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BACKGROUND: In recent years, indocyanine green angiography (ICG-A) has been used increasingly to assist tissue perfusion assessments during plastic and reconstructive surgery procedures, but no guidelines exist regarding its use. We sought to identify areas of consensus and non-consensus among international experts on the use of ICG-A for tissue-perfusion assessments during plastic and reconstructive surgery.METHODS: A two-round, online Delphi survey was conducted of 22 international experts from four continents asking them to vote on 79 statements divided into five modules: module 1 = patient preparation and contraindications (n = 11 statements); module 2 = ICG administration and camera settings (n = 17); module 3 = other factors impacting perfusion assessments (n = 10); module 4 = specific indications, including trauma debridement (n = 9), mastectomy skin flaps (n = 6), and free flap reconstruction (n = 8); and module 5 = general advantages and disadvantages, training, insurance coverage issues, and future directions (n = 18). Consensus was defined as ≥70% inter-voter agreement.RESULTS: Consensus was reached on 73/79 statements, including the overall value, advantages, and limitations of ICG-A in numerous surgical settings; also, on the dose (0.05 mg/kg) and timing of ICG administration (∼20-60 seconds preassessment) and best camera angle (61-90o) and target-to-tissue distance (20-30 cm). However, consensus also was reached that camera angle and distance can vary, depending on the make of camera, and that further research is necessary to technically optimize this imaging tool. The experts also agreed that ambient light, patient body temperature, and vasopressor use impact perfusion assessments.CONCLUSION: ICG-A aids perfusion assessments during plastic and reconstructive surgery and should no longer be considered experimental. It has become an important surgical tool.

The authors describe the vascular anatomy of the fifth anterior intercostal artery perforator and its role for perfusion of the nipple-areola complex following nipple-sparing mastectomy.Twenty fresh cadavers were injected with 20 cc of colored latex through the internal mammary artery. The catheter was placed at the level of the second intercostal space after removal of the rib. The fifth intercostal space was dissected under magnification to observe the origin and trajectory of the fifth anterior intercostal artery perforator. Six selective computed tomographic angiograms of the fifth intercostal artery perforator were performed. A clinical case of nipple-sparing mastectomy in a woman with mammary hypertrophy is provided to demonstrate the utility of preserving the fifth anterior intercostal artery perforator.The fifth anterior intercostal artery perforator was consistently observed in all the cases and confirmed by angiography. The perforator gives rise to several branches that traverse in all directions. The ascending branches of the fifth anterior intercostal artery perforator are directed toward the nipple-areola complex and course within the subcutaneous layer between the skin and the parenchyma. The fourth and fifth anterior intercostal artery perforators are independent of one another.The main ascending branch of the fifth anterior intercostal artery perforator reaches the nipple-areola complex by the subcutaneous tissue independently of the Würinger fascia.

LEARNING OBJECTIVES After studying this article, the participant should be able to: 1. Describe surgical techniques associated with mastopexy and mastopexy augmentation. 2. Understand the evolution of mastopexy and augmentation mastopexy. 3. Address patient goals. 4. Achieve a favorable cosmetic outcome. SUMMARY The surgical techniques associated with mastopexy and mastopexy augmentation have continued to evolve. Traditional mastopexy techniques have included periareolar, circumvertical, and inverted-T patterns; however, adjuncts to these have included the use of various surgical mesh materials, implants, and fat grafting. This evidence-based article reviews how the techniques of mastopexy and augmentation mastopexy have evolved to best address patient goals and provide a favorable cosmetic outcome.

There are no guidelines on the safety of magnetic resonance imaging (MRI) in patients with breast tissue expanders with metallic/magnetic components. This narrative review was conducted to better understand what is currently known and to identify gaps in knowledge.A literature search was performed using PubMed and Embase and the following terms: "breast" AND ("imaging" OR "MRI" OR "resonance") AND "expander," with no date limitations. The authors identified 153 citations in PubMed and 154 citations in Embase.Nineteen publications were relevant for analysis: two retrospective studies, 10 case reports, six nonclinical studies, and one physician survey. All studies acknowledged the risks of using magnetic resonance imaging in patients with tissue expanders. Complications reported included breast/chest pain, discomfort, or burning sensation (46.2 percent); expander or infusion port displacement (38.5 percent); and magnetic resonance signal loss (23.1 percent). Increases in expander/tissue temperature and torque occurred with magnetic resonance imaging, causing pain or expander displacement. In some cases, no complications were reported. The retrospective studies and nonclinical analyses suggested that magnetic resonance imaging may not create serious problems if special precautions are taken. The case reports varied in their recommendations, with some recommending avoiding magnetic resonance imaging and others recommending exercising caution. The survey indicated that surgeons are uncertain about performing magnetic resonance imaging in patients with tissue expanders.The evidence on whether to perform magnetic resonance imaging in patients with tissue expanders with magnetic ports varies but underscores proceeding with caution. The risk-to-benefit profile for each patient must be weighed in each situation.

SUMMARY Current controversies surrounding breast implants are focused not only on the implant but also on the capsule. There has been tremendous discussion regarding how much of the capsule, if any, should be removed during explantation for benign conditions. The appearance of benign capsules is highly variable ranging from a thin membrane to densely fibrotic with calcifications. The options for capsulectomy include none, partial, complete, complete-intact, and en bloc. Some patients are requesting en bloc capsulectomy even in the absence of anaplastic large cell lymphoma; however, the scientific evidence only supports this for patients with capsular malignancies. The purpose of this article is to review the old and new evidence to answer the question regarding how much capsule should be removed during explantation for benign conditions.

Background:. Prepectoral implant-based breast reconstruction is an alternative to subpectoral/dual-plane reconstruction. Methods:. This study examined outcomes of prepectoral reconstruction using a meta-analysis of data pooled with data from our previous review. Thirty studies were included. Results:. Explantation, seroma, and infection were the most common complications with no animation deformity reported. Significantly lower odds of infection were observed with prepectoral compared with dual-plane reconstruction. Conclusions:. Current literature suggests that prepectoral reconstruction may be associated with lower rates of postsurgical infections.

Silicone gel breast implants have been used for breast augmentation and reconstruction since 1962. Since then, multiple generations of implants have been created in an effort to improve safety and efficacy. Before 1990, silicone gel implants were characterized as having thin shells and non-cohesive gel; however, since then devices are created with cohesive silicone gel and a variety of surfaces. Despite improvements, no implant will last forever; however, these devices are safe and effective based on numerous clinical and epidemiologic studies. As with all medical devices, complications using round form-stable implants for breast reconstruction can occur and will be reviewed in this article.

Recent advancements in prosthetic breast reconstruction have provided the foundation for the bioengineered breast. These advancements include improved mastectomy techniques, autologous fat grafting, acellular dermal matrices (ADMs), and improved devices. Device-based breast reconstruction has evolved from subcutaneous, partial or total subpectoral, and now to prepectoral placement of devices. The evidence demonstrating the safety and efficacy of the bioengineered breast continues to increase. This manuscript will review the fundamental components of the bioengineered breast and provide an update of the current evidence.

Autologous fat grafting in the setting of breast augmentation and reconstruction has become globally accepted and routinely performed. There is general consensus that small-volume grafting is reproducible and predictable; however, large-volume fat grafting (>100 mL) is less predictable and is not as commonly performed. The aim of this article was to review outcomes following large-volume and megavolume fat grafting in the setting of breast augmentation and reconstruction. Level of Evidence: 4

Current understanding of the vascular anatomy of the anterior chest wall suggests that perfusion of the deltopectoral flap may be compromised when crossing the midline at the anterior thoracic wall. The traditional deltopectoral flap is designed longitudinally over the ipsilateral side to avoid the risk of distal flap necrosis. The purpose of this article is to present our experience and results with 26 deltopectoral flaps that were designed and raised with the perforating vessels on the ipsilateral side with the majority of the flap crossing the midline extending to the contralateral side. This anatomic variation in flap design indicates that the sternal midline is not a barrier and that the internal mammary perforator flap may be raised on different longitudinal axes.

SUMMARY Breast implant removal and replacement has been a common secondary breast procedure in the long-term maintenance of breast augmentation, but more recently growing concerns about silicone-related systemic illness, breast implant-associated anaplastic large cell lymphoma (BIA-ALCL), and changing perceptions of aesthetic beauty have seen breast implant removal without replacement become increasingly requested by patients. Explantation can be challenging, especially when performed with a total capsulectomy. Currently, there is no evidence regarding whether a partial or total capsulectomy has any effect on BIA-ALCL risk mitigation in patients that have textured implants without disease. Total capsulectomy with incomplete resection of a mass can contribute to hyperprogression of BIA-ALCL and death. There have also been cases of BIA-ALCL diagnosed years after removal of the textured device and "total capsulectomy." Therefore, the common practice of simple prophylactic capsulectomy in a textured implant to mitigate future disease has not been established and at the current time should be discouraged. In addition, aesthetic outcomes can be quite variable, and patients should have appropriate preoperative counseling regarding the indications and contraindications for explantation, associated risks, financial implications, and postoperative appearance. The authors review salient aspects related to the planning and management of breast implant removal.

Autologous breast reconstruction is considered by many to represent the gold standard when evaluating long-term outcomes. Most autologous reconstruction is now performed with perforator-based flap that can arise from a variety of donor sites that include the abdomen, gluteal region, posterior thorax, and the thigh. The most common autologous option is the DIEP flap based on its versatility, ease of harvest, high probability of success, and patient satisfaction. This chapter will review the various options for autologous breast reconstruction following mastectomy.

Numerous innovations and advancements have enabled breast reconstruction following mastectomy to deliver aesthetic outcomes that mimic the natural breast. This is true for prosthetic and autologous reconstruction and the result of improved mastectomy techniques, preservation of the recipient and donor site muscles, and the use of fat grafting. Specific to prosthetic reconstruction is the evolution from subpectoral to prepectoral device placement, the use of acellular dermal matrices, and better breast implants. Specific to autologous reconstruction is the use of perforator-based flaps to minimize donor site morbidities.

Background Prepectoral placement of prosthetic devices is rapidly becoming the preferred method of breast reconstruction. Objectives The objective of this study was to review long-term surgical and aesthetic outcomes following prepectoral prosthetic breast reconstruction. Methods The study included 90 patients (139 breasts). Follow-up for all patients ranged from at least 1 year up to a maximum of 4.3 years. Parameters analyzed included preoperative and postoperative breast symmetry, rippling, edge visibility, and capsular contracture, as well as secondary procedures such as fat grafting, implant exchange, contralateral procedures, and autologous flap conversion. Results The incidence of breast symmetry, which was noted preoperatively in 84.4% of patients, gradually declined to 68.9% after 1 to 2 years and to 56.7% after 2 to 5 years. Rippling and edge visibility were noted in 19.4% and 12.9% of patients, respectively. Explantation without replacement of the device was performed in 12 breasts (8.6%). Secondary procedures included autologous fat grafting (23.7%), implant replacement (7.2%), conversion to an autologous flap (12.2%), and a contralateral breast procedure in 15 of 41 patients (36.6%). Capsular contracture (grade 3-4) was demonstrated in 14 of 139 breasts (10.1%). Conclusions Prepectoral breast reconstruction can provide good to excellent short-term (1-2 years) and longer-term (2-4.3 years) benefits; however, over time, the quality of prepectoral breast reconstruction as well as breast symmetry can change due to various factors. Level of Evidence: 4

Prepectoral prosthetic breast reconstruction has become an acceptable option for women following mastectomy. Benefits include no animation deformity, absence of pectoralis major muscle spasm, and less pain and discomfort. Important aspects of prepectoral reconstruction include working with breast surgeons that are adept at performing an optimal mastectomy. Tissue perfusion and reasonable thickness of the mastectomy are critical components of success. Tissue necrosis, infection, and delayed healing can lead to reconstructive failure. Given the risks and benefits of this procedure, questions regarding indications, patient selection, and specific details related to technique remain because there is no consensus. Whether it is safe to perform prepectoral reconstruction in obese or previously irradiated patients is controversial. The use of acellular dermal matrix is common but not universal. The amount of acellular dermal matrix used is variable, with success being demonstrated with the partial and total wrap techniques. Device selection can vary but is critical in the prepectoral setting. Postoperative care and the management of adverse events are important to understand and can impact surgical and aesthetic outcomes. This article provides current approaches, recommendations, and an algorithm for prepectoral breast reconstruction with an emphasis on patient selection, immediate versus delayed prepectoral reconstruction, specific technical details, and postoperative management.

BACKGROUND The purpose of this study was to determine whether augmentation mammaplasty, implant type, and implant location affect breast cancer detection, stage, and treatment. METHODS An institutional case-control study was performed of patients with prior breast augmentation undergoing breast cancer treatment from 2000 to 2013. Controls were propensity matched and randomized, and data were retrospectively reviewed. RESULTS Forty-eight cases and 302 controls were analyzed. Palpable lesions were detected at a smaller size in augmentation patients (1.6 cm versus 2.3 cm; p < 0.001). Fewer lesions in augmented patients were detected by screening mammography (77.8 percent of cases versus 90.7 percent of controls; p = 0.010). Patients with implants were more likely to undergo an excisional biopsy for diagnosis (20.5 percent versus 4.4 percent; p < 0.001), rather than image-guided core needle biopsy (77.3 percent versus 95.3 percent; p < 0.001). Earlier staging in augmented patients approached but did not reach statistical significance (p = 0.073). Augmented patients had higher mastectomy rates (74.5 percent versus 57.0 percent) and lower rates of breast-conservation therapy (25.5 percent versus 43 percent; p = 0.023). Neither implant fill type nor anatomic location affected method of diagnosis, stage, or treatment. CONCLUSIONS Palpable detection of breast cancer is more likely at a smaller size in augmented patients, yet it is less likely on screening mammography than in controls. Augmentation breast cancer patients have a comparable disease stage and are more likely to undergo mastectomy rather than lumpectomy. Both silicone and saline implants, whether placed submuscularly or subglandularly, have comparable effects on breast imaging, biopsy modality, and surgical intervention. CLINICAL QUESTION/LEVEL OF EVIDENCE Therapeutic, III.

Prosthetic breast reconstruction has evolved over the years to provide results that now mimic that of a natural breast. This is due to a variety of innovations and advancements related to mastectomy techniques, acellular dermal matrices, autologous fat grafting, and improved breast implants. The evolution of prosthetic breast reconstruction has gone full-circle and included prepectoral placement in the 1970s and 80s, partial or total subpectoral placement from 1985 to 2015, and now gradually trending back to prepectoral. There are several techniques and strategies that now allow for patients to achieve results that are superior to any time over the past 50 years. This manuscript will review the salient aspects of prosthetic breast reconstruction and how its evolution has progressed over the years.