Review: How to Review a Plastic Surgery Manuscript

ABSTRACT

Little information is available regarding how to review a plastic surgery manuscript. This vital responsibility ensures that publications meet an acceptable scientific standard. Thoughtful and thorough reviews are essential to protect patients and surgeons from unscientific practices and products. This discussion provides information for the reviewer, gained from the author's experience, including examples of a thorough review, likely to be useful to the editor, and a cursory one that is unhelpful.The first consideration is relevance. Prerequisites for publication include institutional review board approval, disclosure of financial conflicts, and discussion of the regulatory status of devices. Particular attention is needed to check for conflicts of interest, which are endemic in plastic surgery today. In view of the common practice of using computer-generated imaging, reviewers need to be especially vigilant for inauthentic "photoshopped" photographs. Examples of published images that have been digitally altered are provided.If data are available, it may be possible to check the statistical tests. Reviewers need to be aware of the practice of p-hacking. A quick literature search can identify relevant but unreferenced publications. The manuscript needs to be properly organized into sections. Minor points may be made regarding style. The study design and methodology need to be evaluated to be sure that the conclusions are well supported by data. Randomized studies are rarely feasible. Fortunately, well-done prospective observational studies in consecutive patients can be just as useful. Realistic complication rates are expected. Meta-analyses in plastic surgery are often subject to confounding variables. Comments should be available to the authors; confidential comments hidden from authors are discouraged. Like honesty, transparency is the best policy. Manuscripts should be evaluated solely for merit, not the identity of the author or institution. Timeliness of submission of the review is appreciated by authors.Evidence-based medicine is concerned solely with the facts. The 2 basic criteria are a solid scientific basis and reliable evidence of efficacy. Reviewers need to keep an open mind. Studies that challenge the status quo are often the most valuable ones and are needed for the advancement of the specialty.

Complications of Capsulectomies: An Analysis of the American College of Surgeons National Surgical Quality Improvement Program (NSQIP) Database

Background

Although plastic surgeons commonly perform capsulectomies for a variety of peri-prosthetic capsular conditions, the safety of capsulectomy remains unknown, and the literature lacks evidence describing its morbidity and complication rates for patients inquiring about its associated risks.

Objectives

The present study aims to identify and define the complication rates associated with capsulectomies.

Methods

An analysis of the American College of Surgeons National Surgical Quality Improvement Program (NSQIP) database was performed between the years 2015 and 2018. All information pertaining to demographics, patient-related information, surgical indications, procedure-related information, outcomes, and complications were assessed.

Results

The study identified 2231 cases of surgeon-reported capsulectomies; indications most commonly reported included capsular contracture (n = 638, 28.6%) and breast implant rupture (n = 403, 18.1%). In total, 141 patients (6.32%) were hospitalized for longer than 1 postoperative day (range, 2-28 days), while the overall complication rate was 3.0% (n = 67/2231 patients). Incidence of minor complications, representing superficial surgical site infections, was 0.8%, while the major complication rate was 2.24%. These included 7 cases of deep surgical site infections (0.3%), 19 organ space infections (0.9%), and 8 cases of wound dehiscence (0.4%). Eight patients developed sepsis (0.4%); 6 patients required transfusions (0.3%); 1 case of postoperative pneumonia and 1 myocardial infarction were also identified (n = 1 each, 0.0%). The overall reoperation and readmission rates were 2.0%, representing a readmission rate of 66% among patients with complications.

Conclusions

The present study provides the first estimate of the incidence of complications associated with capsulectomies. Although the NSQIP database contains significant limitations, the data presented herein describe a complication profile that plastic surgeons can share with their patients during informed consent.

Level of Evidence: 4

Complete Implant Wrapping with Porcine-Derived Acellular Dermal Matrix for the Treatment of Capsular Contracture in Breast Reconstruction: A Case-Control Study

Background

Capsular contracture (CC) represents one of the most common complications in breast reconstruction surgery, impairing final result and patients’ well-being. The role of acellular dermal matrixes (ADM) has been widely described for the treatment and prevention of contracture. The aim of the study was to evaluate the efficacy and safety of complete implant coverage with porcine-derived ADM in preventing CC limiting complications. In addition, patients’ reported outcomes were evaluated in order to define the role of ADM in improving sexual, physical and psychosocial well-being and satisfaction.

Methods

42 patients who underwent surgical treatment of 46 contracted reconstructed breasts from May 2018th to May 2019th were collected in the two groups (ADM group vs. Control group).

Results

The ADM group showed lower rate of CC recurrence and a higher rate of implant losses and minor complications. A significant difference was observed in red breast syndrome (27.3% in the ADM group vs. absent in control the group) and skin ulceration rates (18.2% in the ADM group vs. 4.18% in the control group). As for patients’ perceived outcomes, the ADM group showed a statistically significant higher postoperative Satisfaction of Breast Scale score compared to the control group. In addition, a significant difference was observed in the improvement of Physical Well-Being of the Chest Scale and the Satisfaction of Breast Scale after surgery, in favor to the ADM group.

Conclusion

Complete implant coverage with ADM may reduce the risk of CC recurrence in breast reconstruction. An accurate patient selection allows minimizing complications improving patient well-being and satisfaction.

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.

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 .

Surgical Treatment of Capsular Contracture (CC): Literature Review and Outcomes Utilizing Implants in Revisionary Surgery

BACKGROUND

The objective of this clinical review is to provide an overview of the use of breast implants after capsular contracture (CC) surgical treatment, with a focus on type of implants used. Furthermore, our experience in this field is also reviewed.

METHODS

MEDLINE, EMBASE, Web of Science, Scopus, the Cochrane Central, and Google Scholar databases were reviewed to identify literature related to surgical treatment of capsular contracture and implant replacement. Each article was reviewed by two independent reviewers to ensure all relevant publications were identified. The literature search identified 54 applicable articles. Of these, 26 were found to have a therapeutic level of evidence. The reference lists in each relevant paper were screened manually to include relevant papers not found through the initial search.

RESULTS

Only four articles report the replacement of implants after surgical treatment of capsular contracture. Six articles reported an implant exchange with only smooth silicone gel filled implants. Two reviews advice to use smooth implants in implant replacement.

CONCLUSION

With our expertise in the field and the results of this up-to-date literature review, it can be concluded that implant exchange is recommended in case of breast revision for capsular contracture, and the use of subpectoral smooth silicone gel breast implants is a good option after surgical treatment in patients with primary or recurrence Baker III-IV.

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 .

Revision Breast Augmentation

Breast augmentation is consistently one of the most commonly performed aesthetic operations every year. Unfortunately, revision rates following primary augmentation remain as high as 36%. There are several causes for revision breast augmentation; however, the most common and challenging of these include capsular contracture, implant malposition, and ptosis of the aging breast following augmentation. Successful management of these problems requires knowledge on how to best treat the implant and capsule with the corresponding soft tissue simultaneously. While surgical management is important, understanding the pathological causes of these entities during the primary operation can reduce the need for revision. This article utilizes the most up-to-date literature to review the appropriate clinical evaluation and surgical management of these complex cases.

Epidemiology and Prevention of Breast Prosthesis Capsular Contracture Recurrence

INTRODUCTION

Baker grade III and IV breast prosthesis capsular contractures represent a major problem for patients undergoing mammoplasties. The risk factors involved in recurrence are debated, and the best surgical approach for their prevention is not established. The objective was to identify these.

MATERIALS AND METHODS

We carried out a retrospective study of patients operated on for capsular contracture at the Saint-Louis Hospital in Paris from 2012 to 2014. The characteristics at inclusion were compared so as to determine the risk factors of recurrence. The surgical approaches were compared between the patients with recurrence and those without at 5 years.

RESULTS

Of the 100 patients included, 24 had a recurrence. The minimal follow-up was 5 years. No risk factors of recurrence of capsular contracture were identified. The surgical approach associated with the lowest rate of recurrence was anterior capsulectomy [OR total capsulectomy = 2.36 (0.73; 8.037) OR capsulotomy = 4.33 (1.37; 14.81)] (p < 0.040) with alteration of the volume of the implant, whether greater or less than initially [OR greater volume = 0.30 (0.096; 0.83); OR smaller volume = 0.14 (0.008; 0.85)] (p < 0.018).

CONCLUSION

The occurrence of capsular contracture is a major problem with prosthetic breast surgery. The main risk factors identified to date are essentially in regard to the occurrence of a first episode. No significant risk factors for recurrence were identified. The best prevention appears to be an anterior capsulectomy with reducing the volume of the implant.

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 . IV.