Outcomes Analysis of Patients Undergoing Autoaugmentation after Breast Implant Removal:

Breast Implant Removal-Only: The Role of Targeted Compression

BACKGROUND

The number of women seeking explantation of their breast implants has increased in recent years. Anxiety due to potential health problems has been one of the major catalysts. Mastopexy with or without autoaugmentation and fat grafting are the main techniques used in breast implant removal surgery.

OBJECTIVES

To analyse the aesthetic and satisfactory outcomes after simple breast implant removal assisted by targeted compression.

METHODS

Twenty-eight patients were included in the series. Targeted compression of the breast after implant removal was performed during the 1st month. A satisfaction survey using a Likert scale was used before and after the final visit. The patients were followed up for 1 year.

RESULTS

The mean age of the patients was 41 years old, and the mean time between implantation and removal was 10 years. Subjective reasons for removal (46.4% of the patients) were more frequent in women with less time since implantation (5 years) versus 15 years for implant-related problems. A total of 57.14% of the women were satisfied with the aesthetic result, and 42.86% were very satisfied. Only 17.8% of the total would consider an aesthetic refinement.

CONCLUSIONS

Simple breast implant removal yields good aesthetic outcomes, and patients are satisfied with the results. Good management of compression of the breast and close follow-up to treat any collection in the pocket provides good adhesion and allows for effective management of the process of deflation and setting of the breast mound.

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.

The "Octopus Head" Dermoglandular Flap: A Novel Technique for Breast Tissue Rearranging after Implant Removal

Background

Patients with previous breast augmentation may need implant removal for mechanical complications or other causes. After prosthesis removal, the residual parenchyma can be reshaped through a mastopexy with rearrangement of breast tissue. Several techniques have been described in the literature, but none of them can be considered the gold standard. In this study, we present our preliminary experience in breast tissue rearranging after implant removal through a novel technique: the "octopus head" dermoglandular flap.

Methods

From January 2019 to October 2022, nine patients (18 breasts) underwent implant removal and simultaneous breast remodeling with the tissue obtained from the dermoglandular excess of the breast and shaped like an octopus head. Patient's demographic and clinical characteristics, postoperative complications, and patient-reported satisfaction were recorded.

Results

Mean age was 46.7 years. Body mass index ranged between 22.5 and 27.6 kg per m2. The majority of patients had moderate ptosis (67%). Breast implants were removed due to bilateral capsular contracture (n = 3), unilateral implant rupture with contralateral capsular contracture (n = 2), bilateral implant rupture (n = 3), and unilateral periprosthetic seroma (n = 1). We observed two minor complications: one postoperative hemorrhage with subsequent hematoma that was managed conservatively, and one nipple-areola complex malposition that underwent revision surgery. All patients were satisfied with the aesthetic and functional result.

Conclusions

The octopus head dermoglandular flap has proved to be a safe and reliable option for breast tissue rearranging after implant removal, providing a good and stable cosmetic result, a low complication rate, and high patient-reported satisfaction.

[Breast implant removal and simultaneous aesthetic optimization : Possibilities, technical considerations and outcome analysis]

BACKGROUND

Breast augmentation is currently the leading aesthetic surgical procedure worldwide. Thus, there is a high prevalence of women with breast implants demanding serious know-how and expertise concerning long-term complication management. Breast implant carriers can suffer from problems and pathologies making implant removal the best solution. The authors of this article have also been confronted more and more with the unspecified complex of symptoms named breast implant disease (BID), also called breast implant illness (BII). The treatment of choice for BID is implant removal.

OBJECTIVE

Analysis of problems and solutions regarding implant removal. Specific patient analysis according to patients' breast and body configuration. Technical considerations for surgery and preoperative planning. Evaluation of the authors' techniques.

PATIENTS AND METHODS

Evaluation of all patients over a period of 3 years requesting implant removal after esthetic augmentation mammoplasty at the authors' department. All patients were treated according to their specific demands regarding breast shape after implant removal. They either received additional mastopexy, lipofilling or both or simple implant removal without further intervention. Demographic, implant-specific, perioperative and postoperative data have been evaluated for all patients. Additionally, all patients were asked to complete a questionnaire regarding satisfaction and outcome.

RESULTS

We observed a trend for more satisfied patients with less invasive procedures (simple implant removal or simultaneous lipofilling vs. explantation and mastopexy ± lipofilling, 1.8 vs. 2.0 or 2.6, p = 0.198). Patients' average scoring was better if they suffered from an implant rupture (1.55 vs. 2.17, p = 0.053). Overall, a high patient satisfaction has been observed for all procedures.

CONCLUSION

Breast implant carriers can suffer from problems and pathologies making implant removal the best solution. Exactly these patients, consulting their doctor for those problems and questions seem to profit from implant removal. Simultaneous lipofilling and mastopexy of the breast are good options to nevertheless generate an esthetically pleasing result.

Inferior and Medially Based Breast Parenchymal Rotation Flap: A New Mastopexy Technique for Replacing Breast Volume After Breast Implant Explantation

BACKGROUND

Recently, a growing number of patients have been opting for the removal of breast implants. This often results in a degree of volume loss that can vary from mild to substantial, contingent on the size of the implant, with many patients requiring a mastopexy. Although autoaugmentation mastopexy serves as the primary surgical approach to restore shape and fill the void left by the implant, the fullness attained with the implant cannot be replicated through autoaugmentation.

OBJECTIVES

Our goal was to present the technical details and utilization of an inferomedial pedicle-based breast parenchymal flap, without rotational restriction from the parenchyma, for autoaugmentation after explantation.

METHODS

A retrospective chart review was performed of 12 patients who underwent surgery with this technique between the years of 2019 to 2022, with emphasis on reasons for explantation, early and late complications, and satisfaction scores on a Likert scale.

RESULTS

Capsular contracture was the most common reason for explantation, and only 2 patients experienced minor wound dehiscence in the early postoperative period. With a mean follow-up of nearly 2 years, no bottoming out was encountered in any of the patients, and satisfactory breast shape was obtained. Further, postoperative satisfaction was significantly higher than preoperative satisfaction.

CONCLUSIONS

The inferomedial-based parenchymal rotation flap is a new procedure that can be applied in this patient group because of its wide rotation arc and reliable vascularity. It is also an effective option for creating the desired conical breast shape in patients who do not want breast implants over the long term.

LEVEL OF EVIDENCE: 4

Breast Explantation With Simultaneous Mastopexy and Volume Restoration: An Analysis of Clinical Outcomes and Prospective Quality of Life

BACKGROUND

An increasing number of patients are undergoing explantation to alleviate symptoms attributed to the presence of a prothesis or dissatisfaction with the appearance of their breasts.

OBJECTIVES

The authors aim to evaluate the clinical effectiveness and quality of life (QoL) of simultaneous explantation, capsulectomy, and mastopexy for patients requesting implant removal.

METHODS

Two hundred sixty-two simultaneous explantation, capsulectomy, and mastopexy (ECM) procedures were performed in 131 patients from 2009 to 2019. Prospective QoL assessment was administered for all patients. Inclusion criteria included a minimum postoperative follow-up of 6 months and completion of a practice-generated patient reported outcomes (PRO) questionnaire. Wilcoxon signed-rank test was performed to compare changes in QoL scores.

RESULTS

Mean follow-up and BMI were 23 months (6 months to 8 years) and 24.8 kg/m2 (18-34 kg/m2), respectively. Mean age was 48.3 years (26-75 years). Autologous fat grafting was performed simultaneously in patients 47.3% (n = 62). The complication rate was 3.8% (n = 10 breasts) in 9 patients (6.9%). The overall reoperation rate was 7.3% of procedures (n = 19 breasts) and 9.2% of patients (n = 12), including secondary autologous fat grafting (11.3%, n = 7). PRO results demonstrated a significant improvement in all QoL domains, including physical well-being (P < .005), psychological well-being (P < .005), sexual well-being (P < .005), breast shape (P < .005), and breast appearance (P < .005). With respect to breast implant illness symptoms, 59 patients (88.1%) noted reduced pain, myalgias/arthralgias, and fatigue after ECM.

CONCLUSIONS

This study presents an effective paradigm to manage implant removal through simultaneous explantation, capsulectomy, and mastopexy with acceptable clinical outcomes and a significant improvement in QoL and breast aesthetics.

LEVEL OF EVIDENCE: 4

Safely Shaping the Breast After Implant Removal and Total Intact Capsulectomy Using the Mammary Imbrication Lift and Fixation Technique

Background

Implant-based breast augmentation is one of the most popular plastic surgery procedures performed worldwide. As the number of patients who have breast implants continues to rise, so does the number of those who request breast implant removal without replacement. There is little in the current scientific literature describing total intact capsulectomy and simultaneous mastopexy procedures.

Objectives

Here, the authors present their current method using the mammary imbrication lift and fixation technique after explant and total capsulectomy.

Methods

Between 2016 and 2021, a total of 64 patients (mean age: 42.95 years; range, 27-78 years) underwent the described mammary imbrication lift and fixation technique with bilateral breast implant removal and total capsulectomy.

Results

Mean follow-up was 6.5 months (range, 1-36 months). Postoperative complications included minor cellulitis in 1 patient (1.6%), late onset hematoma with infection in 1 patient (1.6%), fat necrosis and pulmonary embolism in 1 patient with prior history of thromboembolic events (1.6%), and breast scar irregularity in 4 patients (6.2%) who required subsequent minor scar revision or steroid injections. Two patients (1.6%) underwent revision surgery with bilateral breast fat grafting to improve shape and add volume.

Conclusions

The mammary imbrication lift and fixation technique described here can safely and simultaneously be performed with a total intact capsulectomy and explant procedure. This technique avoids wide undermining, intentionally opening the capsule, performing subtotal capsulectomy, and preserving blood supply to the breast tissue and nipple with low complication rates.

Level of Evidence 3

Simultaneous Salvage Auto-augmentation: Contemporary Strategy for Management of the Breast Explantation Patient

The treatment of patients requiring explantation of breast prostheses is a complicated clinical issue, for which a consensus regarding the best way forward is still evolving. We believe that simultaneous salvage auto-augmentation (SSAA) is a viable option for the treatment of patients with explantation.

Methods

Sixteen cases (32 breasts) were reviewed over a 19-year period. The management of the capsule is based on intraoperative findings and not on preoperative evaluation because of the poor interobserver correlation of Baker grades.

Results

The mean age and clinical follow-up duration were 48 years (range: 41-65) and 9 months, respectively. We observed no complications, and only one patient underwent unilateral surgical revision of the periareolar scar, under local anaesthesia.

Conclusions

This study suggests that SSAA with or without autologous fat injection is a safe option for women undergoing explantation, with potential aesthetic and cost-saving benefits. In the current climate of public anxiety regarding breast implant illness, breast implant-associated atypical large cell lymphoma, and asymptomatic textured implants, it is anticipated that the number of patients desiring explantation and SSAA will continue to increase.

The collagenase of the bacterium Clostridium histolyticum does not favor metastasis of breast cancer

BACKGROUND

Breast cancer is the most common malignancy among women worldwide. As survival rates increase, breast reconstruction and quality of life gain importance. Of all women undergoing breast reconstruction, approximately, 70% opt for silicone implants and 50% of those develop capsular contracture, the most prevalent long-term complication. The collagenase of the bacterium Clostridium histolyticum (CCH) showed promising results in the therapy of capsule contracture; however, its influence on residual cancer cells is unknown. The aim of this study was to investigate whether CCH-treatment negatively impacts breast cancer cells in vitro and in vivo.

METHODS

MDA-MB-231 and MCF-7 cells were used in this study. In vitro, we tested the influence of CCH on proliferation, wound healing, migration and cell cycle by MTT-assay, scratch-assay, transwell-migration-assay, and flow cytometry. In vivo, solid tumors were induced in immune-deficient mice. CCH was injected into the tumors and tumor growth and metastasis formation was monitored by caliper measurement, in vivo bioluminescence imaging and histology. Gene expression analysis was performed by microarray including 27,190 genes.

RESULTS

CCH-incubation led to a dose-dependent reduction in proliferation for both cell lines, while wound healing was reduced only in MDA-MB-231 cells. No morphological alterations were monitored in cell cycle or apoptosis. In vivo, bioluminescence imaging and histology did not show any evidence of metastasis. Although CCH led to changes in gene expression of breast cancer cells, no relevant alterations in metastasis-related genes were monitored.

CONCLUSION

CCH has no impact on tumor growth or metastasis formation in vitro and in vivo. This paves the way for first clinical trials.

One-Stage Mastopexy-Lipofilling after Implant Removal in Cosmetic Breast Surgery

INTRODUCTION

Revising unsatisfactory outcomes in breast augmentation represents one of the most challenging procedures in aesthetic breast surgery. Different techniques for revising unsatisfactory outcomes in breast augmentation have been described, which can be summarized in two options: implant replacement procedures and implant explantation procedures. Implant explantation procedures can be performed alone or in combination with other techniques to restore volume. Depending on the native volume, the shape and the elasticity of the remaining breast tissue, implant removal can be also associated with mastopexy, auto-augmentation mammoplasty or fat graft. This article portrays our series of combined mastopexy and lipofilling after implant explantation for revising unsatisfactory outcomes of breast augmentation.

MATERIAL AND METHOD

A prospective observational study was performed including all patients underwent cosmetic one-stage mastopexy-lipofilling after implant removal. Collected data included patient's age and BMI, smoking, previous scar location (periareolar, inframammary fold or trans-axillary), implant characteristics (size and location), reason why patient wants to remove the implant (capsular contracture, implant rupture, animation deformity, chronic pain, asymmetry), mean liposuction and fat injection volume, type of capsulectomy, mean operating time and postoperative complications. Cosmetic results and patient satisfaction were evaluated using the 5 points Likert scale and BreastQ reduction/mastopexy module, respectively.

RESULTS

A total of 14 patients (28 breasts) were included with a mean follow-up of 11.3 months. Mean liposuction and injection volumes were 980 mL and 295 mL, respectively. Regarding breast volume, a reduction in one-cup size was noted in 100% of cases. Only one patient (7.69%) requested additional breast volume and underwent a second fat grafting session. Regarding aesthetic outcomes, the mean scores for breast volume, shape, symmetry, quality of scars, nipple-areola complex and donor site shape were 4.2, 4.2, 4.9, 4, 4.3 and 4.7, respectively. BreastQ showed an improvement of patients reported satisfaction with a median (Quartile Rank) score increase of 19 points for the "satisfaction with breast" domain (p < .00001) and a decrease of 17 points for the "physical well-being" domain (p < .00001). "Satisfaction with outcomes" median (Quartile Rank) score was 72.

CONCLUSION

Combined mastopexy and lipofilling after implant removal represents a new tool in plastic surgeon armamentarium. This technique is indicated in patients who do not desire anymore breast implant, presenting ptosis of the remaining breast gland and donor site availability. Our article suggested that combined mastopexy and lipofilling achieves satisfactory aesthetic results and excellent patient-reported outcomes.

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 Challenges in Breast Implantation

Breast implantation (BI) is the most common plastic surgery worldwide performed among women. Generally, BI is performed both in aesthetic and oncoplastic procedures. Recently, the prevalence of breast implant-associated anaplastic large cell lymphoma (BIA-ALCL) or breast implant illness (BII) has aroused concerns. As a result, several countries, like Australia, Korea or the United Kingdom, introduced national registries dedicated to the safety and quality of BI surgeries. This narrative review aimed to focus on the clinical challenges, management and the current state of knowledge of BI. Both short and long-term outcomes of BI are determined by various alternatives and differences, which surgeons must consider during the planning and performing breast augmentation along with further complications or risk of reoperation. Proper preoperative decisions and aspects of surgical technique emerged to be equally important. The number of performed breast reconstructions is increasing, providing the finest aesthetic results and improving patient’s quality of life. Choice of prosthesis varies according to individual preferences and anatomical variables. A newly diagnosed cases of BIA-ALCL with lacking data on prevention, diagnosis, and treatment are placing it as a compelling medical challenge. Similarly, BII remains one of the most controversial subjects in reconstructive breast surgery due to unspecified diagnostic procedures, and recommendations.

Implant Replacement or Removal: What Happens after Capsular Contracture? A German Study Examining Breast Implant Revision Surgery and Patient Choices in 946 Cases

Introduction

Capsular contracture most often leads to implant revision surgery for aesthetic or reconstructive purposes. However, little is known about which operation is chosen when revision surgery has to be performed. We performed analysis of revision indications and performed revision surgery considering implant removal or replacement and additional surgical procedures. To our knowledge, this study presents the largest German single-center analysis regarding implant revision surgery after the onset of complications.

Methods

Retrospective 10-year data analysis of a single-center population undergoing breast implant revision surgery.

Results

Capsular contracture was the most frequent finding before reoperation, both removal and replacement (p < 0.05). It was linked to longer duration of in situ implant placement (p < 0.05) and more frequently in reconstructive patients (p < 0.05). Implant replacement was performed more often before definite implant removal for reconstructive patients (p < 0.05). Mean duration of in situ implant placement before definite removal was lower for reconstructive patients (p = 0.005). Overall reconstructive patients were older than aesthetic patients (p < 0.05). After implant removal, 61.7% of aesthetic patients chose to undergo mastopexy, 54.7% of reconstructive patients opted for autologous breast reconstruction, and 25.4% did not choose an additional surgical procedure after implant removal.

Conclusion

Significant differences are observed for reconstructive and aesthetic patients regarding indication leading to revision surgery, time of revision surgery, and the type of performed revision surgery itself. After implant removal, more than 60% of aesthetic patients undergo mastopexy, more than half of reconstructive patients choose autologous breast reconstruction, and over a quarter of patients choose no additional surgical procedures.

Finesse in Mastopexy and Augmentation Mastopexy

LEARNING OBJECTIVES

After studying this article, the participant should be able to: 1. Describe surgical techniques associated with mastopexy and mastopexy augmentation. 2. Understand the evolution of mastopexy and augmentation mastopexy. 3. Address patient goals. 4. Achieve a favorable cosmetic outcome.

SUMMARY

The surgical techniques associated with mastopexy and mastopexy augmentation have continued to evolve. Traditional mastopexy techniques have included periareolar, circumvertical, and inverted-T patterns; however, adjuncts to these have included the use of various surgical mesh materials, implants, and fat grafting. This evidence-based article reviews how the techniques of mastopexy and augmentation mastopexy have evolved to best address patient goals and provide a favorable cosmetic outcome.

The ECLiPSE Procedure as an Alternative to Mastopexy following Implant Removal

With the rise in number of breast implant removals for a variety of indications, strategies to improve aesthetic outcomes, while minimizing scars and operating time, will prove to be of benefit. We present here a novel periareolar sickle skin excision as a good option for women with mild to moderate ptosis and central loss of breast volume following implant removal/capsulectomy.

A Modified Superior Pedicle Mastopexy Technique With an Inferolateral-Based Auto Augmentation Flap

BACKGROUND

Current mastopexy techniques have evolved to decrease scar length and maintain a more consistent upper pole fullness, improving the breast shape. Many different approaches have tried to suspend breast tissues to achieve a more attractive upper pole. Most of the auto-augmentation mastopexy techniques use inferior-based breast parenchymal tissues to fill the upper part.

METHODS

This paper presents a modified approach to fill the breast's upper pole, with an inferolateral-based breast flap. The advantages of changing the inferior-based auto-augmentation technique to the inferolateral comprise improving blood supply and increasing repositioned breast flap's mobility. In our technique, the breast tissue used to auto-augment the upper pole receives its blood supply from pectoral perforators and lateral breast tissue. When surgeons need more flap mobility, they can raise the medial edge of this flap from the pectoral fascia to mobilize this flap higher on the chest wall, depending on the lateral blood supply. One other advantage is that when the inferolateral-based breast tissue is pulled in a superomedial direction to fill the upper part, the lateral ptotic breast tissues come closer to the breast meridian to meet with medial breast parenchyma easily. The tension on the vertical parenchymal suture line is reduced with this approach.

CONCLUSION

Our technique can be used in most mastopexy operations and for all types of ptosis except for cases with insufficient breast volume. It brings safety to the auto-augmentation procedure and is also time-saving. The stability of breast shape and upper pole fullness lasts as long as other auto-augmentation procedures; therefore, it can be an excellent alternative to other techniques.

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 .

The Treatment of Capsular Contracture Around Breast Implants Induced by Fractionated Irradiation: The Collagenase of the Bacterium Clostridium Histolyticum as a Novel Therapeutic Approach

BACKGROUND

Irradiation therapy limits the utilization of silicone implants for breast reconstruction due to a significant risk for capsular contracture. The injection of the collagenase of the bacterium Clostridium histolyticum (CCH) might trivialize this risk by providing a minimal-invasive treatment option by capsular contracture degradation. However, efficacy in degrading breast implant capsules induced by fractionated irradiation remains unclear.

METHODS

Twenty-four rats in three groups received miniature silicone implants in a submuscular pocket. After 3D dose calculation and treatment field definition, rats of two groups underwent fractionated radiotherapy (6 × 8 Gy) using a linear accelerator. A third group served as control. On day 120, one irradiated group received injections of 0.3 mg/ml collagenase. Administration of plain solvent solution served as control in the two other groups. Outcome parameters included CT-imaging, histology, vessel wall analysis, immunohistochemistry, chemical collagen quantification and gene expression analysis.

RESULTS

Fractioned irradiation leads to a significant increase in collagen deposition around silicone implants with higher capsule thickness and collagen density when comparing all groups. Additionally, significant alterations of collagen fiber deposition were evident. Vessel wall thickness was significantly increased after radiotherapy. The injection of collagenase led to a significant reduction of capsule thickness, collagen density and content. However, the collagenase application induced a significant overexpression of TGFβ1. No side effects were monitored.

CONCLUSIONS

The CCH proved to be a safe and effective approach to degrade capsule tissue induced by fractionated irradiation in an animal model. This may pave its way for clinical application in implant-based breast reconstruction patients.

LEVEL OF EVIDENCE

This journal requires that authors assign a level of evidence to each submission to which Evidence-Based Medicine rankings are applicable. This excludes Review Articles, Book Reviews, and manuscripts that concern Basic Science, Animal Studies, Cadaver Studies, and Experimental Studies. 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 .

Fat Grafting and Auto-Augmentation Mastopexy After Breast Implant Removal: Technique and Evaluation of Outcomes Using BREAST-Q

BACKGROUND

Auto-augmentation mastopexy after implant removal has been described as a possible alternative for women who do not opt for implant replacement and decline major reconstructive surgery.

OBJECTIVES

This study aimed to evaluate patient satisfaction after auto-augmentation mastopexy relative to the final breast volume and to assess the role of fat grafting on patients' satisfaction and quality of life according to the BREAST-Q questionnaire.

METHODS

Forty-seven breasts from 28 patients who underwent implant removal and auto-augmentation mastopexy were reviewed; 9 patients (group 1) were primarily treated with several fat grafting sessions with subsequent auto-augmentation, 5 (group 2) were treated primarily with auto-augmentation, but subsequently expressed a wish for breast augmentation by lipofilling, and 14 patients (group 3, control) had only auto-augmentation.

RESULTS

Group 1 patients maintained their breast volume, and showed significant improvements in breast satisfaction, psychosocial well-being, and contentment with breast surgery outcomes (P = 0.01, ˂0.01, and ˂0.01, respectively). However, the physical well-being of this group, as well as response to final cup size or interaction parameters, did not improve (P = 0.06). In group 2, all except 1 patient had breast volume reduction to A cup, as was the case with one-third of the patients in control group 3 (group 3A, n = 5) who scored lower, and thus were less satisfied with the breast auto-augmentation than group 3B, who achieved final bigger cup sizes (P ˂ 0.01).

CONCLUSIONS

Auto-augmentation mastopexy resulted in substantial improvements in the parameters measured by BREAST-Q. Thus, combined auto-augmentation mastopexy and lipofilling provided a better alternative treatment after breast implant removal.

LEVEL OF EVIDENCE: 4

Adjunctive Procedures and Informed Consent with Breast Implant Explantation

BACKGROUND

The use of injectable or implantable materials or devices in the breast for augmentation or reconstruction has a history of innovation and controversy. Staying current in the field of breast implant management today means understanding not just the published literature but also its absence. Cutting edge breast implant treatment also means awareness of patient and media-driven interests and requests.

METHODS

Adjuvant treatments to optimize physical and psychological well-being with breast implant explantation, without replacement, will be addressed through literature review and analysis.

RESULTS

The body of literature demonstrates evidence of variable, and sometimes contradictory, methods to address adjunctive management of systemic concerns, the capsule, soft tissue of the native breast/chest, and treatment timing related to explantation. Few approaches are supported by very strong evidence. Many treatment methodologies are defensible. Any current attempts at optimizing management in patients undergoing explantation will be somewhat impaired by the ongoing nebulousness of related issues, such as breast implant illness. It seems clear, therefore, that plastic surgeons must fulfill their duty as caregivers to provide explantation surgery, either to attempt to improve physical health, mental well-being, or simply to respect patients' wishes. A well-informed surgeon will likely employ a variety of approaches, adapted to the unique patient presentations at hand.

CONCLUSION

It is expected that consultations, incisions, tissue rearrangements, surgical timing, and treatment indications will continue to vary as scientific investigation strives to understand and to optimize treatment of patients experiencing difficulty with breast implants.

Modified anterior intercostal artery perforator flap (AICAP) for autologous breast volume restoration after explantation

Explantation of breast implants has become increasingly common. This study aimed to analyze breast auto-augmentation following implant explantation (using a laterally designed anterior intercostal artery perforator [AICAP] flap) in patients who did not need new implants and required volume preservation. Twenty-four patients (48 breasts) aged 31-67 years (mean, 52.4 years) with body mass index (BMI) between 24.43 and 29.34 (mean, 27.32) kg/m2 underwent this procedure. All patients had implant-related problems, such as recurrent capsular contracture (n=11), seroma (n=2), animation deformity (n=3), rupture-induced bleeding (n=5), and breast implant disease (n=3). Sizes of implants removed ranged from 215 to 355 ml. The mean flap size was 23.9 cm × 7.5 cm, and the average flap thickness was 2.3 cm (range, 2.0-3.2 cm). Flap survival was clinically examined postoperatively by ultrasonography. Pre- and postoperative final breast volumes were compared by direct patient observation and independent photograph observation by three plastic surgeons according to a 4-point scale (bad=1, regular=2, good=3, and excellent=4) and the brassiere size. All flaps were completely viable after harvesting. No postoperative signs of fat necrosis were observed, and independent plastic surgeon evaluation revealed good and excellent results in all cases. Patient satisfaction evaluated by BREAST-Q data was >90%. This new design, AICAP flap (with a lateral thoracic extension), can be safely used for breast volume restitution after breast implant explantation with high patient satisfaction. This flap exhibited reasonable potential of providing additional volume in patients who undergo implant explantation and require the preservation of similar volume.

Simultaneous Mastopexy Explantation With a Vertical Bipedicle and Novel Open Pattern Marking Technique

There are limited studies in the plastic surgery literature that detail technical considerations in simultaneous breast implant removal and mastopexy procedures. These procedures are difficult, with significant potential for complications and poor cosmesis. The current plastic surgery literature describes a limited number of techniques that address these concerns, virtually all of which are variants of superior or superior medial pedicle vertical pattern mastopexy. This paper details a safe technique for simultaneous explantation and mastopexy with a novel open marking pattern and vertical bipedicle, which can restore breast cosmesis following implant removal. The study will briefly retrospectively review the results of a consecutive series of 86 patients who underwent this procedure from November 2018 to November 2019, with no incidence of partial or total nipple-areola complex necrosis. Thus, the technique is safe and allows the flexibility for intraoperative adjustments that are necessary for these procedures. A future study will conduct a more in-depth analysis of the results.

The Effect of Omega-3 Fatty Acids on Capsular Tissue around the Breast Implants

BACKGROUND

One of the most common complications of the use of foreign material, in both reconstructive and cosmetic breast surgery, is capsular contracture. Historically, research on capsular contracture has focused mainly on reducing bacterial contamination through antibiotic solutions. Only secondary studies have focused on pharmacological control of the inflammation process, with particular attention paid to the main inflammation pathway, the arachidonic acid cascade. An important role in the arachidonic acid cascade is played by the omega-3 fatty acids, which are found mainly in oily fish and food supplements. The goal of the present study was to investigate the effects of omega-3 supplements on capsule contraction.

METHODS

Female C57BL/6 mice were implanted with custom-made silicone gel implants and divided into two groups. The treated group received omega-3 oil daily while the control group received water daily by gavage. After mice were euthanized, samples of capsules were collected to evaluate thickness and transforming growth factor (TGF)-β expression.

RESULTS

The results showed that capsules in the omega-3 group were thinner and more transparent than those found in the control group. In addition, a significant downregulation of the TGF-β2 gene transcript was observed in the omega-3 group.

CONCLUSIONS

Omega-3 supplementation seems to be effective in reducing the occurrence of capsular formation, mainly through inhibition of the TGF-β pathway and impairment of collagen deposit. Omega-3 supplementation is a simple and promising method that could be used to prevent or at least reduce capsular contracture after silicone implant surgery.

Long-term results measured by BREAST-Q reveal higher patient satisfaction after "autoimplant-mastopexy" than augmentation-mastopexy

Background

The aim of a mastopexy is to raise the breast projection, tighten the skin envelope, and place the nipples in an optimal position in projection to the inframammary fold. This procedure is often combined with prosthetic implants or an autoimplant. Given the current increasing demand for the use of autologous tissue, we evaluated mastopexies combined with either an autoimplant or prosthetic implant in terms of patient satisfaction and long-term results.

Methods

We evaluated 34 patients who underwent a mastopexy with simultaneous breast prosthesis or an autoimplant. During follow-ups we obtained standardized breast measurements, BREAST-Q score, and pre- and postoperative photographs to perform photometric measurements.

Results

BREAST-Q score of patients that underwent autoimplant-mastopexies revealed a higher patient satisfaction with significant differences in satisfaction with breast appearance (69±18 vs. 55±16, P=0.03) and outcome (71±18 vs. 48±26, P=0.009). Regarding breast shape, photometric evaluations presented a significantly different breast shape with higher upper pole fullness in augmentation-mastopexy patients. No statistical significance between long-term results and complication rates could be observed in either patient groups.

Conclusions

The BREAST-Q score implies a higher overall long-term satisfaction in patients that received autoimplant-mastopexy with similar long-term results compared with augmentation-mastopexy. Nevertheless, individual decision-making is necessary and should be based on the degree of ptosis, existing breast volume, previous operations, and patients' preferences regarding postoperative breast shape and projection.

Breast Auto-augmentation (Mastopexy and Lipofilling): An Option for Quitting Breast Implants

BACKGROUND

Breast augmentation with implants is one of the most commonly performed plastic surgical procedures, but has potential complications-asymmetry, implant displacement, rippling and wrinkling, capsular contracture, late seromas, and benign and malignant tumors-and potential financial costs. The auto-augmentation procedure, with mastopexy and lipofilling, is a second option to offer to patients who do not desire to continue with breast implants in secondary procedures.

OBJECTIVE

This study aimed to present a series of patients who intended to quit having breast implants, and they went to an auto-augmentation procedure, with mastopexy and lipofilling.

METHOD

The study included patients who underwent a mastopexy plus lipofilling following breast implant removal. The indications for the surgical procedure were: desire of not having breast implants anymore and smaller breasts, capsular contracture, and implant rupture. The surgical procedure is detailed. Fat grafting and mastopexy are done immediately at the time of explantation.

RESULTS

A total of 26 patients (mean age 59.1 years) underwent mastopexy plus lipofilling following breast implant removal. The mean follow-up was 18 months. The mean amount of lipofilling was 258 cc. No major complications were observed, no infection, dehiscence, hematoma, or seroma. One patient had an oil cyst which was handled with resection.

CONCLUSION

The auto-augmentation procedure after implant removal with local flaps and lipofilling is the better option for patients in whom breast implants are not an option anymore. Complication and reoperation rates are low and patient satisfaction is good.

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 .

Combined Breast Implant Explantation and Multilevel Mastopexy Technique

Patients dissatisfied with their breast implants are faced with 2 options: secondary augmentation or removal of the implants. Simple removal of breast implants often leads to wide, deflated, and laterally displaced breasts which are notoriously difficult to reconstruct. We present a surgical technique that was specifically developed to recreate the breast mound using the wide laterally displaced breast tissue left after breast implant removal.

The Collagenase of the Bacterium Clostridium histolyticum in the Treatment of Irradiation-Induced Capsular Contracture

BACKGROUND

Irradiation therapy is an important pillar in the treatment of breast cancer. However, it can trigger capsular fibrosis, the most significant complication of implant-based breast reconstruction. As collagen is the main component of fibrotic capsules, the collagenase of the bacterium Clostridium histolyticum poses a potential treatment option for this pathological condition.

METHODS

Thirty-six rats received miniature silicone implants on their backs. On day 1, the implant sites of two groups were irradiated with 10 Gy. On day 120, one irradiated group received collagenase injections into the implant pockets (n = 12). Non-irradiated (n = 12) and irradiated capsules (n = 12) were injected with plain solvent solution serving as controls. Data were analyzed by means of in vivo imaging, histology, immunohistochemistry and gene expression analysis.

RESULTS

Compared with both controls, the injection of collagenase led to significantly thinner capsules. This was verified by in vivo imaging and histology. Although irradiation provoked alterations in capsule collagen structure and vessel wall thickness, the application of collagenase resulted in a significant reduction of collagen density. This was accompanied by an up-regulation of VEGF-A gene expression. Of note, hematoma formation inside the implant pocket occurred in two cases after collagenase injection.

CONCLUSIONS

The collagenase of the bacterium Clostridium histolyticum is effective in degrading irradiation-induced capsular fibrosis around silicone implants. Hematoma formation occurred most likely because of irradiation-induced alterations in vessel wall architecture and capsule vascularization. Further studies need to be performed to address the clinical safety of this novel treatment option.

Mastopexy and Mastopexy-Augmentation

Mastopexy and mastopexy-augmentation are aesthetic breast surgeries that seek to create youthful, beautiful appearing breasts. Age, hormonal changes, or weight loss can lead to alterations that require addressing the skin envelope and breast parenchyma. Many surgical approaches have been described including periareolar, vertical, and Wise pattern techniques, but most modern mastopexies include manipulation of the breast parenchyma to improve the longevity of breast ptosis correction. Mesh support of the ptotic breast is an extension of this paradigm shift and seeks to restore the lost strength of the support structures of the breast. Despite initial controversy, single stage mastopexy-augmentation has been demonstrated to be a safe option for appropriately selected and informed patients who desire both correction of shape and volume. Revisions may still be necessary based on patient and surgeon goals for correction. Evolving technologies will likely continue to enhance the ability of aesthetic plastic surgeons to provide pleasing, durable correction of breast ptosis.

Long-Term Effects of the Collagenase of the Bacterium Clostridium histolyticum for the Treatment of Capsular Fibrosis After Silicone Implants

BACKGROUND

Capsular contracture remains the most frequent long-term complication after augmentation mammoplasty with silicone implants. Thereby, the main part of the fibrotic capsule is collagen. The collagenase of the bacterium Clostridium histolyticum is approved for the treatment of fibrotic diseases and has been demonstrated to be effective for capsular fibrosis treatment in the short term. However, long-term effectiveness is currently unknown but mandatory for clinical utilization.

MATERIALS AND METHODS

Forty-eight rats received miniature silicone implants and an injection with either collagenase (treatment group) or plain solvent solution (control group) 120 days post insertion. Ten and 60 days after the injections, the rats underwent 7-Tesla magnetic resonance imaging (MRI) and high-resolution ultrasound (HR-US). Capsule tissue was harvested, and capsule thickness and collagen density were evaluated through histology. Furthermore, the expression levels of inflammatory (CD68, IL4, IL10, IL12, IL13), pro-, and anti-fibrotic (TGFb1, TGFb3, Smad3, Col1-4) genes were analyzed using qRT-PCR.

RESULTS

On days 10 and 60 after injection of collagenase, histology showed that capsule thickness was significantly reduced in the treatment group when compared with the control (p < 0.05). Thickness measurements were verified by MRI and HR-US analysis. Skin perforation occurred in two cases after collagenase injection. The initial up-regulation of pro-fibrotic and inflammatory genes 10 days after collagenase injection did not persist in the long term. Contrarily, on day 60, a slight trend towards lower expression levels with a significant down-regulation of TGFb3 was detected in the treatment group.

CONCLUSION

The collagenase of the bacterium C. histolyticum effectively degrades capsular fibrosis around silicone implants with stable outcomes throughout 60 days post injection. Skin perforation and adequate and uniform drug distribution within the implant pocket are issues that need to be addressed. Further studies are warranted to clarify whether collagenase injections have the potential to become a viable treatment option for capsular contracture.

NO LEVEL ASSIGNED

This journal requires that authors 46 assign a level of evidence to each article. For a full 47 description of these Evidence-Based Medicine ratings, 48 please refer to the Table of Contents or the online 49 Instructions to Authors. www.springer.com/00266 .

Partial Breast Reconstruction with Goldilocks Technique After Excision of Giant Fibroadenoma: A Case Report

Giant juvenile fibroadenomas are relatively rare, accounting for less than 1% fibroadenomas. Large breast tumors create significant asymmetry and provide unique reconstructive challenges after removal. In this case, we describe a 21-year-old female with delayed presentation of a giant fibroadenoma of the right breast. This represents an unusual presentation of benign breast disease requiring reduction of the skin envelope, extensive glandular resection, lower pole reconstruction, and free nipple grafting to achieve symmetry with the opposite breast. A novel modification of the Goldilocks mastectomy technique is described for partial breast reconstruction. Adaptation of the Goldilocks mastectomy technique provides adequate soft tissue for partial breast reconstruction. Using the lower pole deepithelialization breast skin flap provides autologous vascularized tissue to supplement volume loss after tumor and glandular excision. Benign breast disease can create significant breast deformities. Application and combination of the Goldilocks mastectomy technique allow for partial breast reconstruction without the need for an additional donor site or prosthetic devices.

The Collagenase of the Bacterium Clostridium histolyticum for the Treatment of Capsular Fibrosis after Silicone Implants

BACKGROUND

The main part of the fibrotic capsule in capsular contracture is collagen. The collagenase of the bacterium Clostridium histolyticum is U.S. Food and Drug Administration approved for the treatment of Dupuytren contracture and might be capable of dissolving the fibrotic capsule surrounding silicone implants.

METHODS

One hundred twenty days after insertion of miniature silicone implants the authors performed in vitro studies (n = 14) for optimum dosage-finding and subsequent in vivo studies (n = 36) to evaluate application method and efficiency. Data analysis involved histologic measurements of capsule thickness and collagen density; 7-T magnetic resonance imaging-based in vivo imaging; and polymerase chain reaction analysis of inflammatory, profibrotic, and antifibrotic markers.

RESULTS

Compared with the control group, each dosage showed significantly thinner capsules after in vitro incubation. Skin digestion occurred in 0, 1 (7 percent), and 11 cases (80 percent) after incubation with 0.3, 0.9, and 1.8 mg/ml, respectively. In vivo application showed a dosage-dependent decrease in capsule formation, which was more prominent in lower capsule parts, seen by magnetic resonance imaging. In vivo skin perforation was seen in two (17 percent) and six cases (50 percent) after injection of 0.3 mg/ml and 0.9 mg/ml, respectively. Profibrotic and inflammatory markers were significantly up-regulated 10 days after collagenase injection.

CONCLUSIONS

The collagenase of C. histolyticum is capable of dissolving the fibrotic capsule surrounding silicone implants. Skin perforation occurred most likely because of mechanical irritation after complete digestion of the capsule. Further studies are required to pave the way for safe clinical application.

The BREAST-Q in surgical research: A review of the literature 2009-2015

BACKGROUND

Health outcomes research has gained considerable traction over the past decade as the medical community attempts to move beyond traditional outcome measures such as morbidity and mortality. Since its inception in 2009, the BREAST-Q has provided meaningful and reliable information regarding health-related quality of life (HRQOL) and patient satisfaction for use in both clinical practice and research. In this study, we review how researchers have used the BREAST-Q and how it has enhanced our understanding and practice of plastic and reconstructive breast surgery.

METHODS

An electronic literature review was performed to identify publications that used the BREAST-Q to assess patient outcomes. Studies developing and/or validating the BREAST-Q or an alternate patient-reported outcome measure (PROM), review papers, conference abstracts, discussions, comments and/or responses to previously published papers, studies that modified a version of BREAST-Q, and studies not published in English were excluded.

RESULTS

Our literature review yielded 214 unique articles, 49 of which met our inclusion criteria. Important trends and highlights were further examined.

DISCUSSION

The BREAST-Q has provided important insights into breast surgery highlighted by literature concerning autologous reconstruction, implant type, fat grafting, and patient education. The BREAST-Q has increased the use of PROMs in breast surgery and provided numerous important insights in its brief existence. The increased interest in PROMs as well as the underutilized potential of the BREAST-Q should permit its continued use and ability to foster innovations and improve quality of care.

Breast Auto-Augmentation: A Versatile Method of Breast Rehabilitation-A Retrospective Series of 107 Procedures

Background

Breast auto-augmentation (BAA) using an inferior pedicle dermoglandular flap aims to redistribute the breast tissue in order to increase the fullness in the upper pole and enhance the central projection of the breast at the time of mastopexy in women who want to avoid implants. The procedure achieves mastopexy and an increase in breast volume.

Methods

Between 2003 and 2014, 107 BAA procedures were performed in 53 patients (51 bilateral, 2 unilateral and 3 reoperations) with primary or secondary ptosis of the breast associated with loss of fullness in the upper pole (n=45) or undergoing explantation combined with capsulectomy (n=8). Six patients (11.3%) had prior mastopexy and 2 (3.7%) patients had prior reduction mammoplasty. The mean patients' age was 41 years (range, 19-66 years). All patients had preoperative and postoperative photographs and careful preoperative markings. Follow-up ranged from 6 months to 9 years (mean, 6.6 months).

Results

The range of elevation of the nipple was from 6 to 12 cm (mean, 8 cm). The wounds healed completely with no complications in 50 (94.3%) patients. Three patients had complications including 2 (3.7%) hematomas and 1 (1.9%) partial necrosis of the nipple-areola complex. Three (5.7%) patients were dissatisfied with the level of mastopexy achieved underwent a further procedure. No patient complained of scar hypertrophy.

Conclusions

BAA is a versatile technique for women with small breasts associated with primary or secondary ptosis. It is also an effective technique for the salvage of breasts after capsulectomy and explantation.