A global agenda for advancing freshwater biodiversity research.

Global freshwater biodiversity is declining dramatically, and meeting the challenges of this crisis requires bold goals and the mobilisation of substantial resources. While the reasons are varied, investments in both research and conservation of freshwater biodiversity lag far behind those in the terrestrial and marine realms. Inspired by a global consultation, we identify 15 pressing priority needs, grouped into five research areas, in an effort to support informed stewardship of freshwater biodiversity. The proposed agenda aims to advance freshwater biodiversity research globally as a critical step in improving coordinated actions towards its sustainable management and conservation.

Invasion impacts and dynamics of a European-wide introduced species.

Globalization has led to the introduction of thousands of alien species worldwide. With growing impacts by invasive species, understanding the invasion process remains critical for predicting adverse effects and informing efficient management. Theoretically, invasion dynamics have been assumed to follow an "invasion curve" (S-shaped curve of available area invaded over time), but this dynamic has lacked empirical testing using large-scale data and neglects to consider invader abundances. We propose an "impact curve" describing the impacts generated by invasive species over time based on cumulative abundances. To test this curve's large-scale applicability, we used the data-rich New Zealand mud snail Potamopyrgus antipodarum, one of the most damaging freshwater invaders that has invaded almost all of Europe. Using long-term (1979-2020) abundance and environmental data collected across 306 European sites, we observed that P. antipodarum abundance generally increased through time, with slower population growth at higher latitudes and with lower runoff depth. Fifty-nine percent of these populations followed the impact curve, characterized by first occurrence, exponential growth, then long-term saturation. This behaviour is consistent with boom-bust dynamics, as saturation occurs due to a rapid decline in abundance over time. Across sites, we estimated that impact peaked approximately two decades after first detection, but the rate of progression along the invasion process was influenced by local abiotic conditions. The S-shaped impact curve may be common among many invasive species that undergo complex invasion dynamics. This provides a potentially unifying approach to advance understanding of large-scale invasion dynamics and could inform timely management actions to mitigate impacts on ecosystems and economies.

Stochastic processes and ecological connectivity drive stream invertebrate community responses to short-term drought.

Community responses to and recovery from disturbances depend on local (e.g. presence of refuges) and regional (connectivity to recolonization sources) factors. Droughts are becoming more frequent in boreal regions, and are likely to constitute a severe disturbance for boreal stream communities where organisms largely lack adaptations to such hydrological extremes. We conducted an experiment in 24 semi-natural stream flumes to assess the effects of local and regional factors on the responses of benthic invertebrate communities to a short-term drought. We manipulated flow (drought vs. constant-flow), spatial arrangement of leaf litter patches (aggregated vs. evenly distributed) and colonization from regional species pool (enhanced vs. ambient connectivity) to test the combined effects of disturbance, resource arrangement and connectivity on the structural and functional responses of benthic invertebrate communities. We found that a drought as short as 1 week reduced invertebrate taxonomic richness and abundance, mainly through stochastic extinctions. Such changes in richness were not reflected in functional diversity. This suggests that communities were characterized by a high degree of functional redundancy, which allowed maintenance of functional diversity despite species losses. Feeding groups responded differently to drought, with organic matter decomposers responding more than scrapers and predators. Three weeks were insufficient for complete invertebrate community recovery from drought. However, recovery was greater in channels subjected to enhanced connectivity, which increased taxonomic diversity and abundance of certain taxa. Spatial configuration of resources explained the least variation in our response variables, having a significant effect only on invertebrate abundance and evenness (both sampling occasions) and taxonomic richness (end of recovery period). Even a short drought, if occurring late in the season, may not allow communities to recover before the onset of winter, thus having a potentially long-lasting effect on stream communities. For boreal headwaters, extreme dewatering poses a novel disturbance regime that may trigger substantial and potentially irreversible changes. An improved understanding of such changes is needed to underpin adaptive management strategies in these increasingly fragmented and disturbed ecosystems.

Panarchy and management of lake ecosystems.

A key challenge of the Anthropocene is to confront the dynamic complexity of systems of people and nature to guide robust interventions and adaptations across spatiotemporal scales. Panarchy, a concept rooted in resilience theory, accounts for this complexity, having at its core multiscale organization, interconnectedness of scales, and dynamic system structure at each scale. Despite the increasing use of panarchy in sustainability research, quantitative tests of its premises are scarce, particularly as they pertain to management consequences in ecosystems. In this study we compared the physicochemical environment of managed (limed) and minimally disturbed reference lakes and used time series modeling and correlation analyses to test the premises of panarchy theory: (1) that both lake types show dynamic structure at multiple temporal scales, (2) that this structure differs between lake types due to liming interacting with the natural disturbance regime of lakes, and (3) that liming manifests across temporal scales due to cross-scale connectivity. Hypotheses 1 and 3 were verified whereas support for hypothesis 2 was ambiguous. The literature suggests that liming is a "command-and-control" management form that fails to foster self-organization manifested in lakes returning to pre-liming conditions once management is ceased. In this context, our results suggest that redundance of liming footprints across scales, a feature contributing to resilience, in the physicochemical environment alone may not be enough to create a self-organizing limed lake regime. Further research studying the broader biophysical lake environment, including ecological communities of pelagic and benthic habitats, will contribute to a better understanding of managed lake panarchies. Such insight may further our knowledge of ecosystem management in general and of limed lakes in particular.

Habitat patchiness, ecological connectivity and the uneven recovery of boreal stream ecosystems from an experimental drought.

Ongoing climate change is increasing the occurrence and intensity of drought episodes worldwide, including in boreal regions not previously regarded as drought prone, and where the impacts of drought remain poorly understood. Ecological connectivity is one factor that might influence community structure and ecosystem functioning post-drought, by facilitating the recovery of sensitive species via dispersal at both local (e.g. a nearby habitat patch) and regional (from other systems within the same region) scales. In an outdoor mesocosm experiment, we investigated how impacts of drought on boreal stream ecosystems are altered by the spatial arrangement of local habitat patches within stream channels, and variation in ecological connectivity with a regional species pool. We measured basal ecosystem processes underlying carbon and nutrient cycling: (a) algal biomass accrual; (b) microbial respiration; and (c) decomposition of organic matter, and sampled communities of aquatic fungi and benthic invertebrates. An 8-day drought event had strong impacts on both community structure and ecosystem functioning, including algal accrual, leaf decomposition and microbial respiration, with many of these impacts persisting even after water levels had been restored for 3.5 weeks. Enhanced connectivity with the regional species pool and increased aggregation of habitat patches also affected multiple response variables, especially those associated with microbes, and in some cases reduced the effects of drought to a small extent. This indicates that spatial processes might play a role in the resilience of communities and ecosystem functioning, given enough time. These effects were however insufficient to facilitate significant recovery in algal growth before seasonal dieback began in autumn. The limited resilience of ecosystem functioning in our experiment suggests that even short-term droughts can have extended consequences for stream ecosystems in the world's vast boreal region, and especially on the ecosystem processes and services mediated by algal biofilms.

Linking degradation status with ecosystem vulnerability to environmental change.

Environmental change can cause regime shifts in ecosystems, potentially threatening ecosystem services. It is unclear if the degradation status of ecosystems correlates with their vulnerability to environmental change, and thus the risk of future regime shifts. We assessed resilience in acidified (degraded) and circumneutral (undegraded) lakes with long-term data (1988-2012), using time series modeling. We identified temporal frequencies in invertebrate assemblages, which identifies groups of species whose population dynamics vary at particular temporal scales. We also assessed species with stochastic dynamics, those whose population dynamics vary irregularly and unpredictably over time. We determined the distribution of functional feeding groups of invertebrates within and across the temporal scales identified, and in those species with stochastic dynamics, and assessed attributes hypothesized to contribute to resilience. Three patterns of temporal dynamics, consistent across study lakes, were identified in the invertebrates. The first pattern was one of monotonic change associated with changing abiotic lake conditions. The second and third patterns appeared unrelated to the environmental changes we monitored. Acidified and the circumneutral lakes shared similar levels and patterns of functional richness, evenness, diversity, and redundancy for species within and across the observed temporal scales and for stochastic species groups. These similar resilience characteristics suggest that both lake types did not differ in vulnerability to the environmental changes observed here. Although both lake types appeared equally vulnerable in this study, our approach demonstrates how assessing systemic vulnerability by quantifying ecological resilience can help address uncertainty in predicting ecosystem responses to environmental change across ecosystems.

The Swedish monitoring of surface waters: 50 years of adaptive monitoring.

For more than 50 years, scientific insights from surface water monitoring have supported Swedish evidence-based environmental management. Efforts to understand and control eutrophication in the 1960s led to construction of wastewater treatment plants with phosphorus retention, while acid rain research in the 1970s contributed to international legislation curbing emissions. By the 1990s, long-time series were being used to infer climate effects on surface water chemistry and biology. Monitoring data play a key role in implementing the EU Water Framework Directive and other legislation and have been used to show beneficial effects of agricultural management on Baltic Sea eutrophication. The Swedish experience demonstrates that well-designed and financially supported surface water monitoring can be used to understand and manage a range of stressors and societal concerns. Using scientifically sound adaptive monitoring principles to balance continuity and change has ensured long-time series and the capability to address new questions over time.

Assessing and managing freshwater ecosystems vulnerable to environmental change.

Freshwater ecosystems are important for global biodiversity and provide essential ecosystem services. There is consensus in the scientific literature that freshwater ecosystems are vulnerable to the impacts of environmental change, which may trigger irreversible regime shifts upon which biodiversity and ecosystem services may be lost. There are profound uncertainties regarding the management and assessment of the vulnerability of freshwater ecosystems to environmental change. Quantitative approaches are needed to reduce this uncertainty. We describe available statistical and modeling approaches along with case studies that demonstrate how resilience theory can be applied to aid decision-making in natural resources management. We highlight especially how long-term monitoring efforts combined with ecological theory can provide a novel nexus between ecological impact assessment and management, and the quantification of systemic vulnerability and thus the resilience of ecosystems to environmental change.

Multi-decadal improvements in the ecological quality of European rivers are not consistently reflected in biodiversity metrics.

Humans impact terrestrial, marine and freshwater ecosystems, yet many broad-scale studies have found no systematic, negative biodiversity changes (for example, decreasing abundance or taxon richness). Here we show that mixed biodiversity responses may arise because community metrics show variable responses to anthropogenic impacts across broad spatial scales. We first quantified temporal trends in anthropogenic impacts for 1,365 riverine invertebrate communities from 23 European countries, based on similarity to least-impacted reference communities. Reference comparisons provide necessary, but often missing, baselines for evaluating whether communities are negatively impacted or have improved (less or more similar, respectively). We then determined whether changing impacts were consistently reflected in metrics of community abundance, taxon richness, evenness and composition. Invertebrate communities improved, that is, became more similar to reference conditions, from 1992 until the 2010s, after which improvements plateaued. Improvements were generally reflected by higher taxon richness, providing evidence that certain community metrics can broadly indicate anthropogenic impacts. However, richness responses were highly variable among sites, and we found no consistent responses in community abundance, evenness or composition. These findings suggest that, without sufficient data and careful metric selection, many common community metrics cannot reliably reflect anthropogenic impacts, helping explain the prevalence of mixed biodiversity trends.

Time series of freshwater macroinvertebrate abundances and site characteristics of European streams and rivers.

Freshwater macroinvertebrates are a diverse group and play key ecological roles, including accelerating nutrient cycling, filtering water, controlling primary producers, and providing food for predators. Their differences in tolerances and short generation times manifest in rapid community responses to change. Macroinvertebrate community composition is an indicator of water quality. In Europe, efforts to improve water quality following environmental legislation, primarily starting in the 1980s, may have driven a recovery of macroinvertebrate communities. Towards understanding temporal and spatial variation of these organisms, we compiled the TREAM dataset (Time seRies of European freshwAter Macroinvertebrates), consisting of macroinvertebrate community time series from 1,816 river and stream sites (mean length of 19.2 years and 14.9 sampling years) of 22 European countries sampled between 1968 and 2020. In total, the data include >93 million sampled individuals of 2,648 taxa from 959 genera and 212 families. These data can be used to test questions ranging from identifying drivers of the population dynamics of specific taxa to assessing the success of legislative and management restoration efforts.

The impact of climate on the geographical distribution of phytoplankton species in boreal lakes.

Here, we use a novel space-by-time approach to study large-scale changes in phytoplankton species distribution in Swedish boreal lakes in response to climate variability. Using phytoplankton samples from 27 lakes, evenly distributed across Sweden, all relatively unimpacted by anthropogenic disturbance and sampled annually between 1996 and 2010, we found significant shifts in the geographical distribution of 18 species. We also found significant changes in the prevalence of 45 species (33 became more common and 12 less common) over the study period. Using species distribution models and phytoplankton samples from 60 lakes sampled at least twice between 1992 and 2010, we evaluated the importance of climate variability and other environmental variables on species distribution. We found that temperature (e.g., extreme events and the duration of the growing season) was the most important predictor for species detections. Many cyanobacteria, chlorophytes, and, to a lesser extent, diatoms and zygnematophytes, showed congruent and positive responses to temperature. In contrast, precipitation explained little variation and was important only for a few taxa (e.g., Staurodesmus spp., Trachelomonas volvocina). At the community level, our results suggest a change in community composition at temperatures over 20 °C and growing seasons longer than 40 days. We conclude that climate is an important driver of the distributional patterns of individual phytoplankton species and may drive changes in community composition in minimally disturbed boreal lakes.

Challenges in supplying empirical proof for predictions derived from Species Distribution Models (SDMs): the case of an invasive cyanobacterium.

Species distribution models (SDMs) calibrated with bioclimatic variables revealed a high probability for range expansion of the invasive toxin producing cyanobacterium, Raphidiopsis raciborskii to Sweden, where no reports of its presence have hitherto been recorded. While predictions focused on the importance of climate variables for possible invasion, other barriers to dispersal and successful colonization need to be overcome by the species for successful invasion. In this study, we combine field-based surveys of R. raciborskii (microscopy and molecular analysis using species-specific primers) of 11 Swedish lakes and in-silico screening of environmental DNA using 153 metagenomic datasets from lakes across Europe to validate the SDMs prediction. Field-based studies in lakes with high/low predicted probability of occurrence did not detect the presence of R. raciborskii, and in-silico screening only detected hints of its presence in 5 metagenomes from lakes with probability ranging from 0.059 to 0.825. The inconsistencies between SDMs results and both field-based/in-silico monitoring could be due to either sensitivity of monitoring approaches in detecting early invasions or uncertainties in SDMs that focused solely on climate drivers. However, results highlight the necessity of proactive monitoring with high temporal and spatial frequency.

Breast Reconstruction Outcomes with and without Strattice: Long-Term Outcomes of a Multicenter Study Comparing Strattice Immediate Implant Breast Reconstruction with Submuscular Implant Reconstruction.

BACKGROUND: Over half of immediate implant-based breast reconstructions (IBBR) are performed with an acellular dermal matrix, despite limited long-term outcome data. METHODS: The Breast Reconstruction Outcomes with and without Strattice, or BROWSE, study was a retrospective multicenter cohort study comparing consecutive patients who had undergone immediate Strattice IBBR with those who had undergone immediate IBBR with a submuscular technique between January of 2009 and December of 2015. RESULTS: This study compared 553 Strattice reconstructions with 242 submuscular reconstructions, with a median follow-up of 4.3 years (range, 2 to 9.3 years) and 5.7 years (range, 2 to 8.1 years), respectively, demonstrating an equivalent total complication rate [Strattice, n = 204 (36.9%); submuscular, n = 77 (31.8%); P = 0.17] and implant loss rate (8.5% versus 5.4%, respectively; P = 0.12). Infection rates and wound dehiscence rates were higher in the Strattice cohort [ n = 114 (20.6%) versus n = 31 (12.8%), P = 0.009; and n = 90 (16.3%) versus n = 25 (10.4%), P = 0.03, respectively]. Overall revision rates were comparable [ n = 226 (46.7%) versus n = 79 (41.1%); P = 0.2], but significantly fewer Strattice reconstructions required revision surgery for capsular contracture (5.3% versus 15.6%; P < 0.001). CONCLUSION: Although the risk of complications associated with Strattice reconstruction is numerically higher than that for submuscular coverage, the difference is small and not statistically significant, and likely outweighed by the clear reduced rate of revision surgery because of capsular contracture when Strattice is used. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, III.

Simultaneous increases of filter-feeding fish and bivalves are key for controlling cyanobacterial blooms in a shallow eutrophic lake.

Eutrophication and cyanobacterial blooms have severely affected many freshwater ecosystems. We studied the effects of filter-feeding fish and bivalves on algal populations using a mesocosm experiment and long-term monitoring data from Lake Taihu (China). The mesocosm study, comprised of a two-way factorial design with the clam Corbicula fluminea and the fish Aristichthys nobilis at three biomass levels, resulted in lower chlorophyll a (Chl a) in high fish treatments, but no significant differences in the low and medium fish treatments. Chl a also decreased with an increase in clam biomass in the high fish treatments. Moreover, filter-feeding fish resulted in a decrease in algal sizes (e.g., the colony size of Microcystis aeruginosa was inversely related to fish biomass) which likely increased the filter-feeding efficiency of bivalves. Biomass of filter-feeding fish was found to be a key factor driving the synergistic effects of filter-feeding fish and bivalves in waters dominated by Microcystis colonies. Long-term monitoring revealed increasing trends in Chl a concentration, total fish catch per unit effort (TF-CPUE), and filter-feeding fish (FF-CPUE), and slightly decreasing trends in bivalve biomass and nitrogen to phosphorus ratios (N:P) from 2006 to 2016. Bivalve biomass and N:P were negatively correlated with Chl a, while FF-CPUE was not significantly related to Chl a. The current filter-feeding fish biomass in Lake Taihu is estimated to be too low to drive synergistic algal control effects together with bivalves. Furthermore, the lack of filter feeders in Lake Taihu may lead to top-down control by predators that cannot counteract the bottom-up effects of nutrients on phytoplankton. Collectively, these long-term monitoring and experimental data support the combined use filter-feeding fish and bivalves for managing cyanobacteria blooms in Lake Taihu.

Top-down effects of filter-feeding fish and bivalves moderate bottom-up effects of nutrients on phytoplankton in subtropical shallow lakes: An outdoor mesocosm study.

Biomanipulation has been widely used in the ecological restoration of eutrophic lakes for decades. However, biomanipulation is prone to failure if external nutrient loads are not reduced. In order to explore the importance of filter-feeding fish and bivalves on algal control, an outdoor mesocosm experiment was conducted using different nutrient concentrations. Four treatments simulating daily loads of nutrients in Lake Taihu were studied: current, two times, and three times average daily loads of nutrients with both fish (Aristichthys nobilis) and Asian clam (Corbicula fluminea) and as a control current daily loads without fish or bivalves. Results showed that stocking of filter-feeding fish and bivalves (80 g m-3 bighead carp; 200 g cm-2 clams) at two times daily nutrient loads could effectively control water column Chl a concentrations and phytoplankton biomass. At higher nutrient concentrations (TN ≥ 260 µg L-1 d-1; TP ≥ 10 µg L-1 d-1), top-down control of filter-feeding fish and bivalves was less effective and bottom-up effects resulted in significant increases of Chl a concentration. Thus, as phytoplankton biomass in freshwater ecosystems is determined by both the top-down effects of predators and the bottom-up effects of nutrients, external loadings should be controlled when filter-feeding fish and bivalves are used for algal control to ensure the efficacy of biomanipulation.

Long-term trends in crayfish invasions across European rivers.

Europe has experienced a substantial increase in non-indigenous crayfish species (NICS) since the mid-20th century due to their extensive use in fisheries, aquaculture and, more recently, pet trade. Despite relatively long invasion histories of some NICS and negative impacts on biodiversity and ecosystem functioning, large spatio-temporal analyses of their occurrences are lacking. Here, we used a large freshwater macroinvertebrate database to evaluate what information on NICS can be obtained from widely applied biomonitoring approaches and how usable such data is for descriptions of trends in identified NICS species. We found 160 time-series containing NICS between 1983 and 2019, to infer temporal patterns and environmental drivers of species and region-specific trends. Using a combination of meta-regression and generalized linear models, we found no significant temporal trend for the abundance of any species (Procambarus clarkii, Pacifastacus leniusculus or Faxonius limosus) at the European scale, but identified species-specific predictors of abundances. While analysis of the spatial range expansion of NICS was positive (i.e. increasing spread) in England and negative (significant retreat) in northern Spain, no trend was detected in Hungary and the Dutch-German-Luxembourg region. The average invasion velocity varied among countries, ranging from 30 km/year in England to 90 km/year in Hungary. The average invasion velocity gradually decreased over time in the long term, with declines being fastest in the Dutch-German-Luxembourg region, and much slower in England. Considering that NICS pose a substantial threat to aquatic biodiversity across Europe, our study highlights the utility and importance of collecting high resolution (i.e. annual) biomonitoring data using a sampling protocol that is able to estimate crayfish abundance, enabling a more profound understanding of NICS impacts on biodiversity.

Temporal scales and patterns of invertebrate biodiversity dynamics in boreal lakes recovering from acidification.

Despite international policy implementation to reduce atmospheric acid deposition and restore natural resources from cultural acidification, evidence of ecological recovery is equivocal. Failure to meet recovery goals means that acidification still threatens biodiversity in many areas of the world. Managers thus need information to manage biodiversity, especially its components that are sensitive to stress (acid-sensitive taxa). We analyzed 20-year time series (1988-2007) of water quality and littoral invertebrates in acidified and circum-neutral lakes across Sweden to evaluate regional biodiversity dynamics and the extent to which changes in water quality affect these dynamics. We used multivariate time series modeling to (1) test how individual species groups within invertebrate communities track changes in the abiotic environment and (2) reveal congruencies of taxon contributions to species group change across lakes. Chemical recovery in the lakes was equivocal, and increases of pH and alkalinity were observed in subsets of acidified and circum-neutral lakes. Time series analyses revealed two different patterns of species groups for invertebrate communities across lakes; the first species group showed monotonic change over time, while the second group showed fluctuating temporal patterns. These independent species groups correlated distinctly with different sets of environmental variables. Recovery of pH and alkalinity status was associated with species group patterns only in a few lakes, highlighting an overall weak recovery of invertebrate species. The sets of species, including acid-sensitive taxa, composing these species groups differed markedly across lakes, highlighting context-specific responses of invertebrates to environmental variation. These results are encouraging because disparate local-scale dynamics maintain the diversity of sensitive invertebrate species on a regional scale, despite persisting acidification problems. Our study can inform and help refine current acidification-related policy focused on sensitive biodiversity elements.

Correcting a fundamental error in greenhouse gas accounting related to bioenergy.

Many international policies encourage a switch from fossil fuels to bioenergy based on the premise that its use would not result in carbon accumulation in the atmosphere. Frequently cited bioenergy goals would at least double the present global human use of plant material, the production of which already requires the dedication of roughly 75% of vegetated lands and more than 70% of water withdrawals. However, burning biomass for energy provision increases the amount of carbon in the air just like burning coal, oil or gas if harvesting the biomass decreases the amount of carbon stored in plants and soils, or reduces carbon sequestration. Neglecting this fact results in an accounting error that could be corrected by considering that only the use of 'additional biomass' - biomass from additional plant growth or biomass that would decompose rapidly if not used for bioenergy - can reduce carbon emissions. Failure to correct this accounting flaw will likely have substantial adverse consequences. The article presents recommendations for correcting greenhouse gas accounts related to bioenergy.

Species distribution models as a tool for early detection of the invasive Raphidiopsis raciborskii in European lakes.

In freshwater habitats, invasive species and the increase of cyanobacterial blooms have been identified as a major cause of biodiversity loss. The invasive cyanobacteria Raphidiopsis raciborskii a toxin-producing and bloom-forming species affecting local biodiversity and ecosystem services is currently expanding its range across Europe. We used species distribution models (SDMs) and regional bioclimatic environmental variables, such as temperature and precipitation, to identify suitable areas for the colonization and survival of R. raciborskii, with special focus on the geographic extent of potential habitats in Northern Europe. SDMs predictions uncovered areas of high occurrence probability of R. raciborskii in locations where it has not been recorded yet, e.g. some areas in Central and Northern Europe. In the southeastern part of Sweden, areas of suitable climate for R. raciborskii corresponded with lakes of high concentrations of total phosphorus, increasing the risk of the species to thrive. To our knowledge, this is the first attempt to predict areas at high risk of R. raciborskii colonization in Europe. The results from this study suggest several areas across Europe that would need monitoring programs to determine if the species is present or not, to be able to prevent its potential colonization and population growth. Regarding an undesirable microorganism like R. raciborskii, authorities may need to start information campaigns to avoid or minimize the spread.

BROWSE: A multicentre comparison of nine year outcomes in acellular dermal matrix based and complete submuscular implant-based immediate breast reconstruction-aesthetics, capsular contracture and patient reported outcomes.

Approximately 60% of implant-based breast reconstructions (IBBR) are performed with an acellular dermal matrix (ADM), for which, reliable, good quality long-term outcome data is limited. In a retrospective multicentre cohort study, we aimed to determine long-term aesthetic and quality of life outcomes of IBBR with ADM (Strattice™) compared to a submuscular technique. METHODS: Capsular contracture (Baker III/IV capsule) was determined by clinical examination by an independent researcher. Quality of life was assessed using BREAST-Q and aesthetic outcome by photographic assessment from a breast surgeon, breast care nurse and lay person, blinded to reconstruction type. RESULTS: We recruited 117 (51 bilateral) patients with ADM reconstructions, median follow-up 62 months (range 29-113) and 49 patients (16 bilateral) with submuscular reconstructions, median follow-up 76 months (range 38-111). 17 (10.1%) ADM reconstructions were Baker 3/4 compared to six (9.2%) submuscular (p = 0.85). Of the Baker 1/2 reconstructions six (3.6%) ADM and eight (13.6%) submuscular had previously undergone revision surgery to correct capsular contracture (p = 0.01). Combining both findings gave an estimated rate of capsular contracture of 13.6% in the ADM group and 21.2% in the submuscular (p = 0.14). A higher mean score for satisfaction with breasts was demonstrated when comparing ADM to submuscular (62 and 55, respectively; p = 0.01) but no significant difference in other BREAST-Q domains. The mean 'general satisfaction' score was higher in the ADM group for all three photograph assessors. CONCLUSION: This study provides evidence of improved aesthetic outcome and reduction in capsular contracture with ADM reconstruction when compared to submuscular, consistent over long-term follow-up.