Current Trends and Controversies in Breast Augmentation

Current Trends and Controversies in Breast Augmentation

Plastic & Reconstructive Surgery: April 2016 - Volume 137 - Issue 4 - p 1142–1150


Hidalgo D, Sinno S.

Background: A survey was conducted to study current attitudes and common practices in breast augmentation. Methods: A 35-item electronic questionnaire was sent to the entire active American Society of Plastic Surgeons membership. It was divided into current controversies, new technologies, common practices, secondary procedures, and member demographics. Results: There were 1067 respondents. Fifty percent of surgeons never use anatomically shaped implants and another 42 percent do so less than half the time. Autologous fat is used infrequently as a primary technique but more often as a supplemental technique. Approximately 7 percent report a case of anaplastic large cell lymphoma. Eighty-five percent do not use preoperative three-dimensional imaging. More than half of surgeons use acellular dermal matrix in secondary procedures. Approximately half do not use insertion funnels. Preoperative sizing with silicone implants, inframammary incisions, partial submuscular pockets, and smooth silicone implants larger than 300 cc are dominant practice preferences. Postoperative massage is still popular with over half of respondents. Just over half do not use pharmacologic agents for capsular contracture. Capsular contracture and size change were the most frequent reasons for reoperation. Capsular contracture is typically treated with anterior capsulectomy the first time, and either total capsulectomy or anterior capsulectomy with acellular dermal matrix use when recurrent. Almost half of respondents perform fewer than 50 breast augmentations yearly. Conclusions: There is an established most common approach to breast augmentation among respondents. Most surgeons are slow to embrace controversial practices and to adopt new technologies, although acellular dermal matrix use is becoming more popular. The 7 percent incidence of anaplastic large cell lymphoma was noteworthy.

Shoulder function after breast reconstruction with the latissimus dorsi flap: A prospective cohort study – Combining DASH score and objective evaluation

Shoulder function after breast reconstruction with the latissimus dorsi flap: A prospective cohort study – Combining DASH score and objective evaluation

The Breast June 2016 Volume 27, Pages 78–86


Garusi C et al

The latissimus dorsi (LD) flap is well-known in breast reconstruction especially in previously-irradiated patients, in order to have a low capsular contraction rate whenever an implant is associated. The aim of this study is to closely evaluate the effect of LD flap harvesting on shoulder function as well as specific movements related to the LD, both objectively and subjectively.

Intracystic papillary carcinoma of the breast: A SEER database analysis of implications for therapy

Intracystic papillary carcinoma of the breast: ASEER database analysis of implications for therapy

The Breast June 2016 Volume 27, Pages 87–92

Mogal H et al.


Intracystic papillary carcinoma (IPC) of the breast is a rare breast malignancy with an indolent course. However, patients can develop metastatic disease. Indications for surgery and radiotherapeutic management have not been well elucidated.

Impact of Neoadjuvant and Adjuvant Chemotherapy on Immediate Tissue Expander Breast Reconstruction.

Impact of Neoadjuvant and Adjuvant Chemotherapy on Immediate Tissue Expander Breast Reconstruction.

Ann Surg Oncol. 2016 Mar 4. [Epub ahead of print]

Dolen UC et al

BACKGROUND: Delayed wound healing or infection leads to premature tissue expander (TE) explantation after immediate postmastectomy breast reconstruction. A large study with sufficient duration of follow-up focusing on the impact of chemotherapy (CT) on premature TE removal after immediate breast reconstruction is lacking.
METHODS: A retrospective review of patients undergoing immediate TE reconstruction was conducted. Multivariate analyses identified factors contributing to premature removal of TEs including neoadjuvant and adjuvant CT, specific chemotherapeutic regimens, and other factors like cancer stage, body mass index, smoking, radiation, and age. Kaplan-Meier curves were plotted to study the timing of premature TE removal.
RESULTS: Of 899 patients with TEs, 256 received no, 295 neoadjuvant, and 348 adjuvant CT. Premature removal occurred more frequently in the neoadjuvant (17.3 %) and adjuvant (19.9 %) cohorts than the no-CT (12.5 %) cohort (p = 0.056). Premature TE removal occurred earlier (p = 0.005) in patients who received no CT than those with adjuvant CT. Radiation in patients receiving neoadjuvant CT prolonged the mean time to premature removal (p = 0.003). In the absence of radiation, premature removal occurred significantly sooner with neoadjuvant than adjuvant CT (p = 0.035).

DISCUSSION: Premature removal of a TE occurs more commonly in patients treated with neoadjuvant or adjuvant CT and is most commonly observed 2-3 months after placement-well after the follow-up period recorded by the American College of Surgeons National Surgery Quality Improvement Program (NSQIP) database. These findings can be used to aid preoperative counseling and guide the timing of follow-up for these patients.

Impact of Neoadjuvant and Adjuvant Chemotherapy on Immediate Tissue Expander Breast Reconstruction.

Impact of Neoadjuvant and Adjuvant Chemotherapy on Immediate Tissue Expander Breast Reconstruction.

Ann Surg Oncol. 2016 Mar 4. [Epub ahead of print]

Dolen UC et al


BACKGROUND: Delayed wound healing or infection leads to premature tissue expander (TE) explantation after immediate postmastectomy breast reconstruction. A large study with sufficient duration of follow-up focusing on the impact of chemotherapy (CT) on premature TE removal after immediate breast reconstruction is lacking.
METHODS: A retrospective review of patients undergoing immediate TE reconstruction was conducted. Multivariate analyses identified factors contributing to premature removal of TEs including neoadjuvant and adjuvant CT, specific chemotherapeutic regimens, and other factors like cancer stage, body mass index, smoking, radiation, and age. Kaplan-Meier curves were plotted to study the timing of premature TE removal.
RESULTS: Of 899 patients with TEs, 256 received no, 295 neoadjuvant, and 348 adjuvant CT. Premature removal occurred more frequently in the neoadjuvant (17.3 %) and adjuvant (19.9 %) cohorts than the no-CT (12.5 %) cohort (p = 0.056). Premature TE removal occurred earlier (p = 0.005) in patients who received no CT than those with adjuvant CT. Radiation in patients receiving neoadjuvant CT prolonged the mean time to premature removal (p = 0.003). In the absence of radiation, premature removal occurred significantly sooner with neoadjuvant than adjuvant CT (p = 0.035).

DISCUSSION: Premature removal of a TE occurs more commonly in patients treated with neoadjuvant or adjuvant CT and is most commonly observed 2-3 months after placement-well after the follow-up period recorded by the American College of Surgeons National Surgery Quality Improvement Program (NSQIP) database. These findings can be used to aid preoperative counseling and guide the timing of follow-up for these patients.

Revisiting the Management of Capsular Contracture in Breast Augmentation: A Systematic Review

Revisiting the Management of Capsular Contracture in Breast Augmentation: A Systematic Review

Plastic & Reconstructive Surgery: March 2016 - Volume 137 - Issue 3 - p 826–841 doi: 10.1097/01.prs.0000480095.23356.ae


Wan, D, Rohrich, R



Background: Capsular contracture is a complication of breast augmentation that frequently requires revision surgery. “Capsulectomy, site change, and implant exchange” has been referred to as the gold standard treatment of clinically significant contractures. However, the actual clinical evidence behind this algorithm remains elusive at best. A systematic review of the literature was performed to clarify the true evidence behind the surgical management of capsular contracture. Methods: A search of the MEDLINE database was performed for clinical studies involving the surgical treatment of capsular contracture following breast augmentation. Resulting articles were reviewed using a priori criteria. Results: The systematic review was performed in April of 2015. The primary search for “breast augmentation” yielded 9490 articles. When filtered for “treatment of capsular contracture,” 461 articles resulted. Review of these articles and pertinent references using a priori criteria yielded 24 final articles. No controlled trials met final inclusion criteria. Conclusions: There is limited clinical evidence behind the surgical management of capsular contracture. Site change and implant exchange are associated with reduced contracture recurrence rates and likely play a beneficial role in treating capsular contracture. The data on capsulectomy are less conclusive. Acellular dermal matrix may be a useful adjunct but still requires long-term data.

A Comparison of Methods to Assess Mastectomy Flap Viability in Skin-Sparing Mastectomy and Immediate Reconstruction: A Prospective Cohort Study

A Comparison of Methods to Assess Mastectomy Flap Viability in Skin-Sparing Mastectomy and Immediate Reconstruction: A Prospective Cohort Study

Plastic & Reconstructive Surgery: February 2016 - Volume 137 - Issue 2 - p 395–401 doi: 10.1097/01.prs.0000475744.10344.1e


Rinker, B et al

BACKGROUND: Skin-sparing mastectomy with immediate reconstruction can yield excellent aesthetic results, but high rates of mastectomy flap necrosis have been reported. A prospective cohort study was undertaken to compare three methods of assessing mastectomy flap viability following skin-sparing mastectomy and immediate reconstruction to determine which is most effective in reducing mastectomy flap necrosis.
METHODS: The study group included 60 consecutive patients (99 breasts) undergoing skin-sparing mastectomy and immediate reconstruction with either tissue expanders (n = 39) or transverse rectus abdominis musculocutaneous flaps (n = 21). Mastectomy flap viability was assessed either visually (n = 20), with fluorescein dye and Wood's lamp imaging (n = 20), or by indocyanine green angiography (n = 20). Variation across groups was analyzed using analysis of variance for continuous variables and chi-square test for dichotomous variables.
RESULTS: The mean follow-up was 10 months. There were no significant differences in mean age, body mass index, medical history, smoking history, pathologic diagnosis, chemotherapy, or reconstruction type. Mastectomy flap necrosis was observed in eight of 30 breasts in the direct visualization group (27 percent), compared with 14 percent in the indocyanine green angiography group and 3 percent in the fluorescein group (p = 0.03). The reoperation rate in the direct visualization group was 20 percent, compared with 15 percent in the indocyanine green angiography group and 0 percent in the fluorescein group.

CONCLUSIONS: Fluorescein dye was associated with the lowest rate of complications after skin-sparing mastectomy, but indocyanine green angiography was also shown to reduce mastectomy flap necrosis compared with direct visualization. Routine imaging of mastectomy flap perfusion seems to be beneficial in skin-sparing mastectomy, but intravenous fluorescein may be as effective as more expensive modalities.

Using the Retrograde Internal Mammary System for Stacked Perforator Flap Breast Reconstruction: 71 Breast Reconstructions in 53 Consecutive Patients

Using the Retrograde Internal Mammary System for Stacked Perforator Flap Breast Reconstruction: 71 Breast Reconstructions in 53 Consecutive Patients

Plastic & Reconstructive Surgery: February 2016 - Volume 137 - Issue 2 - p 265e–277e doi:10.1097/01.prs.0000475743.08559.b6

Stalder, M et al


Background: Abdominal tissue is the preferred donor source for autologous breast reconstruction, but in select patients with inadequate tissue, additional volume must be recruited to achieve optimal outcomes. Stacked flaps are an effective approach in these cases, but can be limited by the need for adequate recipient vessels. This article reports outcomes for the use of the retrograde internal mammary system for stacked flap breast reconstruction in a large number of consecutive patients. Methods: Fifty-three patients underwent stacked autologous tissue breast reconstruction with a total of 142 free flaps. Thirty patients underwent unilateral stacked deep inferior epigastric perforator (DIEP) flap reconstruction, five had unilateral stacked profunda artery perforator flap reconstruction, one had bilateral stacked DIEP/superior gluteal artery perforator flap reconstruction, and 17 underwent bilateral stacked DIEP/profunda artery perforator flap reconstruction. In all cases, the antegrade and retrograde internal mammary vessels were used for anastomoses. In situ manometry studies were also conducted comparing the retrograde internal mammary arteries in 10 patients to the corresponding systemic pressures. Results: There were three total flap losses (97.9 percent flap survival rate), two partial flap losses, four reexplorations for venous congestion, and three patients with operable fat necrosis. The mean weight of the stacked flaps for each reconstructed breast was 622.8 g. The retrograde internal mammary mean arterial pressures were on average 76.6 percent of the systemic mean arterial pressures. Conclusions: The results demonstrate that the retrograde internal mammary system is capable of independently supporting free tissue transfer. These vessels provide for convenient dissection and improved efficiency of these cases, with successful postsurgical outcomes.

Time for a randomised clinical trial evaluating breast conserving surgery compared to mastectomy in ipsilateral mutlifocal breast cancer (MFBC)?

Time for a randomised clinical trial evaluating breast conserving surgery compared to mastectomy in ipsilateral mutlifocal breast cancer (MFBC)?

The Breast [Article in Press]

Winters Z et al

Nijenhuis et al. (2015) are to be commended for reviewing the role of breast-conserving surgery (BCS) in the treatment of Multifocal Breast Cancers (MFBC) [1]. Currently, evidence-based guidelines on recommended surgical treatments in MFBC are based on limited evidence. A systematic review [2] critically evaluating the published literature has led us to conclude the following: 1) Studies of MFBC would benefit from standardized imaging, ideally with MRI providing detailed and accurate anatomic extent; 2) Modern trials would ideally evaluate neoadjuvant therapy, where therapeutic response can be evaluated; 3) Tumour subtype (immunohistochemical markers) of each cancer should be used in a minimized randomization design; 4) There is poor clinical evidence for the feasibility of dual tumour bed radiotherapy (RT) boosting and its impact on outcomes; 5) Meta-analyses on RT for unifocal cancers underline the significance of 10-year first recurrence and not breast cancer death; 6) Effect-sizes for 5-year local recurrence requires intergroup comparisons of surgery types (BCS versus mastectomy) far in excess of reported studies, where multicentric cancers are included and MFBC are clinically diagnosed; 7) Lack of convincing outcomes data on 5-year local recurrence after BCS is motivating a large international collaborative supported by respective international and national associations of breast surgery.

Patient-reported outcomes and their predictors at 2- and 3-year follow-up after immediate latissimus dorsi breast reconstruction and adjuvant treatment.

Br J Surg. 2016 Feb 29. doi: 10.1002/bjs.10102. [Epub ahead of print]

Winters Z E, et al


BACKGROUND: The aim of this study was to estimate the impact 2 and 3 years after surgery of implant-assisted latissimus dorsi (LDI) and autologous latissimus dorsi (ALD) flap breast reconstructions on patient-reported outcomes (PROs), and, secondarily, to determine whether baseline characteristics can predict PROs.
METHODS: This was a multicentre prospective cohort study. The European Organization for Research and Treatment of Cancer (EORTC) Quality of Life Core Questionnaire (QLQ-C30) and breast cancer module (QLQ-BR23), Functional Assessment of Cancer Therapy - Breast (FACT-B), and Hospital Anxiety and Depression Scale (HADS) PROs were completed before surgery and at 2 and 3 years after breast reconstruction. The effects of LDI and ALD, adjusted for baseline clinicodemographic characteristics, were estimated with multiple linear regressions. Effect sizes above 0·5 were considered clinically important.
RESULTS: Some 206 patients (LDI 93, ALD 113) were recruited in 2007-2013; 66·5 per cent were node-negative and 34·6 per cent received radiotherapy. Women with adverse clinicopathological factors were more likely to have received radiotherapy and to undergo ALD. Patients in both surgical groups showed clinically important effects at 2 and 3 years, including improvements in emotional scales, but worse physical functioning, social well-being, body image and anxiety. Radiotherapy adversely affected social functioning at 2 years (P = 0·002). Women undergoing ALD reconstruction had significantly improved sexual functioning at 3 years (P = 0·003) relative to those who had LDI procedures, even after adjusting for case mix (P = 0·007). At 3 years, younger women experienced worse physical well-being than older women (P = 0·006), and chemotherapy was associated with worse arm symptoms (P = 0·005).

CONCLUSION: Clinically important changes occurred in physical functioning, breast symptoms, body image and psychological distress. These results will guide selections of key PRO domains and sample-size calculation of future studies.

Implant-based breast reconstruction:Strategies to achieve optimal outcomes and minimize complications.

J Surg Oncol. 2016 Feb 26. doi: 10.1002/jso.24210. [Epub ahead of print]

Nahabedian MY

Abstract: Breast reconstruction using prosthetic devices is the most commonly performed procedure in women following mastectomy. The goal is to provide an outcome that is predictable and reproducible while minimizing complications and optimizing aesthetics. There are various strategies by which this can be achieved. It begins with proper patient selection because most adverse events occur in high-risk patients. This in turn is related to the timing of the reconstruction that can be performed immediately following the mastectomy or on a delayed basis. Many surgeons have been combining the use of acellular dermal matrices with prosthetic devices that require strict attention to detail to ensure success. There are various options for achieving device coverage that include total muscle, partial muscle, and subcutaneous coverage. The radiated patient poses additional challenges and limitations that must be understood to achieve a desired outcome. Finally, autologous fat grafting has become a valuable tool to improve outcomes in both radiated and non-radiated women. These factors will be reviewed with the intent of improving outcomes and minimizing complications in the setting of prosthetic breast reconstruction. 

Lipofilling of the Breast Does Not Increase the Risk of Recurrence of Breast Cancer: A Matched Controlled Study

Lipofilling of the Breast Does Not Increase the Risk of Recurrence of Breast Cancer: A Matched Controlled Study

Plastic & Reconstructive Surgery:

February 2016 - Volume 137 - Issue 2 - p 385–393

Kronowitz, S et al.


Background: Although many plastic surgeons perform autologous fat grafting (lipofilling) for breast reconstruction after oncologic surgery, it has not been established whether postoncologic lipofilling increases the risk of breast cancer recurrence. The authors assessed the risk of locoregional and systemic recurrence in patients who underwent lipofilling for breast reconstruction. Methods: The authors identified all patients who underwent segmental or total mastectomy for breast cancer (719 breasts) (i.e., cases) or breast cancer risk reduction or benign disease (305 cancer-free breasts) followed by breast reconstruction with lipofilling as an adjunct or primary procedure between June of 1981 and February of 2014. They also then identified matched patients with breast cancer treated with segmental or total mastectomy followed by reconstruction without lipofilling (670 breasts) (i.e., controls). The probability of locoregional recurrence was estimated by the Kaplan-Meier method. Results: Mean follow-up times after mastectomy were 60 months for cases, 44 months for controls, and 73 months for cancer-free breasts. Locoregional recurrence was observed in 1.3 percent of cases (nine of 719 breasts) and 2.4 percent of controls (16 of 670 breasts). Breast cancer did not develop in any cancer-free breast. The cumulative 5-year locoregional recurrence rates were 1.6 percent and 4.1 percent for cases and controls, respectively. Systemic recurrence occurred in 2.4 percent of cases and 3.6 percent of controls (p = 0.514). There was no primary breast cancer in healthy breasts reconstructed with lipofilling. Conclusions: The study results showed no increase in locoregional recurrence, systemic recurrence, or second breast cancer. These findings support the oncologic safety of lipofilling in breast reconstruction. CLINICAL QUESTION/LEVEL OF EVIDENCE: Risk, II.

Volumetric Evaluation of the Mammary Gland and Pectoralis Major Muscle following Subglandular and Submuscular Breast Augmentation

Volumetric Evaluation of the Mammary Gland and Pectoralis Major Muscle following Subglandular and Submuscular Breast Augmentation

Plastic & Reconstructive Surgery:

January 2016 - Volume 137 - Issue 1 - p 62–69

Weck Roxo, A et al


Background: Besides being a procedure with high level of patient satisfaction, one of the main causes for reoperation after breast augmentation is related to contour deformities and changes in breast volume. Few objective data are available on postoperative volumetric analysis following breast augmentation. The aim of this study was to evaluate volume changes in the breast parenchyma and pectoralis major muscle after breast augmentation with the placement of silicone implants in the subglandular and submuscular planes. Methods: Fifty-eight women were randomly allocated either to the subglandular group (n = 24) or submuscular group (n = 24) and underwent breast augmentation in the subglandular or submuscular plane, respectively, or to a control group (n = 10) and received no intervention. Volumetric magnetic resonance imaging was performed at inclusion in all participants and either after 6 and 12 months in the control group or at 6 and 12 months after surgery in the intervention groups. Results: Twelve months after breast augmentation, only the subglandular group had a significant reduction in glandular volume (mean, 22.8 percent), while patients in the submuscular group were the only ones showing significant reduction in muscle volume (mean, 49.80 percent). Conclusions: Atrophy of the breast parenchyma occurred after subglandular breast augmentation, but not following submuscular breast augmentation. In contrast, submuscular breast augmentation caused atrophy of the pectoralis major muscle. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, II.

The quality of preoperative diagnostics and surgery and their impact on delays in breast cancer treatment – A population based study

The quality of preoperative diagnostics and surgery and their impact on delays in breast cancer treatment – A population based study

 The Breast April 2016 Volume 26, Pages 80–86

Ojala K, Meretoja TJ, Mattson J, Salminen-Peltola P, Leutola S, Berggren M, . Leidenius M HK.

This study aims to clarify quality of breast cancer surgery in population-based setting. We aim to elucidate factors influencing waiting periods, and to evaluate the effect of hospital volume on surgical treatment policies. Special interest was given to diagnostic and surgical processes and their impact on waiting times.

A Systematic Review of Comparison of Autologous, Allogeneic, and Synthetic Augmentation Grafts in Nipple Reconstruction

A Systematic Review of Comparison of Autologous,Allogeneic, and Synthetic Augmentation Grafts in Nipple Reconstruction

Plastic & Reconstructive Surgery:

January 2016 - Volume 137 - Issue 1 - p 14e–23e

Winocour, S et al.

Background: Many techniques have been described for nipple reconstruction, with the principal limitation being excessive loss of projection. The ideal reconstructed nipple provides sustained projection, the fewest complications, and high levels of patient satisfaction. A variety of materials are available for projection augmentation, including autologous, allogeneic, and synthetic materials. To date, there has been no systematic review to study the efficacy, projection, and complication rates of different materials used in nipple reconstruction. Methods: MEDLINE, Embase, and PubMed databases were searched, from inception to August of 2014, to identify literature reporting on outcomes of autologous, allogeneic, and synthetic grafts in nipple reconstruction. Retrospective and prospective studies with controlled and uncontrolled conditions were included. Studies reporting the use of autologous flap techniques without grafts and articles lacking postoperative outcomes were excluded. Study quality was assessed using the Newcastle-Ottawa Scale. Results: Thirty-one studies met the inclusion criteria. After evidence review, one study represented two of nine stars on the Newcastle-Ottawa Scale, two studies represented three stars, six studies represented four stars, seven studies represented five stars, 11 studies represented six stars, and four studies represented seven stars. Conclusions: The results of this review revealed heterogeneity in the type of material used within each category and inconsistent methodology used in outcomes assessment in nipple reconstruction. Overall, the quality of evidence is low. Synthetic materials have higher complication rates and allogeneic grafts have nipple projection comparable to that of autologous grafts. Further investigation with high-level evidence is necessary to determine the optimal material for nipple reconstruction. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.

DIEAP flap for safe definitive autologous breast reconstruction

DIEAP flap for safe definitive autologous breastreconstruction
The Breast April 2016 Volume 26, Pages 59–66


Katrin Seidenstuecker, Carl van Waes, Beatrix I. Munder, Karel E.Y. Claes, Christian Witzel, Nathalie Roche, Filip Stillaert, Ajay L. Mahajan Christoph Andree, Phillip N. Blondeel


Breast cancer is the commonest form of cancer in women affecting almost a quarter of a million patients in the US annually. 30 percent of these patients and patients with genetic mutations undergo removal of the breast, as highlighted in a high profile celebrity patient. Although breast reconstruction with free microvascular transfer of a DIEAP flap from the abdomen is an ideal form of reconstruction, there have been misgivings about the complexity and potential complications. This study was aimed at clearing these misunderstandings and establishing the value of this form of breast reconstruction. 

Natrelle Silicone Breast Implant Follow-Up Study: Demographics, Lifestyle, and Surgical Characteristics of More Than 50,000 Augmentation Subjects

Natrelle Silicone Breast Implant Follow-Up Study:Demographics, Lifestyle, and Surgical Characteristics of More Than 50,000 Augmentation Subjects

Plastic & Reconstructive Surgery:

January 2016 - Volume 137 - Issue 1 - p 70–81

Singh, N, Picha, G, Murphy, D

Background: A large, multicenter, 10-year observational study is being conducted to compare the long-term safety and effectiveness of Natrelle silicone breast implants with saline implants or national norms. Study baseline data and surgical characteristics are reported here. Methods: Women seeking primary augmentation, revision-augmentation, primary reconstruction, or revision-reconstruction participated. Eligible subjects had completed surgery and received one implant or matching implants. Baseline demographics, health, lifestyle, and surgical characteristics were recorded. Data are presented here for subjects (≥22 years old) who underwent primary augmentation or revision-augmentation. Results: Of 50,979 subjects who underwent augmentation procedures, 35,756 received silicone implants and 15,223 received saline implants. Of these, 86.3 percent underwent primary augmentation, and 13.7 percent underwent revision-augmentation; nearly all subjects (99.3 percent) received bilateral implants. In the primary augmentation group, 67.6 percent of subjects received silicone implants versus 86.1 percent in the revision-augmentation group. Median age was lower in the primary augmentation group compared with the revision-augmentation group (33 versus 42 years old, respectively). Most subjects were white nonsmokers and had attended college. Hispanic subjects and subjects with a body mass index of 25 kg/m2 or greater were more likely to receive saline versus silicone implants. Across groups, the most common characteristics by procedure or implant type included inframammary incision site (54.6 percent), partial (58.2 percent) or complete (31.9 percent) submuscular placement, smooth surface implants (93.1 percent), and implant size of 300 to 399 cc. Incision size was larger for silicone versus saline implants. Conclusion: These data add to the body of knowledge on women undergoing augmentation procedures by providing an unprecedented look at a large number of subjects.

The Use of Autologous Fat Grafting for Treatment of Scar Tissue and Scar-Related Conditions: A Systematic Review

The Use of Autologous Fat Grafting for Treatmentof Scar Tissue and Scar-Related Conditions: A Systematic Review

Plastic & Reconstructive Surgery: January 2016 - Volume 137 - Issue 1 - p 31e–43e

Negenborn, V et al.


Background: Scar tissue can cause cosmetic impairments, functional limitations, pain, and itch. It may also cause emotional, social, and behavioral problems, especially when it is located in exposed areas. To date, no gold standard exists for the treatment of scar tissue. Autologous fat grafting has been introduced as a promising treatment option for scar tissue-related symptoms. However, the scientific evidence for its effectiveness remains unclear. This systematic review aims to evaluate the available evidence regarding the effectiveness of autologous fat grafting for the treatment of scar tissue and scar-related conditions. Methods: A systematic literature review was performed using MEDLINE, Cochrane Library, EMBASE, and Web of Science. No language restrictions were imposed. Results: Twenty-six clinical articles were included, reporting on 905 patients in total. Meta-analysis was not performed because of the heterogeneous methodology demonstrated among the articles. Main outcome measures were scar appearance and skin characteristics, restoration of volume and/or (three-dimensional) contour, itch, and pain. All publications report a beneficial effect of autologous fat grafting on scar tissue. There is statistical significant improvement of the scar appearance, skin characteristics, and pain. Itch and restoration of volume and three-dimensional contour also improved. Conclusions: Autologous fat grafting is used to improve a variety of symptoms related to scar tissue. This systematic review suggests that autologous fat grafting provides beneficial effects with limited side effects. However, the level of evidence and methodological quality are quite low. Future randomized controlled trials with a methodologically strong design are necessary to confirm the effects of autologous fat grafting on scar tissue and scar-related conditions.

Carbon Dioxide versus Saline Tissue Expanders: Does It Matter?

Carbon Dioxide versus Saline Tissue Expanders:Does It Matter?

Plastic & Reconstructive Surgery:

January 2016 - Volume 137 - Issue 1 - p 31–35

Ascherman, J et al

Background: Implant-based breast reconstruction is the most common reconstructive technique in the United States. Despite its popularity, saline-based tissue expansion still has its limitations, including lengthy expansion times, large uncomfortable bolus dosing, and frequent percutaneous injections/expansion visits. Ideally, a novel technology would eliminate frequent, percutaneous saline injections and allow patients to perform expansion at home, reducing the disruptive experience of current tissue expansion. Methods: Within the past 6 years, the AeroForm tissue expander system has used remotely activated carbon dioxide release as the fill medium instead of saline, eliminating many limitations of traditional tissue expanders. In this article, the authors first review the relevant literature concerning carbon dioxide–based tissue expansion in animal and human models. The authors then analyze the similarities and differences between two groundbreaking human trials (i.e., Patient Activated Controlled Expansion and AirXpanders Patient Activated Controlled Tissue Expander) with carbon dioxide–based expanders and discuss the risks and benefits associated with this new technology. Results: At their site, the authors have enrolled 34 patients using 36 experimental devices in total, and have found significantly shorter expansion and overall reconstruction times in the patient-controlled tissue expander group. Conclusions: The authors believe that carbon dioxide–based devices may play a significant role in the future of implant-based breast reconstruction, and may be widely applicable to other areas of plastic surgery that also involve tissue expansion.

Over Troubled Water: An Outbreak of Infection Due to a New Species of Mycobacterium following Implant-Based Breast Surgery

Over Troubled Water: An Outbreak of Infection Due toa New Species of Mycobacterium following Implant-Based Breast Surgery

Plastic & Reconstructive Surgery: January 2016 - Volume 137 - Issue 1 - p 97–105

Scheflan, M, Wixtrom, R


Summary: Mycobacterial infection is a rare complication associated with breast surgery using implants. Over the course of 5 months, one center experienced 12 such cases, 10 of which were linked to a single surgeon. Most presented 3 to 6 weeks postoperatively with clear serous drainage from the incision, minimal local redness, no fever or other systemic signs of infection, and negative standard bacterial cultures. Patients were given empiric broad-spectrum oral antibiotic therapy. In eight cases, implants were removed and exchanged for new devices after irrigation of the pocket with antibiotics; these patients nonetheless experienced recurrent infection, which led to explantation (without immediate exchange for new implants). The last two patients proceeded straight to explantation. Because mycobacteria grow in water, the water supply and air-conditioning system were initially suspected as the source, and both were disinfected. However, this did not stop the outbreak. Eventually, the source was traced to a new species of mycobacteria isolated from a garden hot tub. These bacteria had then been unwittingly transferred to patients during surgery. A Triclosan-containing shampoo effectively ended the outbreak. This series is unique in several respects: the novelty of the pathogen, the heavy colonization of the surgeon, and the mechanism of transmission (the first occurrence of human-to-human mycobacterial transfer published in the plastic surgery literature). Surgeons who perform breast surgery with implants should be aware of the possibility of mycobacterial infection. Proactive culturing of the organism, use of antibiotics, and reoperation are essential to good outcomes.