Breast reconstruction patterns from a Swedish nation-wide survey.

OBJECTIVES: The overall aim of the Swedish Breast Reconstruction Outcome Study was to investigate national long-term outcomes after mastectomy with or without breast reconstruction. The current report evaluates breast reconstruction (BR) patterns in Sweden over time. MATERIALS AND METHODS: This is a cross-sectional, registry-based study where all women operated with mastectomy 2000, 2005, 2010 were identified (N = 5853). Geographical differences in type of BR were investigated using heatmaps. Distribution of continuous variables were compared using the Mann-Whitney U test, categorical variables were compared using the chi-square test. RESULTS: Mean age at survey was 69 years (SD=±11.4) and response rate was 50%, responders were on average six years younger than the non-responders and had a more favourable tumor stage (both p < 0.01). Of the 2904 responders, 31% (895/2904) had received a BR: implant-based in 58% (516/895)autologous in 31% (281/895). BR was immediate in 20% (176/895) and delayed in 80% (719/895) women. Women with BR were on average one year older, more often had a normal BMI, reported to be married or had a partner, had a higher educational level and a higher annual income when compared to those without BR (all p < 0.001). The independent factors of not receiving BR were older age and given radiotherapy. CONCLUSIONS: To our knowledge, this is the first national long-term follow-up study on women undergoing mastectomy with and without BR. Around 30% of the survey responders have had a BR with a significant geographical variation highlighting the importance of information, availability and standardisation of indications for BR.

A Systematic Review of the National Breast Implant Registry for Application in Korea: Can We Predict "Unpredictable" Complications?

Background and Objectives: Since silicone breast implants were introduced to the market several decades ago, the safety of breast implants has remained controversial. Recently, several studies have explored breast implant-associated anaplastic large-cell lymphoma (BIA-ALCL) and breast implant illness (BII). Several countries have developed national breast implant registries to improve the safety and quality of breast implant surgery. We performed a systematic review of the current status of national breast implant registries and propose a pilot form of an appropriate breast implant registry model for Korea. Materials and Methods: The systematic review was conducted in accordance with the "preferred reporting items for systematic reviews and meta-analyses (PRISMA) pro forma". PubMed and Google Scholar databases were searched to identify all articles containing information on national breast implant registries. We limited the search to articles written in the English language from 2010 to 2020. Articles were reviewed by two independent authors. Results: A total of 63 articles related to national breast implant registries, registry principles and national breast implant registry annual reports were identified. After reviewing the literature, 25 national breast implant registry-related articles were included in the full-text synthesis. Currently, four countries, The Netherlands, Australia, Sweden, and the UK, have breast implant registries with well-formed sources for big data. Overall, similarities in data points were detected for three categories: implant-related complications, operation details, and device information. However, there were differences for each registry in terms of governance, funding, and capture rate. Conclusion: After reviewing other countries' experiences, tentative datasets for the Korean Breast Implant Registry (K-BIR) were developed. The K-BIR can improve the quality of breast implant surgery in Korea by providing datasets on overall processes and outcome measures with quality indicators and risk adjustment factors. This approach will register characteristics of patients and monitor breast implants, complications, and surgical procedures to improve the outcomes of breast implant surgery in Korea. In addition, it can be used as a track-and-trace system with automated notifications to patients in the event of a product recall or other safety concerns related to a specific type of implant.

Advances and current concepts in reconstructive surgery for breast cancer.

In this article, we report on recent advancements in reconstructive care of the breast cancer patient. New developments in sensate breast reconstruction to help address the problem of numbness after mastectomy have emerged and show promise. Methods to restore lymphatic physiologic flow after axillary lymphadenectomy using supermicrosurgical techniques have begun to show benefit by reducing the short-term incidence of breast cancer related lymphedema (BRCL). Breast implant safety has received significant recent attention and we explore the emergence of BIA-ALCL (Breast Implant Associated Anaplastic Large Cell Lymphoma) and its implications for the breast cancer patient and their multidisciplinary care team.

How to improve patient safety and quality of care in breast implant surgery? First outcomes from the Dutch Breast Implant Registry (2015-2017).

BACKGROUND: Although the use of breast implants is generally considered to be safe, breast implants are associated with short- and long-term complications. To evaluate and improve the quality of breast implant surgery, and increase our knowledge of implant performance, the national Dutch Breast Implant Registry (DBIR) was established in 2015. DBIR is one of the first up-and-running breast implant registries worldwide and follows an opt-out structure. OBJECTIVE: This article provides an overview of the first outcomes and experiences of the DBIR. METHODS: The national coverage of DBIR was studied using data from the Dutch Health and Youth Care Inspectorate. The incidence rate of breast implants was calculated for 2016 and 2017, and patient, device, and surgery characteristics were compared between cosmetic breast augmentations or reconstructive indications. Four infection control, measures were selected to demonstrate the variation in the Dutch clinical practice. RESULTS: In 2016, 95% of the hospitals and 78% of the private clinics participated in DBIR. Between 2015 and 2017, a total of 15,049 patients and 30,541 breast implants were included. A minimum breast implant incidence rate of 1 per 1,691 women could be determined for 2017. The majority of devices were inserted for a cosmetic indication (85.2%). In general, patient, device, and surgery characteristics differed per indication group. Substantial variation was seen in the use of infection control measures (range 0-100%). CONCLUSION: Preliminary results obtained from DBIR show high national participation rates and support further developments toward the improvement of breast implant surgery and patient safety.

Growing Trends of Contralateral Prophylactic Mastectomy and Reconstruction in Young Breast Cancer.

BACKGROUND: The aim of this study was to evaluate the trends of surgical treatments among young patients in T1N0-1M0 stage based on the Surveillance, Epidemiology, and End Results database. MATERIALS AND METHODS: Patients aged less than 40 y diagnosed between 1998 and 2015 were enrolled, with tumors in T1N0-1M0 stage and not located in the central area. Differences in clinical-pathological characteristics were evaluated using chi-square tests. Multivariate logistic regression was used to measure the various factors associated with contralateral prophylactic mastectomy (CPM). Independent prognostic factors were evaluated by Cox model. RESULTS: The total rate of breast-conserving surgery (BCS) was 51.6%, which declined from 64.5% in 1998 to 39.6% in 2015. The total rate of CPM was 22.7%, which increased from 3.7% in 1998 to 38.7% in 2014 despite a decline to 32.7% in 2015. Meanwhile, the rate of reconstruction increased in line with that of CPM, from 9.4% in 1998 to 35.0% in 2015. There was a trend of increasing use of implant-based reconstruction. Significant higher odds of CPM were found in recent year of diagnosis between 2010 and 2015 and in implant-based reconstruction. Patients undergoing CPM had similar survival outcomes compared with those undergoing BCS and unilateral mastectomy, whereas those undergoing BCS had better survival outcomes compared with those undergoing unilateral mastectomy. CONCLUSIONS: A trend of growing preference for CPM and reconstruction was observed among young patients in early stage in recent years without survival benefits. Efforts should be made to promote efficient communication and evidence-based decision-making.

Current Trends in Breast Augmentation: Analysis of 2011-2015 Maintenance of Certification (MOC) Tracer Data.

BACKGROUND: Breast augmentation is the most common aesthetic surgery performed in the United States. Despite its popularity, there is no consensus on many aspects of the procedure. OBJECTIVES: The authors assessed current trends and changes in breast augmentation from January 1, 2011 to December 31, 2015. METHODS: A retrospective cross-sectional study of 11,756 women who underwent breast augmentation based on the American Board of Plastic Surgery (ABPS) Maintenance of Certification Tracer Database was performed. RESULTS: There were clearly dominant trends in how ABPS-certified plastic surgeons performed breast augmentations. Most surgeries were performed in freestanding outpatient (47.3%) or office operating room (33.7%). The inframammary fold incision was most popular (75.1%), followed by periareolar (17.8%) and transaxillary approaches (4.1%). Implants were more commonly placed in a submuscular pocket (30.6%) compared with dual plane (26.7%) or subglandular (6.7%). Silicone implants (66.8%) were favored over saline (25.1%), with a statistically significant increase in silicone prostheses from 2011 to 2015. Data were "not applicable" or "other" in the remainder of cases. Administration of both preoperative antibiotics (3.8% in 2011, 98.7% in 2015, P < 0.05) and deep venous thromboembolism (DVT) prophylaxis (3.8% in 2011, 90.6% in 2015, P < 0.05) dramatically increased during the study period. Overall adverse events (7.4%) and reoperation rates (2.2%) were low. CONCLUSIONS: Changes in standard of care for breast augmentation are reflected by the evolving practice patterns of plastic surgeons. This is best evidenced by the dramatic increase in use of antibiotic and DVT prophylaxis from 2011 to 2015.

Evolving Trends in Textured Implant Use for Cosmetic Augmentation in the United States.

BACKGROUND: Breast implants have evolved for decades. In 2011, the U.S. Food and Drug Administration identified an association between textured breast implants and breast implant-associated anaplastic large cell lymphoma (BIA-ALCL). The purpose of this study was to identify the trends of textured implant use since that time. METHODS: Maintenance of Certification tracer data were queried between 2011 and 2015 for cosmetic breast augmentation cases submitted by American Board of Plastic Surgery diplomates. A nested random effects logistic regression analysis was used to identify associations between variables. RESULTS: Eleven thousand seven hundred sixteen breast augmentations were performed by 880 unique surgeons. The overall proportion of cases using textured implants increased steadily from 2.3 percent in 2011 to 13.0 percent in 2015 (p < 0.001). The proportion of surgeons whose cases included both textured and smooth implants increased (from 6.2 percent to 24.3 percent), as did those using only textured implants (from 0.4 percent to 4.4 percent) (p < 0.001). Significance remained after controlling for form-stable implants, suggesting an alternative motivation for use of textured implants. Subglandular cases (20.5 percent) were more likely to use a textured implant than submuscular (8.4 percent) or dual-plane (7.8 percent) (p < 0.001) cases. CONCLUSIONS: Maintenance of Certification tracer data represent a random sampling of American Board of Plastic Surgery-certified plastic surgeons spanning the gamut of practice settings. Despite ongoing education regarding the association of BIA-ALCL with textured implants, American Board of Plastic Surgery diplomates have trended toward increased use of textured implants for cosmetic breast augmentation since 2011. This finding does not appear to be driven by the introduction of anatomical implants during the study period.

Current Trends in Breast Augmentation: An International Analysis.

BACKGROUND: Breast augmentation surgery remains the most frequently performed aesthetic surgical procedure worldwide. However, many variations exist regarding preoperative planning, surgical management, and postoperative care. OBJECTIVES: The goal was to evaluate current trends and practices in breast augmentation, with a focus on international variability. METHODS: A questionnaire was sent to over 5000 active breast surgeons in 44 countries worldwide. The survey inquired about current controversies, new technologies, common practices, secondary procedures, and surgeon demographics. The findings and variations were evaluated and correlated to evidence-based literature. RESULTS: There were a total 628 respondents equaling a response rate of approximately 18%. While certain approaches and common practices prevail also on an international basis, there exist several geographic controversies. For example, while almost fifty percent of surgeons in the United States and Latin America never use anatomically shaped implants, in Europe and Oceania most surgeons use them. Similarly, in Latin America, Europe, Asia, and Oceania, over 80% of surgeons use silicone implants only, whereas in the United States only 20% use them - meanwhile US surgeons use the largest implants (78% > 300 cc). Internationally dominant practice preferences include preoperative sizing with silicone implants, as well as the use of inframammary incisions and partial submuscular pockets. CONCLUSIONS: Significant differences exist when comparing most common surgical breast augmentation approaches on an international basis. While certain techniques seem to be universal standards, there still remain several controversies. Further standardizing this most common aesthetic surgical procedure according to evidence-based guidelines will help to improve outcomes.

Current Trends in Postmastectomy Breast Reconstruction.

Postmastectomy immediate breast reconstruction in the U.S. continues to experience an upward trend owing to heightened awareness, innovations in reconstructive technique, growing evidence of improved patient-reported outcomes, and shifts in mastectomy patterns. Women with unilateral breast cancer are increasingly electing to undergo contralateral prophylactic mastectomy, instead of unilateral mastectomy or opting for breast conservation. The ascent in prophylactic surgeries correlates temporally to a shift toward prosthetic methods of reconstruction as the most common technique. Factors associated with the choice for implants include younger age, quicker recovery time, along with documented safety and enhanced aesthetic outcomes with newer generations of devices. Despite advances in autologous transfer, its growth is constrained by the greater technical expertise required to complete microsurgical transfer and potential barriers such as poor relative reimbursement. The increased use of radiation as an adjuvant treatment for management of breast cancer has created additional challenges for plastic surgeons who need to consider the optimal timing and method of breast reconstruction to perform in these patients.

Trends in Post-Mastectomy Reconstruction in an Asian Population: A 12-Year Institutional Review.

Post-mastectomy breast reconstruction is an integral component of breast cancer treatment. It is often perceived that women in Asian countries have a lower rate of post-mastectomy reconstruction than Western populations. This study describes trends in timing and types of breast reconstruction performed in the largest healthcare provider in Singapore, over a period of 12 years. It also reports on the oncological outcomes and surgical safety. A retrospective review of all patients who underwent post-mastectomy reconstruction from January 2001 to December 2012 at the National Cancer Centre Singapore and Singapore General Hospital was performed. Six hundred and twenty post-mastectomy reconstructions were performed in 579 patients. The proportion of reconstructions increased from 4% in 2001 to 18% in 2012. Younger patients (<50 years old) and those with early stage cancer were more likely to undergo reconstruction. Immediate breast reconstruction was favored by more than 90% of patients. Postoperatively, 9% developed acute surgical complications that were treated surgically; 6% had additional surgery for late complications. Only 4% had delay of adjuvant chemotherapy. At median follow-up of 63 months (range 3-166), loco-regional recurrence was 4%, and distant metastases 8%. Post-mastectomy reconstruction for breast cancer is increasingly performed in our institution. Both younger age and lower stage disease were associated with choice for reconstruction in our study. Low rates of delay to adjuvant therapy were noted, and it may safely be offered to suitable women undergoing mastectomy.

Immediate Reconstruction of the Radiated Breast: Recent Trends Contrary to Traditional Standards.

BACKGROUND: Immediate, implant-only breast reconstruction is traditionally discouraged in patients who receive radiation. It is not clear whether this widely recognized mantra of breast reconstruction is observed in practice. The purpose of this study was to evaluate immediate reconstruction trends and practices in patients who have undergone mastectomy and radiation therapy. METHODS: Female patients with unilateral breast cancer who required radiation in addition to mastectomy were extracted from the Surveillance, Epidemiology, and End Results (SEER) database from 2000 through 2010. Patients who underwent immediate reconstruction were identified and analyzed. Univariate and logistic regression analyses were performed to study the relationship between reconstructive method and patient demographic and oncologic characteristics. RESULTS: A total of 5,481 female patients who underwent radiation and breast reconstruction were included for analysis. Postmastectomy radiation therapy was performed in 98.3 % of the patients. The immediate breast reconstruction rate among patients requiring radiation increased from 13.6 to 25.1 %. The percentage of reconstructed patients who had implant-only reconstruction increased from 27 to 52 % (p < 0.001) with a decrease in tissue-only reconstruction from 56 to 32 % (p < 0.001). In regression analysis, the odds of implant reconstruction over autologous reconstruction increased each year by an odds ratio of 1.13 (95 % CI 1.10-1.15). CONCLUSIONS: The frequency of immediate reconstruction continues to increase in the setting of postmastectomy radiation therapy, with immediate implant-based reconstruction representing the most commonly utilized method, contrary to traditional recommendations. These findings likely reflect changing attitudes towards implant reconstruction in the setting of planned postmastectomy radiation.

Implante mamário redondo versus anatômico: algoritmo para escolha da forma adequada / Round versus anatomical breast implants: algorithm for choosing the appropriate form

INTRODUÇÃO: Vários cirurgiões têm suas próprias fórmulas ou protocolos para selecionar os volumes e formato de implantes mamários. Para determinar a escolha do formato, medimos as distâncias entre a borda superior da mama e a papila (A) e entre a papila e sulco submamário (B). Baseados nestas medidas, propomos um algoritmo para selecionar próteses redondas ou anatômicas. MÉTODOS: As avaliações pré-operatórias foram realizadas com a paciente em posição ortostática considerando-se as medidas: 1) da fúrcula esternal à papila, para avaliar a necessidade de retirada de pele supra-areolar; 2) da base da mama, para avaliar o volume do implante; 3) das distâncias A e B, para avaliar a forma do implante. Este algoritmo foi aplicado a 59 pacientes submetidas à mamoplastia de aumento. RESULTADOS: Utilizamos implantes redondos em 27 pacientes; nove tinham distância a = b, e 18 B > A. Empregamos implantes anatômicos em 32 pacientes. Os volumes dos implantes redondos variaram entre 195 cc e 425 cc, enquanto os implantes anatômicos ficaram entre 185 cc e 315 cc. Com relação às medidas pós-operatórias das pacientes que utilizaram implantes redondos, 26 (96,3%) mantiveram a proporção desejada com B > A ou A = B. Entre as pacientes com implantes anatômicos, as medidas de 25 delas (78,1%) mostraram alteração das proporções, de A > B para A = B ou B > A. CONCLUSÕES: Quando a distância A é igual ou menor que a distância B, recomendamos implantes redondos. Quando B < A, recomendamos implantes anatômicos.

INTRODUCTION: Several surgeons have their own formulas or protocols to select the volume and shape of breast implants. To determine the shape, we measured the distances between the upper edge of the breast and the papilla (A), and between the papilla and the inframammary fold (B). Based on these measurements, we propose an algorithm to select round or anatomical implants. METHODS: Preoperative assessment was performed with the patients in the orthostatic position. The following distances were considered: 1) from the sternal notch to the papilla, to assess the need for supra-areolar skin excision; 2) breast base, to assess the volume of the implant; 3) distances A and B, to evaluate the shape of the implant. This algorithm was applied to 59 patients undergoing augmentation mammoplasty. RESULTS: We used round implants in 27 patients; nine had a distance A = B, and 18 had B > A. We utilized anatomical implants in 32 patients. The volume of round implants ranged from 195 to 425 cc, whereas that of anatomical implants ranged from 185 and 315 cc. Regarding postoperative measurements of the patients who used round implants, 26 (96.3%) maintained the desired ratio with B > A or A = B. Among the patients with anatomical implants, 25 (78.1 %) showed proportional changes from A > B to A = B or B > A. CONCLUSIONS: When the distance A is equal to or smaller than the distance B, we recommend round implants. When B < A, we recommend anatomical implants.

The Austrian breast implant register: recent trends in implant-based breast surgery.

INTRODUCTION: Due to the fact that the number of breast implant surgeries for cosmetic and medical purposes is rising yearly, a discussion about the quality of service for both patients and physicians is more important than ever. To this end, we reviewed the Austrian Breast Implant Register with one specific question in mind: What are the trends? MATERIALS AND METHODS: In the statistical analysis of the Austrian Breast Implant Register, we were able to identify 13,112 registered breast implants between 2004 and 2012. The whole dataset was then divided into medical and cosmetic groups. We focused on device size, surface characteristics, filling material, device placement and incision site. All factors were considered for all examined years. RESULTS: In summary, the most used device had a textured surface (97 %) and silicone gel as the filling material (93 %). The mean size of implants for the cosmetic group was 240 cc, placement was submuscular (58 %) and the incision site was inframammary (67 %). In the medical group, the mean size was 250 cc. Yearly registrations had their peak in 2008 (1,898 registered devices); from this year on, registrations decreased annually. A slight trend away from subglandular placement in the cosmetic group was noted. Also, the usage of implants with polyurethane surface characteristics has increased since 2008. The smooth surface implants had a peak usage in 2006 and their usage decreased steadily from then on whereas the textured surface was steady over the years. DISCUSSION AND CONCLUSION: Keeping the problems related to the quality of breast implants in mind, we could recommend an obligatory national register. Organisations of surgeons and governments should develop and establish these registers. Furthermore, an all-encompassing international register should be established by the European Union and the American FDA (Food and Drug Administration); this might be useful in comparing the individual country registers and also would help in delivering "evidence based" medicine in cosmetic and medical procedures. LEVEL OF EVIDENCE V: 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.

MemoryShape: impact of clinical trials, global medical economics, and the future.

The global breast implant business was invented and configured by American plastic surgeons. In 2012, the first shaped silicone implants were approved in the United States by the Food and Drug Administration. It is the peculiar historical course of implant usage in America that has deprived US plastic surgeons of the opportunity to become experts in the use of this device. Most studies indicate significant safety benefits to using shaped devices, despite the technical challenges involved in their use. Upon approval, adoption of the devices has been slow in the United States, running the risk that American plastic surgery may lose the intellectual and clinical practice hegemony it has enjoyed for over 50 years in this area of the specialty. To continue to maintain leadership in the field of breast surgery, US surgeons should evaluate this new modality and either join the global trend or present data to contradict it.

Evolving practices in augmentation operative technique with Sientra HSC round implants.

As of 2012, breast augmentation surgery continues to be the most commonly performed aesthetic surgical procedure in the United States. Surgeons consider a multitude of factors when choosing the type and style of breast implant for a patient. With the continuous evolution of breast implant designs, there are a variety of breast implant options for plastic surgeons to choose from; however, round implants remain the implant of choice for breast augmentation. This article discusses preoperative planning, implant selection, surgical techniques, and postoperative management using Sientra's Silimed brand smooth and textured round implants.

Cost and outcome analysis of breast reconstruction paradigm shift.

Increased bilateral mastectomy for breast cancer treatment has generated an increased demand for bilateral breast reconstruction. This study examines changing patterns of reconstruction over the last decade to accommodate increased case volume and decreased morbidity associated with reconstruction. A single institution series of 3171 consecutive breast reconstruction cases of more than 10 years was divided into 2 periods, that is, 1999 to 2004 and 2005 to 2010. Bilateral breast reconstruction case volume increased 260% from 1999 to 2004 (n = 237) to 2005 to 2010 (n = 634). Mean patient age at diagnosis decreased by 7 years (P < 0.001). In 2005 to 2010, autologous reconstruction decreased from 60% to 26%, implant-based reconstruction increased from 40% to 74%. There was a noted increase in single-stage implant reconstruction and selective application of perforator flaps for bilateral autologous reconstruction (P < 0.001). Two-staged tissue expander reconstruction accounted for the greatest share of total cost (45%) in the later period. A younger patient demographic and increased case volume were accommodated through increased single-staged and prosthesis-based procedures.