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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: 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.)

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.)

Background: Breast implant illness (BII) has become a contentious subject in recent years. Although some studies have reported associations between breast implants and autoimmune diseases, others have failed to establish a definitive link., Objectives: The objective of this study was to provide a comprehensive, up-to-date evaluation of the literature surrounding BII, with an emphasis on identifying patient-related factors that may be associated with BII., Methods: A systematic review was performed following PRISMA guidelines by searching the PubMed (MEDLINE), Embase, and Cochrane databases for relevant studies published in the last 20 years., Results: Thirty-one studies were included, which covered 39,505 implant patients with a mean [standard deviation] age of 44.2 [9.30] years. Fifteen studies reported implant explantation status, with 72.4% patients choosing to remove their implants. Among these, 9 studies reported symptom improvement in 83.5% patients. Fifty-three percent of patients undergoing explantation had total capsulectomy. Twenty-eight studies documented total numbers of patients experiencing symptoms related to BII, with 31.3% patients reporting such symptoms. Among these, 16 studies of 4109 BII patients distinguished whether the reason for implantation was cosmetic augmentation or reconstruction. When specified, more patients experiencing BII-related symptoms received implants for "cosmetic" vs "reconstructive" reasons (cosmetic, 3864/4109 [94.0%] vs reconstruction, 245/4109 [5.96%]; P < .001)., Conclusions: This review provides an overview of the current state of knowledge regarding BII. The study highlights a potential relationship between BII and indication for implants (cosmetic vs reconstructive) among other variables, offering valuable insight on factors associated with BII and directions for future research., (© 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: Nanotextured breast implants (classified as smooth implants by the latest ISO 14607:2018) have been described as possibly reducing major textured implant-related complications such as capsular contracture and breast implant-associated anaplastic large cell lymphoma. On the other hand, microtextured breast implants benefit from an optimal safety profile based on a much larger body of literature., Objectives: The aim of this study was to directly compare the incidence of complications between Motiva Ergonomix (Establishment Labs Holdings, Inc., Alajuela, Costa Rica) and POLYTECH MESMO (POLYTECH Health & Aesthetics GmbH, Dieburg, Germany) breast implants, especially regarding the displacement issues that might arise after breast augmentation., Methods: Consecutive patients who previously underwent surgery by the same physician for placement of Motiva Ergonomix and POLYTECH MESMO implants were included in this study. They were divided into 2 groups according to the type of implant. The onset of complications was assessed through survival analysis., Results: Data were collected from 329 patients, 185 (56.2%) with POLYTECH MESMO and 144 (43.8%) with Motiva Ergonomix implants. The median follow-up was 8 months for both groups. Of the 42 women (12.8%) who experienced at least one complication, 26 belonged to the Motiva Ergonomix subgroup (P = .013). The most represented complications during this period resulted from displacement issues, with a clear prevalence of bottoming out in the Motiva Ergonomix cohort: 15 cases vs 0 cases in the POLYTECH MESMO cohort (P < .001). For 7 patients, a reoperation was required, more frequently for patients with Motiva Ergonomix implants (4.2% vs 0.5%; P = .046)., Conclusions: POLYTECH MESMO devices provided a more favorable outcome. Motiva Ergonomix devices revealed a concerning incidence of displacement issues during the first postsurgery years, with no advantage over other major complications., (© 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: Polyurethane (PU)-coated breast implants are known for their strong integration into breast tissue and the formation of capsules around them. However, capsular contracture can pose both aesthetic and clinical challenges., Objectives: The objectives of this study were to analyze the biological and morphological characteristics of the capsular tissue surrounding PU-coated implants, irrespective of their contracture status, and to assess their potential suitability as a flap in revisional breast surgery for capsular contracture., Methods: A total of 23 tissue samples were harvested from the capsules surrounding PU-coated breast implants in 12 female patients during replacement or revisional surgery. We evaluated collagen abundance, cellular and vascular density, inflammation, collagen band types and alignment, synovial metaplasia, capsule thickness, and the expression of inflammatory biomarkers and myofibroblasts with immunohistochemical techniques. Scanning electron microscopy was employed to assess implant surface characteristics over time., Results: We found a significant association of capsule contraction with longer implantation durations and greater implant surface roughness (P = .018 and P = .033, respectively). Synovial metaplasia was significantly more frequent in noncontracted capsules (P = .0049). Both capsule types consisted of paucicellular, type I collagen-rich compact fibrous tissue with low vascularization. There was a marked reduction in inflammatory cells within the foreign body granuloma. The expression of inflammatory biomarkers in the capsular tissue was negligible., Conclusions: Given the reduced levels of inflammatory and vascular components within the dense, fibrous capsular tissue, we consider them to be viable alternatives for capsular flaps in revisional surgery. This strategy has the potential to mimic the reconstruction achieved with acellular dermal matrix., (© The Author(s) 2024. Published by Oxford University Press on behalf of The Aesthetic Society.)

Background: Despite increasing demand for breast capsular surgery to treat various benign and malignant implant-related pathologies, high-quality evidence elucidating complication profiles of capsulectomy and capsulotomy is lacking., Objectives: The aim of this study was to provide the largest-scale analysis of associated outcomes and complications using the Tracking Operations and Outcomes for Plastic Surgeons (TOPS) database, and to investigate clinical scenarios that may subject patients to increased risks for complications, most notably extent of capsular surgery (complete vs partial) and index indication of implantation (aesthetic vs reconstructive)., Methods: An analysis of the TOPS database from 2008 to 2019 was performed. CPT codes were used to identify complete capsulectomy and partial capsulectomy/capsulotomy cases. Breast implant exchange procedures constituted procedural controls., Results: In total, 7486 patients (10,703 breasts) undergoing capsulectomy or capsulotomy were assessed. Relative to controls, capsulectomy (4.40% vs 5.79%), but not capsulotomy (4.40% vs 4.50%), demonstrated higher overall complication rates. Both capsulectomies (0.83% vs 0.23%) and capsulotomies (0.56% vs 0.23%) also had greater rates of seroma relative to controls. Subgroup analyses demonstrated that reconstructive patients, relative to aesthetic patients, experienced greater overall complications (6.76% vs 4.34%), and increased risks for seroma (1.06% vs 0.47%), dehiscence (0.46% vs 0.14%), surgical site infections (1.03% vs 0.23%), and implant loss (0.52% vs 0.23%). A detailed synthesis of 30-day outcomes, including all patient- and breast-specific complications, for both capsulectomy and capsulotomy, stratified according to all potential confounders, is presented herein., Conclusions: Surgeries on the breast capsule are safe overall, although complete capsulectomies and reconstructive patients are associated with significantly increased operative risks. The present findings will enhance patient selection, counseling, and informed consent., (© The Author(s) 2024. Published by Oxford University Press on behalf of The Aesthetic Society.)

Background: Nanotextured implants, an innovation in implant technology, are designed to enhance tissue interaction, reduce inflammation, and mitigate complications of traditional implants., Objectives: The aim of the study was to evaluate the aesthetic potential and safety profile of nanotextured breast implants in breast augmentation from a single-surgeon experience., Methods: This prospective cohort study included 1000 patients who underwent breast augmentation with nanotextured implants. Aesthetic outcomes were assessed with direct measurements and BCCT.core software, focusing on breast projection, symmetry, and upper pole fullness. Patient satisfaction was measured with BREAST-Q and overall satisfaction surveys. Safety profiles were evaluated based on the incidence of complications such as infection, hematoma, capsular contracture, and implant rupture. Statistical analyses were conducted to assess the outcomes., Results: The study found significant improvements in aesthetic outcomes, with 92.8% of cases achieving substantial aesthetic enhancements. Patient satisfaction was high, with 96.4% of patients reporting enhanced self-esteem and contentment. The safety profile was favorable, with a low incidence of complications (0.7% requiring revisional surgery) and no major complications reported. Long-term follow-up data indicated sustained aesthetic outcomes and a stable safety profile., Conclusions: The synergistic quality of nanotextured implants in relation to the natural breast gland tissue is defined by a significantly wider range of aesthetic options. The findings of this study underscore the positive impact of nanotextured breast implants on enhancing the aesthetic potential of breast augmentation and their contribution to a low incidence of complications., (© 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: Depression is notably common among patients who have undergone mastectomy. Several post-mastectomy patients opt for elective breast reconstruction. However, evidence on the influence of preoperative depression on breast reconstruction outcomes remains limited. This study aimed to evaluate the effect of preoperative depression on the short-term outcomes of autologous breast reconstruction (ABR) and implant-based breast reconstruction (IBR) using a comprehensive national registry., Methods: Patients who underwent ABR or IBR were identified from the national inpatient sample from Q4 2015-2020. Multivariable logistic regressions were used to compare in-hospital outcomes between the patients with and without depression, adjusted for demographics, primary payer status, hospital characteristics, and comorbidities., Results: Among the 12,984 patients who underwent ABR, 1578 (12 %) had depression whereas 1980 (11 %) out of 17,963 patients who underwent IBR had depression. In ABR and IBR, preoperative depression was associated with higher superficial wound complications (ABR, aOR = 1.386, 95 % CI = 1.035-1.856, p = 0.03; IBR, aOR = 1.281, 95 % CI = 1.001-1.638, p = 0.04), hemorrhage/hematoma (ABR, aOR = 1.164, 95 % CI = 1.010-1.355, p = 0.04; IBR, aOR = 1.614, 95 % CI = 1.279-2.037, p < 0.01), and longer hospital length of stay (p < 0.01). In ABR, patients with depression had higher incidences of infection (aOR = 1.906, 95 % CI = 1.246-2.917, p < 0.01) and sepsis (aOR = 15.609, 95 % CI = 1.411-172.65, p = 0.03). In IBR, patients with depression had higher risks of capsular contracture (aOR = 1.477, 95 % CI = 1.105-1.976, p = 0.01) and seroma (aOR = 1.489, 95 % CI = 1.005-2.208, p = 0.04)., Conclusion: Preoperative depression is independently associated with major morbidities after ABR and IBR. Preoperative screening for depression can be beneficial. Findings from this study can facilitate preoperative risk stratification and post-operative care for patients with depression., Competing Interests: Declaration of Competing Interest The authors declare no conflict of interest., (Copyright © 2024 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by Elsevier Ltd. All rights reserved.)

Background: In immediate breast reconstruction (IBR), it is unclear whether there is any difference in the complication rates between prepectoral versus subpectoral implant placement without acellular dermal matrix (ADM)., Aim: To compare the rates of early post-operative complications and time to initiation of adjuvant treatment in patients undergoing IBR between prepectoral and subpectoral implant placement without ADM for the two surgical procedure., Methods: We retrospectively retrieved data of patients who underwent IBR with prepectoral versus subpectoral implant placement between January 1, 2020 and December 31, 2022 in a large cancer center in France., Results: We included 192 patients: 119 in the prepectoral and 73 in the subpectoral group. Their clinical characteristics were similar. Thirty patients (15.6%) received adjuvant chemotherapy, among them 27 (14.1%) received it within 12 weeks, and there was no difference between the groups (p = 0.12). In the prepectoral group, 39 patients (32.8%) received adjuvant radiotherapy versus 5 (6.8%) in the subpectoral group (p < 0.001), but there was no significant difference in time to treatment commencement. Overall, 35 patients (29.4%) in the prepectoral group and 17 (23.3%) in the subpectoral group experienced post-operative complications (p = 0.44). Using multivariable analysis, the only factor associated with post-operative complications was determined to be mastectomy weight (odds ratio 1.98 (1.10-3.59) for weight ≥500 g; p = 0.02)., Conclusion: Prepectoral implant placement without ADM can be proposed to patients undergoing IBR with an indication for adjuvant treatment. However, in our study, the reoperation rate with this technique was slightly higher (p = 0.008). This is partly due to the learning curve for surgeons using this new technique., (Copyright © 2024. Published by Elsevier Ltd.)

Antibiotics Prophylaxis to prevent capsular contracture in prosthesis-based breast surgery is common in clinical practice. However, there is currently a dearth of high-quality evidence concerning the effectiveness of antibiotic usage in this field. To identify all pertinent studies prior to January 2023, a comprehensive literature search was conducted in the PubMed, Embase, Web of Science, Cochrane Library, and Medline databases. The extracted data was then subjected to meta-analysis. Fourteen studies were retained in the analysis. According to the results, perioperative antibiotic prophylaxis did not reduce the risk of capsular contracture (RR 1.15, 95% CI 0.82-1.59, p = 0.55) or surgical-site infection (RD 0.01, 95% CI - 0.01 to 0.03, p = 0.59) compared to nonantibiotic prophylaxis. There was no statistically significant difference between extended antibiotic prophylaxis and perioperative antibiotic prophylaxis in terms of preventing capsular contracture, whether calculated by patient numbers (RD 0.01, 95% CI - 0.01 to 0.02, p = 0.87) or by total procedures (RD 0.00, 95% CI - 0.00 to 0.01, p = 0.88), or controlling surgical-site infection (RR 1.05, 95% CI 0.77-1.44, p = 0.27). Additionally, topical antibiotic irrigation did not decrease the risk of infection (RR 0.61, 95% CI 0.34-1.08, p = 0.29) and capsular contracture, regardless of patient number (RR 0.41, 95% CI 0.27-0.63, p = 0.18) or total number of procedures (RR 1.29, 95% CI 0.73-2.28, p < 0.01). Current evidence revealed that both systemic and topical antibiotic prophylaxis may not provide benefits in preventing capsular contracture in prosthesis-based breast surgery. When the occurrence of surgical-site infections is minimized to the greatest extent, the administration of additional antibiotics for reducing capsular contracture should be carefully and judiciously considered., (© 2024. Italian Society of Surgery (SIC).)

Background: The number of patients undergoing exchange of textured implants for smooth devices has greatly increased because of concern over breast implant-associated anaplastic large-cell lymphoma (BIA-ALCL). The authors examined long-term patient- and surgeon-reported outcomes in terms of aesthetics, comfort, and complications., Methods: Patients who underwent reconstruction with shaped, textured implants replaced with round, smooth implants between 1994 and 2022 and who had a minimum follow-up of 1 year were included. Patient-reported outcomes were collected using the BREAST-Q Reconstruction module and a survey evaluating aesthetics and comfort. Surgeon-reported outcomes included evaluation of aesthetics and capsular contracture., Results: A total of 530 patients were reviewed, and 307 patients were included. Pairwise comparison of BREAST-Q data demonstrated that psychosocial well-being (72.68 to 76.45; P = 0.0075) and physical well-being (78.79 to 81.88; P = 0.0078) increased significantly. Overall breast satisfaction (61.94 to 67.27; P = 0.0082) and sexual well-being (53.89 to 57.98; P = 0.0002) were also significantly higher in parallel with a clinically meaningful increase in BREAST-Q score of 5.33 and 4.09 points, respectively. Most patients felt they appeared better (56.4%) or similar (27.3%) and were more comfortable (54.4%) or similar (39.4%) after the exchange procedure. The senior surgeon (P.G.C.) rated 40.1% of patients as having a better aesthetic grade after replacement and 50.3% as the same; 36.8% of patients were rated as having a decrease in Baker capsular contracture grade; 2.9% of patients experienced a perioperative complication; and there were no reconstructive failures., Conclusion: Exchange of textured to smooth implants is safe, does not sacrifice aesthetic outcome, and provides a more comfortable and satisfactory outcome for patients with minimal complications., Clinical Question/level of Evidence: Therapeutic, IV., (Copyright © 2023 by the American Society of Plastic Surgeons.)

Background: Hybrid breast reconstruction combines free tissue transfer with implant placement. Various mesh products have been successfully used to secure the implant position in these reconstructions. In this study, the authors investigate the impact of mesh type on long-term outcomes following hybrid breast reconstruction., Methods: A retrospective analysis of all patients with at least 24 months of follow-up after immediate bilateral prepectoral hybrid breast reconstruction was performed. Univariate and multivariable regression analyses were used to evaluate long-term outcomes and compare breasts reconstructed with polyglactin mesh versus acellular dermal matrix (ADM)., Results: Thirty-nine patients (78 breasts) who underwent hybrid breast reconstruction with an average follow-up period of 50.4 months (range, 27 to 73 months) were included in the study. Postoperative complications included hematoma ( n = 2 [2.6%]), mastectomy skin necrosis ( n = 12 [15.4%]), and fat necrosis ( n = 6 [7.7%]). There were no instances of implant infection, implant exposure, or flap failure. Polyglactin mesh and ADM were used in 24 breasts and 54 breasts, respectively. Implant malposition and capsular contracture occurred more frequently in the polyglactin cohort leading to 10 (41.7%) instances of reoperation for implant replacement compared with only 1 (1.9%) in the ADM cohort ( P < 0.001). On multivariable regression analysis, polyglactin mesh was associated with a 36-fold greater probability of requiring implant replacement compared with ADM ( P = 0.006)., Conclusion: ADM (versus polyglactin mesh) is associated with lower rates of capsular contracture and implant malposition in the context of hybrid breast reconstruction., Clinical Question/level of Evidence: Therapeutic, III., (Copyright © 2023 by the American Society of Plastic Surgeons.)

Implant-based reconstructions are increasingly utilized following mastectomy in the prevention and treatment of breast cancer. However, these implants are associated with a high rate of infection, which is a major complication that can lead to implant removal, delay in adjuvant radiation and chemotherapy, and increase in health care costs. Early clinical signs and symptoms of infection, such as erythema, warmth, and tenderness, are challenging to discern from expected postsurgical responses. Furthermore, when atypical features are present or the patient's condition does not improve on adequate antimicrobials, the clinician should be prompted to consider an alternative noninfectious etiology. Herein we highlight the key elements of the preventive, diagnostic, and multidisciplinary therapeutic approach to salvaging the infected breast implant; review several infectious disease mimickers; and provide many pearls of wisdom that the practicing clinician must be familiar with and be able to manage in an effective and successful manner., Competing Interests: Declaration of competing interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2024 The Author(s). Published by Elsevier Ltd.. All rights reserved.)

Background: Direct-to-implant (DTI) reconstruction has multiple advantages over a staged tissue expander (TE) approach. However, its use may be limited by concerns of increased complications. This study is the largest series to date comparing postoperative outcomes for DTI versus TE reconstruction in the prepectoral plane., Methods: The authors retrospectively reviewed 348 patients who underwent 536 total immediate, prepectoral implant-based breast reconstructions between January of 2018 and December of 2021. The authors compared the presence of risk factors and the rate of six separate complications between patients who underwent DTI versus TE reconstruction up to 1 year after surgery., Results: Of 348 patients, 147 (42%) and 201 (58%) underwent TE and DTI reconstruction ( P = 0.1813), respectively. The overall infection rate was 16.4% ( n = 57). DTI patients had a significantly greater incidence of wounds ( P < 0.0001), including minor ( P < 0.0011) and major wounds ( P < 0.0053). Significantly greater mastectomy resection weights were found for DTI patients who experienced any complication ( P < 0.0076), postoperative wounds ( P < 0.0001), and major wounds specifically ( P < 0.0035). Compared with medium-thickness acellular dermal matrix (ADM), extra thick ADM was associated with significantly increased rates of infection ( P < 0.0408) and wounds ( P < 0.0001)., Conclusions: Prepectoral DTI reconstruction in patients with adequate flap perfusion may have complication rates comparable to staged TE reconstruction, apart from a higher incidence of postoperative wounds. Greater mastectomy resection weights and thickness of ADM may specifically contribute to infection and wound-healing complications. Prepectoral DTI reconstruction is encouraged in the patients with adequate flap perfusion and moderate to low mastectomy resection weights who desire comparable or smaller implant volumes., Clinical Question/level of Evidence: Therapeutic, III., (Copyright © 2023 by the American Society of Plastic Surgeons.)

Summary: Skin-reducing mastectomy for single-stage reconstruction is an oncologically safe procedure used in women with large and ptotic breasts. This study describes a new technique, the J-pattern skin-reducing breast reconstruction with prepectoral implant and acellular dermal matrix (Braxon fast), which is indicated for patients with large and ptotic breasts who would benefit from a breast reduction and need a mastectomy for curative or prophylactic purposes. The authors present a case series of 35 breasts of 19 women who underwent this procedure from January of 2021 through December of 2022 at the Plastic and Reconstructive Surgery Department of the University Hospital Santa Maria della Misericordia, in Udine, Italy, with a median follow-up of 15 months. The advantages of the J scar consist of a reduced risk of skin necrosis, a reduced bottoming-out rate, simplification of the surgical design, and lower impact of scars not involving the medial quadrants of the breast. Patients were administered the BREAST-Q 2.0 postoperative questionnaire at 3 months postoperatively, which showed a high average level of satisfaction with the reconstruction. This surgical technique is a valid option for patients who have voluminous breasts and adequate pinch test results who wish to undergo immediate heterologous reconstruction along with curative or prophylactic mastectomy., Clinical Question/level of Evidence: Therapeutic, IV., (Copyright © 2023 by the American Society of Plastic Surgeons.)

Background: Breast reconstruction is an integral postoncologic procedure that has been associated with improved mental health and psychological outcomes. The possible interaction between existing psychiatric diagnoses hospital courses and postoperative complications warrants further exploration., Methods: Bilateral breast reconstruction patients were identified from the 2016 to 2018 Healthcare Cost and Utilization Project-National Inpatient Sample (HCUP - NIS). Number and type of psychiatric diagnoses within the cohort were then evaluated using a host of ICD-10 codes. A propensity score analysis was applied to control for confounding variables such as demographics, existing comorbidities, and hospital characteristics. A binary logistic regression model was then used to identify the prediction value of psychiatric diagnosis and its interaction with modality of reconstruction for objective outcomes like length of hospital stay, treatment charge, and postoperative complications., Results: A total of 10,114 patients were identified as the final cohort of breast reconstruction patients. 2621 (25.9%) patients possessed an average of 1.4 ± 0.6 existing psychiatric diagnoses. Presence of at least 1 psychiatric diagnosis was a strong predictor alone for extended length of stay (OR: 1.34, 95% CI: 1.28-1.41, P < .001) and occurrence of postoperative complications (OR: 1.31, 95% CI: 1.21-1.41, P < .001). Psychiatric diagnosis displayed a significant interaction with modality of breast reconstruction and conferred a lower increase in risk of extended length of stay in autologous reconstruction when compared to implant-based reconstruction (OR: 0.80, 95% CI: 0.72-0.89, P < .001)., Conclusion: Existing psychiatric diagnoses were shown to strongly predict and modulate risk of adverse postoperative outcomes depending on modality of reconstruction., Competing Interests: Disclosure All authors have no financial disclosures, conflicts of interest, or products for this manuscript., (Copyright © 2024. Published by Elsevier Inc.)

Background: Postoperative infection of breast implants can lead to implant removal and other complications. This study aimed to investigate the presence of costal cartilage infection following breast implant surgery and the diagnostic role of PET/CT in identifying this rare complication., Patients and Methods: A retrospective study included 16 patients with persistent infections after breast implant removal surgery. Patients underwent PET/CT scans before surgery, and surgical plans were made based on PET/CT findings. Surgical procedures were guided by PET/CT, and specimens were collected for pathological examination and microbiological culture. Follow-up assessments were performed at 1, 3, and 12 months postoperatively., Results: Among the 16 patients, 11 were diagnosed with costal cartilage infection, whereas 5 had subcutaneous soft tissue infections. PET/CT accurately identified costal cartilage infection in all cases and localized the infected costal cartilage in the majority of cases. Microbiological culture results showed various pathogens. All patients were cured with one or staged surgery., Conclusion: Costal cartilage infection following breast implant surgery is a significant concern. PET/CT plays a crucial role in the accurate diagnosis and localization of infected costal cartilage, aiding in appropriate surgical management. Patients should be closely monitored for the possibility of costal cartilage infection when experiencing persistent symptoms after breast implant surgery., (Copyright © 2024 Wolters Kluwer Health, Inc. All rights reserved.)

Introduction: Considerable research has been carried out on the postoperative benefits of extended antibiotic prophylaxis (EAP) in different surgical contexts, generating various results regarding its effectiveness. Some studies indicate positive outcomes, whereas others indicate no significant advantages. Our approach involves conducting a comprehensive systematic review and meta-analysis to provide a more nuanced understanding of the role of extended antibiotic use because of the lack of a consistent consensus., Methods: A thorough search of the Cochrane Library, Embase, and MEDLINE electronic databases was conducted to identify relevant studies. The metafor package in R software was used for meta-analysis. We collected risk ratios (RRs) for surgical site infection (SSI) in the EAP versus non-EAP groups from the included studies to assess the effects of EAP on reducing the risk of SSI. The meta-analysis used a random-effects model, and effect sizes were presented with their corresponding 95% confidence intervals (CIs)., Results: Fourteen studies, involving 12,572 patients who underwent implant-based reconstruction postmastectomy, were included. Pooling the results of the studies that used EAP until drain removal revealed no protective effect of EAP against SSI risk (RR = 0.84; 95% CI: 0.60-1.18). Similarly, our analysis revealed no significant benefit of EAP in studies where EAP was not contingent on drain removal (RR = 0.70; 95% CI: 0.46-1.07)., Conclusions: EAP administration did not decrease the incidence of SSI in individuals undergoing implant-based breast reconstruction surgery postmastectomy., (Copyright © 2024. Published by Elsevier Ltd.)

Background: Necrosis of a cutaneous flap including the nipple-areola complex is a common complication in immediate implant-based breast reconstruction following nipple-sparing mastectomy (NSM)/skin-sparing mastectomy (SSM). This study aimed to evaluate the efficacy of prostaglandin E1 (PGE1) in reducing such complications., Methods: A retrospective analysis of prospectively collected data was conducted at two centers, and the cohort consisted of patients undergoing NSM/SSM followed by immediate reconstruction with a prosthesis. Patients who were randomly allocated to the treatment group were administered daily intravenous PGE1 (10 μg/2 mL) beginning intraoperatively through postoperative day 6. Skin flap complications including nipple/skin necrosis, delayed wound healing, and postoperative wound revision were recorded. Complication rates were compared between the PGE1 and control groups., Results: A total of 276 breasts in 259 patients were included for analysis (139 breasts in the treatment group and 137 breasts in the control group). There was no difference in patient demographics between the control and treatment groups. Reconstructed breasts receiving PGE1 had significantly lower rates of overall skin complications (21.6% versus 34.3%; P = 0.022) and wound revision (2.9% versus 9.5%; P = 0.025). Among NSM cases, the PGE1 group showed a significantly lower rate of nipple necrosis (15.5% versus 29.4%; P = 0.027). In the multivariate analysis, the use of PGE1 significantly reduced the risk of overall skin flap complications (OR, 0.491; P = 0.018) and wound revision (OR, 0.213; P = 0.018) in NSM/SSM cases, and nipple necrosis (OR, 0.357; P = 0.008) in NSM cases., Conclusion: PGE1 can be effective in reducing risk of mastectomy flap complications in immediate implant-based breast reconstructions., Clinical Question/level of Evidence: Therapeutic, III., (Copyright © 2023 by the American Society of Plastic Surgeons.)

Competing Interests: Conflicts of interest and sources of funding: none declared.

Background: Systemic symptoms associated with breast implants (SSBI) is a term used to describe a group of patients who attribute a variety of symptoms to their implants. Previous studies have shown symptom improvement after implant removal in these patients irrespective of whether part or all the implant capsule has been removed., Objectives: The aim of this study was to evaluate implant removal with no capsule removed in symptomatic and control subjects., Methods: Eligible study subjects were sequentially enrolled at 5 investigator sites. The SSBI Cohort included patients with systemic symptoms they attributed to their implants who requested explantation. The Non-SSBI Cohort included subjects without systemic symptoms attributed to their implants who requested explantation with or without replacement. All subjects agreed to undergo explantation without removal of any capsule., Results: Systemic symptom improvement was noted in SSBI subjects without removal of the implant capsule, comparable to the results of our previously published study. SSBI patients showed a 74% reduction in self-reported symptoms at 6 months with no capsulectomy which was not statistically different from partial or total capsulectomies (P = .23)., Conclusions: Explantation with or without capsulectomy provides symptom improvement in patients with systemic symptoms they associate with their implants., (© 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: Since the early 2000s, acellular dermal matrix has been a popular adjunct to prepectoral breast reconstruction to enhance outcomes., Objectives: The aim of this study was to investigate the differences in the postoperative course of 2 standard acellular dermal matrix products, AlloDerm SELECT Ready To Use and DermACELL., Methods: A prospective, patient-blind study of patients undergoing bilateral nipple and/or skin-sparing mastectomies with either tissue expander or silicone implant insertion between 2019 and 2022 were selected for this study. The study design used patients as their own controls between 2 products randomly assigned to the left or right breast. Outcomes between the products included average time for drain removal, infection rate, seroma rate, and incorporation rates., Results: The prospective clinical data of 55 patients (110 breasts) were recorded for 90 days. There were no significant differences between drain removal time, average drain output, or seroma aspiration amount. A higher percentage of seromas was recorded in the breasts with AlloDerm (30.91%) compared with breasts containing DermACELL (14.55%, P < .05), and a statistically significant difference between the incorporation rates of AlloDerm (93.4%) and DermACELL (99.8%, P < .05) was observed., Conclusions: Irrespective of patient demographic disparities, both products had a 94.55% success rate for reconstruction outcomes. AlloDerm was determined to have a higher incidence of seromas as a postoperative complication and a trend to lower incorporation., (© 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: Direct-to-implant (DTI) breast reconstruction after mastectomy has gained increasing popularity. While concerns over ischemic complications related to tension on the mastectomy flap persist, newer techniques and technologies have enhanced safety of this technique., Objectives: To compare clinical and patient-reported outcomes of DTI and 2-stage tissue expander (TE) reconstruction., Methods: A prospective cohort design was utilized to compare the incidence of reconstructive failure among patients undergoing DTI and TE reconstruction by unadjusted bivariate and adjusted multivariable logistic regression analyses. Secondary clinical outcomes of interest included specific complications requiring intervention (infection, seroma, hematoma, mastectomy flap necrosis, incisional dehiscence, device exposure) and time to final drain removal. Patient-reported outcomes on BREAST-Q were also compared., Results: A total of 134 patients (257 breasts) underwent DTI reconstruction and 222 patients (405 breasts) received TEs. DTI patients were significantly younger with lower BMIs; less diabetes, hypertension, and smoking; and smaller breast sizes; they also underwent more nipple-sparing mastectomies with prepectoral reconstructions. Rates of any complication (18% DTI vs 24% TE, P = .047), reconstructive failure (5.1% vs 12%, P = .004), and seroma (3.9% vs 11%, P < .001) were significantly lower in the DTI cohort on unadjusted analyses; however, there were no significant differences on adjusted regressions. Patient-reported satisfaction with breasts, psychosocial well-being, and sexual well-being were more substantively improved with DTI reconstruction., Conclusions: Prepectoral DTI reconstruction is a viable option for postmastectomy reconstruction in carefully selected patients, with no significant increase in reconstructive failure or other complications., (© 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: Broad evidence supports the use of antiseptic pocket rinse in breast implant surgery to minimize the risk of capsular contracture or other complications. However, there is limited consensus or standardization of antiseptic rinse in practice., Objectives: In this preliminary study, we sought to determine contemporary trends in antiseptic rinse use in primary breast implant surgery based on Australian Breast Device Registry (ABDR) data, and whether these trends align with the suggestions of the 14-point plan. This further served as a feasibility study for subsequent comparison of antiseptic rinse effects on clinical outcomes., Methods: Institutional ethics approval was obtained and national ABDR data for primary breast implant surgery from 2015 to 2020 were analyzed for the use and type of antiseptic rinse. The surgeon-reported data were homogenized with regard to terminology and categorized by major trends, and the literature was reviewed., Results: We analyzed data for 37,143 patients, totaling 73,935 primary implants. Antiseptic rinse included povidone-iodine (PVP-I) in 35,859 (48.5%), no antiseptic use in 24,216 (32.8%), other concentrations of PVP-I in 4200 (5.7%), and Betadine triple antibiotic in 1831 implants (2.5%). Multiple other antiseptic permutations were noted in 7004 implants (9.5%)., Conclusions: The majority (56.7%) of Australian practitioners utilize previously described antiseptic pocket irrigation solutions that align with the 14-point plan. A third (32.8%), however, do not record any antiseptic pocket irrigation. These findings will permit a subsequent (ongoing) study of outcomes comparing PVP-I pocket rinse to no antiseptic pocket rinse, which will likely constitute the largest study of its kind., (© The Author(s) 2023. Published by Oxford University Press on behalf of The Aesthetic Society. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.)

Background: Implant rotation is a known complication to breast reconstruction using anatomical implants. However, there is a lack of large studies investigating the risk of implant rotation and potential predisposing risk factors., Method: We reviewed the medical records of all patients who underwent breast reconstruction with Mentor anatomical implants from 2010 to 2021 at two Danish hospitals. We compared the risk of implant rotation between one- and two-stage breast reconstruction using univariate logistic regression. We analyzed the effect of biological mesh, immediate versus delayed reconstruction, and use of a higher final expander volume than the permanent implant volume on the risk of implant rotation. Finally, we analyzed the success rate of revision surgery for implant rotation., Results: In total, 1134 patients were enrolled. Patients who underwent two-stage breast reconstruction (n = 720) had a significantly higher risk of implant rotation than those who underwent one-stage breast reconstruction (n = 426; 11% vs. 5%, p < 0.01). There was no significant association between implant rotation and the use of biological mesh, immediate breast reconstruction, or use of a higher final expander volume than the permanent implant volume. The success rate of revision surgery after implant rotation was 73% (62/85 rotations)., Conclusions: Two-stage breast reconstruction significantly increased the risk of implant rotation compared to one-stage breast reconstruction. The overall risk of implant rotation was low and success rate of revision surgery was high. These findings suggest that anatomical implants are safe to use for breast reconstruction. However, surgeons and patients should be aware of the increased risk of implant rotation after two-stage reconstruction., (Copyright © 2024 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by Elsevier Ltd. All rights reserved.)

Background: Textured implants have been linked to breast implant-associated anaplastic large-cell lymphoma (BIA-ALCL). Patients who undergo explantation have options for reconstruction, but data on safety and patient-reported outcomes (PROs) are limited. The purpose of this study was to classify complications and PROs in patients opting for surgical management of textured implants., Methods: Complication rates and BREAST-Q scores were compared between (1) asymptomatic patients who underwent conversion from textured to smooth implants ( n = 224), (2) symptomatic patients who underwent conversion from textured to smooth implants ( n = 83), (3) patients who underwent explantation without replacement ( n = 44), and (4) patients who underwent replacement with autologous reconstruction ( n = 33). Linear regression examined PROs controlling for clinical and surgical variables., Results: Overall complication rates in 384 patients (637 implants) differed across groups ( P = 0.034), with the highest rate (25%) in patients who underwent explantation without replacement. These patients were specifically more impacted by minor complications, notably seroma. Capsulectomy extent did not significantly impact complications. Asymptomatic and symptomatic smooth implant patients had improvements in Satisfaction with Breasts ( P < 0.05). Autologous reconstruction patients had significant improvements in Satisfaction with Breasts sustained after 3 months postoperatively ( P < 0.01) and Sexual Well-being sustained after 6-months postoperatively ( P < 0.05). Patients who underwent removal without replacement had lower Physical Well-being of the Chest scores at 1 year or more than the other groups., Conclusions: Replacement of textured implants with smooth implants or flaps is safe and is associated with improved satisfaction with breasts and quality of life. The degree of capsulectomy does not appear to impact the incidence of perioperative complications., Clinical Question/level of Evidence: Therapeutic, III., (Copyright © 2023 by the American Society of Plastic Surgeons.)

Background: Antibiotic implant irrigation is increasingly used to prevent deep infection after implant-based breast reconstruction. However, there is limited evidence of the clinical effect. In this study, the authors compare the risk of a deep infection in a Danish population of women who received antibiotic implant irrigation with either gentamicin or vancomycin, or no irrigation., Methods: The authors retrospectively reviewed consecutive patients undergoing all types of breast reconstruction with implants at Rigshospitalet and Herlev Hospital, Denmark, from 2010 to 2019. Logistic regression was used to compare the risk of deep infection between no irrigation and irrigation with gentamicin or vancomycin, and to account for the difference in risk between patient subgroups and risk factors., Results: The authors included 1508 patients who received antibiotic irrigation with gentamicin (500 patients), vancomycin (304 patients), or no irrigation (704 patients). The univariable risk analysis showed a significant decreased risk of deep infection using gentamicin irrigation compared with no irrigation (OR, 0.58; P < 0.05). However, when adjusting for risk factors for infection, there was no significant decrease in the risk of infection when using gentamicin (OR, 0.90; P = 0.71) or vancomycin (OR, 1.0; P = 0.99) compared with the control group., Conclusions: The authors found no significant effect of using antibiotic implant irrigation after isolating it from risk factors for deep infection. However, because of the limitations of the study, the authors cannot conclude that there is no effect of antibiotic implant irrigation. There is a need for a randomized, placebo-controlled trial to investigate the effect, and potential side-effects, of antibiotic implant irrigation., Clinical Question/level of Evidence: Risk, II., (Copyright © 2023 by the American Society of Plastic Surgeons.)

Background: The majority of postmastectomy breast reconstructions (PMBRs) are currently performed in two stages using a tissue expander (TE). However, complications during the expansion phase occur regularly, leading to unplanned reoperations and/or reconstruction failure. This study aimed to identify risk factors for unplanned reoperation after TE placement, assessed the time until unplanned and planned reoperation, and investigated indications for unplanned reoperation., Methods: Patient- and surgery-related characteristics of patients who underwent two-stage PMBR between 2017 and 2021 were collected from the Dutch Breast Implant Registry (DBIR). Unplanned reoperation was defined as TE explantation followed by either no replacement or replacement with the same or a different TE. Covariate-adjusted characteristics associated with unplanned reoperation were determined using backward stepwise selection and multivariable logistic regression analyses., Results: In total, 2529 patients (mean age, 50.2 years) were included. Unplanned reoperation occurred in 19.4% of all registered TEs ( n = 3190). Independent factors associated with unplanned reoperation were body mass index (BMI) greater than or equal to 25 kg/m 2 (adjusted OR [aOR], 1.63, 99% CI, 1.20 to 2.57 for BMI of 25 to 29.9 kg/m 2 ; aOR, 2.57, 99% CI, 1.74 to 3.78 for BMI ≥30 kg/m 2 ), low institutional volume (aOR, 1.51; 99% CI, 1.06 to 2.18), no drains (aOR, 2.06; 99% CI, 1.15 to 3.60), subcutaneous TE placement (aOR, 5.71; 99% CI, 3.59 to 9.10), and partial pectoralis major muscle coverage (aOR, 1.35; 99% CI, 1.02 to 1.79). Age younger than 40 years (aOR, 0.49; 99% CI, 0.32 to 0.74) and delayed PMBR (aOR, 0.35; 99% CI, 0.19 to 0.60) reduced the risk of unplanned reoperation. Median time until reoperation was 97 days for unplanned and 213 days for planned reoperation. Deep wound infections were most often registered as indication for unplanned reoperation (34.4%)., Conclusion: This study identified several risk factors for unplanned reoperation that may be used to reduce complications in expander-based PMBR., Clinical Question/level of Evidence: Risk, III., (Copyright © 2023 by the American Society of Plastic Surgeons.)

Background: The central pedicle technique (CPT) is rarely used to perform mastopexy or mastopexy with implant augmentation despite having robust perfusion and allowing for great exposure, resulting in reproducible results. This study was conducted to review one surgeon's experience using the CPT for both mastopexy and mastopexy with implant augmentation., Method: A retrospective review of consecutive patients who had a mastopexy or mastopexy with augmentation using a standardized CPT from 2017 through 2021 was performed., Results: A total of 201 patients were identified for inclusion: 120 had a bilateral central pedicle mastopexy, 75 had bilateral central pedicle mastopexy and implants, and 6 had unilateral central pedicle mastopexy with implants because of asymmetry. Mean follow-up was 11.2 months. The average age was 45.4 years, body mass index 25.1 kg/m², and implant size 275 cc. The overall complication rate was 9.5%: 9.2% for CPT mastopexy and 9.9% for CPT mastopexy with implants. No revisional surgery was requested. None of the patients experienced nipple or skin necrosis., Conclusions: This study demonstrates that CPT mastopexy with or without an implant can be performed safely with a low complication rate. Additional benefits include standardized markings before surgery, visualization of the entire breast mound, and reliable perfusion. The technique excels in correcting asymmetry. CPT mastopexy with or without an implant is a safe and effective option for the treatment of breast ptosis., Clinical Question/level of Evidence: Therapeutic, IV., (Copyright © 2023 by the American Society of Plastic Surgeons.)

Background: After approval of Sientra silicone gel breast implants in March of 2012, the U.S. Food and Drug Administration required completion of a 10-year U.S. postapproval study. The authors present results from the first 6 years of this study., Methods: An ongoing, open-label, prospective, multicenter study is being conducted to evaluate the long-term clinical performance of Sientra implants in patients undergoing breast augmentation, reconstruction, and revision in the postmarket environment. Enrollment of 5197 patients (10,327 implants) was completed on March 6, 2015 (4046 primary augmentation, 895 revision-augmentation, 149 primary reconstruction, and 107 revision-reconstruction). Analyses were conducted at year 6 (database lock: January 24, 2022)., Results: Across all cohorts who received an implant, the Kaplan-Meier risk of investigator-reported Baker grade III/IV capsular contracture was 4.1% (3.9% with submuscular placement and 6.75%with subglandular placement), the risk of reoperation was 11.6%, and the risk of implant removal was 7.8% (5.9% with implant replacement and 2.0% without replacement). The primary reason (>50%) for reoperation was aesthetic (eg, style/size change). The Kaplan-Meier risk of rupture, calculated for patients who underwent explantation or MRI for rupture evaluation, was 5.8%. Overall, 82.6% of patients were highly satisfied/happy with their implant. No cases of breast implant-associated anaplastic large cell lymphoma were reported., Conclusion: Six-year results of the postapproval study were consistent with the 10-year core study and provide additional evidence in a large data set supporting the comprehensive safety and effectiveness profile of the Sientra implants., (Copyright © 2023 The Authors. Published by Wolters Kluwer Health, Inc. on behalf of the American Society of Plastic Surgeons.)