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Background: Silicone breast implant design has evolved over the last 50 years. Regulatory bodies including the FDA require data to support the modifications designed to improve the safety, efficacy, longevity, and biocompatibility of breast implants., Objectives: The authors reviewed the 3-year data on the safety and effectiveness of Motiva (Establishment Labs Holdings, Inc., Alajuela, Costa Rica) SmoothSilk silicone gel-filled breast implants submitted to the FDA. The current submitted data include the primary breast augmentation and revisional augmentation cohorts., Methods: The Motiva IDE is a prospective, single-arm, multicenter, 10-year pivotal study in which data are collected on breast augmentation, reconstruction, and revisional surgery. Three-year data were submitted to the FDA on adverse events, reoperations, patient and physician satisfaction, connective tissue diseases, and quality of life validated instruments. A subset of the patients underwent annual magnetic resonance imaging (MRI) at years 1, 2, and 3 to screen for implant rupture., Results: A total of 451 patients were implanted in the primary augmentation cohort and 109 patients in the revisional augmentation cohort. There were 218 patients enrolled in the MRI cohort. Reported rates for reoperation for any reason were 6.1% in the primary augmentation cohort (92.4% follow-up) and 25.8% in the revisional augmentation cohort (88.7% follow-up)., Discussion: Motiva implants were first introduced in 2010. The 3-year Motiva data suggests that the leading cause of revisional surgery has shifted from capsular contracture and rupture to more subjective indications for reoperation such as malposition and size change., Conclusions: Three-year data from the primary augmentation and revisional augmentation cohorts submitted to the FDA demonstrate the safety and efficacy of the Motiva implants. There were low complication rates for implant-related complications and high surgeon and patient satisfaction., (© The Author(s) 2024. Published by Oxford University Press on behalf of The Aesthetic Society.)

Background: A delayed seroma around breast implants is the most common clinical presentation of breast implant-associated anaplastic large cell lymphoma (BIA-ALCL). Interleukin-9 (IL-9), IL-10, and IL-13 concentrations are significantly higher in BIA-ALCL than in benign seromas, offering a means to distinguish between these conditions., Objectives: The aim of this research was to test the ability of a lateral flow assay (LFA) to detect high concentrations of IL-9 rapidly. In addition, the authors compared CD30 and IL-9 LFAs for distinguishing BIA-ALCL from benign seromas., Methods: Samples of 26 seromas (15 benign, 11 malignant) were tested on in-house-prepared LFA strips for IL-9 and CD30. Nanoparticle-conjugated antibodies specific to IL-9 and CD30 were used for detection. The intensity of both the test line (TL) and a control line (CL) were analyzed and the TL/CL ratio was calculated. IL-9 protein and IL-9 transcription factor PU.1 were stained in BIA-ALCL lines and clinical samples., Results: The IL-9 LFA could reliably distinguish BIA-ALCL from benign seromas when the IL-9 concentration was >10 ng/ml. The CD30 LFA was positive in all 11 malignant cases. In 1 case with only faint CD30 and IL-10 TLs, the IL-9 LFA was clearly positive. Immunohistochemistry showed that IL-9 and PU.1 were present in tumor cells in BIA-ALCL lines and clinical samples., Conclusions: Concentrations of IL-9 >10 ng/ml reliably distinguished BIA-ALCL from benign seromas. Moreover, the IL-9 LFA could detect BIA-ALCL when both the CD30 and IL-10 LFAs were not definitive, suggesting a multiplex LFA measuring IL-9, CD30, and IL-10 might be more effective in detecting BIA-ALCL in selected cases., (© The Author(s) 2024. Published by Oxford University Press on behalf of The Aesthetic Society. All rights reserved. For commercial re-use, please contact reprints@oup.com for reprints and translation rights for reprints. All other permissions can be obtained through our RightsLink service via the Permissions link on the article page on our site—for further information please contact journals.permissions@oup.com.)

Background: Cosmetic breast surgeries such as augmentation, mastopexy, and reduction are common aesthetic medical procedures for enhancing physical appearance. Despite their popularity, the influence of these surgeries on subsequent breast reconstruction for cancer patients remains underexplored., Objectives: In this study we sought to investigate the effects of previous cosmetic breast surgeries on the outcomes of breast reconstruction., Methods: A retrospective chart review was conducted from January 2011 to May 2023. This analysis compared patients with histories of implant augmentation, breast reduction, mastopexy, and augmentation mastopexy with those receiving reconstruction without any cosmetic surgery history. Demographics, comorbidities, complications, revisions, and BREAST-Q surveys were collected. Statistical analysis was performed with SPSS, with significance set at P < .05., Results: The study included 124 patients (50 autologous, 74 implant) with a history of cosmetic breast surgery (102 implant augmentations, 17 breast reductions, 5 mastopexies, and 9 augmentation mastopexies). They were analyzed in comparison with 1307 patients (683 autologous, 624 implant) without previous cosmetic breast surgery. Patients with previous cosmetic surgeries showed a higher incidence of hematoma with tissue expander placement. A preference for implant-based reconstruction was more common among patients with an augmentation history (P < .001), whereas autologous reconstruction was more common in those with a history of breast reduction (P = .047). Patients with a history of breast augmentation had on average significantly more breast revisions (P < .05)., Conclusions: In this study we demonstrate a significantly higher hematoma rate and number of revisions in patients with previous cosmetic breast surgery when compared to patients without a history of cosmetic surgery. Furthermore, we suggest that types of cosmetic breast surgery influence the decision-making process regarding implant vs autologous reconstruction., (© The Author(s) 2024. Published by Oxford University Press on behalf of The Aesthetic Society. All rights reserved. For commercial re-use, please contact reprints@oup.com for reprints and translation rights for reprints. All other permissions can be obtained through our RightsLink service via the Permissions link on the article page on our site—for further information please contact journals.permissions@oup.com.)

Background: Immediate breast reconstruction (IBR) with direct to implant (DTI) is the preferred method of reconstruction by many surgeons and patients, however, acellular dermal matrix (ADM) and other synthetic meshes are expensive especially in low- and middle-income countries. AIM OF THE WORK: To evaluate the technique, indications, aesthetic outcomes, and short and long-term complications of DTI breast reconstruction performed with Ultrapro®, a low-cost alternative mesh to ADM and other synthetic meshes., Methods: Our study is a prospective cohort study that was conducted on 133 patients who experienced IBR following nipple-sparing mastectomy (NSM) or skin sparing mastectomy (SSM) using silicone implants and Ultrapro® mesh between December 2020 and December 2023. Techniques used were either sub-pectoral or pre-pectoral, evaluating aesthetic outcome, complication rate and patient satisfaction using breast Q questionnaire., Results: We included 133 patients (141 breasts) with a median age of 39 years. Mean duration of follow up: 20.364 ± 5.39 months. The sub-pectoral and the pre pectoral techniques were used for 80 breasts and 61 breasts respectively. We used the Ultrapro® mesh in all our patients. Smooth round silicone implants were used. The overall Major complications rate was 16.3%. 8 implants (5.7%) were lost within 6 months post-operatively while 2 implants were removed in the late post-operative period (after 6 months) one due to rupture and the other due to local recurrence. Capsular contracture Baker 3 and 4 was observed in 36 breasts (25%), 31 of them had post mastectomy radiotherapy treatment. 11 (7.8%) were managed by capsulotomies and re-insertion of the same implant. Radiotherapy was a significant risk factors for major complications and capsular contracture with p value of (0.01) and (0.0001) respectively., Conclusion: DTI in properly selected patients offers excellent outcomes and patient satisfaction. The complication rate is low and improves with the experience of the surgeon. The Ultrapro® mesh is a safe, low-cost alternative to ADM or other synthetic meshes especially in low socioeconomic countries. Radiotherapy is a significant risk factor for major complications and capsular contractures., Competing Interests: Declarations Ethics approval and consent to participate Ethical approval was obtained from Baheya Research Ethics committee (BEC) at Baheya Center for Early Detection and Treatment of Breast Cancer in Egypt. Baheya IRB protocol number: 202006030013. Consent for publication All patients provided signed written informed consent for publication. Competing interests The authors declare no competing interests., (© 2024. The Author(s).)

Background: Capsular contracture after implant-based breast reconstruction is not an uncommon problem and affects reconstruction outcomes. It can be influenced by various factors, such as the plane of implant placement, implant surface and implant type. This systematic review and meta-analysis aimed to evaluate how the abovementioned risk factors can affect capsular contracture rates., Methods: A systematic review and meta-analysis was performed. PubMed MEDLINE, EMBASE (OvidSP) and Cochrane Library were searched. Comparison groups included subpectoral versus prepectoral implant placement, smooth versus textured implants and saline versus silicone implants. Odds ratios (ORs) were calculated for capsular contracture for each group. The level of evidence was evaluated using the Oxford Centre for Evidence-Based Medicine., Results: Twenty-three studies met the inclusion criteria. Sixteen studies compared subpectoral versus prepectoral implant placement, with no statistically significant differences in capsular contracture rates [OR, 1.21; 95% confidence interval (95% CI), 0.75-1.95; P = 0.44]. Five studies compared smooth versus textured implants, with no statistically significant differences in capsular contracture rates (OR, 0.99; 95% CI, 0.50-1.93; P = 0.97). Two studies compared saline versus silicone implants for capsular contracture. Patients receiving saline implants had significantly lower capsular contracture rates than silicone implants (OR, 0.19; 95% CI, 0.08-0.43; P < 0.0001)., Conclusions: Implant-based breast reconstruction using saline implants demonstrated reduced capsular contracture rates compared to silicone implants. However, no significant differences were observed in capsular contracture rates between subpectoral versus prepectoral implant placement and smooth versus textured implants., (Copyright © 2024 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by Elsevier Ltd. All rights reserved.)

Purpose: Implant-based breast reconstruction (IBR) is being increasingly performed with implant placed above the pectoral muscle (pre-pectoral), instead of below the pectoral muscle (sub-pectoral). Currently, there is a lack of comparative data on clinical and patient-perceived outcomes between pre- vs. sub-pectoral IBR. We investigated whether this difference in surgical approach influenced clinical or patient-perceived outcomes., Methods: This prospective non-randomised longitudinal cohort study (ClinicalTrials.gov identifier: NCT04842240) recruited patients undergoing immediate IBR at the Leeds Breast Unit (Sep 2019-Sep 2021). Data collection included patient characteristics and post-operative complications. Patient-Reported Outcome Measures were collected using the BREAST-Q questionnaire at baseline, 2 weeks, 3- and 12-months post-surgery., Results: Seventy-eight patients underwent IBR (46 patients pre-pectoral; 59% vs. 32 patients sub-pectoral; 41%). Similar complication rates were observed (15.2% pre-pectoral vs. 9.4% sub-pectoral; p = 0.44). Overall implant loss rate was 3.8% (6.5% pre-pectoral vs. 0% sub-pectoral; p = 0.13). Respective median Breast-Q scores for pre- and sub-pectoral IBR at 3 months were: breast satisfaction (58 vs. 48; p = 0.01), psychosocial well-being (60 vs. 57; p = 0.9), physical well-being (68 vs. 76; p = 0.53), and Animation Q scores (73 vs. 76; p = 0.45). Respective Breast-Q scores at 12 months were: breast satisfaction (58 vs. 53; p = 0.3), psychosocial well-being (59 vs. 60; p = 0.9), physical well-being (68 vs. 78; p = 0.18), and Animation Q scores (69 vs. 73; p = 0.4)., Conclusions: This study demonstrates equivalent clinical and patient-perceived outcomes between pre- and sub-pectoral IBR. The study findings can be utilised to aid informed decision making regarding either surgical option., (© 2024. Crown.)

Background: This study explored the surgical management and reconstruction options for augmented breasts in the context of breast conservation therapy (BCT) for breast cancer. The authors hypothesized that there would be no difference in the rates of complications, revisions, or patient satisfaction in patients who maintained their breast augmentation versus those who had their implants removed in the context of BCT., Methods: The authors conducted a retrospective review of 142 patients who underwent BCT at a single center from March of 2016 to March of 2022. The study included patients who had a preexistent cosmetic augmentation at the time of breast cancer diagnosis and BCT. Patient demographics, clinical and treatment characteristics, breast implant details, reconstructive technique, complications, and revisions were recorded. Patient-reported outcomes were assessed using the BREAST-Q BCT module., Results: Ninety-three patients (65.5%) chose to maintain their implants, whereas 49 (34.5%) elected to have them removed during BCT. Patients with submuscular implants were more likely to maintain their implants. Oncoplastic mastopexy was associated with higher complication rates, particularly in patients opting for implant downsizing. However, multivariate logistic regression did not identify implant management strategy as an independent predictor for complications or revisions. Surgical-site infection was the only predictor of implant explantation. Patient-reported outcomes did not differ significantly between the different implant management cohorts., Conclusions: This study demonstrates that maintaining breast implants during BCT does not increase the risk of complications or revisions. Overall, BCT in augmented women was found to be a safe approach, with high patient satisfaction., Clinical Question/level of Evidence: Risk, III., (Copyright © 2024 by the American Society of Plastic Surgeons.)

Background: Breast implants are not lifelong, with implant rupture being the third leading cause of revisional surgery in augmented women. Noncontrast MRI is a reliable tool to assess implant integrity; however, false positive and false negative diagnoses have been reported due to an incorrect interpretation of MRI signs. This study aims to investigate the incidence of these misleading results, comparing MRI findings with intraoperative surgical observations and exploring signs of nonunivocal interpretation., Materials and Methods: Between March 2019 and October 2022, our hospital, a referral center for breast cancer care, conducted 139 breast MRI examinations to evaluate implant integrity. Surgical intervention was deemed necessary for patients diagnosed with suspected or confirmed implant rupture at MRI. Those patients who did not undergo any surgical procedure (63 cases) or had surgery at different institutes (11 cases) were excluded., Results: Among the 65 patients who underwent preoperative MRI and subsequent surgery at our institute, surgical findings confirmed the preoperative MRI diagnosis in 48 women. Notably, 17 women exhibited a discordance between MRI and surgical findings: three false negatives, 11 false positives and three possible ruptures not confirmed. Signs of nonunivocal or misleading interpretation were assessed on a patient-by-patient basis. The importance of obtaining detailed information about a patient's breast implant, including fill materials, number of lumens, manufacturer and shape, proved immensely beneficial for interpreting MRI signs accurately., Conclusion: Pre-MRI knowledge of implant details and a meticulous evaluation of non-univocal signs can aid radiologists in accurately assessing implant integrity, reducing the risk of unnecessary revisional surgeries, and potentially averting allegations of medical malpractice., (Copyright © 2024 Wolters Kluwer Health, Inc. All rights reserved.)

Background: The difficulty in obtaining long-term data with the use of breast implants is well known. The majority of available data are from multicenter studies with different surgical techniques, and different implants., Methods: The authors provide retrospective 10-year study data (2001 to 2011) with Mentor Contour Profile Gel implants after a mean of 13 years of follow-up, in the first single-center study of such size and length. This study included 835 patients with 1674 Mentor implants across 6 surgery types, all of them performed with a consistent surgical technique developed by the senior author (J.L.M.Y.). Long-term complication rates were analyzed. For the safety analysis, Kaplan-Meier risk rates were calculated., Results: A total of 85% of the patients had long-term follow-up data (at least 7 years). The overall complication rate was 13.2%. The reoperation rate was 12.3%, being just 6.2% caused by complications. The 21-year Kaplan Meier cumulative incidence rate was 1.7% for capsular contracture and 5.1% for implant rupture. The periareolar approach and having a previous capsular contracture were found to be risk factors to develop a new capsular contracture. Low-height, high-projected implants had a significant higher risk of implant rotation. No breast implant-associated anaplastic large cell lymphoma or breast implant illness cases were found; 89.2% of the patients reported being satisfied or very satisfied with the surgery and the implant., Conclusion: With a consistent surgical technique, these 21-year follow-up data of the Mentor Contour Profile Gel implants reaffirm the very strong safety profile of these implants, and continued patient satisfaction with them., Clinical Question/level of Evidence: Therapeutic, IV., (Copyright © 2024 by the American Society of Plastic Surgeons.)

Background: An increasing number of women are undergoing breast implantation for cosmetic purposes or for reconstructive purposes after breast excision. The surface morphology of the breast implant is a key factor associated with the induction of capsule contraction. The effect of surface morphology on the inflammatory response after implant insertion remains unclear, however. The authors conducted comparative analyses to determine the effect of the textured and smooth surface morphology of silicone sheets., Methods: Each type of silicone sheet was inserted into the subcutaneous pocket below the panniculus carnosus in C57BL/6 mice and mice with genetic disruption of CARD9 , Dectin-1 , Dectin-2 , or Mincle . The authors analyzed collagen fiber capsule thickness, histologic findings, and macrophage inflammatory response, including transforming growth factor (TGF)-β synthesis., Results: The authors found that textured surface morphology contributed to the formation of collagen fiber capsules and the accumulation of fibroblasts and myofibroblasts, and was accompanied by the accumulation of TGF-β-expressing macrophages and foreign-body giant cells. CARD9 deficiency attenuated collagen fiber capsule formation, macrophage responses, and TGF-β synthesis, although the responsible C-type lectin receptors remain to be clarified., Conclusion: These results suggest that CARD9 may have a strong impact on silicone sheet morphology through the regulation of macrophage responses., Clinical Relevance Statement: Silicone breast implants have been widely used for postmastectomy and cosmetic augmentation mammaplasty breast reconstruction. The authors sought to elucidate the surface morphology of the breast implant as one of the key factors associated with the formation of collagen fiber capsules., Clinical Question/level of Evidence: Therapeutic, V., (Copyright © 2023 by the American Society of Plastic Surgeons.)

Background: Ptosis recurrence often leads to unsatisfactory results after mastopexy, even more so when additional stress is provided by implants on compromised native tissue. The poly-4-hydroxybutyrate(P4HB) scaffold (GalaFLEX) with its favorable safety profile and proven long-term mechanical strength represents a preferred option for soft tissue support., Objectives: The primary endpoint was assessment of lower pole stretch from the early postoperative period up to 3 years., Methods: Out of 151 patients who underwent surgery by G.B. from March 2020 to December 2023, a total of 72 with a 12-month-mininum follow-up who had primary (46) or secondary (26) augmentation mastopexy with subfascial round smooth implants and P4HB scaffold support were included in the study. Three-dimensional artificial intelligence software was utilized for all measurements. Further analysis included evaluation of ptosis recurrence and all complications., Results: No recurrent ptosis, bottoming out, implant displacement, or capsular contracture was reported during follow-up (mean, 24.8 months). The lower pole arch's elongation was 8.04% and 9.44% at 1 and 3 years respectively, comparing favorably with previous reports. Statistically significant correlation (P < .05) between implant size and lower pole stretch was noted, this being greater for larger implants (> 400 cc; P = .0011) and primary cases (P = .1376). Progressive volume redistribution from upper to lower pole was observed in the first year, with substantial stability thereafter., Conclusions: This is the largest published series reporting long-term results (up to 45 months) in mastopexy augmentation with GalaFLEX, suggesting its supportive role in lower pole stability even in the setting of concurrent breast augmentation with smooth implants in a subfascial plane., (© The Author(s) 2024. Published by Oxford University Press on behalf of The Aesthetic Society. All rights reserved. For commercial re-use, please contact reprints@oup.com for reprints and translation rights for reprints. All other permissions can be obtained through our RightsLink service via the Permissions link on the article page on our site—for further information please contact journals.permissions@oup.com.)

Background: Silicone implants are by far the most widely used implant globally for breast augmentation. Despite technological advancements, complications persist, with silicone lymphadenopathy (siliconoma) being a noteworthy concern. This phenomenon has been inadequately addressed in the existing literature., Objectives: The aim of this study was to characterize axillary siliconomas and identify potential risk factors to help reduce their occurrence., Methods: The authors conducted a retrospective observational cross-sectional study spanning between 2011 and 2021 at the Shamir Assaf Harofeh Medical Center, Israel. Preoperative ultrasound examination was conducted, categorizing patients into those with siliconomas and those without., Results: A total of 614 women (1209 breasts) met the inclusion criteria. The incidence of siliconomas was 13.6% (165 breasts). In univariate analysis, older age (47 years vs 43 years, P < .001), older implant age (12.2 years vs 11 years, P = .026), ruptured implants (59.4% vs 17.7%, P < .001), subpectoral placement (P = .019), severe capsular contracture, and the use of Mentor implants (Irvine, CA; P = .007) and Poly Implant Prothèse implants (PIP; La Seyne-sur-Mer, France; P = .001) correlated significantly with the presence of siliconomas. In a multivariate analysis, implant rupture (odds ratio [OR] = 6.342), and implant manufacturer-Mentor (OR = 3.047) and PIP (OR = 3.475)-were identified as independent risk factors associated with a higher incidence of siliconomas. Severe capsular contracture was also associated with a higher incidence of siliconomas (OR = 1.65)., Conclusions: Surgeons should inform candidates about the potential risk of silicone migration. Patients with ruptured implants, significant capsular contracture, and Mentor and PIP implants face an increased risk for developing siliconomas. Closer monitoring for the detection of siliconomas in the axilla for these patients is advisable, and potential prophylactic replacement or removal of implants may be warranted to mitigate siliconoma risk., (© The Author(s) 2024. Published by Oxford University Press on behalf of The Aesthetic Society. All rights reserved. For commercial re-use, please contact reprints@oup.com for reprints and translation rights for reprints. All other permissions can be obtained through our RightsLink service via the Permissions link on the article page on our site—for further information please contact journals.permissions@oup.com.)

Background and Objectives : Breast cancer in patients with prior breast augmentation poses unique challenges for detection, diagnosis, and management. Mastectomy rates are increasing, and patients with prior augmentation often have a lower body mass index, making autologous techniques unsuitable. This study aims to assess the best reconstructive option in patients with a history of subglandular or dual-plane breast augmentation. Materials and methods : A prospective analysis was conducted on patients who underwent breast reconstruction after mastectomy. Patients with subglandular or dual-plane breast augmentation were included. Patients were divided into submuscular breast reconstruction (Group 2) or prepectoral breast reconstruction (Group 1) groups. Demographic and surgical data were collected. Results : A total of 47 patients were included, with 23 in Group 1 and 24 in Group 2. Complications occurred in 11 patients (23.4%), with significant differences between groups. The most common complication was seroma formation. Implant loss occurred in 4.3% of cases in Group 1, while no implant loss was observed in Group 2. Patient-reported satisfaction scores were similar between groups at 12 months postoperatively. Conclusions : Subpectoral breast reconstruction with a tissue expander seems a safer and effective technique for patients with prior breast augmentation. It resulted in fewer complications. This approach should be considered as an option for breast reconstruction after mastectomy in this cohort of patients.

Background: Acellular dermal matrix (ADM) has become popular in various reconstructive procedures of different anatomic regions. There are different needs depending on the clinical application, including breast, abdominal wall, and any other soft-tissue reconstruction. Removal of the basement membrane, which consists of collagen fibers, may help achieve natural and soft breast reconstruction, which requires highly elastic ADMs. Given the lack of knowledge of the effectiveness of ADM without the basement membrane, the authors compared the clinical outcomes of ADMs with and without basement membrane in breast reconstruction., Methods: The authors conducted a single-blind randomized controlled trial to evaluate differences in clinical outcomes. The patients were randomized into 2 groups: ADM with or without basement membrane. Both groups underwent immediate prepectoral direct-to-implant breast reconstruction. Demographic characteristics, surgical outcomes, and breast shape change using nipple position were compared between the 2 groups., Results: A total of 56 patients were divided into 2 groups: ADM with basement membrane (n = 30 [53.6%]) or ADM without basement membrane (n = 26 [46.4%]). Clinical and surgical characteristics were similar between the 2 groups. The authors detected no statistically significant differences in the overall rate of complications or breast shape change between the 2 groups. However, the rate of seromas was higher in the ADM with basement membrane group than in the ADM without basement membrane group (10% versus 0%; P = 0.09)., Conclusions: The 2 groups showed similar surgical outcomes. ADM without basement membrane in implant-based breast reconstruction was safe, and had mechanical properties of lower tensile strength and higher elasticity., Clinical Question/level of Evidence: Therapeutic, II., (Copyright © 2023 by the American Society of Plastic Surgeons.)

Introduction: Indocyanine green (ICG) angiography for the intraoperative evaluation of tissue perfusion is commonly used in implant-based breast reconstruction (IBR). The assessment of ICG images depends on the surgeon's interpretation and is qualitative or semiqualitative in nature. To quantify ICG metrics, this study aimed to apply a novel assessment of fill-rate dynamics to predict wound-healing complications and provide pragmatic assessment tools in IBR., Methods: This was a retrospective cohort study of patients who underwent IBR with ICG using the photodynamic eye (PDE-Neo II) qualitative imaging system between April 2021 and September 2023. ICG recordings were reviewed to quantify the relative surface area and fluorescence intensity of visual perfusion deficits using ImageJ. The primary outcome was the incidence of wound-healing complications. t-tests and logistic regression were performed for statistical testing., Results: A total of 112 patients (201 breasts) were included. The incidence of wound-healing complications was 12.9%. A higher relative surface area of ischemic regions was significantly associated with wound-healing complications (3.3% vs. 0.90%; p = 0.001). The rate of change in the surface area of ischemic regions was significantly associated with wound-healing complications (0.35% per second vs. 1.29% per second; p = 0.003%). On average, the duration of transient ischemic areas was significantly longer in breasts with wound-healing complications (46.0 s vs. 36.0 s, p = 0.01)., Conclusion: A transient ischemic area of > 5% of the breast and/or failure to resolve transient ischemic areas after 60 s may predict wound-healing complications and inform surgical reconstructive decision-making in IBR., (Published by Elsevier Ltd.)

Background: The inframammary fold (IMF) is an important landmark in breast aesthetic surgery. In augmentation mastopexy procedures, secure and accurate placement of the IMF is essential to aesthetic outcomes and to allow the new IMF to heal in the correct position without displacement. The authors present a simple and efficient four-layer wound closure technique using barbed sutures for closure of the repositioned IMF in augmentation mastopexy procedures. This method was previously described by the first author for reset of the IMF in breast augmentation surgery and has been adapted to the longer IMF incision in augmentation mastopexy procedures., Methods: A retrospective review was undertaken of 335 patients who underwent bilateral breast augmentation mastopexy procedures with a Wise pattern technique at a single unit. The newly reset IMF was closed using barbed sutures and a four-layer closure technique., Results: There were no cases of complications related to wound healing or wound dehiscence. One patient required explantation for an infected implant., Conclusion: The four-layer wound closure technique with barbed sutures provides a quick and efficient method for accurate closure of the newly reset IMF, with positive outcomes related to wound healing. Secure and accurate placement of the inframammary fold is crucial in augmentation mastopexy procedures. The use of a four-layer wound closure technique with barbed sutures provides an efficient method for accurate closure of the newly reset inframammary fold. This method was previously described by the first author for reset of the IMF in breast augmentation surgery and has been adapted to the longer IMF incision in augmentation mastopexy procedures., 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 www.springer.com/00266 ., (© 2024. Springer Science+Business Media, LLC, part of Springer Nature and International Society of Aesthetic Plastic Surgery.)

Hypothyroidism has high prevalence in elderly women, which overlaps with the patient population who opt for post-mastectomy breast reconstruction. While hypothyroidism was shown to impact outcomes in other surgeries, its effect on breast reconstruction has not been established. This study aimed to compare the short-term outcomes of patients with and without hypothyroidism who underwent autologous (ABR) and implant-based breast reconstruction (IBR), respectively. Patients having ABR or IBR were identified in the National Inpatient Sample from Q4 2015-2020. Multivariable logistic regressions were used to compare in-hospital outcomes between patients with and without hypothyroidism, adjusted for demographics, socioeconomic status, comorbidities, and hospital characteristics. There were 12,765 patients underwent ABR, where 1591 (12.46%) of them had hypothyroidism, while 17,670 patients had IBR with 1,984 (11.23%) having hypothyroidism. Hypothyroid patients had a higher risk of hemorrhage/hematoma (aOR = 1.254, 95 CI 1.079-1.457, p < 0.01) after ABR. However, there were no differences in terms of mortality and organ system complications, nor wound dehiscence, superficial/deep wound complications, seroma, flap revision, excessive scarring, venous thromboembolism, pulmonary embolism, vascular complications, infection, sepsis, transfer out, length of stay (LOS), nor hospital charge between patients with and without hypothyroidism after ABR. All postoperative outcomes were comparable between hypothyroid patients and controls after IBR. While breast reconstruction is generally safe for hypothyroid patients, preoperative screening for hypothyroidism may be beneficial for those undergoing ABR. In ABR, hypothyroidism correction and blood management may help prevent bleeding complications in hypothyroid patients. Future studies should explore the long-term prognosis of hypothyroid patients after breast reconstruction., (© 2024. Italian Society of Surgery (SIC).)

Background: The goals of mastopexy differ significantly from those of augmentation mammoplasty. Mastopexy is designed to lift and reshape the breasts, while augmentation mammoplasty is designed to increase the volume of the breasts. This conflict causes that one-stage augmentation mastopexies showed a revision rate from 8.7 to 23.2%. The aim of our study is to present some technical refinements for reducing the risk of implant exposure and reoperation., Methods: We designed a retrospective matched cohort study, including 216 consecutive patients, undergone augmentation mastopexy between January 2013 and December 2022. We divided them in two groups: Group A undergone an inverted-T superomedial pedicled augmentation mastopexy and Group B undergone our inverted-T modified augmentation mastopexy. The groups were matched for clinical and surgical variables, with the surgical technique the only difference between the two., Results: Complications were registered in ten patients (9.3%) in Group A (two wound breakdowns at T with implant exposure and eight wound dehiscences), six of which required surgical revision. In contrast, only three patients (2.8%) in Group B reported a complication, which was wound dehiscence without implant exposure in all cases. None of the dehiscence required surgical revision. The difference between complication and revision rates was statistically significant., Conclusions: Separating the implant and the mastopexy dissection planes reduces the implant exposure and the reoperation rate in one-stage augmentation mastopexy., 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 https://link.springer.com/journal/00266 ., (© 2024. The Author(s).)

Background: Tumescent local anesthesia (TLA) involves the infusion of a saline solution containing lidocaine and epinephrine into tissues to achieve localized anesthesia and vasoconstriction. While the use of TLA in sub-glandular augmentation mammoplasty has been documented, we present a modified TLA approach for primary sub-muscular breast augmentation in transgender patients based on our experience over the past years., Methods: Between the years 2014 and 2021, we performed primary sub-muscular breast augmentation on 20 transgender patients under TLA and conscious sedation. The tumescent solution consisted of 25 mL of 2% lidocaine, 8 mEq of sodium bicarbonate, and 1 mL of epinephrine (1 mg/1 mL) in 1000 mL of 0.9% saline solution. Initially, the solution was infiltrated between the pectoral fascia and the mammary gland, and subsequently, during the surgery, under the pectoralis major muscle., Results: The average volume of tumescent solution infiltrated during TLA was 740 mL per breast. There were no reports of adrenaline or lidocaine toxicity, and no cases required a conversion to general anesthesia. Patients experienced no pain or discomfort during the preoperative infiltration or surgical procedure. Reoperations due to short-term complications never occurred. We observed a major complication rate of 5%, represented by 1 hematoma. Long-term complications comprised one case of implant dislocation and one occurrence of dystrophic scar formation. No cases of capsular contracture needing reoperation, asymmetry, and implant rupture occurred. In total, one individual (5%) requested larger implants. Follow-up time ranged from 30 days to 1 years., Conclusions: Overall, augmentation mammaplasty is a valuable choice for transgender women aiming to enhance their feminine characteristics and alleviate gender dysphoria. It is imperative for patients to conduct thorough research, grasp the potential pros and cons, and consult experienced healthcare professionals in transgender care. Additionally, tumescent local anesthesia (TLA) has proven to be a safe and efficient method for sub-muscular breast augmentation, providing effective pain control with minimal postoperative complications, resulting in high patient 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 ., (© 2024. The Author(s).)

Purpose: The Area Deprivation Index (ADI) ranks neighborhoods by deprivation based on US Census data. This study utilizes ADI scores to investigate the impact of neighborhood deprivation on complication rates following breast reconstruction., Patients and Methods: Patients who received implant-based reconstruction from 2019 to 2023 were identified at a single institution in New York. Patients were linked to a state-specific ADI score and categorized into groups: "High ADI" (6-10) and "Low ADI" (1-5). Patient characteristics and complication rates were compared between the ADI groups with Chi-Square analysis and t-tests. The predictive value of ADI scores on complication rates was assessed using logistic regression models., Results: In total, 471 patients were included, of which 16% (n = 73) were in the High ADI group, and 84% (n = 398) were in the Low ADI group. There were no baseline differences between the 2 groups, except that there were more patients of Hispanic descent in the High ADI group (30% vs. 15%, P < .01). The High ADI group had a higher overall complication rate than the Low ADI group (34% vs. 21%, P < .01), as well as higher individual rates of hematoma (12% vs. 3%, P < .01) and unexpected reoperations (18% vs. 7%, P < .01). After adjusting for differences in race, High ADI scores predicted hematoma, reoperations, and any complication (P < .05)., Conclusion: Patients living in neighborhoods with high ADI had a higher incidence of postoperative complications, independent of comorbidities and race. This measure of disparity should be considered when counselling patients about their risk of complications following procedures like implant-based breast reconstruction., Competing Interests: Disclosure The authors have no other potential conflicts of interest to disclose., (Copyright © 2024 Elsevier Inc. All rights reserved.)

Background: Several acellular dermal matrices (ADMs) are used for soft-tissue support in prosthetic breast reconstruction. Little high-level evidence supports the use of one ADM over another. The authors sought to compare Cortiva 1-mm Allograft Dermis with AlloDerm RTU (ready to use), the most studied ADM in the literature., Methods: A single-blinded randomized controlled trial comparing Cortiva with AlloDerm in prepectoral and subpectoral immediate prosthetic breast reconstruction was performed at 2 academic hospitals from March of 2017 to December of 2021. Reconstructions were direct to implant (DTI) or tissue expander (TE). Primary outcome was reconstructive failure, defined as TE explantation before planned further reconstruction, or explantation of DTI reconstructions before 3 months postoperatively. Secondary outcomes were additional complications, patient-reported outcomes (PROs), and cost., Results: There were 302 patients included: 151 AlloDerm (280 breasts), 151 Cortiva (277 breasts). The majority of reconstructions in both cohorts consisted of TE (62% versus 38% DTI), smooth device (68% versus 32% textured), and prepectoral (80% versus 20% subpectoral). Reconstructive failure was no different between ADMs (AlloDerm 9.3% versus Cortiva 8.3%; P = 0.68). There were no additional differences in any complications or PROs between ADMs. Seromas occurred in 7.6% of Cortiva but 12% of AlloDerm cases, in which the odds of seroma formation were two-fold higher (odds ratio, 1.93 [95% CI, 1.01 to 3.67]; P = 0.047). AlloDerm variable cost was 10% to 15% more than Cortiva, and there were no additional cost differences., Conclusion: When assessing safety, clinical performance, PROs, and cost, Cortiva is noninferior to AlloDerm in immediate prosthetic breast reconstruction, and may be less expensive, with lower risk of seroma formation., Clinical Question/level of Evidence: Therapeutic, I., (Copyright © 2023 The Authors. Published by Wolters Kluwer Health, Inc. on behalf of the American Society of Plastic Surgeons.)

Introduction: Post-mastectomy radiation therapy is an important component of adjuvant therapy for high-risk patients. However, radiation to reconstructed breasts can cause various complications. Recently, hypofractionated (HF) protocols have been adopted in several countries. Here, we aimed to assess the impact of HF protocols on implant-reconstructed breasts through a meta-analysis and systematic review of the currently available literature., Methods: Records published until August 2023 were systematically searched in PubMed, Cochrane Library, and EMBASE databases. Keywords included hypofractionation radiotherapy, mastectomy, and breast reconstruction. Studies that utilized HF and conventional fractionation (CF) after prosthetic reconstruction were selected. Due to the rarity of events in outcomes, Mantel-Haenszel's odds ratios were calculated using a fixed-effect model to compare the complication rates between HF and CF groups. For analysis with high heterogeneity, a random effect model was used., Results: Seven articles with 924 implant reconstructions, in which 506 (54.8 %) underwent HF were included. HF patients received 43.8 Gy on average, while CF patients received 51.2 Gy. Mean follow-up ranged from 10.6 to 35 months. Seven studies were included in the meta-analysis. HF groups had a significantly lower risk of capsular contracture (OR 0.25, 95 % CI 0.11-0.55), major revision surgery (OR 0.19, 95 % CI 0.05-0.80), and wound dehiscence (OR 0.24, 95 % CI 0.07-0.78) compared to CF groups. The risks of other complications were not statistically significant., Conclusion: This study indicates that HF protocols are associated with fewer complications than CF protocols in implant-reconstructed patients. These findings suggest that the application of HF PMRT in implant-reconstructed patients with breast cancer is plausible., (Copyright © 2024 The Authors. Published by Elsevier Ltd.. All rights reserved.)

Breast reconstructive surgery has evolved significantly over the years. One of the recent advancements is the use of prepectoral implants in combination with synthetic and biological material as a natural and effective coverage. To date, there is little published data on breast reconstruction using acellular bovine pericardium matrix and most concern submuscular breast reconstruction. This study aimed to describe the multicentric-multisurgeon experience in performing direct to implant (DTI) prepectoral breast reconstructions using acellular bovine pericardium matrix (ABPM) pocket. A retrospective multicentric data collection of the all the immediate prepectoral breast reconstructions using acellular bovine pericardium was carried out by the authors. Surgical data including type of mastectomy, axillary surgery, type and size of implant, size of ABPM, duration of surgery were collected for each patient. Postoperative data including adjuvant treatments, complications, necessity to perform other interventions, patient's satisfaction were collected. Cosmetic results were also evaluated by 7 different observers at minimum 1 year follow-up. A total of 65 breast reconstruction were included in the study. Mean follow up was 21.3 months. Average surgical time was 1,42 hours. Minor complications occurred in 4 breasts; major complications occurred in 2 breasts. After 6 months follow-up, 7 patients underwent fat grafting to correct any rippling and /or wrinkling. Breast aesthetic and patients reported outcomes were satisfactory. Not significant capsular contracture was noted at the follow up control. To date, this is the largest study about prepectoral breast reconstruction with ABPM. On the basis of our results, prepectoral breast reconstruction ABPM assisted is a reliable, safe and suitable option providing good patient satisfaction outcomes., Competing Interests: Disclosure Prof. De Vita is a temporary consultant for Exashape. The other authors have no conflict of interest to declare., (Copyright © 2024. Published by Elsevier Inc.)

Background: Breast cancer is the most common malignancy among women in the UK. Reconstruction - of which implant-based breast reconstruction (IBBR) is the most common - forms a core part of surgical management of breast cancer. More recently, pre-pectoral IBBR has become common as technology and operative techniques have evolved. Many surgeons use acellular dermal matrix (ADM) in reconstruction however there is little evidence in literature that this improves surgical outcomes. This review will assess available evidence for surgical outcomes for breast reconstructions using ADM versus non-use of ADM., Methods: A database search was performed of Ovid Medline, Embase, Cochrane Central Register of Controlled Trials and Cochrane Database of Systematic Reviews (2012-2022). Studies were screened using inclusion and exclusion criteria. Risk of Bias was assessed using the Newcastle Ottawa scale and ROBIS tools. Analysis and meta-analysis were performed., Results: This review included 22 studies (3822 breast reconstructions). No significant difference between overall complications and failure rates between ADM and non-ADM use was demonstrated. Capsular contracture, wound dehiscence and implant rippling had significant differences however these results demonstrated high heterogeneity thus wider generalisation may be inaccurate. Patient quality of life scores were not recorded consistently or comparably between papers., Conclusions: This review suggests a lack of significant differences in most complications between ADM use and non-use for pre-pectoral IBBR. If no increase in complications exists between groups, this has significant implications for surgical and legislative decision-making. There is, however, inadequate evidence available on the topic and further research is required., (© 2024. The Author(s).)

Background: Anxiety disorders, both with and without comorbid depression, are widespread globally. In this study we investigate the intersection of anxiety, depression, and self-reported breast implant illness (BII) in females undergoing aesthetic breast surgery., Objectives: The objective of our research was to enhance understanding about mental health history, psychotropic medication use, and its relation to BII symptoms., Methods: A cohort of 240 consecutive female patients undergoing elective breast surgery was studied. In the study we categorized patients by groups based on the presence of self-reported BII symptoms and the type of breast surgery performed. Mental health history, psychotropic medication use, and time spent in treatment for mental illness were scrutinized. Statistical analyses were conducted, including multiple regression analysis., Results: Results revealed that patients with self-reported BII symptoms often had a preexisting anxiety/depression disorder treated medically before obtaining breast implants, and this disorder predicted the occurrence of BII symptoms. These patients tended to be diagnosed with anxiety and depression at a younger age, initiate medication therapy earlier, take more medications for their condition, and spend more time in therapy compared with others undergoing elective breast surgery., Conclusions: Implications of this study highlight the need for comprehensive counseling between plastic surgeons and patients with self-reported BII symptoms. Understanding the role of anxiety/depression in the pathogenesis of self-reported BII is crucial, and collaboration with psychiatrists and other mental health professionals can ensure improved supportive care. The findings contribute to a better understanding of the psychological aspects surrounding breast implant surgery and self-reported BII and emphasize the importance of preoperative mental health assessments in appropriate patient selection for elective breast surgery., (© The Author(s) 2024. Published by Oxford University Press on behalf of The Aesthetic Society.)

Background: Implant malposition is a well-recognized complication of prosthetic breast implants. However, to date, no objective classification system has been described., Objectives: The aim of this study was to perform a prospective trial of an objective and reproducible classification system for implant malposition formulated by analyzing retrospective data from a large cohort of patients with implant malposition., Methods: The authors retrospectively analyzed the degree of medial/lateral and inferior/superior implant malposition relative to their optimal position within the breast footprint in a series of 189 breasts (n = 100 patients). An objective classification system for implant malposition was devised and then applied to a prospective cohort of 53 breasts in 28 patients with implant malposition., Results: The degree of malposition in a single or combination of axes was categorized according to the distance (measured in centimeters) from the ideal breast footprint. The classification system incorporated the axis of malposition and distance to generate a treatment decision-making guide. Cases of Grade 1 malposition did not warrant surgical intervention, whereas surgical correction was warranted in all Grade 3 cases. In the combined patient cohort (n = 242 breasts, 128 patients), lateral, inferior, medial, and superior displacement ranged between Grades 1 and 3. There was no interobserver variability in the grades assigned to 9 out of 10 patients in the prospective group., Conclusions: A simple and reproducible classification system for implant malposition has been created that allows surgeons to objectively record the extent of malposition, guides surgical decision-making, and can be used to document the results of any intervention., (© The Author(s) 2024. Published by Oxford University Press on behalf of The Aesthetic Society. All rights reserved. For commercial re-use, please contact reprints@oup.com for reprints and translation rights for reprints. All other permissions can be obtained through our RightsLink service via the Permissions link on the article page on our site—for further information please contact journals.permissions@oup.com.)

Background: In 2021, the US FDA issued a new checklist, labeling, and rupture-screening recommendations for breast implants to improve the decision-making process., Objectives: The aim of this study was to understand plastic surgeons' perspective on these changes and their perceived impact on clinical practice., Methods: In September 2023, a 27-question multiple-choice cross-sectional survey was distributed to 4352 active members of the American Society of Plastic Surgeons to evaluate attitudes on the FDA's black-box warning, informed decision checklist, and updated rupture-screening recommendations., Results: A total of 591 responses were collected (13.6%). The majority of respondents were between the ages of 45 and 64 years (58%) and had been in practice for more than 20 years (52%). Surgeons felt that some additions were appropriate; however, the majority (57%) stated that the informed decision checklist did not have a positive impact on workflow; 66% were also neutral or disagreed with the reported incidence rates related to complications and cancer. Nearly half of respondents (47%) did not feel the black-box warning improved their patients' understanding of the risks and benefits. Additionally, 47% of respondents also believed these requirements, in combination, did not improve the overall patient experience with implants., Conclusions: Respondents had an overall positive response towards the addition of risk information provided by the FDA-issued guidance and updates to rupture-screening recommendations. However, they remained divided as to whether the black-box warning and patient decision checklist had an overall positive impact on clinical practice patterns., (© The Author(s) 2024. Published by Oxford University Press on behalf of The Aesthetic Society. All rights reserved. For commercial re-use, please contact reprints@oup.com for reprints and translation rights for reprints. All other permissions can be obtained through our RightsLink service via the Permissions link on the article page on our site—for further information please contact journals.permissions@oup.com.)

Background: A subset of females with breast implants have reported a myriad of nonspecific systemic symptoms collectively termed systemic symptoms associated with breast implants (SSBI). SSBI symptoms are similar to manifestations associated with autoimmune and connective tissue disorders. Breast tissue is rich in adipose cells, comprised of lipids. Insertion of an implant creates an oxidative environment leading to lipid oxidation. Oxylipins can influence immune responses and inflammatory processes., Objectives: In this study we explored the abundance of a spectrum of oxylipins in the periprosthetic tissue surrounding the breast implant. Because oxylipins are immunogenic, we sought to determine if they were associated with the SSBI patients. We have also attempted to determine if the common manifestations exhibited by such patients have any association with oxylipin abundance., Methods: The study included 120 patients divided into 3 cohorts. We analyzed 46 patients with breast implants exhibiting manifestations associated with SSBI; 29 patients with breast implants not exhibiting manifestations associated with SSBI (control cohort I, non-SSBI); and 45 patients without implants (control cohort II, no-implant tissue). Lipid extraction and oxylipin quantification were performed with liquid chromatography mass spectrometry (LC-MS/MS). LC-MS/MS targeted analysis of the breast adipose tissue was performed., Results: Of the 15 oxylipins analyzed, 5 exhibited increased abundance in the SSBI cohort when compared to the non-SSBI and no-implant cohorts., Conclusions: The study documents the association of the oxylipins with each manifestation reported by the patient. This study provides an objective assessment of the subjective questionnaire, highlighting which symptoms may be more relevant than the others., (© The Author(s) 2024. Published by Oxford University Press on behalf of The Aesthetic Society.)

Background: Capsular contracture is a significant complication following mammaplasty, with varying incidence rates and symptoms. The etiology of capsular contracture is multifactorial, with postoperative hematoma recognized as a potential contributing factor., Objectives: In this study we aimed to investigate the impact of postoperative hematoma on capsular contracture following mammaplasty, utilizing pig models and modified biomechanical testing. We sought to compare the severity of capsular contracture between smooth and textured implants in the presence of hematoma, assess the biomechanical properties of the capsules, and explore the histological and molecular changes associated with the condition., Methods: The study involved 5 female miniature pigs, implanted with both smooth and textured implants. Hematoma models were established, and various methods were employed to evaluate the impact of the prosthesis surface and hematoma on capsular contracture, including ultrasound assessment, biomechanical tests, scanning electron microscopy, histological analysis, and transcriptome sequencing., Results: Capsules in hematoma groups were classified as Baker III/IV, with significantly unfavorable thickness, elastic modulus, and relaxation and creep amounts compared to nonhematoma groups. Smooth implants under hematoma conditions exhibited increased muscle content and biomechanical strength of the capsule. Transcriptomic analysis highlighted differential gene expression related to muscle development and contraction in smooth implants with hematomas., Conclusions: Hematomas increase the risk of capsular contracture, with smooth implants exacerbating this effect by enhancing pathways related to muscle development and contraction. This underscores the importance of hematoma prevention and treatment strategies, particularly when placing smooth implants, to minimize the occurrence of capsular contracture. The study provides insights into the mechanisms underlying capsular contracture and offers evidence to guide surgical and postoperative management strategies., (© The Author(s) 2024. Published by Oxford University Press on behalf of The Aesthetic Society. All rights reserved. For commercial re-use, please contact reprints@oup.com for reprints and translation rights for reprints. All other permissions can be obtained through our RightsLink service via the Permissions link on the article page on our site—for further information please contact journals.permissions@oup.com.)

Background: While immediate breast reconstruction rates in breast cancer are increasing, they remain low in women over 65 years old. The aim was to investigate surgical outcomes in women older than 65 years receiving implant-based immediate breast reconstruction., Method: The population-based Stockholm Breast Reconstruction Database includes all adult women with breast cancer receiving an implant-based immediate breast reconstruction in Stockholm, Sweden, 2005-2015. Primary outcomes within 30 days from immediate breast reconstruction were: infection requiring antibiotics and reoperation on. Implant removal was a secondary outcome. Women more than 65 years were compared with younger age groups. Chi-square tests and multivariable logistic regression were applied for the primary outcomes, and Kaplan-Meier analysis for the secondary outcome., Results: Among 1749 cases of immediate breast reconstruction, 140 (8.0%) were in women more than 65 years. Median follow-up was 74 months (1-198). Postoperative infection was not more common in women older than 65 years old (22 of 140, 15.7%) than in women under 65 years old (303 of 1609, 18.8%; P = 0.221). Reoperation on was more frequent in women older than 65 years than in other age groups (more than 65: 8.6%; 50-64: 6.5%; 40-49: 3.5%; less than 40: 1.6%; P < 0.001), however, age older than 65 years was not an independent risk factor in the multivariable analysis (OR 1.00, 95% c.i. 0.44 to 2.28). Overall, 6-year probability of implant removal was 11.4%, (8.1% due to complications and 3.3% due to patient preference). There was no statistically significant difference between age groups for either reason (P = 0.085 and P = 0.794 respectively)., Conclusion: Older age alone was not associated with worse surgical outcomes after implant-based immediate breast reconstruction in highly selected patients older than 65 years when compared with their younger counterparts., (© The Author(s) 2024. Published by Oxford University Press on behalf of BJS Foundation Ltd.)

Introduction: There has been a rising trend in the use of silicone breast implants for breast reconstructions after breast cancer treatment, as well as in the aesthetic breast procedures. A cluster of non-specific symptoms related to the presence of silicone implant has been called breast implant illness (BII). However, there are no strict criteria of BII which would specifically define this term. The increasing interest in BII among patients and physicians urges verifying own cases of "on-demand" explantations., Material and Methods: In this paper, we discussed a case of a patient with initial BII diagnosis, after breast reconstruction, and reviewed the literature on the BII symptoms and aetiology. A decision for aesthetic revision, not explantation, was made as the diagnosis of BII was questioned, and somatisation due to dissatisfaction with the aesthetic result of breast reconstruction was diagnosed., Results: Improving aesthetics by implant exchange and contralateral mastopexy caused a full recovery from patient's symptoms., Conclusion: Based on our case, we point on the fact that BII diagnosis in patients after breast reconstruction is challenging. We suggest that while considering such a diagnosis and further proceedings, e.g. explantation, especially in patients after breast reconstruction, some exclusion criteria should be considered. Dissatisfaction with the result of the surgery can also lead to somatisation and the presence of real clinical symptoms, which should not be confused with the possible autoimmune reaction to silicone particles., 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 ., (© 2024. Springer Science+Business Media, LLC, part of Springer Nature and International Society of Aesthetic Plastic Surgery.)

Breast augmentation procedures using silicone implants have become increasingly popular over the past six decades. This article addresses the concerns of patients regarding implant strength by providing clinicians with valuable information in addition to video and pictorial evidence to share, fostering reassurance. The article focuses on the structural integrity and stability of breast implants, which play a critical role in their long-term performance and patient satisfaction. Specifically, it examines the industry standards outlined by the International Organization for Standardization (ISO), with a particular emphasis on ISO14607-2018, which encompasses a range of mechanical and physio-mechanical tests, including the assessment of silicone gel-fill firmness, evaluation of shell integrity, and examination of the impact of environmental conditions on implant performance. Breast implants are not static devices and are subject to aging and fatigue-based degradation. This emphasizes the need for ongoing monitoring and evaluation to ensure the long-term safety and satisfaction of patients. By providing a comprehensive examination of breast implant structure and industry standards, this article equips clinicians with the necessary knowledge to address patient concerns and foster confidence in the safety and longevity of breast augmentation procedures using silicone implants.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 ., (© 2024. Springer Science+Business Media, LLC, part of Springer Nature and International Society of Aesthetic Plastic Surgery.)

Breast implant insertion for breast reconstruction or breast augmentation is a developing procedure, with high demand worldwide-being the second most common plastic surgery in the US as of 2022. Breast-implant-associated anaplastic large cell lymphoma (BIA-ALCL) is T-cell, non-Hodgkin lymphoma, typically CD30+, ALK-, presenting with fluid collection in the inner aspect of the peri-implant capsule in most patients, with the onset exceeding 1-year after implantation. The mean time between breast implant insertion and BIA-ALCL development is 7-10 years. The main risk factor is the use of textured implants because of their susceptibility to triggering local inflammation and immune stimulation finally leading to lymphoproliferation. Genetic predispositions to hereditary breast cancer increase the risk of disease development as well. BIA-ALCL seems to be underestimated in many countries and the initial symptom-seroma might be overlooked and misdiagnosed. Despite its rarity, the awareness of the disease should be improved among patients and medical professionals. This paper summarizes epidemiology, etiopathogenesis, differential diagnosis, and treatment-both surgical and hematological approaches., Competing Interests: Disclosure None., (Copyright © 2024 The Author(s). Published by Elsevier Inc. All rights reserved.)

Background: Although mesh-based implant breast reconstruction surgery is emerging as the primary surgical procedure for breast reconstruction, mesh use remains controversial in implant breast reconstruction surgery, especially in terms of how to select the ideal mesh. Our aim is to elaborate relevant prognosis in the mesh-based implant breast reconstruction surgery., Methods: Relevant studies were identified from PubMed, Web of Science, EMBASE, and Cochrane library searches. Extracted data included study type, basic characteristics, mesh information, complications, etc. We analyzed the included cohort studies and randomized controlled trials that reported mesh-related implant breast reconstruction complications and breast quality scale scores., Results: A total of 32 studies including 7475 subjects were included. The results showed that the overall complication rate was 2.07 times higher in the biological mesh group than in the synthetic mesh group (risk ratio [RR]: 2.07, 95% CI 1.14-3.78). The risk of seroma was 4.50 times higher in the biological mesh group than in the synthetic mesh group (RR: 4.50, 95% CI 2.27-8.95). In terms of comparing breast quality scale scores, the mesh group had scores that were 1.49 (95% CI 0.19-2.78) higher than the non-mesh group for "physical well-being" and 2.05 (95% CI 0.08-4.02) higher for "sexual well-being.", Conclusions: Our study found that the risk of total complications was higher with biological mesh than with synthetic mesh in implant breast reconstruction surgery. Based on short-term cost, healthcare burden, and healthcare benefits, synthetic meshes are superior to biological meshes., 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 ., (© 2024. Springer Science+Business Media, LLC, part of Springer Nature and International Society of Aesthetic Plastic Surgery.)

Background: The authors performed a retrospective review to analyze operative outcomes of breast mound reconstruction after robot-assisted mastectomy., Methods: Patients who underwent nipple-sparing mastectomy (NSM) with a robotic device (Da Vinci Xi) and immediate prepectoral prosthetic reconstruction by lateral incision from June of 2018 to July of 2019 were enrolled. Patient characteristics, complications, and satisfaction rates as assessed by BREAST-Q were analyzed. The surgical technique was described in detail., Results: Thirty-nine cases, including 7 bilateral cases (total 46 breasts), underwent robot-assisted NSM followed by immediate prepectoral prosthetic implant reconstruction. The median patient age was 46.63 years (range, 21 to 63 years). The mean operation time for each prepectoral breast mound reconstruction using the direct-to-implant technique was 126.55 minutes. Robot-assisted reconstruction resulted in superior BREAST-Q scores compared with the conventional reconstruction method. Major infection occurred in 7 cases (15.2%), and complete nipple loss occurred in 3 cases (6.6%). Severe complications requiring breast implant removal occurred in 4 breasts (8.7%). Two cases were due to the coexistence of infection and skin necrosis; in 1 case, the skin flap became congested on postoperative day 3 and required additional surgery to change the expander. Other complications were resolved with conservative care or minor revision., Conclusions: This report is the first concerning robot-assisted NSM followed by prepectoral acellular dermal matrix-wrapped prosthetic reconstruction. This procedure was not inferior to other methods. Further prospective research to evaluate oncologic outcomes is warranted., Clinical Question/level of Evidence: Therapeutic, IV., (Copyright © 2023 by the American Society of Plastic Surgeons.)

Background: Transumbilical breast augmentation (TUBA) with saline implants has been considered a safe and efficient technique for decades. However, because silicone implants are more popular than saline ones, TUBA with saline implants is not widely performed. In 2014, we published a report on transumbilical breast augmentation using silicone cohesive gel implants. As we have performed transumbilical silicone breast augmentation (TUSBA) for 13 years with slight modifications, this study aimed to describe this novel technique and present accompanying patient outcomes over 5 years., Methods: We enrolled patients desiring breast augmentation at a single center. The preoperative design was initially determined with the patients in standing positions before they underwent surgery under general anesthesia in a supine position., Results: Between January 2018 and December 2022, 69 women and one man underwent TUSBA at a single center. All patients underwent cohesive gel silicone implantation in the subpectoral pocket. The implant size varied from 225 to 300 mL (average 272 mL) because two patients underwent surgery with implants of different sizes due to breast asymmetry. All patients were satisfied with the surgery outcome except one who was dissatisfied because of abdominal bulging., Conclusions: TUSBA offers advantages such as minimal scarring and unrestricted arm movement; thus, it can be an alternative option for patients seeking breast augmentation., 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 https://www.springer.com/00266 ., (© 2024. Springer Science+Business Media, LLC, part of Springer Nature and International Society of Aesthetic Plastic Surgery.)

Background: Despite high complication rates, patients persistently present for single-stage augmentation mastopexy. In empty, deflated breasts, we perform one-stage augmentation mastopexy; however, in heavy ptotic breasts, our preference is to stage the procedure with mastopexy and fat graft first. With volume from fat grafting focussing on the upper pole and cleavage areas, many of our patients avoid implants altogether. This reduces subsequent risks of waterfall deformity, implant displacement, rupture and a lifetime of implant exchanges., Objectives: We aim to describe our findings and technique for reducing progression to the second stage of a two-stage augmentation mastopexy with the appropriate use of moderate to high volume of fat grafting at the primary operation., Methods: This is a retrospective review of all patients who presented to the senior author (KT) requesting breast implants and requiring mastopexy, from January 2018 to December 2022., Results: Over the five-year period, 137 patients were identified. Seventy-one (51.8%) underwent single-stage augmentation mastopexy, 55 (40.1%) underwent mastopexy with fat grafting and 11 (8.0%) underwent mastopexy with no fat grafting. Our key finding in this study is that 52 of 66 (78.8%) of planned staged patients, who underwent mastopexy with or without fat grafting, were happy with the volume attained and no longer wished to undergo further implant augmentation., Conclusion: In selected patients, appropriate volume and position of fat grafting at the time of primary mastopexy can significantly obviate the need for a second stage implant (alloplastic) augmentation., 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 www.springer.com/00266 ., (© 2024. Springer Science+Business Media, LLC, part of Springer Nature and International Society of Aesthetic Plastic Surgery.)

Summary: In transumbilical breast augmentation (TUBA) with prefilled silicone implants, technical challenges remain to accommodate more implant options and dissection planes. The authors aimed to demonstrate the feasibility of TUBA using various types of prefilled silicone implants (TUSBA) and its applicability for subglandular, subfascial, dual-plane implantation. In the early stage, TUSBA was primarily performed using endoscope-assisted blunt dissection, and later converted to full endoscopy dissection to achieve better results. An endoscope was used to confirm the pocket and check bleeding for both groups. For the endoscope-assisted group, surgical techniques were modified from conventional TUBA. In full endoscopy TUSBA, the entire dissection process was performed under endoscopic monitoring. Preliminary data of patients undergoing TUSBA from June of 2016 to April of 2021 were retrospectively reviewed. Breast implants with smooth, textured, or nanotextured surface properties and round or anatomic shapes were used, with sizes up to 500 mL. Seventy-four patients with a mean age of 36.4 years (range, 21 to 55 years) were enrolled in this study. Follow-up ranged from 1 month to 4.5 years (mean, 15.6 months). No excessive postoperative pain in breast or abdomen was reported. Surgery outcomes were aesthetically pleasing in both groups. In the endoscope-assisted group, 3 patients (4.6%) required major revisional procedures. No revision was required in the full-endoscopy group. TUSBA with various types of silicone implants is feasible and accommodable to all dissection planes. The full-endoscopy technique is helpful in reducing the higher complication rate., Clinical Question/level of Evidence: Therapeutic, IV., (Copyright © 2023 by the American Society of Plastic Surgeons.)

Infection after implant-based breast reconstruction remains challenging, with infection rates up to 24%. Best clinical practice indicates prophylactic oral antibiotics are ineffective at preventing infection. Absorbable antibiotic beads have been routinely used in other surgical subspecialties such as orthopedic and vascular procedures for continuous local antibiotic delivery to the surgical site when implants are placed. Biodegradable calcium sulfate antibiotic beads have been shown to normalize incidence of infection when used prophylactically for a high-risk prepectoral patient population. The purpose of this study is to evaluate the effect of prophylactic biodegradable antibiotic beads when used non-selectively for all prepectoral immediate tissue expander (TE) reconstruction. Patients who underwent mastectomy and immediate prepectoral TE reconstruction on the same day between 2018 and 2024 were reviewed. Patients were divided into two groups: those who received antibiotic beads (Group 1) and those who did not (Group 2). Absorbable calcium-sulfate beads were reconstituted with 1 g vancomycin and 240 mg gentamicin. There were 33 patients (63 TEs) in Group 1 and 330 patients (545 TEs) in Group 2. TE loss was present in 1.5% (1/65 TEs) Group 1 compared to 9.4% (51/545 TEs) in Group 2 (p = 0.032). The mean follow-up time was 178 days (range 93-266 days). Prophylactic biodegradable antibiotic beads used during immediate tissue expander reconstruction decreased implant loss rate. There was one occurrence of SSI in the antibiotic bead group. Antibiotic beads may potentially decrease complications in immediate TE reconstruction when used non-selectively for all patients., (Copyright © 2024 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by Elsevier Ltd. All rights reserved.)

Background: In the absence of high-quality evidence, there is a need for guidelines and multidisciplinary consensus recommendations on breast implant-associated anaplastic large-cell lymphoma (BIA-ALCL). The purpose of this expert consensus conference was to evaluate the existing evidence regarding the diagnosis and management of BIA-ALCL caused by textured implants. This article aims to provide evidence-based recommendations regarding the management and prevention of BIA-ALCL., Methods: A comprehensive search was conducted in the MEDLINE, Cochrane Library, and Embase databases, and supplemented by manual searches of relevant English-language articles and "related articles" sections. Studies focusing on breast surgery and lymphoma associated with breast implants were included for analysis. Meta-analyses were performed and reviewed by experts selected by the American Association of Plastic Surgeons using a Delphi consensus method., Results: A total of 840 articles published between January of 2011 and January of 2023 were initially identified and screened. The full text of 188 articles was assessed. An additional 43 articles were excluded for focus, and 145 articles were included in the synthesis of results, with 105 of them being case reports or case series. The analysis encompassed a comprehensive examination of the selected articles to determine the incidence, risk factors, clinical presentation, diagnostic approaches, and treatment modalities related to BIA-ALCL., Conclusions: Plastic surgeons should be aware of the elevated risks by implant surface type, implement appropriate patient surveillance, and follow the recommendations outlined in this statement to ensure patient safety and optimize outcomes. Ongoing research on the pathogenesis, genetic drivers, and preventative and prophylactic measures for BIA-ALCL is crucial for improving patient care., Clinical Question/level of Evidence: Risk, V., (Copyright © 2024 The Authors. Published by Wolters Kluwer Health, Inc. on behalf of the American Society of Plastic Surgeons.)

Background: Textured implants were developed with the goal of reducing rates of capsular contracture and preventing implant malposition (eg, malrotation). Recent evidence has questioned whether textured implants are as resistant to malrotation as previously reported., Methods: Women presenting to a single health care system for removal of textured implants were prospectively enrolled in the study from September of 2019 to July of 2022. Patients who underwent removal of an anatomical, textured implant in the operating room were included in the study; whereas those who did not undergo implant removal, or were found to have a smooth implant, or a round, textured implant, were excluded. The degree of implant rotation on removal of the implant was measured intraoperatively. Information regarding implant-specific factors, patient demographics, clinical factors, and operative characteristics, was collected., Results: A total of 51 patients (80 implants) were included in the study; 45% of implants were malrotated (rotated >30 degrees), and the median degree of rotation was 30 degrees. Having more than one previous revision of the breast pocket was predictive of implant rotation (42 degrees) on multivariate linear regression analysis. Patients who presented with a complaint of "aesthetic dissatisfaction" had 2.89 increased odds of having an implant rotated greater than 30 degrees., Conclusion: The authors' study found a high rate of malrotation of textured shaped implants on explantation., Clinical Question/level of Evidence: Risk, III., (Copyright © 2023 by the American Society of Plastic Surgeons.)

Breast augmentation is the most commonly performed aesthetic surgery procedure in women worldwide. The use of the subfascial plane has been suggested to decrease the incidence of capsular contracture compared with the subglandular plane, while simultaneously avoiding the complication of animation deformity in the subpectoral plane. The aim of this systematic review and meta-analysis was to compare the adverse outcomes of subfascial vs subglandular planes in breast augmentation. This review was registered a priori on OSF (https://osf.io/pm92e/). A search from inception to June 2023 was performed on MEDLINE, Embase, and CENTRAL. A hand search was also performed. All randomized and comparative cohort studies that assessed the use of the subfascial plane for breast augmentation were included. Outcomes evaluated included the incidences of seroma, hematoma, infection, rippling, capsular contracture, and revision surgery. Ten studies were included in this systematic review. Three randomized controlled trials and 7 comparative cohort studies were used for quantitative synthesis. There was a significant difference favoring subfascial compared with subglandular planes in the incidence of hematoma, rippling, and capsular contracture. All included studies had a high risk of bias. The current evidence suggests that the subfascial plane for breast augmentation decreases the risk of capsular contracture, hematoma, and rippling compared with the subglandular plane. Further randomized evidence with high methodological rigor is still required to validate these findings., (© The Author(s) 2024. Published by Oxford University Press on behalf of The Aesthetic Society. All rights reserved. For commercial re-use, please contact reprints@oup.com for reprints and translation rights for reprints. All other permissions can be obtained through our RightsLink service via the Permissions link on the article page on our site—for further information please contact journals.permissions@oup.com.)