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.

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.

What Can Breast and Plastic Surgeons Do to Help Fight the Opioid Crisis: The Interpectoral Block for Pain Control Following Aesthetic and Reconstructive Breast Surgery.

With the heightened awareness of the dangers of opioid administration, the importance of providing effective non-opioid postoperative pain management is evident. Regional analgesia for breast surgery has been described, but it is unclear how widely it is utilized. The authors describe a simple block performed during ablative, aesthetic, and reconstructive breast surgery to improve postoperative pain control and significantly decrease the need for postoperative pain medications. The interpectoral (PECS I) block covers the lateral and medial pectoral nerves and can be administered by the anesthesiologist under ultrasound guidance after induction of general anesthesia, or by the surgeon under direct vision, using a blunt cannula, at the time of surgery. The authors have been practicing this technique in every patient undergoing aesthetic, ablative, and reconstructive breast surgery in the last 4 years. In approximately 350 patients, none received opioids after discharge, which was either same day or the following day. The authors provide a brief review of the literature and a detailed description of the technique along with a video demonstrating the procedures. Intraoperative pectoral block is a simple and effective technique for decreasing postoperative pain and analgesic requirements and could be widely adopted as a standard of care in breast surgery.

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.

Cellular Optimization of Nanofat: Comparison of Two Nanofat Processing Devices in Terms of Cell Count and Viability.

BACKGROUND: Nanofat was introduced by Tonnard and Verpaele in 2013. Their initial observations in intradermal applications showed improvement in the appearance of the skin. Since then, a number of Nanofat devices have been introduced. The cellular content in the processing of Nanofat is not the same in every device, yet the cellular composition is responsible for the biologic action of Nanofat. The authors sought to find a different means to produce a matrix rich Nanofat to optimize the cellular content. OBJECTIVES: The primary objective of this study was to compare cell counts, cultures, and cell viabilities produced by LipocubeNano (Lipocube, Inc., London, UK) in comparison to Tulip's NanoTransfer (Tulip Medical, San Diego, CA) processing methods. METHODS: Twenty milliliters of fat were harvested from 10 patients in order to test two methods of Nanofat production. Ten milliliters of fat were used to assess each method and, after the final product was obtained, enzymatic digestion for stromal vascular fraction (SVF) isolation was performed. A Muse Flow-cytometer was used to measure cell counts and cell viabilities, cell cultures were performed, and cell images were taken with a florescent microscope. RESULTS: The LipocubeNano was shown to be superior to Tulip's NanoTransfer system of progressive downsizing with final filtering, which appeared to trap more fibrous tissue leading to lower amounts of SVF. LipocubeNano resulted in higher cell counts (2.24 × 106/cc), whereas Tulip's NanoTransfer method resulted in a lower cell count at 1.44 × 106/cc. Cell viability was the same (96.05%) in both groups. CONCLUSIONS: Nanofat from LipocubeNano has a higher regenerative cell count and more SVF cells than the other common mechanical method of Nanofat processing. This new means of mechanical processing preserves more matrix, optimizing the cellular content of the Nanofat, thus having potentially a higher regenerative effect.

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.

Histopathological Study of Meshed Versus Solid Sheet Acellular Dermal Matrices in a Porcine Model.

BACKGROUND: Acellular dermal matrices (ADMs) are commonly used to support implant-based breast reconstruction. However, there is little comparative data on the incorporation process of different ADMs, and the value of meshing or fenestration versus solid sheet has not been established, although early clinical data suggest seroma rates may be reduced. This was a preclinical assessment of the incorporation process at optimal conditions in a pig model. METHODS: SurgiMend and AlloDerm matrices were implanted in subcutaneous pockets on the backs of 15-week-old female pigs. Half of the samples were meshed 1:2.5; the remainder was grafted as a fenestrated (SurgiMend) or solid sheet (AlloDerm). Tissues were harvested at 3 months. Histological slides were prepared for hematoxylin and eosin staining, and Masson trichrome and immunostaining with anticollagen type I fluorescein isothiocyanate stain. Histological parameters (inflammation, giant cell reaction, neovascularization, fibroplasias, and scar tissue formation) were graded blindly on a scale of 0 (no reaction) to 3 (severe reaction). RESULTS: All explanted ADMs (SurgiMend, n = 23; AlloDerm, n = 20) were firmly incorporated within the host tissue. SurgiMend showed more fibroplasia (P = 0.029) compared with AlloDerm in meshed or solid sheet form. Meshed ADMs showed a trend toward increased inflammation (P = 0.074) and giant cell reaction (P = 0.053) compared with solid sheet/fenestrated ADM. CONCLUSIONS: Meshing ADM may allow cells to populate matrices more rapidly, promoting integration compared with solid sheet ADMs. This study sets the histological basis for further clinical investigations, with the aim of demonstrating lower complication rates (and particularly reduced seroma formation) with meshed ADMs.

Bovine Acellular Dermal Matrix in Immediate Breast Reconstruction: A Retrospective, Observational Study with SurgiMend.

BACKGROUND: Acellular dermal matrices can be combined with implant-based breast reconstruction to help optimize outcomes. SurgiMend PRS is a fetal bovine dermis-derived acellular dermal matrix composed of type I collagen and approximately 30 percent type III collagen, sharing many of the properties of human cadaveric acellular dermal matrix. METHODS: This was a retrospective, single-center analysis of 111 adult patients (147 breasts) undergoing one-stage (83.7 percent) or two-stage (16.3 percent) immediate breast reconstruction after mastectomy. The aims were to characterize the safety profile of SurgiMend and investigate associations between risk factors and complications. RESULTS: The mean age of the patients was 47.9 years and the mean body mass index was 24.7 kg/m. After a median follow-up of 24.3 months, the overall rates of minor and major complications were 25.2 percent (n = 37 of 147) and 12.9 percent (n = 19 of 147), respectively. The most common major complications were seroma [n = 12 (8.2 percent)] and necrosis [n = 9 (6.1 percent)]. All occurred within 3 months after surgery. The rate of capsular contracture was 2.7 percent (n = 4). A total of 2.7 percent of implanted breasts (n = 4) required explantation. In a univariate analysis, smokers had a greater risk of major complications (p = 0.013), and postoperative radiation therapy and obesity were associated with an increased risk of capsular contracture (p = 0.006) and explantation (p = 0.006), respectively. In a multivariate analysis, several factors were associated with complications or explantation, including obesity (p < 0.05), preoperative chemotherapy (p < 0.001), and mastectomy weight (p < 0.05). These associations align with other studies of implant-based reconstruction and do not appear to be specific to this acellular dermal matrix. CONCLUSION: The results are consistent with previous analyses of SurgiMend, and support its value in implant-based breast reconstruction. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.

Immediate breast reconstruction with anatomical implants following mastectomy: The radiation perspective.

Immediate implant-based breast reconstruction followed by postmastectomy radiation therapy (PMRT) is controversial because of the risk of compromised treatment plans and concerns regarding cosmetic outcomes. We evaluated the effects of immediate direct-to-implant breast reconstruction with anatomical implants on the quality of PMRT delivered by 3-dimensional conformal radiotherapy (3D-CRT). In this retrospective, single-institution study, patients who had undergone reconstruction with direct anatomic implant, performed by a single surgeon, received 3D-CRT between 2008 and 2013. For each patient, 2 plans (including or excluding internal mammary nodes [IMN]) were created and calculated. The primary end point was the dose distribution among reconstructed breasts, heart, lungs, and IMNs, and between right and left breasts. Of 29 consecutive patients, 11 received right-sided and 18 received left-sided PMRT to a total dose of 50Gy. For plans excluding IMN coverage, mean Dmean for right and left reconstructed breasts was 49.09Gy (98.2% of the prescribed dose) and 48.51Gy (97.0%), respectively. For plans including IMNs, mean Dmean was 49.15Gy (98.3%) for right and 48.46Gy (96.9%) for left reconstructed breasts; the mean IMN Dmean was 47.27Gy (right) and 47.89Gy (left). Heart Dmean was below 1.56Gy for all plans. Mean total lung volume receiving a dose of ≥ 20Gy was 13.80% to 19.47%. PMRT can be delivered effectively and safely by 3D-CRT after direct-to-implant breast reconstruction with anatomical implants, even if patients require IMN treatment.

Over Troubled Water: An Outbreak of Infection Due to a New Species of Mycobacterium following Implant-Based Breast Surgery.

Mycobacterial infection is a rare complication associated with breast surgery using implants. Over the course of 5 months, one center experienced 12 such cases, 10 of which were linked to a single surgeon. Most presented 3 to 6 weeks postoperatively with clear serous drainage from the incision, minimal local redness, no fever or other systemic signs of infection, and negative standard bacterial cultures. Patients were given empiric broad-spectrum oral antibiotic therapy. In eight cases, implants were removed and exchanged for new devices after irrigation of the pocket with antibiotics; these patients nonetheless experienced recurrent infection, which led to explantation (without immediate exchange for new implants). The last two patients proceeded straight to explantation. Because mycobacteria grow in water, the water supply and air-conditioning system were initially suspected as the source, and both were disinfected. However, this did not stop the outbreak. Eventually, the source was traced to a new species of mycobacteria isolated from a garden hot tub. These bacteria had then been unwittingly transferred to patients during surgery. A Triclosan-containing shampoo effectively ended the outbreak. This series is unique in several respects: the novelty of the pathogen, the heavy colonization of the surgeon, and the mechanism of transmission (the first occurrence of human-to-human mycobacterial transfer published in the plastic surgery literature). Surgeons who perform breast surgery with implants should be aware of the possibility of mycobacterial infection. Proactive culturing of the organism, use of antibiotics, and reoperation are essential to good outcomes.

Three-dimensional Imaging and Simulation in Breast Augmentation: What Is the Current State of the Art?

This article discusses perception of three-dimensional objects and binocular vision. High-resolution three-dimensional images of the breast can be captured using a camera system consisting of 3 separate stereoscopic pairs of digital cameras. The images (surfaces) are then joined to form a 220° surface of the torso, including the breasts. The images can be rotated freely in space. Simulation of augmentation with or without mastopexy is presented. Three-dimensional imaging and computer simulation of breast augmentation has become an emerging technology in many breast augmentation practices. This technology can be integrated in different ways into the consultation and informed consent process.

Anatomical and Round Breast Implants: How to Select and Indications for Use.

UNLABELLED: Choosing between round and anatomical form-stable implants is a key decision in the process of breast augmentation. Anatomical devices have been subject to a number of misconceptions that have limited their use. However, in optimal clinical practice, the benefits and risks of both anatomical and round implants should be considered for any given patient. Patient and surgeon education is fundamental in ensuring that misunderstandings are addressed. The choice between anatomical and round devices should be based on a combination of patient desires, anatomy, and surgical history. This report presents experience-based recommendations on indications and contraindications for each type, and a proposed algorithm for decision making in clinical practice. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, V.

[The history of plastic surgery in Israel].

The medical institutions in the country have advanced together with the development of the state of Israel. Plastic surgery, which has progressed significantly during the 20th century, has also grown rapidly in the new state. The arrival of Jewish plastic surgeons from all over the world with the knowledge and experience gained in their countries of origin, as well as the need for reconstructive surgical treatment for many combat injured soldiers, also contributed to the development of plastic surgery. This review tells the story of plastic surgery in Israel, since its foundation until nowadays. This article reviews the work of the founders of plastic surgery in Israel, indicating significant milestones in its development, and clinical and scientific contribution to the international plastic surgery profession. Moreover, the article describes the current condition of the field of plastic surgery in Israel and presents the trends and the future challenges facing the next generation of plastic surgery in Israel.

Tissue Reinforcement in Implant-based Breast Reconstruction.

BACKGROUND: Tissue reinforcement with allogeneic or xenogeneic acellular dermal matrices (ADMs) is increasingly used in single-stage (direct-to-implant) and 2-stage implant-based breast reconstruction following mastectomy. ADMs allow surgeons to control implant position and obviate the need for submuscular implant placement. Here, we review the benefits and risks of using ADMs in implant-based breast reconstruction based on available data. METHODS: A comprehensive analysis of the literature with focus on recent publications was performed. Additional information regarding the proper use of ADMs was based on our institutional experience. RESULTS: ADM use may improve definition of the lateral confines of the breast and lower pole projection. It may facilitate direct-to-implant procedures and improve aesthetic outcomes. The effect of ADMs on complication rates remains controversial. Known patient risk factors such as obesity, smoking, and radiotherapy should be considered during patient selection. For patients with healthy, well-vascularized skin envelopes, ADM-assisted direct-to- implant reconstruction is a safe and cost-effective alternative to 2-stage implant reconstruction, with low complication rates. ADMs may be used to treat capsular contracture, and limited available data further suggest the possibility that ADMs may reduce the risk of capsular contracture. Novel synthetic or biosynthetic tissue reinforcement devices with different physical and ease-of-use properties than ADMs are emerging options for reconstructive surgeons and patients who seek to avoid tissue products from human or mammalian cadavers. CONCLUSIONS: ADM-assisted implant-based breast reconstruction may improve aesthetic outcomes. However, appropriate patient selection, surgical technique, and postoperative management are critical for its success, including minimizing the risk of complications.

Benefits and Limitations of Macrotextured Breast Implants and Consensus Recommendations for Optimizing Their Effectiveness.

Implant texture is an important factor influencing implant selection for breast augmentation. Natrelle Biocell implants are characterized by macrotextured shell surfaces containing irregularly arranged concavities with large open-pore diameters and depths. These properties facilitate adhesion of the implant to the surrounding tissue, thereby promoting implant immobilization. Relative to implants with other surfaces, macrotextured implants offer low rates of capsular contracture; low rates of malposition, rotation, and rippling; and high rates of patient satisfaction. However, macrotextured implants are associated with a slightly higher risk of double capsule and late seroma. The surgeon can minimize these risks with straightforward techniques that encourage tissue adhesion. This report presents experience-based recommendations to optimize the effectiveness of Biocell anatomic implants. The authors discuss the application of best practices to all aspects of the breast implantation process, from implant selection and surgical planning to operative technique and postoperative management. LEVEL OF EVIDENCE 3.

A position statement on optimizing the role of oncoplastic breast surgery.

OBJECTIVES: To propose initiatives and actions that could improve access to and outcomes from oncoplastic breast surgery. METHODS: The author group met in May 2010 to draft position statements on key unmet needs in oncoplastic breast surgery and how these may be addressed. At a second meeting in December 2010, the statements were voted upon and adjusted as necessary to achieve unanimous agreement. RESULTS: It was agreed that every patient undergoing breast cancer surgery should be assessed by an oncoplastic team capable of offering the full range of surgical options. However, currently, not all women are adequately informed about the surgical options available. Furthermore, levels of multidisciplinary working, standards of care, and levels of surgical training in the full range of breast oncoplastic techniques are suboptimal. Institution-specific guidelines relating to the optimal patient pathway, the definition of clinical standards, and improved education in reconstructive surgery are required. Oncoplastic breast surgery should be offered to all patients, within the context of multidisciplinary teams that include accredited surgeons who consult with each other early in the treatment pathway. These teams should be focused on achieving not just positive oncologic outcomes, but also esthetic outcomes in line with patient wishes, to achieve optimal quality of life. CONCLUSIONS: There is a desire within the surgical community to improve patient outcomes by better incorporating oncoplastic procedures into the treatment pathways for breast cancer. These position statements represent the perspectives of a group of European plastic surgeons on the key elements required to achieve this goal.