Gel Cohesivity and Breast Augmentation: Applications to Clinical Practice.

Matching breast implant gel cohesivity to the patient's needs based on anatomical and soft-tissue considerations and patient preferences is essential to optimizing aesthetic outcomes and patient satisfaction. Generally, gel cohesivity contributes to the feel and shape of the breast, which reflects volume distribution within the breast. Studies on the physical properties of silicone gel breast implants have established the relative cohesivity of implants from several manufacturers. Comprehensive patient education, tissue-based preoperative planning, and a thorough understanding of how implant properties may affect outcomes are recommended before breast augmentation. This review summarizes the literature on breast implant physical properties with a focus on gel cohesivity and translates gel cohesivity to practical considerations in choosing the right implant for the right patient in primary augmentation. Based on clinical experience, the authors generally recommend lower cohesivity implants for patients who desire a tapered upper pole or a natural appearance/"anatomic shape" as well as for those with a high BMI or a large amount of native breast tissue. Medium-cohesivity implants are most widely used and are appropriate for those with ptosis/augmentation mastopexy, patients with tight skin envelope, and for those seeking upper pole fullness. A high-cohesivity implant is recommended for patients desiring a round shape, patients with constricted lower poles, and patients with a postpartum loose envelope, a thin, soft tissue envelope, or fibrous breast tissue.

Use of Magnetic Resonance Imaging in Patients with Breast Tissue Expanders.

BACKGROUND: There are no guidelines on the safety of magnetic resonance imaging (MRI) in patients with breast tissue expanders with metallic/magnetic components. This narrative review was conducted to better understand what is currently known and to identify gaps in knowledge. METHODS: A literature search was performed using PubMed and Embase and the following terms: "breast" AND ("imaging" OR "MRI" OR "resonance") AND "expander," with no date limitations. The authors identified 153 citations in PubMed and 154 citations in Embase. RESULTS: Nineteen publications were relevant for analysis: two retrospective studies, 10 case reports, six nonclinical studies, and one physician survey. All studies acknowledged the risks of using magnetic resonance imaging in patients with tissue expanders. Complications reported included breast/chest pain, discomfort, or burning sensation (46.2 percent); expander or infusion port displacement (38.5 percent); and magnetic resonance signal loss (23.1 percent). Increases in expander/tissue temperature and torque occurred with magnetic resonance imaging, causing pain or expander displacement. In some cases, no complications were reported. The retrospective studies and nonclinical analyses suggested that magnetic resonance imaging may not create serious problems if special precautions are taken. The case reports varied in their recommendations, with some recommending avoiding magnetic resonance imaging and others recommending exercising caution. The survey indicated that surgeons are uncertain about performing magnetic resonance imaging in patients with tissue expanders. CONCLUSIONS: The evidence on whether to perform magnetic resonance imaging in patients with tissue expanders with magnetic ports varies but underscores proceeding with caution. The risk-to-benefit profile for each patient must be weighed in each situation.

Acellular Dermal Matrices in Breast Reconstruction: CARE Trial 5-Year Outcomes Data for More Than 9500 Patients.

Few studies have assessed long-term complications in women undergoing implant-based breast reconstruction with use of an acellular dermal matrix (ADM). This study compared outcomes over 5 years in women undergoing breast reconstruction procedures with and without ADM. Methods: Complications data in patients enrolled in the prospective Continued Access Reconstruction/Revision Expansion trial were segregated by use of ADM versus no ADM in patients undergoing primary breast reconstruction or revision-reconstruction. Continued Access Reconstruction/Revision Expansion trial evaluated long-term safety and effectiveness of shaped, textured, silicone implants. Results: Of the 9502 women, 257 had primary (n = 160) or revision-reconstruction (n = 97) with ADMs; 9245 had primary (n = 6977) or revision-reconstruction (n = 2268) without ADMs. Capsular contracture rates in primary reconstruction were lower with ADM than without at year 5 (3.2% versus 7.4%); rates were similar at year 1 (≤2.4%). Capsular contracture rates in revision-reconstruction were lower with ADM than without at year 5 (1.4% versus 8.9%); rates were similar at year 1 (≤2.5%). Seroma rates were low and sustained for all cohorts throughout the 5 years (≤2.9%). Reoperation rates increased over time in all cohorts, with similar rates between groups (2.4%-47.3% from week 4 to year 5 across cohorts). Other trends over time included lower rates for asymmetry and implant malposition with ADM than without. Conclusion: These long-term data suggest that the use of ADM in breast reconstruction procedures may provide a benefit in reducing complications, such as capsular contracture, and may sustain low rates of seroma.

A Practical Guide to Managing Patients With Systemic Symptoms and Breast Implants.

Numerous studies have explored the possibility of an association between breast implants and systemic symptoms potentially linked to exposure to silicone. Some studies show no direct association whereas others provide insufficient scientific evidence to prove or disprove an association. Nonetheless, some patients with breast implants remain concerned about the possible role of their implants in systemic symptoms they may be experiencing. This paper provides a practical approach for plastic surgeons in managing patients with breast implants who present with systemic symptoms, including recommendations for patient counseling, clinical and laboratory assessment of symptoms, and/or referral. Integral components of patient counseling include listening attentively, providing unbiased information, and discussing the risks and benefits of options for evaluation and treatment. A thorough history and assessment of symptoms, including appropriate laboratory tests, may identify underlying conditions to expeditiously address patients' health issues through a specialist referral. Diagnosing and treating disorders that are causing a patient's symptoms, if unrelated to their implant, would avoid a potentially unnecessary surgery. Ultimately, better information is needed to reliably guide patients in an evidence-based fashion. Long-term follow-up of patients who are explanted to see what symptoms may or may not improve could be useful in educating patients. Control groups in studies prospectively following women with implants for development of systemic symptoms would also be useful because the symptoms reported are common in women without implants. Cases are presented to illustrate the recommendations for a practical approach toward management of women reporting systemic symptoms with breast implants.

Assessing Postsurgical Outcomes with Prepectoral Breast Reconstruction: A Literature Review and Meta-analysis Update.

BACKGROUND: Prepectoral implant-based breast reconstruction is an alternative to subpectoral/dual-plane reconstruction. METHODS: This study examined outcomes of prepectoral reconstruction using a meta-analysis of data pooled with data from our previous review. Thirty studies were included. RESULTS: Explantation, seroma, and infection were the most common complications with no animation deformity reported. Significantly lower odds of infection were observed with prepectoral compared with dual-plane reconstruction. CONCLUSIONS: Current literature suggests that prepectoral reconstruction may be associated with lower rates of postsurgical infections.

Local Extreme Heat Planning: an Interactive Tool to Examine a Heat Vulnerability Index for Philadelphia, Pennsylvania.

Exposure to extreme heat contributes to high morbidity and mortality relative to other climate hazards. The city of Philadelphia, PA is particularly vulnerable to the impacts of extreme heat, due to the urban heat island effect and high prevalence of sensitive populations. We developed a heat vulnerability index, which identified priority areas that are most at-risk of experiencing adverse heat-related health outcomes and in need of preparedness and mitigation interventions. An interactive website was created to display the maps and allow the public to navigate the data with links to potential resources for relief from extreme heat days. Such methods can be adapted for other cities that wish to identify and target long-term priority areas.

Planning for Food Access During Emergencies: Missed Meals in Philadelphia.

OBJECTIVES: To illustrate the effects that minor social or environmental disruptions could have on the food access of low-income households in Philadelphia, Pennsylvania, and provide suggestions for how cities can better incorporate food into emergency planning. METHODS: Using publicly available data and stakeholder interviews (n = 8) in 2017, we projected the number of meals that would be missed during environmental and social disruptions in Philadelphia, a major US city with a high poverty rate. RESULTS: As our projections in Philadelphia indicate, even just 3 days of school closures could result in as many as 405 600 missed meals for school-aged children. CONCLUSIONS: These scenarios provide valuable lessons for other cities to proactively plan for food access continuity in times of uncertainty. Public Health Implications. City planners and other city agencies need to include food as a routine part of emergency planning and redefine the threshold at which emergency response protocols are triggered to better ensure protection of low-income and underserved populations.