Autologous Fat Breast Reconstruction with Implant Completion-Experience with 29 Consecutive Cases and 33 Breasts.

BACKGROUND: Implant-based breast reconstruction is the most prevalent form of breast reconstruction. Autologous fat grafting (AFG) was conceptualized as an alternative to implant-based breast reconstruction and was found to be a reliable reconstruction modality. However, usually, a few grafting rounds are required to create the desired shape and size of the breast. Current literature describes ample experience with AFG as an adjunct to implant-based breast reconstruction for improving appearance. However, the utilization of breast implants following initial AFG has been sparingly described. The primary advantage of this study is the creation of new fat tissue as a breast mound. The reconstruction is then concluded by inserting an implant into this new mound. This approach reduces the overall number of fat injections needed to achieve the desired outcome, as well as the total volume of the implant. METHODS: This IRB-approved retrospective study was conducted between January 2015 and December 2021. All women who underwent delayed breast reconstruction with AFG during this timeframe and wanted to complete it with a silicone implant as a last stage were included in the study. RESULTS: A total of 29 patients (33 breasts) underwent delayed breast reconstruction with AFG and a silicone implant as the final stage. In all cases, the results were satisfying without any major complications. Minor complications were observed with one patient and included an infection. CONCLUSIONS: The findings of this study have demonstrated the effectiveness of this procedure together with patient satisfaction, thus highlighting the potential advantages that this approach offers. LEVEL OF EVIDENCE III: 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 Table of Contents or the online Instructions to Authors www.springer.com/00266 .

The impact of germline BRCA pathogenic variants in locally advanced, triple negative breast cancer treated with platinum-based neoadjuvant chemotherapy.

BACKGROUND: Whether germline BRCA (gBRCA) pathogenic variants (PV) affect prognosis of women with triple negative breast cancer (TNBC) and whether it has implications for treatment decisions in the neoadjuvant setting is unclear. METHODS: This is a retrospective two-center cohort study comprising all women with early stage TNBC who have completed genetic testing and were treated with neoadjuvant dose-dense doxorubicin and cyclophosphamide followed by paclitaxel and carboplatin. All eligible patients treated between 10.2014 and 3.2020 were included. Data on clinico-pathological, pathological response, overall survival (OS) and disease-free survival (DFS) were evaluated. Differences in clinico-pathological features and outcomes were analyzed according to gBRCA status. RESULTS: Sixty-four women were included in the final analysis, of which 31 had gBRCA PV (gBRCA carriers) and 33 were gBRCA wild-type. Clinico-pathological characteristics were similar between both groups. The odds for pathological complete response (pCR) were significantly higher in gBRCA carriers (74.2%) compared to BRCA wild-type women (48.5%), p = 0.035. At a median follow-up of 30 months, gBRCA carriers had significantly favorable OS (HR = 8.64, 95% CI 1.08-69.21, p = 0.042). The difference in DFS did not reach statistical significance (HR = 7.4, 95% CI 0.91-60.27, p = 0.062). The favorable OS for gBRCA carriers remained significant in multivariate analysis (p = 0.029) and was noted regardless of pathological response (p = 0.018). CONCLUSION: Compared to wild-type, gBRCA carriers with locally advanced TNBC treated with neoadjuvant chemotherapy containing carboplatin had a higher pCR rate and better outcomes. These results strengthen the contention that gBRCA status should be considered when tailoring treatment decisions in women with locally advanced TNBC.

An Innovative Surgical Device for Removal of Breast Implants.

SUMMARY: The use of breast implants is consistently on the rise owing to increases in aesthetic and reconstructive breast surgery. Implant rupture is a potential complication, the rate of which has increased over time. Therefore, implant removal or replacement is a common procedure, and needed for most breast implants at some point during the patient's lifetime. Surgical removal of ruptured implants is messy, cumbersome, time-consuming, and, overall, unpleasant. The authors have developed a custom-made device that effectively removes a silicone implant, whether ruptured or intact. To determine its efficiency, the authors conducted a prospective clinical trial of 25 women (45 breasts) undergoing removal or replacement of breast implants with the device between January of 2019 and January of 2022. Device safety and efficiency were assessed, and the need for the device was evaluated through a survey among 25 board-certified plastic surgeons. The mean implant age was 12.8 years, and mean volume was 370 g. The mean time to extract the implant with the device was 10.7 seconds. Twenty-two implants (49%) were ruptured. There were no minor or major complications during the procedure or follow-up. The mean follow-up period was 6 months. Surgeons' intention to use this device in their own practices for removal of intact and ruptured implants was very high. This novel device may prove indispensable for explantation of both intact and ruptured silicone implants. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.

Autologous Fat Grafting With CO2 Tissue Preparation (Carbo-pneumodissection): A Safe Method for Expanding and Enhancing Recipient Site Capacity and Aesthetic Outcomes.

BACKGROUND: Autologous fat grafting (AFG) is commonly used as part of aesthetic and reconstruction procedures, but expanding and enhancing the recipient site capacity remains a major challenge. OBJECTIVES: The aim of this study was to describe and assess an innovative intraoperative carbon dioxide (CO2) pneumodissection (CPD) recipient site preconditioning procedure intended to improve recipient site capacity and AFG outcomes. METHODS: From June 2019 to August 2021, 53 patients after mastectomy or lumpectomy (76 breasts) underwent 96 AFG procedures as a separate stage immediately following tissue preconditioning with CPD. RESULTS: There were no systemic or major local complications. The mean number of AFG procedures required to complete the reconstruction was 1.3 per breast. The vast majority of patients achieved a final satisfactory aesthetic outcome with either 1 or 2 procedures (77.6% and 18.4%, respectively). The volume of fat graft delivered into the recipient site per session following CPD was higher than previous literature reports for all study groups. Furthermore, the CPD procedure was associated with a reduced need for subsequent AFG to complete the reconstruction. The positive effect of CPD, in terms of AFG volume delivered, was even more prominent among scarred irradiated breasts. Despite the large fat graft volumes delivered in our study, only 5.3% of breasts experienced fat necrosis following the procedure. CONCLUSIONS: CPD constitutes a safe, innovative, intraoperative method to expand and enhance recipient site capacity and fat grafting outcome. CPD allows cavernous expansion alongside preservation of the microcirculation. CPD works for both healthy and compromised tissues, in either reconstructive or aesthetic procedures.

What 736 Plastic Surgeons Think about Explantation and Capsulectomy: A Global Opinion Poll.

BACKGROUND: Breast implant illness, although not classified as a disease entity, has recently gained significant attention globally. The purpose of this study was to assess the status of explantation practices, discuss plastic surgeon's attitude toward requests for explantation and capsulectomy, and evaluate surgical management when accepting these challenges. METHODS: Twenty closed-ended multiple choice questions were formulated to an opinion poll. The anonymous opinion poll was distributed to members of American Society for Aesthetic Plastic Surgery and presidents of plastic surgery societies on all continents. RESULTS: A total of 736 plastic surgeons responded to the opinion poll. Although geographic variation was noted, a majority of 69.8 percent stated that explantation surgery had increased in their practice compared to the previous year. Requests for explantation without capsulectomy met with high acceptance rates among surgeons, regardless of whether patients were asymptomatic or not. Patients who also requested capsulectomy received less enthusiastic replies depending on the type of practice, years in practice, implant position, and type of capsulectomy (en bloc, total, or partial). When fat grafting was indicated, 68.7 percent stated that simultaneous lipofilling is limited when capsulectomy is performed, yet 44.5 percent stated that they would remove thin normal capsules in a symptomatic patient even when simultaneous fat grafting is requested by the patient. CONCLUSION: The opinion poll supports the hypothesis that demand for explantation and capsulectomy increased globally among symptomatic and asymptomatic patients; that attitudes toward simultaneous capsulectomy are divided; and that management may differ according to geographic location, experience, and type of practice.

Treatment of scars with autologous fat grafting and 1540 nm non-ablative erbium laser.

Scars may be devastating for patients. Fat grafting and non-ablative lasers are available options for improvement. The former reshapes and improves scar quality by adding volume and regenerative adipose-derived stem cells, whereas the latter facilitates synthesis and deposition of new dermal collagen. The combination may be synergic, leading to better cosmetic outcome.This was a prospective study of 16 consecutive patients treated with autologous fat grafting and non-ablative 1540-nm erbium laser for facial scars between January 2015 and December 2015. Treatment protocol included fat injection followed by five treatments with 1540-nm erbium laser (ICONTM Cynosure; Westford, MA, USA) a month later. We evaluated patients before, after treatments, and 6 months after the final treatment.Sixteen patients participated in our study. Mean patient age was 42 years (range 16-59 years). Scars were either traumatic (73%) or acne induced (27%). Traumatic scars were mainly new scars, with the majority of patients were treated within 30 days of injury. There were no reported complications. Scars improved in both texture and appearance and patient satisfaction was high in all cases.Treatment of scars with autologous fat grafting and fractional non-ablative 1540-nm erbium laser is safe and efficient and results in improved scar appearance and texture.

Hybrid Prepectoral Direct-to-Implant and Autologous Fat Graft Simultaneously in Immediate Breast Reconstruction: A Single Surgeon's Experience with 25 Breasts in 15 Consecutive Cases.

BACKGROUND: The direct-to-implant method depends on the quality of the mastectomy flaps and can be used only when the flaps are adequately perfused. Even though the method was designed to be a definitive reconstruction procedure, it has been associated with an increased likelihood that additional operative revision will be required in order to achieve the expected final cosmetic outcome. The authors describe a hybrid prepectoral direct-to-implant method that combines autologous fat grafting in the superior medial pole with immediate reconstruction. METHODS: In this prospective study, 15 patients (25 reconstructed breasts) underwent simultaneous hybrid prepectoral direct-to-implant reconstruction together with autologous fat grafting performed by a single senior plastic surgeon (Y.G). RESULTS: The mean quantity of autologous fat grafted in the superior medial aspect of the breast was 59.4 ± 12.8 cc. The mean total volume of the hybrid reconstructed breast, including implant and autologous fat graft, was 497.2 ± 89.1 cc. Satisfying final outcomes were achieved in all cases. There were no major complications, although minor complications were observed. CONCLUSIONS: The authors' hybrid approach allows the surgeon to achieve a more satisfying outcome with regard to the cleavage area. It results in a better natural appearance, an improved contour, and reduced upper pole rippling and deflation, with a lower likelihood that an additional operative revision will be required to achieve the desired final aesthetic outcome. The authors believe that their hybrid approach should be implemented as an integral part of the direct-to-implant prepectoral reconstruction procedure. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.

Meshed Acellular Dermal Matrix in Immediate Prepectoral Implant-based Breast Reconstruction.

Prepectoral implant placement has many potential advantages in immediate breast reconstruction. Acellular dermal matrices (ADMs) are commonly used in these surgeries. ADM meshing may enhance integration, decrease seroma and infection rates, and reduce surgical costs. METHODS: This was a retrospective, single-center study of 49 women (71 breasts) undergoing immediate, prepectoral, implant-based breast reconstruction with 2:1 meshed, bovine-derived ADM (SurgiMend). Outcomes were compared against those of 77 patients (105 breasts) undergoing a similar procedure but with partial subpectoral implant placement. RESULTS: In the prepectoral group, the mean age was 49.1 years and mean body mass index was 24.7 kg/m2. There were no significant differences in baseline characteristics versus the partial subpectoral control group. Mean follow-up was 18.6 months (prepectoral) and 21.3 months (partial subpectoral). Mean time to drain removal was reduced in the prepectoral group (6.5 versus 8.5 days; P < 0.001). Rates of minor and major complications with prepectoral implant placement were 15.5% and 11.3%, respectively - similar to partial subpectoral placement (15.2% and 14.3%) (overall P = 0.690). Capsular contracture and explantation were associated with radiation therapy, and rates were similar between groups. CONCLUSIONS: Prepectoral implant placement with meshed ADM is a safe and reproducible alternative to partial muscle coverage with meshed ADM. Recovery may be easier and animation deformity avoided. It could therefore become the standard of care for implant-based breast reconstruction.

[BREAST RECONSTRUCTION WITH THE BRAVA DEVICE AND AUTOLOGOUS FAT].

AIMS: To report our experience and results in BRAVA breast pretreatment for full breast reconstruction by autologous fat grafting. BACKGROUND: BRAVA (bra like vacuum-based external tissue expander) is a method developed to expand the skin envelope, thus creating more space for the fat graft for breast reconstruction. METHODS: Since 2015 we began to perform a full breast reconstruction by BRAVA and autologous fat grafting. This is a multiprocedure breast reconstruction that includes pretreatment by using the BRAVA device for 180 hours before each surgery. We will focus on the number of procedures and time duration that was needed to complete the breast reconstruction the aesthetic results and the complication rates. RESULTS: Between the years 2015-2019 we preformed 13 late full breast reconstructions using the BRAVA. Six women were post-radiotherapy and they completed their breast reconstruction after 5.7±1.3 rounds during 20.3± 5.3 months. Non-irradiated patients completed their breast reconstruction after 2.7±0.5 rounds during 9.4±2.6 months. We grafted an average volume of 218±16.7 ml of fat per surgery. This was in comparison to an average of 100ml fat volume grafted in surgery without pre-expansion according to the literature. We had no complications and the aesthetic results were satisficing. CONCLUSIONS: The addition of BRAVA expansion procedure before autologous fat grafting leads to a larger volume of fat that can be injected in every operation and reduction of procedures. The procedure is safe and with good aesthetic results.

Comparative Study of Meshed and Nonmeshed Acellular Dermal Matrix in Immediate Breast Reconstruction.

BACKGROUND: Acellular dermal matrices are commonly used to support implant-based breast reconstruction. Meshing may enhance integration, reduce drain time and seroma, and decrease surgical costs. METHODS: This was a retrospective, single-center analysis of 83 adult women (115 breasts) undergoing one-stage (84.3 percent) or two-stage (15.7 percent) immediate breast reconstruction with bovine-derived acellular dermal matrix (SurgiMend) meshed at a 2:1 ratio. Outcomes were compared with previously published data from a control group of 111 patients (147 breasts) undergoing the same procedure with nonmeshed (fenestrated) acellular dermal matrix. RESULTS: The mean age of patients receiving meshed acellular dermal matrix was 48.3 years and the mean body mass index was 23.6 kg/m. There were no significant differences in baseline characteristics versus controls, other than chemotherapy history (received by fewer patients in the meshed acellular dermal matrix group). Mean follow-up was 23.6 months. Overall rates of minor and major complications in the meshed acellular dermal matrix group were 16.5 percent and 13.0 percent, respectively-similar to controls (25.2 percent and 12.9 percent). However, with meshed acellular dermal matrix, there were significantly fewer major seromas (0 percent versus 8.2 percent; OR, ∞; 95 percent CI, 1.927 to ∞), fewer total hematomas (0 percent versus 4.8 percent; OR, ∞; 95 percent CI, 1.022 to ∞), and fewer total infections (10.4 percent versus 23.8 percent; OR, 2.682; 95 percent CI, 1.259 to 5.802) compared with controls. Time to drain removal was reduced. Rates of capsular contracture (5.2 percent versus 2.7 percent) and explantation (5.2 percent versus 2.7 percent) were similar in the meshed acellular dermal matrix and control groups. CONCLUSION: Acellular dermal matrix meshing reduces rates of postoperative seroma, hematoma, and infection and decreases drain removal time compared with nonmeshed acellular dermal matrix. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, III.

Trans-Vertical Mastectomy With Immediate Implant-Based Reconstruction: A Retrospective, Observational Study.

BACKGROUND: In women with large and ptotic breasts who require a mastectomy and immediate, implant-based reconstruction, long flaps pose a high risk for flap ischemia and necrosis. A new trans-vertical incision for skin-reducing mastectomy is described, which reduces the skin envelope and lifts the breast. OBJECTIVES: The authors sought to describe the new mastectomy access incision and assess its efficacy and safety when followed by immediate implant-based reconstruction. METHODS: This retrospective analysis included 70 consecutive patients (101 breasts) with large and ptotic breasts who underwent a unilateral (n = 39; 55.7%) or bilateral (n = 31; 44.3%), skin-reducing mastectomy utilizing the trans-vertical approach for either breast cancer or risk reduction. All received immediate one- (n = 86; 85.5%) or two-stage (n = 15; 14.5%), implant-based reconstruction utilizing acellular dermal matrix. RESULTS: Mean age was 50.1 years and mean body mass index was 25.6 kg/m2. After a median follow-up of 4.9 years, the number of breasts with minor and major complications was 21 (20.8%) and 26 (25.7%), respectively. The most common major complications were skin-flap necrosis (n = 12; 11.9%) and infection (n = 8; 7.9%). All occurred within 3 months postsurgically. There were 7 cases of capsular contracture (6.9%) and 5 reconstruction failures (5.0%). Higher body mass index (P < 0.01) and breast weight (P < 0.05) were associated with increased complication rates. According to BREAST-Q, 55/64 patients (85.9%) were somewhat or very satisfied with the aesthetic outcome. CONCLUSIONS: The trans-vertical approach is an effective, reproducible, and safe alternative to conventional skin-reducing mastectomy, with favorable aesthetic outcomes, in patients with large and ptotic breasts.

Post-burn breast reconstruction using an artificial dermis-a long-term follow-up.

BACKGROUND: Full thickness burns of the chest in childhood are a devastating problem that requires challenging reconstructive options. Integra is a bilaminate artificial dermis composed of shark chondroitin 6-sulfate and bovine collagen. The dermal matrix serves as a scaffold for fibroblasts and endothelial cells. Vascularization of the matrix begins after 2-3 weeks, and eventually, the matrix incorporates with the tissue to create a new dermis. The main advantage of the Integra is that the neodermis is of the same quality as a native dermis. CASE PRESENTATION: In this case report, we present post-burn breast reconstruction of a 12-year-old girl using Integra, with a long follow-up of 7 years. To the best of our knowledge, there is no published follow-up of breast development after reconstruction with Integra from its beginning point at the age of puberty until after the growing process has terminated. CONCLUSIONS: Integra is a reliable reconstructive tool for burned breast. If done before puberty, it can help in getting normal developing tissue with satisfying esthetic results of size, shape and symmetry.

Analysis of 109 Consecutive Explanted Breast Implants: Correlation Between Suspected Implant Rupture and Surgical Findings.

INTRODUCTION: The use of breast implants is on the rise due to increases in breast reconstructive and aesthetic surgery. Implant rupture is a possible complication. Among assessment modalities for implant rupture detection, MRI is considered the gold standard. METHODS: We conducted a prospective analysis of 57 women after breast augmentation or postmastectomy reconstruction (109 implants), admitted to our department between 2010 and 2015 due to suspected implant rupture. We correlated surgical findings with symptoms, physical examination, imaging, and device specifications. RESULTS: Seventy-four explanted implants were preoperatively suspected as ruptured. Over a third were intact and unjustifiably explanted. MRI evaluation was the most accurate modality. Interestingly, 61 % of ruptured implants were left-sided. Patient's age, comorbidities, smoking, medications, presenting symptoms, implant duration, and volume did not correlate with implant rupture. CONCLUSIONS: Our study confirmed preexisting data regarding the importance of imaging diagnosis, with MRI being the most accurate modality in both diagnosing and ruling out implant rupture. Interestingly, our study showed that MRI was accurate in detecting all intact implants, unlike lower detection rates reported in previous studies, thus preventing unnecessary explantation. Another unique finding was that the left-sided implants were significantly prone for rupture. As iatrogenic damage is the most common cause of implant rupture, with most surgeons being right-handed, awareness during surgery must be augmented, with further investigation required for potential causes of this unexpected difference. Our study emphasizes the importance of understanding the causes of rupture and the need for evidence-based indications regarding imaging and replacement of implants. LEVEL OF EVIDENCE III: 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 .