Mamoplastia de aumento via abdominal: revisão de 10 anos de experiência no Hospital do Servidor Público Municipal de São Paulo / Abdominal breast augmentation: review of 10 years of experience at the Hospital do Servidor Público Municipal de São Paulo

Introdução: Com o passar dos anos a técnica de mamoplastia de aumento foi sendo aprimorada. Novos instrumentos para auxílio cirúrgico foram adicionados, incluindo o uso de afastadores luminosos para produção de túneis subcutâneos e descolamento subglandular ou retromuscular. Por essa técnica, em um só estágio, é possível obter o formato, volume e simetria adequada das mamas, assim como correção da flacidez abdominal, com cicatriz localizada apenas no abdome. Objetivo: Demonstrar a experiência do Serviço de Cirurgia Plástica do Hospital do Servidor Público Municipal de São Paulo com a técnica cirúrgica de inclusão dos implantes mamários através da dermolipectomia abdominal. Método: Foram selecionados prontuários de pacientes operadas entre março de 2011 e novembro de 2021 que foram submetidas à inclusão dos implantes mamários através da abdominoplastia. Resultados: A amostra deste estudo foi constituída por 24 pacientes do sexo feminino, com média de idade de 37,6 ± 8,1 anos, e IMC médio de 23,5 ± 2,0 kg/m2, todas submetidas à abdominoplastia concomitantemente ao aumento das mamas. Em média, foram colocadas próteses no volume de 293,5 ± 32,2 ml e o peso dos retalhos uma média de 734,2 ± 320,0 g. A duração média das cirurgias foi de 205,9 ± 34 minutos. Avaliando as complicações relacionadas aos procedimentos, deiscência associada à cicatriz hipertrófica foi observada em 3 pacientes (12,5%), contratura capsular em 3 (12,5%), formação de queloide em 2 (8%), ruptura de prótese em 1 (4%), granuloma na cicatriz em 1 (4%), seroma em 1 (4%), e rippling associado à ptose de grau I em 1 (4%). Conclusão: Este levantamento pontual demonstrou que a inclusão dos implantes mamários através da dermolipectomia abdominal traz excelentes resultados, eliminando as cicatrizes mamárias e com baixa taxa de complicações. Palavras-chave: Cirurgia plástica. Implantes de mama. Mamoplastia. Abdominoplastia. Procedimentos de Cirurgia Plástica.

Effect of Immediate Implant-Based Breast Reconstruction After Mastectomy With and Without Acellular Dermal Matrix Among Women With Breast Cancer: A Randomized Clinical Trial.

Importance: The use of acellular dermal matrix (ADM) in implant-based breast reconstructions (IBBRs) is established practice. Existing evidence validating ADMs proposed advantages, including improved cosmetics and more single-stage IBBRs, is lacking. Objective: To evaluate whether IBBR with ADM results in fewer reoperations and increased health-related quality of life (HRQoL) compared with conventional IBBR without ADM. Design, Setting, and Participants: This was an open-label, multicenter, randomized clinical trial of women with primary breast cancer who planned for mastectomy and immediate IBBR, with a 2-year follow-up for all participants. Participants were enrolled at 5 breast cancer units in Sweden and the United Kingdom between 2014 and May 2017. Exclusion criteria included previous radiotherapy and neo-adjuvant chemotherapy. Data were analyzed until August 2017. Interventions: Participants were allocated to immediate IBBR with or without ADM. Main Outcomes and Measures: The primary trial end point was number of reoperations at 2 years. HRQoL, a secondary end point, was measured as patient-reported outcome measures using 3 instruments from the European Organization for Research and Treatment of Cancer Quality of life Questionnaire. Results: From start of enrollment on April 24, 2014, to close of trial on May 10, 2017, a total of 135 women were enrolled (mean [SD] age, 50.4 [9.5] years); 64 were assigned to have an IBBR procedure with ADM and 65 to the control group who had IBBR without ADM. There was no statistically significant difference between groups for the primary outcome. Of 129 patients analyzed at 2-year follow-up, 44 of 64 (69%) had at least 1 surgical event in the ADM group vs 43 of 65 (66%) in the control group. In the ADM group, 31 patients (48%) had at least 1 reoperation on the ipsilateral side vs 35 (54%) in the control group. The overall number of reoperations on the ipsilateral side were 42 and 43 respectively. Within the follow-up time of 24 months, 9 patients (14%) in the ADM group had the implant removed compared with 7 (11%) in the control group. We found no significant mean differences in postoperative patient-reported HRQoL domains, including perception of body image (mean difference, 3; 99% CI, -11 to 17; P = .57) and satisfaction with cosmetic outcome (mean difference, 8; 99% CI, -6 to 20; P = .11). Conclusions and Relevance: Immediate IBBR with ADM did not yield fewer reoperations compared with conventional IBBR without ADM, nor was IBBR with ADM superior in terms of HRQoL or patient-reported cosmetic outcomes. Patients treated for breast cancer contemplating ADM-supported IBBR should be informed about the lack of evidence validating ADM's suggested benefits. Trial Registration: ClinicalTrials.gov Identifier: NCT02061527.

Final opinion on the safety of breast implants in relation to anaplastic large cell lymphoma: Report of the scientific committee on health, emerging and environmental risks (SCHEER).

The Scientific Committee on Health, Environmental and Emerging Risks (SCHEER) was requested by the European Commission (EC) to provide a scientific opinion on the safety of breast implants in relation to anaplastic large cell lymphoma (ALCL). There are several types of textured breast implants; surface textures of breast implants are not all manufactured in the same way, and breast implants with diverse surface textures may also present different benefits. The magnitude of the risk per type of textured implant is difficult to establish due to the low incidence of the breast implants associated anaplastic large cell lymphoma (BIA-ALCL). Therefore, risk assessments per implant type are needed. Overall SCHEER considers that there is a moderate weight of evidence for a causal relationship between textured breast implants and BIA-ALCL, particularly in relation to implants with an intermediate to high surface roughness.The pathogenic mechanisms are not fully elucidated; current hypotheses include genetic drivers, chronic inflammation resulting either from bacterial contamination, shell shedding of particulates, or shell surface characteristics leading to friction, or by implant associated reactive compounds. Reporting of new BIA-ALCL cases by the national clinical registries is critically important to obtain a better estimate of the risk of BIA-ALCL for patients with a breast implant.

Breast Device Surgery in Australia: Early Results from the Australian Breast Device Registry.

BACKGROUND: The Australian Breast Device Registry (ABDR) is a clinical quality registry designed to monitor the performance of breast devices; and the quality and safety of breast device surgery. OBJECTIVE: To report on breast device surgery characteristics across Australia. METHODS: Participants were registered patients in the ABDR from 2012 to 2018. Results are described using percentages, mean and median. Revision rates were calculated using survival analysis methods. RESULTS: A total of 37,603 patients were registered and had undergone reconstruction (post-cancer 15.1%, risk-reducing mastectomy 3.4% and developmental deformity 2.4%) or cosmetic augmentation (74.7%) procedures. The majority of breast implant devices were silicone filled with textured surface (reconstruction 74.0% and augmentation 64.0%). Sub-pectoral plane was the most common for both reconstruction (60.1%) and augmentation (76.6%) procedures. For reconstruction surgery, the most common surgical incision was previous mastectomy scar (44.0%) and inframammary (31.8%), and for augmentation, it was inframammary (83.4%). Intraoperative/postoperative antibiotic usage for reconstruction was 85.8% and augmentation was 89.4%. Revision incidence due to complication at 12 months post-cancer reconstruction was 5.1%, risk-reducing reconstruction 5.7% and developmental deformity implants 4.5%. Revision incidence due to complication at 12 months after augmentation procedure was 1.1%. Patient-reported outcome measures (PROMs) indicate high levels of satisfaction at 1 year for augmentation and reconstruction procedures. CONCLUSION: We report on early data from the ABDR and reflect on the uptake of the registry by surgeons and patients. The registry also benefits from international collaborative approaches to addressing challenges and is committed to facilitate international post-market surveillance.

The Impact of the COVID-19 Pandemic on Breast Reconstruction Practices in the United States.

BACKGROUND/AIM: We employed a survey to the American Society of Plastic Surgeons (ASPS) to investigate the management of breast reconstruction across the US during the COVID-19 pandemic. PATIENTS AND METHODS: An electronic survey on breast reconstruction practice demographics, COVID-19-related restrictions on breast reconstruction, and pertinent dates of restrictions was employed. RESULTS: A total of 228 responses were obtained. Demographics were balanced for geography with most respondents located in either urban or suburban settings (91.2%). The majority proceeded with mastectomy/reconstruction as originally planned (39.0%), followed by hormonal/chemotherapy only (22.6%). The most common reconstructive option was tissue expander/implant-based reconstruction (47.7%). Most institutions implemented restrictions between March 11-20th (59%). Almost all respondents (91.8%) reported mandatory pre-operative SARS-Cov-2 testing once cases resumed. CONCLUSION: COVID-19 has forced the breast surgical team to adapt to new conditions to the detriment of women with breast cancer requiring reconstruction. Varying restrictions have limited access to breast reconstruction, carrying consequences yet to be determined.

Retrospective multicenter cohort analysis of 621 cases of BellaGel silicone breast implants with study of physicochemical properties and surface topography.

This study aimed to assess the effectiveness and safety of BellaGel implants after implantation in Asian women and inform surgeons of another option for use in breast augmentation and reconstruction. This study was conducted in eight hospitals from November 27, 2015 to April 30, 2018. All patients underwent augmentation mammoplasty or implant-based breast reconstruction with BellaGel implants. Complication rates were compared between groups, and the cumulative hazard function was compared using the Kaplan-Meier survival analysis. Implants were grouped by surface type, and the cumulative hazard functions of total complication cases were compared. The biomechanical properties of the BellaGel implant and other company representative implants were tested using a mechanical testing machine, and surface topography was analyzed using a 3D laser scanning confocal microscope. There was a significant difference in the incidence of complications between the reconstruction (17.1%) and augmentation (4.7%) groups, but no significant difference in the complication rates of each group. There was no difference in the reoperation or revision rates between the groups. The log rank test showed a statistically significant difference in cumulative hazard function between the groups. Among the three types of implants (smooth, textured, and microtextured), the microtextured type had the lowest complication rate. The BellaGel microtexture implant had the highest maximal tensile load and displacement value. The BellaGel and Silksurface implants had the highest stored energy, although there was no significant difference. BellaGel implants can serve as a criterion for the selection of safe and effective implants among currently available implants.

Pathology of breast lesions in female transgender / Patología de las lesiones mamarias en las mujeres transgénero

Female transgender (male to female) is an individual assigned male sex at birth born but who identifies itself and desires to live as female. To achieve and maintain these characteristics, sometimes, it is necessary to undergo hormone therapy and/or surgical treatment. Benign lesions have been described including: fibroadenoma, lobular hyperplasia, pseudoangiomatous stromal hyperplasia, myofibroblastoma, angiolipoma and benign prosthesic reactions. And malignant pathology such as: ductal carcinoma in situ, Paget's disease, infiltrating carcinoma of non-special type (ductal, NOS), secretory adenocarcinoma, malignant phyllodes tumor and breast implant associated anaplastic large cell lymphoma. The described cases of each of these entities are reviewed. In conclusion, hormonal action or prosthesis implantation in female transgender can lead to associated pathologies in the mammary gland that follow a similar pattern to that found in the male breast. Although breast cancer is less frequent than in cisgender women, gynecological control or screening is recommended by some associations

La mujer transgénero (hombre a mujer) es aquella persona nacida varón pero que se identifica y desea vivir como una mujer. Para lograr este objetivo muchas veces precisa de tratamiento hormonal o quirúrgico para alcanzar los atributos sexuales de una mujer. La patología mamaria que estos pacientes pueden presentar es superponible a la patología de la mama masculina, a la patología derivada del tratamiento hormonal y a la relacionada con los implantes mamarios sintéticos. Se han descrito lesiones benignas que incluyen: fibroadenoma, hiperplasia lobulillar, hiperplasia estromal seudoangiomatosa, miofibroblastoma, angiolipoma y reacciones benignas a la prótesis. Y patología maligna como: carcinoma ductal in situ, enfermedad de Paget, carcinoma infiltrante de tipo no especial (ductal, NOS), adenocarcinoma secretor, tumor filoides maligno y linfoma anaplásico de célula grande asociado a prótesis. Se revisan los casos descritos de cada una de estas entidades. En conclusión, la acción hormonal o la implantación de prótesis en las mujeres transgénero pueden llevar asociadas patologías en la glándula mamaria que siguen un patrón similar al de la patología encontrada en la mama del varón. Aunque el cáncer de mama es menos frecuente que en las mujeres cisgénicas, se recomienda un control ginecológico o mediante cribado igual al de estas

Preferencias de uso de implantes mamarios entre los miembros de la Asociación Española de Cirugía Estética Plástica: encuesta 2019 / Breast implants preferences among members of the Spanish Association of Aesthetic Plastic Surgery: 2019 survey

INTRODUCCIÓN Y OBJETIVO: Últimamente ha surgido gran controversia sobre diversos aspectos de los implantes mamarios. De hecho, la posible relación entre la texturación del implante y el linfoma anaplásico de células grandes llevó a la retirada voluntaria del mercado de los implantes con cubierta Biocell(R) de Allergan en julio de 2019. El propósito principal de este estudio fue evaluar las preferencias y prácticas habituales de los miembros de la Asociación Española de Cirugía Plástica Estética (AECEP) con respecto a la cirugía con implantes mamarios. Además, analizamos los cambios en la práctica clínica experimentados desde la encuesta publicada en 2016. MATERIAL Y MÉTODO: Llevamos a cabo una encuesta con 15 preguntas relativas a la selección y diferentes aspectos clínicos relacionados con el aumento mamario, en diciembre del año 2019 entre los miembros de la AECEP. Por otro lado, hacemos un estudio comparativo entre los datos actuales y los obtenidos en la encuesta publicada en el año 2017. RESULTADOS: Los 146 miembros de la AECEP recibieron una invitación a participar en la encuesta, de los cuales respondieron 74 (50.7%). De las respuestas obtenidas, 50 (67.6%) correspondieron a hombres. El 89.2% (n=66) tenían una experiencia profesional superior a 10 años y un 70.2% (n=52) tenían una edad comprendida entre los 46 y los 65 años. Respecto al tipo de implante, un 52.7% (n=39) mostró preferencia por los implantes microtexturizados redondos y un 47.3% (n=35) prefirió los microtexturizados anatómicos. En comparación con la encuesta del 2017, una proporción significativamente mayor de participantes prefirió los implantes microtexturizados redondos y microtexturizados anatómicos (p = 0.0025 y p = 0.0015 respectivamente). Por el contrario, una proporción significativamente menor prefirió el uso de implantes macrotexturizados redondos (p = 0.0018) y macrotexturizados anatómicos (p < 0.0001). El plano submuscular fue de elección para el 44.6% de los participantes (n=33). La contractura capsular grado III/IV fue la principal indicación de capsulectomia total para el 94.5% (n=70). La mayor parte fueron partidarios de una actitud vigilante en pacientes con implantes con cubierta Biocell(R) (n=68, 93.1%). El 85.1% (n=63) recomendó vigilancia con técnicas de imagen y sólo 19 participantes (25.7%) fueron partidarios de prohibir el uso de implantes macrotexturizados. CONCLUSIONES: Los resultados de esta encuesta muestran un cambio significativo en la práctica clínica habitual de los encuestados. Respecto a 2017 se ha producido un incremento significativo en el uso de implantes mamarios lisos/nanotexturizados y microtexturizados, mientras que se ha reducido, de forma significativa, el uso de implantes mamarios macrotexturizados

BACKGROUND AND OBJECTIVE: Over the last several years there has been great controversy about different aspects related to breast implants. In fact, the potential relationship between implant texture and anaplastic large cell lymphoma led to the voluntary recall of Biocell(R) coated implants (Allergan(R)) in July 2019. The main purpose of this study was to evaluate the preferences and daily practice of members of Spanish Association of Aesthetic Plastic Surgery (AECEP) regarding to breast implant surgery. Additionally, we assessed possible changes experienced in clinical practice since our survey published in 2017. METHODS: A 15 questions survey, regarding to the selection and different clinical aspects related to breast augmentation, was carried out between January and March 2019 among AECEP members. In addition, a comparative study between current data and those reported in 2017 survey was conducted. RESULTS: The 146 members of the AECEP received an invitation to participate in the survey, of whom 74 (50.7%) responded to it. Of the responses obtained, 67.6% (n=50) corresponded to men, 89.2% (n=66) had more than 10 years of professional experience and 70.2% (n=52) had an age between 46 and 65 years. Regarding the type of implant, 52.7% (n=39) showed a preference for round microtextured implants and 47.3% (n=35) preferred anatomical microtextured implants. Compared to the 2017 survey, a significantly greater proportion of participants preferred round microtextured and anatomical microtextured implants (p = 0.0025 and p = 0.0015, respectively). In contrast, a significantly lower proportion preferred the use of round macrotextured implants (p = 0.0018) and anatomical macrotextured ones (p <0.0001). The submuscular plane was of choice for 44.6% (n=33). Grade III / IV capsular contracture was the main indication for total capsulectomy for 94.5% (n=70). Most of participants ( 93.1%, n=68) were in favor of a vigilant attitude in patients with Biocell(R)-coated implants. 85.1% (n=63) recommended surveillance with imaging techniques and only 25.7% (n=19) thought that the use of macro-textured implants must be prohibited. CONCLUSIONS: The results of this survey showed a significant change in the current clinical practices among the participants. Comparing with 2017 survey, there has been a significant increase in the use of smooth / nano-textured and microtextured breast implants, while the use of macro-textured breast implants has been significantly reduced

Breast Implant-Associated Anaplastic Large Cell Lymphoma: What the Primary Care Physician Needs to Know.

This manuscript aims to outline the pertinent epidemiology, presentation, diagnosis, and treatment of patients who present with breast implant-associated anaplastic large cell lymphoma (BIA-ALCL) as it pertains to primary care, such that the primary care physician (PCP) is able to appropriately care for patients with breast implants and counsel on risks of BIA-ALCL.

Meta-analysis of prepectoral implant-based breast reconstruction: guide to patient selection and current outcomes.

PURPOSE:  This meta-analysis provides a large-scale comparison of prepectoral vs. subpectoral implant-based breast reconstruction, with primary outcomes of patient safety and efficacy. METHODS: Literature review was performed via PRISMA criteria, 33 studies met inclusion criteria for prepectoral review and 13 studies met inclusion criteria for meta-analysis. Patient characteristics and per-breast complications were collected. Data were analyzed using Cochrane RevMan and IBM SPSS. RESULTS: In 4692 breasts of 3014 patients that underwent prepectoral breast reconstruction, rippling was observed as the most common complication, followed by seroma and skin flap necrosis. Meta-analysis demonstrated statistically significant decrease in odds of skin flap necrosis and capsular contracture in prepectoral groups compared to subpectoral groups. Odds of infection, seroma, and hematoma were equal between the two groups. CONCLUSIONS: Prepectoral breast reconstruction has surged in popularity in recent years. This review and large-scale analysis corroborates current literature reporting a favorable safety profile with emphasis on patient selection. Variability in skin flap thickness and vascularity mandates thoughtful selection of patients whose overall health and intra-operative skin flap assessment can tolerate a muscle-sparing reconstruction.

Skin- and Nipple-Areola-Sparing Mastectomy with Immediate Breast Reconstruction Using Transverse Rectus Abdominis Myocutaneous Flap and Silicone Implants in Breast Carcinoma Patients.

BACKGROUND: We aimed to assess patient satisfaction and aesthetic outcome in breast cancer patients undergoing nipple-sparing mastectomy (NSM) and immediate breast reconstruction. MATERIALS AND METHODS: The study population comprised 215 patients with histopathologically diagnosed breast cancer. The inclusion criteria were as follows: a diagnosis of breast cancer, a tumor of any size, any stage of nodal metastasis, and a tumor margin >2.0 cm from the margin of the nipple-areola complex. To measure the aesthetic outcome, the Lowery scale was used. After mastectomy, immediate breast reconstruction was performed using the transverse rectus abdominis myocutaneous (TRAM) flap, and by pacing the silicone implant. RESULTS: Most of the patients were aged between 40 and 51 years. Lymphadenopathy was positive in 87 out of 215 subjects; among these 87 subjects, 61 showed macrometastasis and 26 micrometastasis. A lateral incision was performed for mastectomy in all cases, and immediate breast reconstruction was performed using autologous grafts: the latissimus dorsi myocutaneous (TRAM) flap in 83% of cases, and silicone implants in 17% of cases were used for reconstruction. An excellent aesthetic outcome was seen in 70% of the cases, and 22% showed a good outcome. CONCLUSIONS: NSM is a very safe and technically feasible procedure that provides a high level of patient satisfaction and an excellent aesthetic outcome.

Patient satisfaction in one-stage immediate breast reconstruction after mastectomy: A multi-center comparative patient evaluation of prosthesis, LDMF, and TRAM techniques.

To analyze patient satisfaction and the predictive factors characterizing three types of one-stage immediate breast reconstruction (IBR) after mastectomy, including prosthesis, latissimus dorsi myocutaneous flap (LDMF), transverse rectus abdominis myocutaneous (TRAM) flap techniques.Data were collected via face-to-face or telephone interviews from eight breast centers in China from January 2012 to December 2016. A standardized questionnaire that evaluated the general satisfaction and aesthetic satisfaction was sent to patients who had undergone IBR. Logistic regression analysis was performed to identify risk factors associated with patient satisfaction among the three types of breast reconstruction.A total of 412 questionnaires were sent out, and 309 copies were collected including 226 prosthesis, 46 LDMF, and 37 pedicle TRAM reconstruction. Logistic regression analysis showed that general satisfaction and aesthetic satisfaction were significantly correlated with radiotherapy (P < .001, P = .018), respectively. Besides, the aesthetic satisfaction was also associated with nipple-areola complex (NAC) preservation (P < .001).Our multi-center study identified factors of higher patient satisfaction, like NAC preservation and absence of radiotherapy, in order to help breast surgeons make better decisions about individualized reconstruction plan.

Postmastectomy Breast Reconstruction: Exploring Plastic Surgeon Practice Patterns and Perspectives.

BACKGROUND: Within the multidisciplinary management of breast cancer, variations exist in the reconstructive options offered and care provided. The authors evaluated plastic surgeon perspectives on important issues related to breast cancer management and reconstruction and provide some insight into factors that influence these perspectives. METHODS: Women diagnosed with early-stage breast cancer (stages 0 to II) between July of 2013 and September of 2014 were identified through the Georgia and Los Angeles Surveillance, Epidemiology, and End Results registries. These women were surveyed and identified their treating plastic surgeons. Surveys were sent to the identified plastic surgeons to collect data on specific reconstruction practices. RESULTS: Responses from 134 plastic surgeons (74.4 percent response rate) were received. Immediate reconstruction (79.7 percent) was the most common approach to timing, and expander/implant reconstruction (72.6 percent) was the most common technique reported. Nearly one-third of respondents (32.1 percent) reported that reimbursement influenced the proportion of autologous reconstructions performed. Most (82.8 percent) reported that discussions about contralateral prophylactic mastectomy were initiated by patients. Most surgeons (81.3 to 84.3 percent) felt that good symmetry is achieved with unilateral autologous reconstruction with contralateral symmetry procedures in patients with small or large breasts; a less pronounced majority (62.7 percent) favored unilateral implant reconstructions in patients with large breasts. In patients requiring postmastectomy radiation therapy, one-fourth of the surgeons (27.6 percent) reported that they seldom recommend delayed reconstruction, and 64.9 percent reported recommending immediate expander/implant reconstruction. CONCLUSIONS: Reconstructive practices in a modern cohort of plastic surgeons suggest that immediate and implant reconstructions are performed preferentially. Respondents perceived a number of factors, including surgeon training, time spent in the operating room, and insurance reimbursement, to negatively influence the performance of autologous reconstruction.

Factors Associated with Reconstruction in Patients Undergoing Mastectomy.

Postmastectomy reconstruction has been shown to be oncologically safe, but few studies have investigated factors influencing the type of reconstruction chosen, if at all. Records of female patients with stages 0 to 3 breast cancer undergoing mastectomy at a large academic institution between January 2010 and March 2018 were reviewed. Nine hundred sixty patients were included in this cohort; 784 patients had reconstruction. Younger age, earlier disease stage, private insurance, no history of diabetes, and bilateral mastectomy (BM) were associated with reconstruction. On multivariate analysis, younger age, BM, private insurance, and earlier disease stage predicted reconstruction. Of reconstruction patients, 453 had implants. Race, BMI, and later disease stage influenced the type of reconstruction; on multivariate analysis, higher BMI and later disease stage predicted flap reconstruction. Younger age, BM, private insurance, and earlier disease stage were associated with reconstruction, but the type of reconstruction was affected primarily by BMI and disease stage.