Saline Implants Research Articles

Implant outcomes following breast conservation therapy in patients with history of augmentation mammoplasty

BackgroundIn women who are eligible, breast conservation therapy (BCT) is often the preferred local treatment for early-stage BC. Concern for implant contracture in patients undergoing BCT including radiation therapy (RT) with prior augmentation mammoplasty has been expressed in several prior studies. The exact incidence of patient dissatisfaction remains unknown. MethodsA single institution retrospective review was performed for patients with prior augmentation mammoplasty who received BCT for BC between 2010 and 2020. 77 patients met inclusion criteria. Of these, 34 were consented and completed study survey which included validated BREAST-Q modules. Data was reviewed with primarily descriptive analyses. P-values were calculated from Fisher’s exact test and Kruskal-Wallis rank sum test. Results34 patients completed study survey, with 55.9 % of patients (n=19) having silicone implants and 44.1 % (n=15) having saline. Most implants (91.1 %, n=31) were retropectoral. Median total dose of RT was 4005 cGy and median age of implants at BC diagnosis was 16 years (range 2, 40). 41 % (n=14) of patients reported dissatisfaction with breast appearance, with median BREAST-Q RASCH score for satisfaction with breasts 48 (range 20–82). No differences in breast satisfaction were seen in patients with silicone implants compared to saline (p= 0.171) although there were improved reported physical well-being chest scores in patients with saline implants (median 100 vs 89; p = 0.039). ConclusionsA large proportion of women are dissatisfied with implant appearance following BCT with RT. Future larger studies are needed to explore contributing factors for dissatisfaction including implant type, location, RT dosing and fractionation.

Abstract PO1-20-08: Primary breast implant-associated squamous cell carcinoma with subsequent TEMPUS testing and failure of immunotherapy

Abstract Primary squamous cell carcinoma of the breast is a rare entity, and there are a limited number of cases in the literature describing squamous cell carcinoma arising from breast implants. It has been hypothesized that these implant-associated cancers may arise from epithelialization of the implant capsule followed by chronic inflammation. None of the cases in the literature were treated with immunotherapy. We present a case of an aggressive, primary sarcomatoid squamous cell carcinoma of the breast arising from a breast implant that was treated unsuccessfully with simultaneous chemotherapy and immunotherapy following TEMPUS testing. Introduction: Breast augmentation is the most common plastic surgery procedure performed worldwide, with more than 300,000 done in the United States every year. While breast implant-associated anaplastic large cell lymphoma (BIA-ALCL) is extensively discussed in recent literature, other breast implant-associated cancers are rarer and less studied. Breast implant-associated squamous cell carcinoma (BIA-SCC) specifically is an extremely rare complication of breast augmentation and no guidelines for treatment exist. The American Society of Plastic Surgeons (ASPS) released a statement on BIA-SCC on 9/2022 following a safety communication from the FDA, and it is recommended health care providers submit case reports of BIA-SCC to a patient registry. Case study: We present the case of a female patient who underwent bilateral breast augmentation in 2006 with Mcghan textured, pre-pectoral, areolar saline implants. In 2022, she presented with swelling and a lump in her breast and underwent bilateral breast implant removal with capsulectomy. Pathology showed triple negative sarcomatoid squamous cell carcinoma of the right breast capsule. TEMPUS testing on the breast biopsy revealed a PIK3CA mutation and PD-L1 negative status. Her case was discussed with a multi-disciplinary team including plastic surgery, multiple oncologists, and radiation oncology and her clinical picture was determined to be most consistent with BIA-SCC. Based on the KEYNOTE-522 study, she was determined to be a candidate for neoadjuvant therapy with pembrolizumab and chemotherapy as she was newly diagnosed, previously untreated, nonmetastatic, and had a triple negative tumor. She received two cycles of carboplatin, paclitaxel, and pembrolizumab but unfortunately rapidly progressed with chest wall extension, multiple new pulmonary nodules, worsening lymphadenopathy, right ventricular tumor thrombus, and new malignant pleural effusion and was transitioned to hospice. Discussion: Seven cases of BIA-SCC, one case of squamous cell carcinoma (SCC) after liquid silicone injection augmentation, one case of squamous metaplasia on the breast implant capsule, and one case of epithelization of the breast implant capsule have been previously described in the literature (Table 1). None of the available cases of BIA-SCC report TEMPUS testing, and none of the patients were treated with immunotherapy. The origin of BIA-SCC is unclear, but several theories have been described including chronic inflammation leading to conversion of epithelial tissue on the capsule to SCC. It is unknown how the breast implant capsule might become epithelialized to begin with – introduction of epithelium intraoperatively during augmentation, rupture of epidermal cysts, existence of epithelium in the area from a childhood injury or from birth, or epithelization from chronic shear forces from the augmentation or leakage of the implant are all possibilities. With the ongoing data gathering through the FDA patient registry, we will continue to learn more about these rare cancers and potentially get further insight into their origins. Table 1 An overview of cases of BIA-SCC in the literature Citation Format: Emily Podany, Katherine Clifton. Primary breast implant-associated squamous cell carcinoma with subsequent TEMPUS testing and failure of immunotherapy [abstract]. In: Proceedings of the 2023 San Antonio Breast Cancer Symposium; 2023 Dec 5-9; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2024;84(9 Suppl):Abstract nr PO1-20-08.

Transumbilical Silicone Breast Augmentation: A 13-Year Experience and 5-Year Analysis.

Transumbilical breast augmentation (TUBA) with saline implants has been considered a safe and efficient technique for decades. However, because silicone implants are more popular than saline ones, TUBA with saline implants is not widely performed. In 2014, we published a report on transumbilical breast augmentation using silicone cohesive gel implants. As we have performed transumbilical silicone breast augmentation (TUSBA) for 13 years with slight modifications, this study aimed to describe this novel technique and present accompanying patient outcomes over 5 years. We enrolled patients desiring breast augmentation at a single center. The preoperative design was initially determined with the patients in standing positions before they underwent surgery under general anesthesia in a supine position. Between January 2018 and December 2022, 69 women and one man underwent TUSBA at a single center. All patients underwent cohesive gel silicone implantation in the subpectoral pocket. The implant size varied from 225 to 300mL (average 272mL) because two patients underwent surgery with implants of different sizes due to breast asymmetry. All patients were satisfied with the surgery outcome except one who was dissatisfied because of abdominal bulging. TUSBA offers advantages such as minimal scarring and unrestricted arm movement; thus, it can be an alternative option for patients seeking breast augmentation. This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors https://www.springer.com/00266 .

Systematic review of breast implant associated squamous cell carcinoma.

e12508 Background: Breast augmentation is a cosmetic procedure with low rates of complication like bleeding, infection, implant rupture, and capsular contracture. However, rare cases of breast implant-associated (BIA) malignancies, including anaplastic large cell lymphoma (ALCL) and squamous cell carcinoma (SCC), have been reported. BIA-SCC is rarer than ALCL and current literature is limited to case reports. In 2022, the American Society of Plastic Surgeons (ASPS) issued a BIA-SCC summary statement based on 16 reported cases in response to an FDA safety communication. The aim of this study is to review published cases of BIA-SCC and present clinical and outcome data systematically. Methods: We conducted a literature search in English to identify studies reporting BIA-SCC from inception to October 2022. Patient characteristics and relevant outcomes were gathered from the studies. The mortality rates at 6 and 12 months were calculated as the inverse of the Kaplan-Meier survival estimate and presented with a 95% confidence interval (CI). Results: 14 articles and 18 cases of BIA-SCC were identified through a literature search. A rising trend in case reporting was observed, with 4 cases in the 1990s and 14 cases since 2010. The mean patient age was 56 years (range 40-81), and the mean time from breast augmentation to symptom appearance was 21 years (range 10-35). Most patients (13/18, 72%) underwent the procedure for cosmetic reasons. Out of 17 cases with available implant information, 11 cases had silicone based implants and 6 cases saline implants. Implant surface information was available in 5 cases, 4 smooth and 1 textured. 16 patients had swelling of the breast and 15 patients had breast pain at presentation of BIA-SCC. All patients had their implants removed and 10 underwent mastectomy after a diagnosis of SCC. Of the 12 cases with available treatment information, 7 received adjuvant chemotherapy and/or radiotherapy, 2 received neoadjuvant chemotherapy, and 3 did not receive perioperative chemotherapy or radiotherapy. Follow-up data was available for 10 cases. The 6-month and 12-month mortality rates were 11.1% (95% CI: 0.5% to 40.6%) and 23.8% (95% CI: 2.8% to 56.1%). Conclusions: The estimated 6-month mortality rate of 11% (95% CI: 0.5%-40.6%) should be interpreted cautiously due to the small sample size. It is lower than the rate reported by ASPS (44%), but the reason for this difference cannot be accurately explained as the methodology for determining then mortality rate is not provided in the ASPS statement. This study provides a valuable systematic review of a rare and poorly understood condition with a poor prognosis. Monitoring and sharing information is crucial to improve detection and management of BIA-SCC. [Table: see text]

Literature Review on the Different Types of Breast Implants: Advantages and Disadvantages

Breast implants are devices used in cosmetic and reconstructive surgery to increase the volume and improve the shape of the breasts. In this study, the different types of breast implants available in clinical practice were investigated. Four main types were identified: saline implants, silicone gel implants, highly cohesive silicone gel implants, and double lumen implants. Saline implants consist of a silicone shell filled with sterile saline. They have advantages such as the ability to adjust volume during surgery, easy rupture detection and lower cost. However, they may have a less natural feel and a higher risk of wrinkling and rippling. Silicone gel implants are widely used because of their more natural look and feel. Silicone gel is cohesive and offers a consistency similar to breast tissue. They have a lower incidence of wrinkling and rippling, greater durability and less sensitivity to cold. However, detection of ruptures can be more difficult and there is a potential risk of capsular contracture. Highly cohesive silicone gel implants, also known as anatomical implants, are designed to mimic the natural shape and projection of the breast. They have predictable aesthetic results, a lower incidence of capsular contracture and greater resistance to displacement. However, they may require longer incisions and have a higher cost. Double lumen implants have two separate shell layers, one internal with cohesive silicone gel and the other external with saline solution. They offer an additional layer of security in case of rupture of the inner shell and allow volume adjustment during surgery. However, they may have a less natural feel and greater technical complexity.

Atypical Capsular Contracture with Delayed Intracapsular Hematoma After Breast Implantation for Reconstruction

Late spontaneous hematoma (> 6 months postoperatively) after breast reconstruction using implant is rare complication. We experienced a case of capsular contracture with a unique clinical form of intracapsular hematoma 13 years after implantation of smooth saline filled implants. This report presented the mechanism of complication examined through chart-review, histological morphological analysis, and literature review to help evaluation and treatment of various symptoms around the breast implant capsule. A 51-year-old woman underwent a unilateral breast reconstruction using tissue expander insertion in 2005, and underwent saline implant insertion after a year. A patient has been assessed through computed tomography (CT) and ultrasonography annually for cancer screening in General Surgery department, and in 14 years after implantation, she was referred to the Plastic Surgery department as a finding intracapsular multi-layering lesion around implant. She underwent implant removal and capsulectomy. The excised capsule was sent for histological evaluation. There were no trauma event, calcifications, or implant rupture. Symptoms of swelling and stiffness gradually developed. The etiology of late hematoma following implantation has been poorly characterized. There are opinions that delayed hematoma can be induced by capsule microfracture, which may be due to the rigidity of the contracted capsule, and that it may be caused by friction between the capsule and the implant when there is pathological contracture. It is thought to be an old hematoma capsule contracture that can be mistaken for tumor lesions, and it was concluded that our case corresponds.

An Update on Tissue Contraction in Immediate Breast Reconstruction Using an Adjustable Implant Partially Filled With Air.

Background With the use of nipple-sparing mastectomy (NSM) and skin-sparing mastectomy (SSM) techniques, utilizing a prepectoral underfilled adjustable saline implant allows for tissue contraction and thickening of the flap. This procedure allows for immediate reconstruction using an adjustable implant as a spacer with less risk of skin flap compromise and improves cosmetic outcomes. Methods A retrospective chart review of patients presenting to a single surgeon from September 2013 to September 2021 for breast reconstruction utilizing an underfilled prepectoral adjustable implant following SSM or NSM was performed. Baseline patient demographics, clinical information, postoperative complications, conversion to silicone implant, and contraction distance were recorded and analyzed. Results Fifty-four patients underwent prepectoral breast reconstruction using a Spectrum™ adjustable implant following an NSM or SSM. Tissue contraction and skin flap elevation were observed in all patients. The amount of tissue contraction averaged 4.4 cm (mean). Seven patients (12.96%) developed seromas. Four patients (7.41%) developed hematomas in the early postoperative period. Two patients (3.67%) developed capsular contracture. Two patients (3.67%) had a displaced port. After converting the air to saline, 25 patients (46.29%) opted for a secondary reconstructive procedure to exchange the saline implants for silicone gel implants. Conclusion Tissue contraction reduces the need for skin excision in ptotic breasts undergoing reconstruction procedures following NSM or SSM. The partially filled implant initially functions as a spacer to prevent flap adherence to the pectoral muscleand minimizes tension on the flap to promote flap thickening, elevation around the underfilled implant, and maximizes breast projection and overall aesthetic outcome.

Silicone particles in capsules around breast implants: Establishment of a new pathological methodology to assess the number of particles around breast implants

The presence of silicone particles in breast implant capsules has been observed since the 1970s. Since then, little data has been published regarding the amount of silicone that is susceptible to migrate into the capsule. Quantifying the amount of silicone migration from the implant to the capsule could inform on the level of silicone exposure a patient with breast implants may experience in the short- or long-term. The objective of this study is to present a histological quantification methodology of the number of silicone particles present in breast implant capsules. A prospective study was performed on capsule samples from patients requiring revision surgery. The slides were digitalized and analyzed with a viewer software. For each sample, we (1) manually counted each silicone particle, (2) measured the average particle size, (3) measured the capsule surface area, and (4) calculated the particle number density in each capsule sample. The average of all capsule samples' particle number densities was then compared to the total volume of the capsule to estimate the total number of silicone particles found within the capsule of each breast implant. Six capsules from six different patients were analyzed. Two capsules were from saline implants while four capsules were from silicone implants. All four silicone implant capsules contained between 352,928 and 9,002,235 silicone particles. The particle number density ranged from 20.5 to 683.5 particles per mm3 of capsule. The two saline-filled implant capsules were free of silicone particles. The average of all capsule samples' particle number densities was then compared to the total volume of the capsule to estimate the total number of silicone particles found within the capsule of each breast implant. We describe a new and reproducible methodology to quantify realistically the silicone particles in the periprosthetic capsule of breast implants.

Breast Implant Capsule-Associated Squamous Cell Carcinoma during Pregnancy: A Mimicker of Breast Implant-Associated Anaplastic Large-Cell Lymphoma.

Breast Implant Capsule-Associated Squamous Cell Carcinoma during Pregnancy: A Mimicker of Breast Implant-Associated Anaplastic Large-Cell Lymphoma.

Implant-based Breast Reconstruction after Mastectomy for Breast Cancer: A Systematic Review and Meta-analysis.

Background:Women undergoing implant-based reconstruction (IBR) after mastectomy for breast cancer have numerous options, including timing of IBR relative to radiation and chemotherapy, implant materials, anatomic planes, and use of human acellular dermal matrices. We conducted a systematic review to evaluate these options.Methods:We searched Medline, Embase, Cochrane CENTRAL, CINAHL, and ClinicalTrials.gov for studies, from inception to March 23, 2021, without language restriction. We assessed risk of bias and strength of evidence (SoE) using standard methods.Results:We screened 15,936 citations. Thirty-six mostly high or moderate risk of bias studies (48,419 patients) met criteria. Timing of IBR before or after radiation may result in comparable physical, psychosocial, and sexual well-being, and satisfaction with breasts (all low SoE), and probably comparable risks of implant failure/loss or explantation (moderate SoE). No studies addressed timing relative to chemotherapy. Silicone and saline implants may result in clinically comparable satisfaction with breasts (low SoE). Whether the implant is in the prepectoral or total submuscular plane may not impact risk of infections (low SoE). Acellular dermal matrix use probably increases the risk of implant failure/loss or need for explant surgery (moderate SoE) and may increase the risk of infections (low SoE). Risks of seroma and unplanned repeat surgeries for revision are probably comparable (moderate SoE), and risk of necrosis may be comparable with or without human acellular dermal matrices (low SoE).Conclusions:Evidence regarding IBR options is mostly of low SoE. New high-quality research is needed, especially for timing, implant materials, and anatomic planes of implant placement.

One-Stage Hybrid Breast Reconstruction with Inflatable Saline Implants: Minimizing the Need for Major Revision Surgery

Autologous breast reconstruction is an appealing choice for breast cancer undergoing mastectomy. Evaluating for adequate donor tissue volume is a highly subjective process with potentials for miscommunication. It is not uncommon for patients to desire significant augmentation of their autologous breast reconstruction with delayed insertion of an implant. However, flap elevation in the pre-pectoral plane can be treacherous. Our novel technique combines autologous abdominal free flaps with immediate pre-pectoral adjustable saline implants to provide a customizable, single-stage strategy. A retrospective review of patients undergoing breast reconstruction with abdominal free tissue transfer and either immediate placement of adjustable saline implants or delayed placement of implants for augmentation was performed. Patient characteristics, operative details and complications were recorded. Complications, patient satisfaction and ability to achieve goal breast size was compared between the immediate adjustable saline implant group and delayed implant placement group. Twenty-four patients (41 breasts) were identified and met inclusion criteria. Sixteen patients received implants in a delayed manner (28 breasts), while 8 received adjustable saline implants immediately with flap reconstruction (13 breasts). High patient satisfaction with breast size and shape was noted across both cohorts. Nearly all patients across both cohorts believed that it was beneficial to be able to adjust breast volumes post-reconstruction. Immediate saline implant placement was demonstrated to increased odds of patient-reported satisfaction by multivariable analysis. A single-stage hybrid approach breast reconstruction with a pre-pectoral adjustable saline implant and abdominal free flap is feasible. This novel technique reduces the rate of major revision surgery and optimizes patient satisfaction in autologous breast reconstruction.

Improving Aesthetics By Combining Autologous- and Adjustable Implant-Based Breast Reconstruction

Purpose: Combined autologous abdominally based free flaps (DIEP, ms-TRAM, SIEA) and implants for breast reconstruction after mastectomy can optimize aesthetic outcomes for women who have inadequate tissue volume. Immediate placement of adjustable saline implants at the time of autologous reconstruction is beneficial compared to conventional delayed implant placement after autologous reconstruction. Methods: A retrospective chart review of a single surgeon’s patients who had undergone autologous abdominally based free flaps with immediate placement of Mentor smooth round spectrum saline implants (immediate group) compared to those who had delayed implant placement (delayed group) was performed. Results: Five patients in the immediate group and 16 patients in the delayed group were identified. For patients who had an adjustable saline implant placed, the final implant fill volume average was 275 mL (150–450 mL), while the delayed implant volume average was 236 mL (158-457 mL). Patients in the delayed group had an average length of time from autologous reconstruction to implant placement of 10.5 months (3-30 months). One patient in each group returned to the OR. In the immediate group the patient had a kinked venous anastomosis that was salvageable, while the delayed group patient had a hematoma that was evacuated. Conclusions: Combined immediate autologous flap with adjustable saline implants can achieve an excellent aesthetic result. This combined approach allows for volume adjustment, the ability to achieve larger volume augmentation without compromising the pedicle, improved shape, and the option to have the prosthesis be their permanent implant without increased complications.

Prospective Study of Saline versus Silicone Gel Implants for Subpectoral Breast Augmentation.

Silicone gel implants are regarded as esthetically superior to saline implants, offering a more natural consistency. They are also considered less susceptible to rippling. However, objective measurements and patient-reported outcome studies are lacking. Similarly, minimal data are available quantitating animation deformity. A 3-year prospective study was undertaken among 223 women undergoing primary subpectoral breast augmentation using either saline (n = 145) or silicone gel (n = 78) implants. Photographs obtained included frontal views with the patient flexing the pectoral muscles. Images were matched, and vertical differences in nipple position were measured. Breast implants were evaluated using high-resolution ultrasound to detect any ripples or folds at least 3 months after surgery. Outcome surveys were administered. Statistical analysis included the χ2 test, point-biserial correlations, and a power analysis. Respondents reported visible rippling in 18% of women and palpable rippling in 32% of patients, with no significant difference between women treated with saline and silicone gel implants. Ripples were detected on ultrasound scans in 24% of women with saline implants and in 27% of women with silicone gel implants (difference not significant). Ripples were more common in women with lower body mass indices. Fifty percent of patients demonstrated nipple displacement <1 cm on animation. Nipple displacement occurred either up or down with equal frequency and a mean overall nipple displacement of zero. Saline and silicone breast implants produce similar degrees of rippling, as determined on outcome surveys and ultrasound examination. Animation deformities tend to be minor and well-tolerated.

PMD50 USING SOCIAL MEDIA TO CHARACTERIZE ADVERSE EVENTS: A CASE STUDY OF BREAST IMPLANT ILLNESS

Reports from recipients of breast implants about a diverse set of symptoms has led to the use of the term “breast implant illness” (BII), though no precise clinical definition of a symptom complex has been established. Breast implant options include both saline- and silicone-containing devices with textured or smooth surfaces. Using social media analysis, we qualitatively explored patients’ experience of complaints associated with different types of breast implants. We identified posts on 3 breast implant patient support websites between 2010-2019. Using natural language processing, we searched the post texts for symptoms from the FDA’s list of suspected BII symptoms, such as redness, swelling, skin rash, fatigue and any other mentioned complications. We tabulated complaints reported in posts by implant type. Posts included ≥1 complaint. There were 2,518 posts mentioning saline and 5,470 mentioning silicone gel breast implants. The most common complaints for saline implants were rupture (19.5%), wrinkling/rippling (19.2%), redness/bruising/skin rash (16.1%), inflammation/irritation (10.4%), malposition/displacement/ asymmetry (6.4%), infection (6.1%), deflation (4.9%), capsular contracture (4.0%), and tiredness/fatigue (2.9%). The complaints for silicone implants followed a similar pattern except that redness/bruising/skin rash was more frequent (24.2%), wrinkling/rippling (14.0%) and deflation were less common (0.7%). Brain fog and trouble concentrating were rarely mentioned (<1%). Comparing smooth and textured breast implants, wrinkling/rippling was more frequently mentioned for textured (25.3%) vs smooth (14.9%), while redness/bruising/skin rash was more frequent with smooth (33.0%) vs textured (21.6%). Malposition/displacement was more common for textured (5.4%) vs smooth implants (1.6%). Tiredness/fatigue (4.8% vs 1.7%) and brain fog/trouble concentrating/confusion/not thinking clearly (1.3% vs 0.5%) were mentioned more for smooth vs textured implants. Social media analysis using NLP may be useful to provide insights and qualitative characterization of experience of complications among breast implant recipients. However, multiple factors may influence differences, not just implant type.

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.

Surgical correction of postpneumonectomy syndrome with adjustable saline implants and transoesophageal echocardiography.

Postpneumonectomy syndrome can have a significant clinical impact on a patient. It presents as progressive dyspnoea due to compression of the contralateral bronchus and/or pulmonary veins. Herein, we present a patient who over a 2-year period developed progressive dyspnoea on exertion and eventually also at rest, due to compression of her left mainstem bronchus and her left inferior pulmonary vein. Surgical correction with implantable adjustable saline implants was undertaken to ameliorate her symptoms. Concurrent use of intraoperative transoesophageal echocardiography permitted real-time adjustment of the implants. This allowed objective measurement and demonstration of normalization of pulmonary vein velocity, which resulted in complete symptom resolution.

Our Experience With Transumbilical Breast Augmentation: Largest Published Series to Date With 2263 Patients

Transumbilical Breast Augmentation (TUBA) represents a unique approach for breast augmentation (BA). The endoscopic-guided procedure allows for placement of saline breast implants above or below the pectoralis major muscle without placing any incisions on or near the breast. The procedure has not been widely adopted likely due to the high learning curve and the need for advanced endoscopic skills. In addition, silicone implants have increasingly become more popular than saline implants for multiple reasons over the years, which has naturally decreased the number of TUBA cases. Here, we present the largest series of TUBA cases performed at a single institution and present our standardized reproducible technique to promote wider application of TUBA in Cosmetic Surgery. This is a single-institution retrospective study that included 2263 patients (4526 implants) between 1994 and 2017. All cases were performed under tumescence anesthesia with monitored intravenous sedation. Operating time, conversion to another approach, early and late complications, and patient satisfaction were studied. Our data were compared with the available studies via an extensive literature review. In total, 2263 patients (4526 implants) were included in the study. There was 1 case that required unilateral intraoperative conversion to periareolar approach in the initial experience for technical difficulty. Five small postoperative hematomas occurred that were successfully treated with conservative management and did not require evacuation, and 4 out of 5 postoperative hematomas occurred in subpectoral BA and 1 occurred in subglandular BA. Average operating time was 45 minutes. Remote Grade III and IV capsular contracture occurred in 113 patients requiring capsulectomy through periareolar approach. There were 3 cases of superficial umbilical wound infection that occurred, 1 in subglandular BA and 2 in subpectoral BA. These cases were treated with oral antibiotics and local wound care. No implant infection occurred. There were 32 cases of mild asymmetry that were acceptable by patients and did not require a revision, 19 cases occurred in the subpectoral BA group, and 13 cases occurred in the subglandular BA group. The procedure yielded a very high satisfaction rate. TUBA is a safe and reproducible procedure for BA with short operative time, high patient satisfaction, and comparable outcomes with other approaches.

Response to: “One-Stage Correction of Tuberous Breast Deformity Using Saline Implants: Without the Need for Radial Scoring or Lowering the Inframammary Fold”

Response to: “One-Stage Correction of Tuberous Breast Deformity Using Saline Implants: Without the Need for Radial Scoring or Lowering the Inframammary Fold”

Can It Be Safe and Aesthetic? An Eight-year Retrospective Review of Mastopexy with Concurrent Breast Augmentation.

The safety of concurrently performing mastopexy and breast augmentation is controversial, due to the risk of breast tissue and nipple neurovascular compromise and overall potential high complications rates. This article describes a concurrent procedure of augmentation with implants and a "Tailor-Tack" mastopexy that consistently achieves an aesthetically pleasing breast with acceptable complication rates. This is a retrospective chart review of all consecutive breast augmentations performed concurrently with mastopexy using the "Tailor-Tack" technique by the 2 senior authors (M.M. and O.T.) over an 8-year period. Independent variables were patient demographics, surgical approach, implant type, shape, size, duration of follow-up, and complications. Complications were categorized as "early" (ie, first 30 days) or "late" (ie, after 30 days). Potential early complications include hematoma, skin necrosis, infection, and nipple loss. Potential late complications include recurrent breast ptosis, poor shape of the nipple areolar complex, hypertrophic scarring, implant rupture, capsular contracture, decreased nipple sensation, implant extrusion, reoperation, and scar revisions. The key principle of the technique is to place the breast implant in the dual plane first, and then perform the tailor tacking of the skin for the mastopexy second. Fifty-six consecutive patients underwent augmentation and mastopexy over 8 years with this technique. The average age of the studied patients was 41.2 years. The average follow-up time period was 2.1 years (±8.9 months). Fifty-four patients (96.4%) had implants placed through the periareolar approach, 2 patients (3.6%) had implants placed via the inframammary approach. All implants were placed in a dual plane. Fifty-two patients (92.9%) received silicone implants and 4 patients (7.1%) received saline implants. Patient preference determined implant choice. All but 5 patients had textured implants. Average implant size was 277 cm3 (range 120-800 cm3). Ten patients had complications (17.9%). Complications included hypertrophic scarring in 5 (8.9%) patients; poor nipple-areola complex shape in 4 patients (7.1%); implant ruptures in 3 patients (5.4%); capsular contracture in 3 patients (5.4%); and recurrent ptosis in 2 patients (3.6%). There were no reported early complications such as nipple loss, breast skin necrosis, decreased nipple sensation, implant infections, or extrusions. However, 6 patients (10.7%) required return trips to the operating room for revisions, and 1 patient (1.8%) had a nipple areolar complex scar revised in the office, yielding a 12.5% surgical revision rate for the late complications. It is safe to concurrently perform mastopexy and breast augmentation. In our 8-year review, there were no early catastrophic complications such as skin loss, nipple loss, implant extrusion, or infection. The complications that occurred were the same complications known to occur with the independent performance of mastopexy alone or breast augmentation alone, and they occurred at rates comparable to or less than the national averages for those procedures when they are performed independently. The paramount principle for the success of this technique is to first adjust breast volume and then perform an intraoperatively determined skin resection to fit the new breast volume.

Breast Augmentation

Breast augmentation is a complicated process that goes far beyond placing an implant in a pocket. The implants and techniques of breast augmentation have undergone significant evolution over the past 50 years, and this is now one of the most commonly performed cosmetic procedures worldwide. Advancements in shell barrier technology and silicone form stability have improved implant functional characteristics and mechanical properties. Tissue-based planning uses measurable patient characteristics to match an implant to the patient’s tissue for greater control of the aesthetic result while minimizing complications. The realization of three-dimensional modeling systems allows a more sophisticated approach to implant selection and establishment of patient expectations. Specific surgical techniques, including pocket plane and incision location, ensure ideal implant placement. Optimal patient outcomes are achieved by integrating patient education, implant selection with tissue-based planning, refined surgical technique, and detailed postoperative recovery. This review contains 12 figures, 6 tables, 1 video, and 74 references. Key Words: breast augmentation, breast implants, breast implant-associated anaplastic large cell lymphoma, dual plane, capsular contracture, saline implants, silicone implants, tissue-based planning, three-dimensional imaging