The cellular and molecular properties of capsule surrounding silicone implants in humans vary uniquely according to the tissue type adjacent to the implant.

The foreign body reaction (FBR) to biomaterials results in fibrous encapsulation. Excessive capsule fibrosis (capsular contracture) is a major challenge to the long-term stability of implants. Clinical data suggests that the tissue type in contact with silicone breast implants alters susceptibility to developing capsular contracture; however, the tissue-specific inflammatory and fibrotic characteristics of capsule have not been well characterized at the cellular and molecular level. In this study, 60 breast implant capsule samples are collected from patients and stratified by the adjacent tissue type including subcutaneous tissue, glandular breast tissue, or muscle tissue. Capsule thickness, collagen organization, immune and fibrotic cellular populations, and expression of inflammatory and fibrotic markers is quantified with histological staining, immunohistochemistry, and real-time PCR. The findings suggest there are significant differences in M1-like macrophages, CD4+ T cells, CD26+ fibroblasts, and expression of IL-1ß, IL-6, TGF-ß, and collagen type 1 depending on the tissue type abutting the implant. Subglandular breast implant capsule displays a significant increase in inflammatory and fibrotic markers. These findings suggest that the tissue microenvironment contributes uniquely to the FBR. This data could provide new avenues for research and clinical applications to improve the site-specific biocompatibility and longevity of implantable devices.

Immediate Prepectoral Tissue Expander Breast Reconstruction Without Acellular Dermal Matrix Is Equally Safe Following Skin-Sparing and Nipple-Sparing Mastectomy.

BACKGROUND: Prepectoral breast reconstruction has become increasingly popular over the last decade. There is a paucity of data surrounding the impact of mastectomy type on clinical outcomes when comparing prepectoral immediate breast reconstruction without acellular dermal matrix (ADM) using tissue expansion. The purpose of this study was to compare 90-day reconstructive surgical outcomes in immediate prepectoral tissue expander reconstruction between patients with nipple-sparing mastectomy (NSM) and skin-sparing mastectomy (SSM). METHODS: A retrospective review of patient records was carried out on all patients undergoing NSM or SSM with immediate prepectoral tissue expander reconstruction without ADM, in a single institution, from June 2020 to December 2021. All complications were recorded, categorized, and statistically analyzed for significance. RESULTS: Seventy-nine patients (97 breasts) were studied. The mean age was 51 years old (range, 31-77). Twenty-two patients suffered complications recorded in 22 breasts (22.7%). There was no statistically significant difference in the total complications between the NSM (25.7%) and SSM (21.0%) groups or in the incidence of all major and minor complications. CONCLUSIONS: Breast reconstruction using tissue expanders without ADM has similar reconstructive outcomes in both NSM and SSM. There were no significant differences in complication rates between either groups. Breast reconstruction without ADM can confer institutional cost savings without compromising safety.

Altered Foreign Body Response at the Posterior Surface Compared to the Anterior Surface of Human Silicone Breast Implants.

Soft implantable devices are crucial to optimizing form and function for many patients. However, periprosthetic capsule fibrosis is one of the major challenges limiting the use of implants. Currently, little is understood about how spatial and temporal factors influence capsule physiology and how the local capsule environment affects the implant structure. In this work, we analyzed breast implant capsule specimens with staining, immunohistochemistry, and real-time polymerase chain reaction to investigate spatiotemporal differences in inflammation and fibrosis. We demonstrated that in comparison to the anterior capsule against the convex surface of breast implants, the posterior capsule against the flat surface of the breast implant displays several features of a dysregulated foreign body reaction including increased capsule thickness, abnormal extracellular remodeling, and infiltration of macrophages. Furthermore, the expression of pro-inflammatory cytokines increased in the posterior capsule across the lifespan of the device, but not in the anterior capsule. We also analyzed the surface oxidation of breast explant samples with XPS analysis. No significant differences in surface oxidation were identified either spatially or temporally. Collectively, our results support spatiotemporal heterogeneity in inflammation and fibrosis within the breast implant capsule. These findings presented here provide a more detailed picture of the complexity of the foreign body reaction surrounding implants destined for human use and could lead to key research avenues and clinical applications to treat periprosthetic fibrosis and improve device longevity.

Complications of Aesthetic and Reconstructive Breast Implant Capsulectomy: An Analysis of 7486 Patients Using Nationwide Outcomes Data.

BACKGROUND: Despite increasing demand for breast capsular surgery to treat various benign and malignant implant-related pathologies, high-quality evidence elucidating complication profiles of capsulectomy and capsulotomy is lacking. OBJECTIVES: We provide the largest-scale analysis of associated outcomes and complications using the Tracking Operations and Outcomes for Plastic Surgeons (TOPS) database, and investigate clinical scenarios that may subject patients to increased risks for complications, most notably, extent of capsular surgery (complete vs partial), and index indication of implantation (aesthetic vs reconstructive). METHODS: An analysis of the TOPS database from 2008-2019 was performed. CPT codes were used to identify complete capsulectomy and partial capsulectomy/capsulotomy cases. Breast implant exchange procedures constituted procedural controls. RESULTS: In total, 7,486 patients (10,703 breasts) undergoing capsulectomy or capsulotomy were assessed. Relative to controls, capsulectomy (4.40% vs 5.79%; p = 0.0154), but not capsulotomy (4.40% vs 4.50%; p = 0.8876), demonstrated higher overall complication rates. Both capsulectomies (0.83% vs 0.23%; p < 0.0001) and capsulotomies (0.56% vs 0.23%; p = 0.0307) also had greater rates of seroma relative to controls. Subgroup analyses demonstrated that reconstructive patients, relative to aesthetic patients, experienced greater overall complications (6.76% vs 4.34%; p < 0.0001), and increased risks for seroma (1.06% vs 0.47%; p = 0.0016), dehiscence (0.46% vs 0.14%; p = 0.0059), surgical site infections (1.03% vs 0.23%; p < 0.0001), and implant loss (0.52% vs 0.23%; p = 0.0401). A detailed synthesis of 30-day outcomes, including all patient- and breast-specific complications, for both capsulectomy and capsulotomy, stratified according to all potential confounders, is presented herein. CONCLUSIONS: Surgeries on the breast capsule are overall safe, though complete capsulectomies and reconstructive patients were associated with significantly increased operative risks. Present findings will enhance patient selection, counselling, and informed consent.

Evolution of chromosome-arm aberrations in breast cancer through genetic network rewiring.

The basal breast cancer subtype is enriched for triple-negative breast cancer (TNBC) and displays consistent large chromosomal deletions. Here, we characterize evolution and maintenance of chromosome 4p (chr4p) loss in basal breast cancer. Analysis of The Cancer Genome Atlas data shows recurrent deletion of chr4p in basal breast cancer. Phylogenetic analysis of a panel of 23 primary tumor/patient-derived xenograft basal breast cancers reveals early evolution of chr4p deletion. Mechanistically we show that chr4p loss is associated with enhanced proliferation. Gene function studies identify an unknown gene, C4orf19, within chr4p, which suppresses proliferation when overexpressed-a member of the PDCD10-GCKIII kinase module we name PGCKA1. Genome-wide pooled overexpression screens using a barcoded library of human open reading frames identify chromosomal regions, including chr4p, that suppress proliferation when overexpressed in a context-dependent manner, implicating network interactions. Together, these results shed light on the early emergence of complex aneuploid karyotypes involving chr4p and adaptive landscapes shaping breast cancer genomes.

Demystifying vascularized lymph node transfers and lymphatico-venous anastomoses.

Lymphedema continues to be a widely prevalent condition with no definitive cure. It affects a wide range of patients across different ages and backgrounds. The significant burden of this chronic and debilitating condition necessitates more research and comprehensive healthcare coverage for affected patients. In developed countries, cancer survivors are disproportionality affected by this condition. Risk factors including lymph node dissections and radiation render many cancer patients more susceptible to the development of lymphedema. Part of the challenge with lymphedema care, is that it exits on a broad spectrum with significant variability of symptoms. Advances and broader availability of various imaging modalities continue to foster progress in lymphedema surgery. The conservative management of lymphedema remains the primary initial management option. However, lymphedema surgeries can provide significant hope and may pave the way for significant improvements in the quality-of-life for many patients afflicted by this progressive and enfeebling condition. Reductive and physiologic procedures are becoming an important part of the armamentarium of the modern plastic and reconstructive surgeon. Recent advances in physiologic lymphedema surgeries are accelerating their transition from experimental surgeries to broadly adopted and widely accepted procedures that can lead to major successes in the fight against this condition. Prophylactic lymphedema surgery also presents a promising choice for many patients and can help prevent lymphedema development in high-risk patients.

Implant-based breast surgery and capsular formation: when, how and why?-a narrative review.

Background and Objective: Implant-based breast surgery is a common procedure for both reconstructive and aesthetic purposes. Breast implants, like any foreign object, trigger the formation of a capsule around them. While generally harmless, the capsule can undergo fibrotic changes leading to capsular contracture, which can negatively impact surgical outcomes and patient well-being. Additionally, rare but serious complications, such as breast implant-associated anaplastic large cell lymphoma (BIA-ALCL) and capsule-associated squamous cell carcinoma, have been reported. This paper aims to review the physiology of capsular formation, identify factors contributing to capsule-related pathologies, and discuss their clinical implications. Methods: A review of relevant literature was conducted by searching databases for articles published between inception and September 2022. The search included but not limited to terms such as "capsular formation" and "capsular contracture". Selected articles were critically analyzed to address the objectives of this review. Key Content and Findings: Capsular formation involves interactions between the implant surface, surrounding tissues, and the immune system. Factors influencing pathological changes in the capsule include genetic predisposition, bacterial contamination, implant characteristics, and surgical techniques. Capsular contracture, characterized by tissue hardening, pain, and implant distortion, remains the most common complication. Rare but life-threatening conditions, such as BIA-ALCL and capsule-associated squamous cell carcinoma, necessitate vigilant monitoring and early detection. Conclusions: Understanding the physiology of capsular formation and its associated pathologies is crucial for healthcare providers involved in implant-based breast surgery. Efforts should focus on minimizing the risk of capsular contracture through improved implant materials, surgical techniques, and infection prevention. The emergence of BIA-ALCL and capsule-associated squamous cell carcinoma underscores the importance of long-term surveillance and prompt diagnosis. Further research is needed to uncover underlying mechanisms and develop preventive measures and treatments for these complications. Enhancing our knowledge and clinical management of capsular formation will lead to safer and more successful outcomes in implant-based breast surgery.

Alternative surgical management of penile siliconoma using partial degloving and resurfacing.

INTRODUCTION: Siliconoma represents an inflammatory tissue response to extravasated silicone. Penile enhancing silicone injections have been described for over 50 years. Most of the publications report complications including negative effects on penile appearance and function which require corrective procedures. Penile circumferential skin and siliconoma excision with skin grafting has been described in multiple case reports and series as an effective and feasible option to remove the silicone and achieve good esthetic results. METHODS: We describe a simple and feasible single stage procedure removing the siliconoma with adjacent non-viable skin while preserving 50% of healthy penile skin and resurfacing the defect with a split-thickness skin graft to treat a long-term complication of penile silicone injection associated with recurrent infections and a chronic skin ulceration. CONCLUSION: Partial excision of the affected penile skin and sili-conoma with defect resurfacing with a split-thickness skin graft is a feasible with good functional and cosmetic outcomes.

Topical Tranexamic Acid in Breast Reconstruction: A Double-Blind Randomized Controlled Trial.

BACKGROUND: Excess fluid accumulation (seroma/hematoma) around the breast implant after reconstruction can lead to significant complications. Topical administration of tranexamic acid (TXA) may reduce fluid accumulation and reduce postoperative complications. This trial aims to investigate whether TXA-treated mastectomy pockets will exhibit less postoperative fluid production and complications. METHODS: This paired, double-blind, randomized, controlled trial enrolled patients undergoing bilateral mastectomies with immediate direct-to-implant reconstruction. In each patient, one breast was randomized to receive 3 g of TXA (100 cc), and the other received 100 cc of normal saline. The blinded solutions were soaked in the mastectomy pocket for 5 minutes before implant placement. Postoperatively, daily drain outputs, complications, and baseline demographics were recorded. RESULTS: Fifty-three eligible patients, representing 106 breasts, were enrolled. All patients underwent bilateral nipple-sparing mastectomies. After randomization, TXA was placed in the right breast in 30 patients (56.6%). The use of topical TXA resulted in a mean drain output reduction of 30.5% (range, -83.6% to 26.6%). Drains on the TXA-treated breast were eligible for removal 1.4 days (range, 0 to 4 days) sooner than the control side. The TXA-treated group had three complications (5.67%) versus 15 (28.3%) in the control group (OR, 0.1920; P = 0.0129). Specifically, for operative hematomas, the TXA group had none (0%), versus three in the control group (5.7%) (OR, 0.1348; P = 0.18). CONCLUSIONS: Soaking the mastectomy bed with 3% topical TXA before implant insertion leads to a decrease in drain output and a decrease in complications. Topical administration of TXA represents an option to decrease complications in alloplastic breast reconstruction. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, I.

Breast Implant-Related Adverse Events During Mammography: An Assessment of the Food and Drug Administration Manufacturer and User Facility Device Experience Database.

BACKGROUND: Adverse events arising in patients with breast implants during mammography reported by the Food and Drug Administration include implant rupture, pain, and impaired visualization. However, data supporting these claims were collected in 2004, and since, newer implant generations have been developed with overall rate of implantation increasing by 48%. OBJECTIVES: This article aims to determine the current incidence of implant-related adverse events arising during mammography. METHODS: We analyzed reports regarding silicone and saline breast implants published in the Food and Drug Administration Manufacturer and User Facility Device Experience database between 2008 and November 2018. Search terms included "mammogram," "mammography," "radiograph," "breast cancer screening," "breast cancer test," and "x-ray." RESULTS: Of the 20 539 implant-related adverse events available in the Manufacturer and User Facility Device Experience database, 427 were retrieved using our search strategy and 41 were related to mammography. Thirty-five of identified cases (85.4%) reported implant rupture, of which 19 (54.3%) were confirmed by a healthcare professional, 9 (25.7%) were clinically confirmed by saline implant deflation, and 7 (20.0%) were unverified reports by patients. Sixteen ruptures (45.7%) occurred with silicone implants, whereas 19 ruptures (54.3%) occurred with saline. Other adverse events included pain (29.3%), change in implant appearance (14.6%), and swelling (7.3%). CONCLUSIONS: Although implant rupture, pain, change in implant appearance, and swelling may occur, minimal implant-related adverse events arise during mammography. Given the extremely low reported risk of implant rupture, this should neither prevent patients from adhering to breast cancer screening programs nor deter patients from seeking breast implants. Patients should be aware of these reported risks and discuss screening options with their breast cancer screening team.

Unlocking Performance Excellence: Review of Evidence-Based Mindful Meditation.

SUMMARY: Mindfulness has recently been implemented by advanced military combatants, firefighters, and those in other very intellectually demanding and fast-paced professions. A surgeon, similarly, is faced with many difficult challenges, whether it be a complex and meticulous surgery, extensive clinical responsibilities, or simply the challenges faced in residency. In current curricula, there is no training to introspectively deal with these stressors. Regardless of what we face in our personal lives, the lives of patients are literately in our hands. Would it not be prudent and wise to train our brain to not only deliver care to our patients but also be able to take care of us and maybe even improve our performance? Regular practice of mindfulness has been shown to decrease rates of burnout, decrease medical errors, improve sleep, and even improve surgical performance. With the ever-changing pandemic situation and increasing stressors in the hospital, mindful meditation is perfectly primed to be added to our armamentarium as surgeons and physicians. This review aims to explain how mindfulness can enhance a surgeon's performance, mindset, interactions, and execution through a review of recent scientific advancements and evidence.

Complications of Capsulectomies: An Analysis of the American College of Surgeons National Surgical Quality Improvement Program Database.

Background: Although plastic surgeons commonly perform capsulectomies for a variety of peri-prosthetic capsular conditions, the safety of capsulectomy remains unknown, and the literature lacks evidence describing its morbidity and complication rates for patients inquiring about its associated risks. Objectives: The present study aims to identify and define the complication rates associated with capsulectomies. Methods: An analysis of the American College of Surgeons National Surgical Quality Improvement Program (NSQIP) database was performed between the years 2015 and 2018. All information pertaining to demographics, patient-related information, surgical indications, procedure-related information, outcomes, and complications were assessed. Results: The study identified 2231 cases of surgeon-reported capsulectomies; indications most commonly reported included capsular contracture (n = 638, 28.6%) and breast implant rupture (n = 403, 18.1%). In total, 141 patients (6.32%) were hospitalized for longer than 1 postoperative day (range, 2-28 days), while the overall complication rate was 3.0% (n = 67/2231 patients). Incidence of minor complications, representing superficial surgical site infections, was 0.8%, while the major complication rate was 2.24%. These included 7 cases of deep surgical site infections (0.3%), 19 organ space infections (0.9%), and 8 cases of wound dehiscence (0.4%). Eight patients developed sepsis (0.4%); 6 patients required transfusions (0.3%); 1 case of postoperative pneumonia and 1 myocardial infarction were also identified (n = 1 each, 0.0%). The overall reoperation and readmission rates were 2.0%, representing a readmission rate of 66% among patients with complications. Conclusions: The present study provides the first estimate of the incidence of complications associated with capsulectomies. Although the NSQIP database contains significant limitations, the data presented herein describe a complication profile that plastic surgeons can share with their patients during informed consent.

Nerve Blocks in Breast Plastic Surgery: Outcomes, Complications, and Comparative Efficacy.

BACKGROUND: As plastic surgeons continue to evaluate the utility of nonopioid analgesic alternatives, nerve block use in breast plastic surgery remains limited and unstandardized, with no syntheses of the available evidence to guide consensus on optimal approach. METHODS: A systematic review was performed to evaluate the role of pectoralis nerve blocks, paravertebral nerve blocks, transversus abdominus plane blocks, and intercostal nerve blocks in flap-based breast reconstruction, prosthetic-based reconstruction, and aesthetic breast plastic surgery, independently. RESULTS: Thirty-one articles reporting on a total of 2820 patients were included in the final analysis; 1500 patients (53 percent) received nerve blocks, and 1320 (47 percent) served as controls. Outcomes and complications were stratified according to procedures performed, blocks employed, techniques of administration, and anesthetic agents used. Overall, statistically significant reductions in opioid consumption were reported in 91 percent of studies evaluated, postoperative pain in 68 percent, postanesthesia care unit stay in 67 percent, postoperative nausea and vomiting in 53 percent, and duration of hospitalization in 50 percent. Nerve blocks did not significantly alter surgery and/or anesthesia time in 83 percent of studies assessed, whereas the overall, pooled complication rate was 1.6 percent. CONCLUSIONS: Transversus abdominus plane blocks provided excellent outcomes in autologous breast reconstruction, whereas both paravertebral nerve blocks and pectoralis nerve blocks demonstrated notable efficacy and versatility in an array of reconstructive and aesthetic procedures. Ultrasound guidance may minimize block-related complications, whereas the efficacy of adjunctive postoperative infusions was proven to be limited. As newer anesthetic agents and adjuvants continue to emerge, nerve blocks are set to represent essential components of the multimodal analgesic approach in breast plastic surgery.

"Locoregional perforator flaps in breast reconstruction: An anatomic review & quadrant algorithm".

BACKGROUND: Plastic surgeons' firm grasp of perforator anatomy allows them to be increasingly mindful of esthetic outcomes, patient satisfaction, and donor-site function when approaching breast reconstruction. Mindfulness of these outcomes has contributed to the widespread use of locoregional perforator flaps in post-mastectomy and post-BCS reconstruction. METHODS: A literature search of the PubMed database was performed to identify relevant studies reporting the use of locoregional perforator flaps in post-mastectomy breast reconstruction. Selected manuscripts were analyzed and grouped by pedicled flap category. Articles were additionally assessed for the advantages and disadvantages of each flap and reported complications. RESULTS: Following three rounds of review, 30 of 101 (29.7%) articles were retained as specifically pertinent to the use of locoregional flaps in breast reconstruction surgery. They were categorized by locoregional perforator flap used (TDAP, LICAP, AICAP, LTAP, or IMAP). In total, the included studies reported on the use of perforator flaps in 829 patients, with complications occurring in 73 of 418 patients (17.5%). Commonly reported complications across all included studies were hematomas (n = 10), infection (n = 7), fat necrosis/steatofibrosis (n = 31), extruded expanders (n = 1), dehiscence (n = 2), seroma (n = 2), required cosmetic correction of the donor area (n = 5), flap congestion (n = 11), flap failure (n = 2), poor esthetic outcome (n = 4), grade II capsular contracture (n = 3, all of whom received postoperative radiation), and keloid scars(n = 1). CONCLUSIONS: Though the available literature remains anecdotal, locoregional flap-based reconstruction may provide some benefit in post-BCS reconstruction by sparing donor-site musculature and nerve supply and by minimizing adverse events.

Wound Healing: A Comprehensive Review.

Wound healing is an intricate, tightly regulated process that is critical to maintaining the barrier function of skin along with preserving all other skin functions. This process can be influenced by a variety of modifiable and nonmodifiable factors. As wound healing takes place in all parts of the human body, this review focuses on cutaneous wound healing and highlights the classical wound healing phases. Alterations in any of these phases can promote chronic wound development and may impede wound healing.

Current Advances in Hypertrophic Scar and Keloid Management.

Hypertrophic scars and keloids are caused by excessive tissue response to dermal injury due to local fibroblast proliferation and collagen overproduction. This response occurs because of pathologic wound healing due to dysregulation in the inflammatory, proliferative, and/or remodeling phase. Patients with hypertrophic scars or keloids report reduced quality of life, physical status, and psychological health. Hypertrophic scars or keloids will develop in 30 to 90% of individuals, and despite their prevalence, treatment remains a challenge. Of the treatments currently available for hypertrophic scars and keloids few have been adequately supported by studies with appropriate experimental design. Here, we aim to review the available literature to provide up-to-date information on the etiology, epidemiology, histology, pathophysiology, prevention, and management options available for the treatment of hypertrophic scars and keloids and highlight areas where further research is required.