Bilateral Breast Augmentation Research Articles

Can gender-affirming surgeries be safely combined? An NSQIP analysis of 30-day outcomes and case planning factors

As gender-affirming surgeries are being performed, new techniques have been developed to meet patient desires, including recent reports of several gender-affirming procedures being combined into a single operative encounter. Such a development may provide several advantages to both patients and providers. However, it is less clear whether combining these procedures affects patient safety and surgical case planning factors. To address this, we compared the complication rates and the length of hospital stay and operative time for standalone and combined gender-affirming procedures (e.g., hysterectomy and bilateral mastectomy, breast augmentation, and vaginoplasty) performed between 2005 and 2019 in the National Surgical Quality Improvement Program database. There were 1857 standalone mastectomies, 826 standalone hysterectomies, and 30 cases where they were combined. There were 379 vaginoplasties, 648 breast augmentations, and 31 cases where they were combined. There was no evidence of differences in overall health status between those undergoing combined and standalone procedures. Two-sample proportion testing did not find significant differences in any of the complications experienced between standalone and combined procedures. Similarly, two-sample t-tests did not find significant differences in the length of the hospital stays nor in the length of the operative encounter between standalone and combined masculinizing surgeries. Combining breast augmentation and vaginoplasty, however, saved an average of 97.86min (p=.000) of operating time. These results suggest that combining gender-affirming procedures may be a safe and viable option for individuals who desire multiple gender-affirming procedures and may even be an advantageous option for patients and practitioners alike.

The impact of parity in primary breast augmentation: A clinical and cost-effective case control study

Breast augmentation is one of the most commonly performed aesthetic procedures in women. Despite the structural changes which occur during pregnancy and lactation have been extensively studied, there is no clarity in terms of the time required for the parenchymal angiogenic changes to regress or if these neovessels are preserved even years after the last lactating period. This study investigated whether these post-pregnancy structural changes on the breasts may influence the surgical efficiency, affect the rates of complications and have an impact on cost-effectiveness in primary breast augmentation. This study encompasses a retrospective review of all patients who underwent implant-based bilateral primary breast augmentation, through inframammary fold (IMF) incision under general anaesthetic, by a single surgeon. The age, height, weight and parity (nulliparous or multiparous status), characteristics of implants used and clinical outcomes after a minimum of 6-month post-operative follow-up were recorded. A further prospective comparative trial investigated the effects of parity in the surgical efficiency and cost-effectiveness in primary breast augmentation. The surgical efficiency (total operative time) and the immediate complications of 85 consecutive cohort of patients were recorded by an independent observer. Statistical correlation investigated the relevance of parity as predictors of surgical efficiency and cost-effectiveness. A total of 894 patients were included with a minimum of 6-month follow-up following implants-based primary breast augmentation. There were 445 (49.8%) nulliparous and 449 (50.2%) patients had at least one child at the time of surgery. The average parity index was calculated to be 1.05. The average body mass index (BMI) was 20.8kg/m2 (15.9-30.8). The mean implant volume used was 314ml. Fifteen percent (n=134) presented with post-operative complications, with an average follow-up period of 12.8 (6-116) months. The differences between parity and incidence of complications were not statistically significant (p=0.82). Surgical efficiency parameters from 85 women (54 multiparous and 31 nulliparous) demonstrated total operative time difference; 35±6.3min for multiparous and 30.2±5min for nulliparous. There was a clinical average difference of 4.8min, with a maximum difference of 16.1min. These statistically significant difference account for an average increase of 13.7% in the operating time in multiparous versus nulliparous (p-value=0.0004, 95% CI=2.2-7.4min). Primary breast augmentation in parous women faces parenchymal and vascular histological breast tissue transformations which may not fully revert to the pre-pregnant state. These changes encountered during pocket dissection seem to have an impact on the operating time, cost-effectiveness and can therefore affect negatively surgical efficiency. Nevertheless, when surgical technique is based on sharp, precise dissection and proactive haemostasis, parity does not show to have an impact on the rates of complications, despite longer operation times.

BreastGAN: Artificial Intelligence-Enabled Breast Augmentation Simulation.

BackgroundManaging patient expectations is important to ensuring patient satisfaction in aesthetic medicine. To this end, computer technology developed to photograph, digitize, and manipulate three-dimensional (3D) objects has been applied to the female breast. However, the systems remain complex, physically cumbersome, and extremely expensive.ObjectivesThe authors of the current study wish to introduce the plastic surgery community to BreastGAN, a portable, artificial intelligence (AI)-equipped tool trained on real clinical images to simulate breast augmentation outcomes.MethodsCharts of all patients who underwent bilateral breast augmentation performed by the senior author were retrieved and analyzed. Frontal before and after images were collected from each patient’s chart, cropped in a standardized fashion, and used to train a neural network designed to manipulate before images to simulate a surgical result. AI-generated frontal after images were then compared with the real surgical results.ResultsStandardizing the evaluation of surgical results is a timeless challenge which persists in the context of AI-synthesized after images. In this study, AI-generated images were comparable to real surgical results.ConclusionsThis study features a portable, cost-effective neural network trained on real clinical images and designed to simulate surgical results following bilateral breast augmentation. Tools trained on a larger dataset of standardized surgical image pairs will be the subject of future studies.

Pain Medication Prescribing Patterns in Augmentation Mammoplasty.

The rate of opioid prescribing after low-risk surgical procedures has increased over the past decade, and surgeons are responsible for prescribing approximately one-third of all opioid medications. There is additional supporting evidence that patients only consume about half of the opioids prescribed to them after outpatient plastic surgery. Currently, there is no literature to provide surgeons with reference ranges for how much opioid medication will adequately provide analgesia for patients after undergoing bilateral breast augmentation (BBA) surgery. To quantify the amount of opioid medication required to adequately control pain for patients after undergoing BBA and use these data to provide recommendations on opioid prescribing practices. Cross-sectional prospective data were obtained through a take-home medication and pain tracking questionnaire for 56 patients after they underwent either subpectoral or subglandular BBA. Patients documented their pain scores on a 0 to 10 analogue scale and documented the type and amount of pain medication they took for a 7-day period. Our study demonstrated that patients in the subglandular BBA group required an average of either 25 ± 1.2 Tylenol #3 or 19.3 ± 2.3 Tramacet tablets, and the subpectoral group required 27.7 ± 1.7 Tylenol #3 or 25.6 ± 0.9 Tramacet tablets over a 7-day period. There was no statistically significant difference between the 2 surgical groups. We propose a reference range of medication required on average for patients undergoing BBA to obtain adequate pain control in the initial postoperative period that falls within the most recent Canadian guidelines for safe opioid prescribing practices.

Outpatient Cosmetic Breast Augmentation with DIEP Flaps

BACKGROUND: Breast augmentation ranks as one of the most commonly performed cosmetic procedures. It is a relatively inexpensive and straightforward procedure that yields good results with low risk. However, potential problems with implants exist such as deflation, leaks, malposition, pain, and capsular contraction. Breast Implant Illness (BII) or Breast Implant Associated Lymphoma (BIA-ALCL) remains a high concern for many patients. As a reliable alternative or treatment for these issues and concerns, the authors describe the use the deep inferior epigastric perforator (DIEP) flap in outpatient cosmetic breast augmentation and mastopexy. METHODS: We reviewed patients who had undergone cosmetic breast augmentation with DIEP flaps over a 12-month period. Any patient who desired breast augmentation, implant exchange, or augmentation mastopexy with concomitant abdominoplasty was considered a candidate for the procedure. Charts were reviewed for all patients who elected to proceed with cosmetic DIEP flaps. All patients underwent our early recovery protocol, including microfascial incisions to harvest the DIEP flaps, and rib preservation in addition to ERAS protocols with intraoperative anesthetic blocks. RESULTS: Eleven consecutive patients underwent bilateral cosmetic breast augmentation with DIEP flaps and mastopexy. Overall, all patients referred dissatisfaction with their abdomen and breasts. Three patients presented with ptotic breasts following recent pregnancies. Four patients were displeased with their breasts following augmentation with prosthetic implants. Three patients were experiencing pain and discomfort due to bilateral capsular contractures, with two of them being consistent with Breast Implant Illness. Lastly, one patient decided to undergo breast augmentation following bariatric surgery. Microfascial incisions for single perforator abdominal flaps (n = 17) averaged 1.7 cm (range 1.3–2.4), while flaps with multiple perforators (n = 5) averaged 2.4 cm (range 2-–2.5). Dissection of recipient IMA vessels was performed without disruption of the rib. No fascia or muscle tissue was taken during flap dissection. All patients had strong Doppler signals before discharge within 23 hours. No partial or total flap losses were reported, without major complications or take-backs. Average follow-up was 15 weeks. One patient required in-office debridement and closure due to suture granuloma at the abdominal incision. One patient developed minimal T-zone necrosis of the mastopexy site, which healed secondarily. Another patient, who had undergone prior mini-abdominoplasty, had limited flap edge necrosis that also healed secondarily. DISCUSSION: Combined breast augmentation or augmentation mastopexy with abdominoplasty is a commonly performed surgical procedure. Patients who desire abdominoplasty and augmentations are ideal candidates for this procedure. Breast augmentation with autologous tissue, particularly the DIEP flap, is an attractive option inherent to the additional abdominal tissue available to harvest. Likewise, women with implant complications like severe capsular contractures, or patients who have concerns for BIA-ALCL or have Breast Implant Illness, yet would like to maintain breast volumes, are excellent candidates. These conditions and the fear of these problems required other reliable options for breast augmentation or removal of implants secondary to refractory illness. Our early recovery protocol allows us to perform microsurgical breast reconstructions and augmentations in an outpatient setting, with outstanding results and no total or partial flap losses, thus offsetting the high costs associated with the DIEP flap.

Breast Equalization Augmentation: The Use of Ultrasonic Assisted Liposuction for Correction of Primary Breast Asymmetry with Bilateral Augmentation.

The purpose of this study was to determine the effectiveness of using ultrasonic assisted liposuction (UAL) to achieve sufficient breast symmetry allowing for the use of same sized implants in patients presenting for elective breast augmentation surgery. A retrospective review was performed of patients presenting for augmentation mammoplasty with breast asymmetry who underwent ultrasonic assisted liposuction in combination with implant augmentation. Pre-operative differences in breast volumes were determined using water displacement, and these measurements were compared to final lipoaspirates required to achieve symmetry. To estimate the volume of lipoaspirate required, we suggested to aim for twice the volume difference obtained by water displacement. The success of the procedure was measured by the ability to use the same size implants bilaterally. A total of 35 patients were included in this review. In 85% of patients, UAL was sufficient to permit the use of equally sized implants bilaterally. However, when different sized implants were required, the size difference between implants was not greater than 25cc. The UAL was also effective in correcting minor ptosis and nipple position. The main observed disadvantage was prolonged bruising and swelling. The use of UAL for correction of primary breast asymmetry with bilateral breast augmentation allows balancing of breast tissue volumes and the use of same size implants and eliminates the need for balancing mastopexy procedures. This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266.

Breast Implant-Associated Anaplastic Large Cell Lymphoma: A Case Report

Breast implant-associated anaplastic large cell lymphoma (ALCL) is a recently recognized type of T-cell lymphoma that can develop following breast implants, with morphologic and immunophenotypic features indistinguishable from those of ALK-negative ALCL. Here we report a case of a 58-year-old woman with a history of subglandular silicone implants placed for bilateral breast augmentation 25 years ago, who presented with bilateral breast pain and was found to have bilateral Baker Grade III capsular contracture, and heterogenous fluid collection centered near the left third costochondral articulation, a suspicious left chest wall lesion, and left axillary lymphadenopathy on imaging. A left axillary lymph node core biopsy and an aspiration of the fluid were performed, and no malignant cells were identified. The patient underwent bilateral removal of breast implants and total capsulectomies. Microscopic examination of the capsule surrounding the left breast implant revealed large pleomorphic tumor cells in a fibrinous exudate. By immunohistochemistry, the tumor cells were found to be positive for CD3 (subset), CD4, CD7, CD30 (strong and uniform), and CD43, and negative for CD2, CD5, CD8, and ALK1, supporting the diagnosis of breast implant-associated ALCL. No lymphoma cells were identified in the right breast capsule, confirmed by CD30 stain. Breast implant-associated ALCL is a very rare disease that can develop many years after breast implant placement. Proper evaluation with breast imaging and pathologic workup is essential to confirm the diagnosis in suspected cases. Our case highlights that adequate sampling is important in the investigation of patients with suspected breast implant-associated ALCL.

Use of Single-recipient Vessels for Cross-chest Abdominal Flap-based Breast Augmentation as an Outpatient.

Background:Breast reconstruction with autologous tissue following mastectomy for breast cancer has become the standard of care. Microvascular breast augmentation is an alternative for patients with failed breast prostheses, including painful capsular contractures or poor cosmetic outcomes. We present a series of 4 patients who underwent microvascular breast augmentation with cross-chest flap recipient vessels.Methods:We perform a bilateral DIEP flap reconstruction in an outpatient setting following a modified recovery protocol, focused on decreasing postoperative pain and narcotic requirements, allowing early ambulation and discharge. This includes harvest of the flap via abdominal microfascial incisions and rib-sparing vessel dissection. Cosmetic microvascular augmentation of the contralateral breast was performed via cross-chest flap recipient vessel anastomoses, where the pedicle was tunneled across the chest and anastomosed to the primary flap.Results:Four patients underwent flap-based breast augmentation with cross-chest recipient vessels. Two patients underwent immediate DIEP flap breast reconstruction of the affected side and contralateral flap-based augmentation, while 2 patients underwent bilateral breast augmentation with DIEP flaps for cosmetic purposes due to undesired cosmetic results following implant-based augmentations. No intraoperative complications were reported, and all patients were discharged within 23 hours without signs of flap compromise or need for operative take-backs. Mean follow-up was 23 weeks.Conclusions:The DIEP flap is recognized as an option for breast augmentation, although its limitations are several, including the pain and recovery associated with autologous tissue-based breast reconstruction. Enhanced recovery protocols help reduce this burden, making it more acceptable and feasible.

04. ARE WE OVERTREATING BREAST CANCERS FOLLOWING PREVIOUS BREAST AUGMENTATION? LESSONS FROM IBRA

Introduction: Bilateral breast augmentation (BBA) remains the most commonly performed cosmetic operation in the UK, but there is no consensus regarding the surgical management of these patients that subsequently develop breast cancer. We aimed to identify current UK practice regarding mastectomy and IBR in this group and assess its safety profile.

Immediate unilateral breast reconstruction and contralateral breast augmentation with bilateral free deep inferior epigastric perforator flaps.

A 42-year-old woman was referred for consideration of left-sided mastectomy and immediate reconstruction. She previously had a bilateral breast augmentation using silicone implants. She desired to maintain her breast size and natural appearance. Owing to the availability of sufficient abdominal tissue, the option of an immediate unilateral breast reconstruction and contralateral augmentation with a differentially split deep inferior epigastric perforator flaps was offered to the patient. The patient had a successful reconstructive and contralateral symmetrising procedure with an uneventful postoperative recovery. She was satisfied with her breast size, which was achieved without the use of implants. In selected patients the free deep inferior epigastric perforator flap provides an appropriate option for unilateral breast reconstruction and contralateral breast augmentation. It has numerous advantages including making use of available excess abdominal tissue and avoiding implant related complications.

Abstract 180: Demystifying Systemic Anaplastic Large Cell Lymphoma After Breast Augmentation: Separating Fact From Fiction

Purpose: Breast implant associated anaplastic large cell lymphoma (BIA-ALCL) has been a major concern in patients with history of breast augmentation. Rarely is peri-implant breast swelling, pain and lymphadenopathy associated with other types of ALCL. Here we describe a unique case of systemic CD30 positive ALK-1 negative anaplastic large cell lymphoma (ALCL) causing pain and swelling around a textured breast implant Methods: The clinical course and diagnosis of a patient presenting with right axilla, breast pain and swelling 16 years post-bilateral breast augmentation. Results: We present the case of a 44-year-old female with past medical history significant for bilateral submuscular breast augmentation with textured anatomic saline implants performed in 2002. She presented with late onset peri-implant seroma formation, right breast mass, upper extremity swelling, supra-clavicular, mediastinal and mammary lymphadenopathy and pectoralis muscle swelling. Lymph node biopsy was notable for CD30 positive ALK-1 negative ALCL. Brentuximab vedotin in combination with cyclophosphamide, doxorubicin, and prednisone (Bv-CHP) and brentuximabchemotherapy was initiated. Cytology from the bilateral capsulectomies and removal of saline implants were negative for BIA-ALCL markers. Conclusion: To our knowledge, this is the first documented case report of non-BIA-ALCL systemic ALCL involving a breast implant. Systemic ALCL likely triggered an inflammatory response heightened by the presence of the textured material.Plastic surgeons should be aware of various ways breast implants may be involved in a malignant process. Multi-disciplinary management with chemotherapy and implant removal is recommended. Any reconstruction should be delayed until systemic ALCL has been addressed.

Siliconosis: an unknown entity in aesthetic breast surgery

Background: Siliconosis was first described in the late 1980s and it is still remaining as a rare condition and mainly as a diagnosis of exclusion after breast cancer investigation. There are only limited cases reported and published with even smaller amount related to the breast implants (31 studies and 8 related to breast implants found in PubMed search in December 2019). Case presentation: Authors present the case of siliconosis secondary to bilateral cosmetic breast augmentation performed back in 1989. The patient was troubled with a myriad of complications and underwent an exchange of implants with Trilucent™ implants in 1997 and their subsequent removal in 1998. Later, they underwent bilateral mastopexy and is currently free of implants. Ever-since the first operation patient complained of pain, localized tenderness, swelling, axillary fullness, paraesthesia and partial paralysis in her upper limbs amongst other symptoms. Objective investigations including plain radiographs, USS, CT, MRI, nerve conduction studies, rheumatological screen yielded essentially negative results. Thoroughly investigation for breast cancer was conducted, including several operations and biopsies of axillary swellings with confirming reactive lymphadenopathy. A working diagnosis of siliconosis has been made and the patient was treated expectantly. Conclusion: This case should remind our colleagues of the ethical and professional responsibilities we have toward our patients in explaining all the potential risks involved in breast augmentation and also to keep an open mind when meeting patients complaining of systemic symptoms post breast augmentation.

Capsulectomy, Implant Exchange, and Placement of Acellular Dermal Matrix Is Effective in Treating Capsular Contracture in Breast Augmentation Patients.

Capsular contracture is a common complication of breast augmentation surgery and many techniques to prevent and treat it have been suggested with inconsistent or variably effective results. The aim of this paper was to describe a protocol for treating established capsular contracture after breast augmentation with a low recurrence rate. From January 2009 to December 2012, 79 previous bilateral breast augmentation patients presented for treatment of established capsular contracture. There were 135 breasts with capsular contracture: 56 were bilateral and 23 were unilateral. Ten patients opted for no treatment; 2 patients opted for implant removal. Twenty-four were treated with the ICES (implant exchange, capsulectomy, and possible exchange of site) protocol and 43 were treated with the SPICES (Strattice placement in the reconstructive position, implant exchange, capsulectomy, and possible exchange of site) protocol. The 24 patients treated with the ICES protocol had a recurrent capsular contracture rate of 15%. The 43 patients treated with the SPICES protocol had a 2.7% recurrent capsular contracture incidence and an 2.7% complication rate. Capsular contracture after breast augmentation, whether primary or recurrent, can be successfully treated with the SPICES protocol.

An extended 7-year review of textured breast implants for primary breast augmentation: Allergan® versus Mentor®

Background: Breast augmentation is one of the most commonly performed aesthetic procedures worldwide. Textured implants are used widely throughout Europe and in the United States. The senior author uses both Allergan ® and Mentor ® implants. We discuss our long term follow up in the light of the withdrawal of textured Allergan ® implants amidst safety concerns regarding breast implant associated anaplastic large cell lymphoma (BIA-ALCL). Methods: Data was collected on all primary bilateral breast augmentations (BBA) performed by the senior author over a 7-year period. Early and late post-operative outcomes were gathered throughout an extended follow up period and were compared between implant manufacturers. Results: A total of 172 primary augmentations were performed. All implants used were textured. Allergan ® implants were placed in 103 patients (60%) and 69 patients had Mentor ® (40%). Dual plane was the commonest pocket type (89%) and 94% were round implants. The overall haematoma rate was 1%. Capsular contraction rate was 2% with all 3 cases in patients with Allergan ® implants. Rupture rate was 3% overall but 5% in the Allergan ® group and 1% in the Mentor ® group. Two patients developed a late seroma but no patient had a confirmed diagnosis of BIA-ALCL during follow up. Conclusions: The most concerning complications following augmentation are capsular contracture, implant rupture and the development of BIA-ALCL. We have shown low rates of these complications with both Allergan and Mentor. The majority are even lower than rates quoted in original trials. We discuss the recent withdrawal of Allergan textured implants as well as the most recent information on BIA-ALCL.

SUN-438 Spontaneous Recovery of the Hypothalamic-Pituitary-Gonadal (HPG) Axis in a Female with Kallmann Syndrome

Background: Kallmann Syndrome (KS) is characterized by hypogonadotropic hypogonadism (HH) due to isolated GnRH deficiency (IGD) and anosmia. While reversal of KS has been described, predominantly in males, few cases have been described in females. We report a female with KS who demonstrated spontaneous recovery of her HPG axis. Case Report: A 34-year-old woman with a history of KS was referred to the NIH Clinical Center for evaluation. She was evaluated for absent thelarche and primary amenorrhea at age 18 when, due to her history of vigorous exercise and low BMI, she was assumed to have hypothalamic amenorrhea. At age 22, she was first noted to be anosmic by her endocrinologist who diagnosed her with KS. She underwent bilateral breast augmentation, and oral contraceptive pills (OCPs) induced regular menstrual bleeding. OCPs were self-discontinued after 1 year and amenorrhea recurred. By her late 20s, her level of exercise had decreased and her BMI normalized. She reported 3 episodes of spontaneous menstrual spotting in the six months preceding her visit, cyclical but irregular breast tenderness and emotional lability in the absence of hormonal treatment. Her medications included only fluoxetine. Physical examination revealed a BMI of 19.1 kg/m2, bilateral breast implants, a high-arched palate and bilateral fifth digit clinodactyly. Her laboratory evaluation revealed a serum LH of 8 U/L, FSH of 9 U/L and E2 of 19 pg/mL; all other anterior pituitary hormones were normal. Frequent blood sampling revealed a high-frequency pattern of LH pulsatility (24 pulses/24 hrs) with sleep augmentation and mean LH of 6.8 U/L. Formal smell testing confirmed anosmia. Her pelvic ultrasound revealed normal ovaries with follicles and normal uterus with a 4 mm endometrial stripe. A brain MRI was normal except for absent olfactory bulbs. Clinical testing of 14 IGD genes showed a novel heterozygous ANOS1 variant (c.298C>A p.Q100K) of unknown significance that was also present in her unaffected mother. A maternal half-uncle was reportedly anosmic but is now deceased. Discussion: This KS female exhibited spontaneous recovery of her HPG axis, which has been reported in very few cases. Her olfactory bulb aplasia is consistent with a congenital defect in GnRH neuronal development given their common ontogeny, suggesting that her HH and recovery were not simply due to changes in body weight nor exercise. Although females with heterozygous ANOS1 variants have been reported to demonstrate features of HH, the role of this novel ANOS1 variant remains unclear due lack of functional data and the presence of the same variant in her asymptomatic mother. Conclusions: Reversal of the reproductive phenotype in women with KS is rare with little known about their genetic abnormalities and long-term outcomes. Further study of such cases is warranted to gain insight into the mechanisms required for activation of the HPG axis.

Breast-Shape Classification and Implant Construction Method for Unilateral Breast Reconstruction

Unilateral breast reconstruction is different from bilateral breast reconstruction and breast augmentation, as it requires more consideration of the symmetry between the reconstructed breast and the contralateral breast. However, there are currently no implants specifically targeted to unilateral breast reconstruction, nor is there is objective classification criteria for breast appearance type. A total of 212 breasts from 153 patients were measured. Breast measurements, breast surface curvature distributions, and elliptic Fourier coefficients were used to describe breast features. We objectively classified the appearance of breasts using machine learning and used the resulting cluster centers to construct the most adaptive implants for each type of breast. All of the breasts clustered into 4 types. The implants corresponding to each type of breast were constructed using cluster centers. The resulting cluster centers were then used to choose a suitable implant for patients requiring unilateral breast reconstruction. Contour coefficients were used to evaluate the clustering results, with an average score of 0.53. The two breasts that develop normally in the same person were treated as the same class. The score obtained after statistical classification was 0.47. These results demonstrate that our proposed method can improve the classification of breasts of different shapes. This method provides a foundation for improving the symmetry of unilateral breast reconstruction and the construction and selection of implants.

Breast Implant Mycobacterial Infections: An Epidemiologic Review and Outcome Analysis.

Epidemiologic evidence of periprosthetic mycobacterial infections is limited. The recent boom in cosmetic surgery tourism has been associated with a rise of surgical-site infections in returning patients. This review aims to explore available data, examine trends of documented periprosthetic mycobacterial infections, and analyze outcomes of management techniques. A search in the Biosis, Embase, LILACS, MEDLINE, and Web of Science databases from inception until December of 2017 for "Breast Implants" and "Mycobacterial Infections" and equivalents was performed. Data were pooled after two screening rounds following full-text retrieval and cross-referencing. Forty-one reports describing 171 female patients who had breast prosthesis-related mycobacterial infections were identified. Bibliometric case-based analysis revealed a rise of periprosthetic mycobacterial infections in developing countries since the start of the millennium. The mean patient's age was 37.9 years and the majority of patients had undergone bilateral breast augmentation. Most patients presented with breast pain or tenderness, after an average incubation period of 9 months. Mycobacterium fortuitum was isolated from 90 cases (52.6 percent). Immediate explantation with or without delayed reimplantation was the most commonly used surgical strategy, complemented by combination antimicrobial therapy for an average of 4.6 months. The mean follow-up time was 39.7 months, during which recurrence was observed in 21 of 171 patients (12.3 percent). The emergence of periprosthetic mycobacterial infections in relation to cosmetic medical tourism alerts clinicians to the importance of educating the public about the associated risks. In addition, this study identifies risk factors associated with recurrence of periprosthetic mycobacterial infections.

Bilateral breast reconstruction and pectus excavatum correction: a case and review of the literature

Pectus excavatum is a chest wall malformation characterized by anterior chest wall depression. It is often associated with hypoplastic breasts, sternal rotation, and consequent breast asymmetry. We present here the case of a 52-year-old female with pectus excavatum, a bilateral nipple-sparing mastectomy for breast cancer, and immediate autologous breast reconstruction using bilateral deep inferior epigastric perforator flaps. To correct reconstructed breast deformities and pectus excavatum depression and to enhance breast volume to treat hypoplastic breasts, three sessions of Brava-assisted fat grafting were performed. These postoperative courses were uneventful and without any complications. The patient was satisfied with the final esthetic results. There are only two case reports to perform bilateral breast reconstruction and surgical correction of pectus excavatum, which were used with both pedicle musculocutaneous flap and breast implant, with or without a sternal implant. In this study, we discuss indications and surgical options for bilateral breast reconstruction, pectus excavatum, and breast augmentation. Level of Evidence: Level V, therapeutic study.

Surgical Breast Pocket Irrigation With Hypochlorous Acid (HOCl): An In Vivo Evaluation of Pocket Protein Content and Potential HOCl Antimicrobial Capacity.

Hypochlorous acid (HOCl) demonstrates rapid and broad antimicrobial activity against planktonic and biofilm phenotype bacteria in vitro. To identify the protein content present in breast pockets in vivo and calculate the estimated active concentration of HOCl, (PhaseOne, Integrated Healing Technologies, Franklin, TN) following HOCl-protein interactions. Fluid samples were collected prior to implant insertion in 18 consecutive patients, representing 36 pocket samples, with all cases being bilateral primary breast augmentations. Samples were evaluated by an independent CLIA approved laboratory for albumin and total protein concentration in g/dL. Results were compared to HOCl solution concentration and protein binding potential to determine availability of free HOCl. The mean tissue sample concentration (right and left breast) was 31.6 mg/dL which translates to 0.0001 mmol per 20 cc of interstitial fluid. Mean total protein levels (right and left breast) were 62.3 mg/dL or 0.000187 mmol per 20 cc interstitial fluid. Based upon potential stoichiometric neutralization of HOCl by proteins in either a 1:1 or 3:1 ratio, using 115 cc of HOCl solution (per breast) at a concentration of 250 ppm/mL or 0.025% HOCl or = 0.48 mmol HOCl/dL, there would be 2950 times the amount of active HOCl at a 1:1 reaction ratio, or 983 times more HOCl assuming a 3:1 reaction ratio. Based on the range of identified levels of protein in individual surgical pockets in the study, there is an estimated 242 to 12,500 times more HOCl molecules than protein at a 3:1 molar ratio of binding or reactive protein. n estimated range of 983-2950 times more HOCl molecules are present during irrigation with 230 cc of PhaseOne® (115 cc for each breast) than available protein. This supports the antimicrobial and anti-biofilm activity as described in previous in vitro studies when using PhaseOne® as part of pocket irrigation.

Sub-muscular Breast Augmentation Using Tumescent Local Anesthesia.

Tumescent local anesthesia (TLA) consists of infiltration of saline solution with lidocaine and epinephrine into the tissues to obtain regional anesthesia and vasoconstriction. The use of TLA in augmentation mammoplasty has been described for sub-glandular positioning. We describe a modified TLA technique for primary sub-muscular breast augmentation reporting our experience during the past 7years. From 2010 to 2017, 300 patients underwent bilateral primary sub-muscular breast augmentation under TLA and conscious sedation. The tumescent solution was prepared with 25mL of 2% lidocaine, 8mEq of sodium bicarbonate, and 1mL of epinephrine (1mg/1mL) in 1000mL of 0.9% saline solution. Firstly, the solution was infiltrated between the pectoral fascia and the mammary gland, secondarily, during surgery, under the pectoralis major muscle. The average amount of tumescent solution infiltrated while performing TLA was 740mL per breast. No signs of adrenaline or lidocaine toxicity were reported and conversion to general anesthesia was never required. In all patients, no pain nor discomfort was reported during the pre-operating infiltration and surgical procedure. We reported a major complication rate of 3.3% (4 hematomas and 6 seromas) and a minor complication rate of 6.0% (8 implant dislocation and 10 dystrophic scars formation). TLA represents a safe and efficacious technique for performing breast augmentation surgery with sub-muscular implant positioning. This technique guarantees good pain control during and after surgery and has low incidence of postoperative side effects. Patients subjected to sub-muscular breast augmentation with TLA were satisfied. This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .