Tuesday 16 May 2017

Subfascial Primary Breast Augmentation with Fat Grafting: A Review of 156 Cases

Subfascial Primary Breast Augmentation with Fat Grafting: A Review of 156 Cases

Kerfant, N et al
Plastic & Reconstructive Surgery: May 2017 - Volume 139 - Issue 5 - p 1080e–1085e

Background: Composite breast augmentation with fat grafting and an implant has become very popular in the past 5 years. This achieves the core volume projection of an implant complemented by the natural appearance and feel of fat. However, no study has looked at the complications and reoperation rates of this technique. Methods: A retrospective chart review examined all patients who underwent the combined use of an implant and fat grafting for primary breast augmentation. Results: The study identified 156 patients between 2007 and 2013. The mean patient age was 31.7 years and the average body mass index was 18.85 kg/m2. The average implant size was 252 cc. Patients received a mean of 126 cc of fat (range, 30 to 250 cc) in subcutaneous soft tissue. Follow-up averaged 22.25 months (range, 1 to 86 months). The total complication rate was 7.7 percent and the reoperation rate was 9.94 percent. Baker grade II/III contracture was the most common complication [Baker grade II, n = 4 (2.56 percent); Baker grade III, n = 2 (2 percent)], followed by infections [n = 2 (1.28 percent)], hematoma [n = 2 (1.28 percent)], and malrotation [n = 1 (0.64 percent)]. Delayed reoperation was performed in nine patients (9.94 percent) after a mean interval of 31.7 months. Two patients who developed Baker grade III contractures needed surgery to correct the problem. Three cases (1.92 percent) required additional fat grafting for insufficient soft-tissue coverage. The mean volume of fat reinjection was 170 cc. Conclusions: Composite breast augmentation is a valuable, stable, reliable technique in breast aesthetic surgery with good, natural-appearing results. It provides long-term aesthetic benefits and avoids the submuscular plane.

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

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

Khavanin N et al
Plastic & Reconstructive Surgery: May 2017 - Volume 139 - Issue 5 - p1063 -1070

Background: Since the 2012 approval of shaped implants, their use in breast reconstruction has increased in the United States. However, large-scale comparisons of complications and patient-reported outcomes are lacking. The authors endeavored to compare surgical and patient-reported outcomes across implant types. 
Methods: The Mastectomy Reconstruction Outcomes Consortium database was queried for expander/implant reconstructions with at least 1-year postexchange follow-up (mean, 18.5 months). Outcomes of interest included postoperative complications, 1-year revisions, and patient-reported outcomes. Bivariate and mixed-effects regression analyses evaluated the effect of implant type on patient outcomes. 
Results: Overall, 822 patients (73.5 percent) received round and 297 patients (26.5 percent) received shaped implants. Patients undergoing unilateral reconstructions with round implants underwent more contralateral symmetry procedures, including augmentations (round, 18.7 percent; shaped, 6.8 percent; p = 0.003) and reductions (round, 32.2 percent; shaped, 20.5 percent; p = 0.019). Shaped implants were associated with higher rates of infection (shaped, 6.1 percent; round, 2.3 percent; p = 0.002), that remained significant after multivariable adjustment. Other complication rates did not differ significantly between cohorts. Round and shaped implants experienced similar 2-year patient-reported outcome scores. 
Conclusions: This prospective, multicenter study is the largest evaluating outcomes of shaped versus round implants in breast reconstruction. Although recipients of round implants demonstrated lower infection rates compared with shaped implants, these patients were more likely to undergo contralateral symmetry procedures. Both implant types yielded comparable patient-reported outcome scores. With appropriate patient selection, both shaped and round implants can provide acceptable outcomes in breast reconstruction.

What Is the Standard Volume to Increase a Cup Size for Breast Augmentation Surgery? A Novel Three-Dimensional Computed Tomographic Approach

What Is the Standard Volume to Increase a Cup Size for Breast Augmentation Surgery? A Novel Three-Dimensional Computed Tomographic Approach

King, N et al
Plastic & Reconstructive Surgery: May 2017 - Volume 139 - Issue 5 - p 1084–1089

Background: Breast augmentation surgery poses many challenges, and meeting the patient’s expectations is one of the most important. Previous reports equate 100 cc to a one-cup-size increase; however, no studies have confirmed this between commercially available bras. The aim of this study was to identify the volume increase between cup sizes across different brands and the relationship with implant selection. 
Methods: Five bra cup sizes from three different companies were analyzed for their volume capacity. Three methods were used to calculate the volume of the bras: (1) linear measurements; (2) volume measurement by means of water displacement; and (3) volume calculation after three-dimensional reconstruction of serial radiographic data (computed tomography). The clinical arm consisted of 79 patients who underwent breast augmentation surgery from February 1, 2014, to June 30, 2016. Answers from a short questionnaire in combination with the implant volume were analyzed. Results: Across all three brands, the interval volume increase varied between sizes, but not all were above 100 cc. There was some variation in the volume capacity of the same cup size among the different brands. The average incremental increase in bra cup size across all three brands in the laboratory arm was 135 cc. The mean volume increase per cup size was 138.23 cc in the clinical arm. Conclusions: This article confirms that there is no standardization within the bra manufacturing industry. On the basis of this study, patients should be advised that 130 to 150 cc equates to a one-cup-size increase. Bras with narrower band widths need 130 cc and wider band widths require 150 cc to increase one cup size.

Global Adverse Event Reports of Breast Implant–Associated ALCL: An International Review of 40 Government Authority Databases

Global Adverse Event Reports of Breast Implant–Associated ALCL: An International Review of 40 Government Authority Databases

Srinivasa, D R et al
Plastic & Reconstructive Surgery: May 2017 - Volume 139 - Issue 5 - p 1029–1039

Background: Tracking world cases of breast implant–associated anaplastic large cell lymphoma (ALCL) is currently limited to patient registries at a few academic centers, dependent upon patient referral and case reports in the literature. The purpose of this study was to review and compare federal database adverse event reports of breast implant–associated ALCL encompassing the major breast implant markets worldwide. 
Methods: Federal implantable device regulatory bodies were contacted and database queries were performed for 40 countries. Demographics, device characteristics, pathology, treatment modalities, and outcomes were assessed when available. Results: For the countries queried, 363 unique cases were reported for breast implant–associated ALCL. Search terms “anaplastic” and “ALCL” were queried of the U.S. Manufacturer and User Facility Device Experience (MAUDE) database and yielded 258 unique cases as of September 2015, of which only 130 had pathologic markers performed. Implant surface was textured significantly more than smooth (50 percent versus 4.2 percent; p = 0.0001). Treatment, when reported (n = 136), included explantation [n = 125 (91.9 percent)], chemotherapy [n = 42 (30.8 percent)], radiation therapy [n = 25 (18.4 percent)], and/or stem cell transplant [n = 9 (6.6 percent)], and five deaths were reported. 
Conclusions: Federal reporting of breast implant–associated ALCL has limitations in providing clinical history, treatment, and oncologic follow-up. Worldwide and country-specific total and textured implant sales data are needed to determine critical incidence and prevalence analysis. International multi-institutional collaborations and centralized tissue consortiums working in concert with federal authorities are necessary to acquire accurate complete data on breast implant–associated ALCL.

Adolescent Desire for Cosmetic Surgery: Associations with Bullying and Psychological Functioning

Adolescent Desire for Cosmetic Surgery: Associations with Bullying and Psychological Functioning

Lee, K M et al
Plastic & Reconstructive Surgery: May 2017 - Volume 139 - Issue 5 - p 1109–1118

Background: Adolescent bullying may be a key driver of interest in cosmetic surgery. This study examined the extent of such interest and whether any effect was sex-specific, and examined psychological functioning as a potential mechanism through which bullying involvement may lead to a wish for cosmetic surgery. 
Methods: A two-stage design was used. In the first stage, 2782 adolescents (aged 11 to 16 years) were screened for bullying involvement using self-reports and peer nominations. In the second stage, 752 adolescents who were bullies, victims, bully-victims, or uninvolved in bullying reported their desire for cosmetic surgery. Psychological functioning was constructed as a composite of self-esteem and emotional problems (assessed at stage 1) and body-esteem scores (assessed at stage 2). 
Results: Adolescents involved in bullying in any role were significantly more interested in cosmetic surgery than uninvolved adolescents. Desire for cosmetic surgery was greatest in adolescents who were bullied (victims and bully-victims) and girls. Desire for cosmetic surgery was highest in girls, but sex did not interact with bullying role. Being victimized by peers resulted in poor psychological functioning, which increased desire for cosmetic surgery. In contrast, desire for cosmetic surgery in bullies was not related to psychological functioning, which was in the normal range. 
Conclusions: Bullying victimization is related to poor psychological functioning, and both are related to a greater desire for cosmetic surgery in adolescents. Cosmetic surgeons should screen candidates for psychological vulnerability and may want to include a short screening questionnaire for a history of peer victimization.

Is Enhanced Recovery the New Standard of Care in Microsurgical Breast Reconstruction?

Is Enhanced Recovery the New Standard of Care in Microsurgical Breast Reconstruction?

Afonso, A et al

Plastic & Reconstructive Surgery: May 2017 - Volume 139 - Issue 5 - p 1053–1061

Background: At present, there are limited data available regarding the use and feasibility of enhanced recovery pathways for patients undergoing microsurgical breast reconstruction. The authors sought to assess patient outcomes before and after the introduction of an enhanced recovery pathway that was adopted at a single cancer center. 
Methods: A multidisciplinary enhanced recovery pathway was developed for patients undergoing deep inferior epigastric perforator or free transverse rectus abdominis myocutaneous flap breast reconstruction. Core elements of the enhanced recovery pathway included substituting intravenous patient-controlled analgesia with ketorolac and transversus abdominis plane blocks using liposomal bupivacaine, as well as intraoperative goal-directed fluid management. Patients who underwent surgery between April and August of 2015 using the enhanced recovery pathway were compared with a historical control cohort. The primary endpoints were hospital length of stay and total postoperative opioid consumption. 
Results: In total, 91 consecutive patients were analyzed (enhanced recovery pathway, n = 42; pre–enhanced recovery pathway, n = 49). Mean hospital length of stay was significantly shorter in the enhanced recovery pathway group than in the pre–enhanced recovery pathway group (4.0 days versus 5.0 days; p < 0.0001). Total postoperative morphine equivalent consumption was also lower in the enhanced recovery pathway group (46.0 mg versus 70.5 mg; p = 0.003). There was no difference in the incidence of 30-day complications between the groups (p = 0.6). 
Conclusion: The adoption of an enhanced recovery pathway for deep inferior epigastric perforator and transverse rectus abdominis myocutaneous flap reconstruction by multiple surgeons significantly decreased opioid consumption and reduced length of stay by 1 day.

The Challenges of Augmentation Mastopexy in the Massive Weight Loss Patient: Technical Considerations

The Challenges of Augmentation Mastopexy in the Massive Weight Loss Patient: Technical Considerations
Coombs, D M et al
Plastic & Reconstructive Surgery: May 2017 - Volume 139 - Issue 5 - p 1090–1099

Background: Augmentation mastopexy in the massive weight loss population is challenging because of poor skin elasticity and lack of inframammary support. Despite several large studies of augmentation mastopexy in the literature, few data exist regarding this unique patient population. The authors examine early postoperative ptosis, implant malposition, and strategies to optimize outcomes. Methods: A retrospective review of massive weight loss patients who underwent augmentation mastopexy from 2003 to 2011 was performed to record age, body mass index, implant characteristics, postoperative ptosis, and implant malposition. Results: Thirty patients were identified with a mean age of 44.8 ± 8.5 years, mean current body mass index of 26.1 ± 3.9 kg/m2, and mean follow-up time of 283.5 days (range, 7 to 1095 days). Preoperatively, patients mostly presented with grade 3 ptosis (63.3 percent). Five patients (16.7 percent) developed postoperative ptosis within the first 3 months after surgery, with no increase after this time. Implant malposition increased significantly with time: 61.9 percent by 12 months (p = 0.006), with a median time for implant malposition of 160 days. Postoperative ptosis was significantly related to age (p = 0.039) and a larger left-side implant (p = 0.022). Implant malposition was significantly related to higher current body mass index (p = 0.047), but not to implant size. Two patients (6.6 percent) underwent revision procedures. Conclusion: Massive weight loss patients have an increased risk of early postoperative ptosis or implant malposition, reinforcing the need for appropriate preoperative counseling to manage patient expectations. 

U.S. Epidemiology of Breast Implant–Associated Anaplastic Large Cell Lymphoma

U.S. Epidemiology of Breast Implant–Associated Anaplastic Large Cell Lymphoma

Doren, E L et al
Plastic & Reconstructive Surgery: May 2017 - Volume 139 - Issue 5 - p 1042–1050

Background: Breast implant–associated anaplastic large cell lymphoma (ALCL) is a distinctive type of T-cell lymphoma that arises around breast implants. Although rare, all cases with adequate history have involved a textured breast implant. The objective of this study was to determine the U.S. incidence and lifetime prevalence of breast implant–associated ALCL in women with textured breast implants. 
Methods: This is a retrospective review of documented cases of breast implant–associated ALCL in the United States from 1996 to 2015. The incidence and prevalence were determined based on a literature and institutional database review of breast implant–associated ALCL cases and textured breast implant sales figures from implant manufacturers’ annualized data. 
Results: One hundred pathologically confirmed breast implant–associated ALCL cases were identified in the United States. Mean age at diagnosis was 53.2 ± 12.3 years. Mean interval from implant placement to diagnosis was 10.7 ± 4.6 years. Forty-nine patients had breast implants placed for cosmetic reasons, 44 for mastectomy reconstruction, and seven for unknown reasons. Assuming that breast implant–associated ALCL occurs only in textured breast implants, the incidence rate is 2.03 per 1 million person-years (203 per 100 million person-years), which is 67.6 times higher than that of primary ALCL of the breast in the general population (three per 100 million per year; p < 0.001). Lifetime prevalence was 33 per 1 million persons with textured breast implants. 
Conclusions: This study demonstrates a statistically significant association between textured breast implants and breast implant–associated ALCL. Although women with a textured breast implant have a low risk of developing breast implant–associated ALCL, the current U.S. incidence is significantly higher than that of primary ALCL of the breast in the general population.

Role of Mitomycin C in Preventing Capsular Contracture in Implant-Based Reconstructive Breast Surgery: A Randomized Controlled Trial

Role of Mitomycin C in Preventing Capsular Contracture in Implant-Based Reconstructive Breast Surgery: A Randomized Controlled Trial

Nava, M B et al

Plastic & Reconstructive Surgery: April 2017 - Volume 139 - Issue 4 - p 819–826

Background: Capsular contracture represents the most frequent complication after implant-based breast reconstruction. An experimental study on mice demonstrated that capsule formation around breast implants is considerably diminished after topical application of mitomycin C. The authors conducted a randomized controlled clinical trial investigating the efficacy of mitomycin C in reducing capsular contracture rates following implant-based breast reconstruction after mastectomy for breast cancer. 
Methods: The authors randomized all women older than 18 years scheduled for the second stage of an implant-based breast reconstruction after mastectomy for breast cancer at the National Cancer Institute in Milan from October of 2005 to February of 2010 to receive or not receive the topical application of mitomycin C during surgery. The authors assessed capsular contracture, major postoperative complications, and aesthetic outcome.
 Results: The authors randomized 322 patients to receive mitomycin C or not at the second stage of implant-based breast reconstruction. One hundred sixty-two patients were allocated to the mitomycin C group and 160 patients were allocated to the control group. The relative risk of capsular contracture in the mitomycin C group was 0.92 (95 percent CI, 0.60 to 1.41). Major complications leading to reintervention, oncologic outcomes, and aesthetic outcomes were comparable between the two groups. 
Conclusions: This is the first trial reporting data about the use of mitomycin C in breast reconstructive surgery in a clinical setting. Mitomycin C seems not to significantly affect capsular contracture rate and severity following implant-based reconstructive breast surgery at the tested doses. 

Direct-to-Implant Breast Reconstruction without the Use of an Acellular Dermal Matrix Is Cost Effective and Oncologically Safe

Direct-to-Implant Breast Reconstruction without the Use of an Acellular Dermal Matrix Is Cost Effective and Oncologically Safe

Serrurie,L.C et al
Plastic and Reconstructive Surgery: April 2017 - Volume 139 - Issue 4 - p 809–817

Background: Direct-to-implant breast reconstruction is a predictable, reliable, and cost-effective reconstruction. Most units performing direct-to-implant reconstructions recommend the use of an acellular dermal matrix or a mesh to reinforce the lower pole of the breast reconstruction. 
Methods: Two hundred seventy-two consecutive patients with 488 immediate direct-to-implant breast reconstructions performed in a 34-month period are included in this group. Mean follow-up of this group is 35 months. 
Results: Four hundred eight reconstructions were performed through a lazy-S mastectomy, and 80 were performed through a Wise pattern mastectomy. Two local recurrences occurred. Minor complications accounted for 5.5 percent (n = 27): seromas, 3.4 percent (n = 17); wound healing problems, 0.6 percent (n = 3); and grade 2 capsular contracture, 1.4 percent (n = 7). Major complications accounted for 4.3 percent (n = 21): infection, 0.8 percent (n = 4); prosthetic loss, 0.4 percent (n = 2); hematoma, 0.4 percent (n = 2); and wounds requiring débridement, 2 percent (n = 10). The additional cost of acellular dermal matrix is dependent on manufacturer and size, but increases the cost of the procedure by 35.5 to 47.7 percent. 
Conclusions: This reconstruction method compares very favorably with published data from other units as far as early and late complications and cosmetic outcome are concerned. It has a complication rate similar to that of reconstructions using an acellular dermal matrix and is more cost effective.