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Background A significant number of patients with a previous submuscular breast augmentation require a revision surgical procedure during their long-term follow-up period that involves changing the implant pocket from submuscular to subglandular. Reduced soft tissue thickness represents a major concern, discouraging surgeons from undertaking this approach. Objectives The aim of this study was to determine whether a synthetic resorbable mesh used as a supplemental covering device was safe and yielded improved soft tissue thickness and protection against capsular contracture in patients undergoing implant plane shift to subglandular. Methods A retrospective review of 34 patients who underwent revision of a previous breast augmentation involving implant change in a subglandular pocket and upper pole GalaFLEX (Galatea Surgical, BD; Franklin Lakes, NJ) mesh coverage was conducted. Onset of minor and major complications was recorded during short- and medium-term follow-up. Patient satisfaction was assessed via an anonymous questionnaire administered 6 months postoperatively. Results During the follow-up period, which ranged from a minimum of 6 months to a maximum of 28 months, no minor or major complications were reported. In particular, no wrinkling/rippling or significant capsular contracture onset was observed. High levels of patient satisfaction were determined, according to self-reporting questionnaires. Conclusions The initial results of this preliminary report from this case series demonstrate the safety of GalaFLEX as a supplemental device in terms of improved soft tissue coverage of the implant for complex revisional cases in breast augmentation. Level of Evidence: 4

BACKGROUND Although abdominoplasty is a mainstay of the plastic surgeon, the safety of the Brazilian butt lift (BBL) has been questioned, effectively being prohibited in some countries. The central rationale for the safety concern over the BBL stems from a publication stating a mortality rate of one in 3000. The question remains: What is the real safety of these procedures? METHODS Focusing on mortality, literature searches were performed for BBL and for abdominoplasty. The 2017 Aesthetic Surgery Education and Research Foundation survey data and publication were examined and analyzed. Additional data from the American Association for Accreditation of Ambulatory Surgical Facilities were obtained independently. RESULTS Abdominoplasty and BBL appear to have similar safety based on mortality; however, the nature of their mortalities is different. Although most abdominoplasty deaths are secondary to deep venous thrombosis/pulmonary embolism-inherent circulatory thrombotic abnormality-BBL mortality is associated with iatrogenic pulmonary fat embolism. BBL mortality rates from more recent surveys on BBL safety demonstrate a mortality of one in 15,000. CONCLUSIONS Although deep venous thrombosis/pulmonary embolism will always remain an abdominoplasty risk, intraoperative BBL pulmonary fat embolism has the potential to be reduced dramatically with a better understanding of dynamic anatomy, surgical instrumentation, and technique. The authors are now presented with a better lens with which to view a more accurate safety profile of BBL surgery, including its place among other commonly performed aesthetic procedures.

Background The popularity of utilizing mesh in the breast has varied over the years. It is well described, and yet there has been poor uptake of its utilization in aesthetic breast surgery. Poly-4-huydroxybutarate (P4HB; GalaFLEX, Galatea, Lexington, MA) has recently been described as a useful adjunct in supporting poor tissue quality with positive early outcomes and low complication rates. Objectives The authors sought to determine the outcome and range of indications of PH4B in aesthetic breast surgery to document its effectiveness in assisting with long-term outcomes in mastopexy. Methods Firstly, an observational study was undertaken standardizing mastopexy techniques with P4HB included in the procedure. Photographic measurements were taken to determine the extent of lower pole descent and lower pole stretch at 3 months and 1 year postoperative to observe change over time. Secondly, other indications were explored, including the correction of secondary defects such as inferior malposition and symmastia. Results The results of the mastopexy study were highly encouraging and comparable with those previously published in the literature, confirming sustained stability of the lower pole over time for mastopexies and implant mastopexies. In addition, the GalaFLEX was successfully employed in correcting many secondary defects. Conclusions P4HB is extremely versatile and easy to utilize and has low complication rates. The results have led to a change in practice, with routine incorporation of GalaFLEX for all routine mastopexies. It has also replaced the utilization of acellular dermal matrices in aesthetic breast surgery. Level of Evidence: 4

Background Laboratory and clinical research on breast implant–associated anaplastic large cell lymphoma (BIA-ALCL) is rapidly evolving. Changes in standard of care and insights into best practice were recently presented at the 3rd World Consensus Conference on BIA-ALCL. Objectives The authors sought to provide practice recommendations from a consensus of experts, supplemented with a literature review regarding epidemiology, etiology, pathogenesis, diagnosis, treatment, socio-psychological aspects, and international authority guidance. Methods A literature search of all manuscripts between 1997 and August 2021 for the above areas of BIA-ALCL was conducted with the PubMed database. Manuscripts in different languages, on non-human subjects, and/or discussing conditions separate from BIA-ALCL were excluded. The study was conducted employing the Delphi process, gathering 18 experts panelists and utilizing email-based questionnaires to record the level of agreement with each statement by applying a 5-point Likert Scale. Median response, interquartile range, and comments were employed to accept, reject, or revise each statement. Results The literature search initially yielded 764 manuscripts, of which 405 were discarded. From the remaining 359, only 218 were included in the review and utilized to prepare 36 statements subdivided into 5 sections. After 1 round, panelists agreed on all criteria. Conclusions BIA-ALCL is uncommon and still largely underreported. Mandatory implant registries and actions by regulatory authorities are needed to better understand disease epidemiology and address initial lymphomagenesis and progression. Deviation from current diagnosis and treatment protocols can lead to disease recurrence, and research on breast implant risk factors provide insight to etiology. Level of Evidence: 4

The choice between anatomical and round implants is an important decision in breast augmentation surgery; however, both have their place and the decision between them that should be made on a patient-by-patient basis, taking into account the patient's desires, anatomy, and surgical history. In some individuals, there are clear indications for using either anatomical or round devices, and there is good evidence that aesthetic outcomes are better with anatomical implants in some instances. When both types are an option, anatomical devices may offer increased flexibility and, despite a longer learning curve needed to properly manage them, they are associated with positive long-term outcomes and high levels of patient satisfaction. Concerns about implant rotation can be minimized with proper patient selection and surgical technique, and the overall complication rate may favor anatomical over round devices in appropriate patients. Breast implant-associated anaplastic large-cell lymphoma is an important issue, and while rare, it must be considered in the context of the entire patient risk profile. Both anatomical and round implants remain key elements of a complete surgical toolbox in breast augmentation. LEVEL OF EVIDENCE IV: This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266.

The article summarizes the author's experience with Inspira implants. They were first introduced into the European market in 2006. The advent of the Inspira range heralded a fundamental change in the way round implants were perceived. The comprehensive matrix, the form stability of the gels, along with sophisticated manufacturing of the shell placed them as a premium product for use in both aesthetic and reconstructive breast surgery. The same principles of precise tissue-based planning, developed for anatomical implants, were being adopted for use with Inspira, leading to more predictable outcomes with high levels of patient satisfaction.

Anatomic implants were introduced in the late 1980s, gaining popularity through the 1990s and beyond. The moratorium on silicone meant that the use of theses devices was less diffuse in the US and has remained so. Fifth-generation devices had improved form stability with more aggressive texturization to enhance soft tissue interaction. The ability to vary height, width and projection independently creates much versatility in their use for complex anatomical situations producing natural results. The impact of BIA-ALCL has had a significant impact on their use.

The Keller funnel is an easy-to-use mechanical device that aids breast implant insertion. This study analyzed implant insertion time and incision length using the Keller funnel versus conventional manual insertion. This was an analysis of two cohorts of adult patients undergoing primary breast augmentation with anatomical implants at a single center. In the ‘insertion time cohort’ (N = 20), implants were inserted with a Keller funnel on one side and manually on the other; follow-up lasted 4 years. In the ‘incision length cohort,’ both implants were inserted with a Keller funnel (N = 50) or manually (N = 50), with follow-up lasting 12 months. In the insertion time cohort, mean total insertion time (from implant sterile-package opening to final positioning in the pocket) was 35 s (range 13–76 s) with the Keller funnel and 25 s (range 13–43 s) using manual insertion (p = 0.07); the mean time needed to push the implant through the incision was 6 s (range 3–10 s) with the Keller funnel and 16 s (range 13–40 s) with manual insertion (p = 0.04). In the incision length cohort, mean incision length was shorter with the Keller funnel versus manual insertion (35.5 ± 2.1 mm vs. 46.2 ± 3.2 mm; p < 0.001). There were no differences in complications based on insertion method. The Keller funnel was associated with decreased incision length and reduced time to push the implant through the incision. This brings potential clinical advantages in minimizing scarring and reducing contamination of the device. This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Background:The authors’ published studies have helped define breast beauty in outlining key parameters that contribute to breast attractiveness. The “ICE” principle puts design into practice. It is a simplified formula for inframammary fold incision planning as part of the process for determining im

There are few objective analyses in the plastic surgical literature to define an aesthetically pleasing template for breast shape and proportion. The authors previously identified key objective parameters that define breast aesthetic ideals in 2 studies: an observational analysis of 100 models with natural breasts, and a population analysis with 1315 respondents. From these data a simple yet reproducible formula for surgical planning in breast augmentation has been developed to consistently achieve beautiful breasts, namely the ICE principle. This article proposes that this principle be used as the basis for design in aesthetic breast surgery.

We propose a safe, simple, and novel method to harvest fat using a standard liposuction cannula and a Redivac or alternative closed-suction drain. The authors have used this technique for both 'dry' and 'wet' liposuction. This technique is both easy to perform and cost-effective whilst providing both a silent and relatively atraumatic fat harvest. The lower negative pressure compared with traditional harvesting systems likely preserves fat integrity for lipofilling. This method maximises resources already held within a hospital environment.

Breast implant-associated anaplastic large cell lymphoma (BIA-ALCL) is an uncommon neoplasia occurring in women with either cosmetic or reconstructive breast implants. The actual knowledge about BIA-ALCL deriving from the literature presents several limits, and it remains difficult to make inferences about BIA-ALCL epidemiology, cause, and pathogenesis. This is the reason why the authors decided to organize an evidence-based consensus conference during the Maurizio Bruno Nava (MBN 2016) Aesthetic Breast Meeting held in Milan in December of 2016. Twenty key opinion leaders in the field of plastic surgery from all over the world have been invited to express and discuss their opinion about some key questions on BIA-ALCL, trying to reach a consensus about BIA-ALCL cause, pathogenesis, diagnosis, and treatment in light of the actual best evidence.

Bacteria/biofilm on breast implant surfaces has been implicated in capsular contracture and breast implant-associated anaplastic large-cell lymphoma (ALCL). Macrotextured breast implants have been shown to harbor more bacteria than smooth or microtextured implants. Recent reports also suggest that macrotextured implants are associated with a significantly higher incidence of breast implant-associated ALCL. Using techniques to reduce the number of bacteria around implants, specifically, the 14-point plan, has successfully minimized the occurrence of capsular contracture. The authors hypothesize that a similar effect may be seen in reducing the risk of breast implant-associated ALCL.Pooled data from eight plastic surgeons assessed the use of macrotextured breast implants (Biocell and polyurethane) and known cases of breast implant-associated ALCL. Surgeon adherence to the 14-point plan was also analyzed.A total of 42,035 Biocell implants were placed in 21,650 patients; mean follow-up was 11.7 years (range, 1 to 14 years). A total of 704 polyurethane implants were used, with a mean follow-up of 8.0 years (range, 1 to 20 years). The overall capsular contracture rate was 2.2 percent. There were no cases of implant-associated ALCL. All surgeons routinely performed all 13 perioperative components of the 14-point plan; two surgeons do not routinely prescribe prophylaxis for subsequent unrelated procedures.Mounting evidence implicates the role of a sustained T-cell response to implant bacteria/biofilm in the development of breast implant-associated ALCL. Using the principles of the 14-point plan to minimize bacterial load at the time of surgery, the development and subsequent sequelae of capsular contracture and breast implant-associated ALCL may be reduced, especially with higher-risk macrotextured implants.Therapeutic, IV.

Background The authors previously identified key objective parameters that define the aesthetic ideal of the breast in a study of 100 models with natural breasts. In this follow-up article, the opinion of the general public on ideal breast proportions was surveyed. Methods One thousand three hundred fifteen respondents were asked to rank the attractiveness of images of four women with varying breast sizes. Each of the women's breasts were morphed into four different proportions. One of the key features was the upper pole-to-lower pole percentage proportion, corresponding to ratios of 35:65, 45:55, 50:50, and 55:45. Rankings were analyzed according to population demographics. Effects of age, sex, nationality, and ethnicity were evaluated. The responses of 53 plastic surgeons were included. Results Breasts with an upper pole-to-lower pole ratio of 45:55 were universally scored highest, in particular, by 87 percent of women in their thirties (n = 190), 90 percent of men (n = 655), 94 percent of plastic surgeons (n = 53), 92 percent of North Americans (n = 89), 95 percent of South Americans (n = 23), 86 percent of Europeans (n = 982), 87 percent of Caucasians (n = 1016), and 87 percent of Asians (n = 209). Conclusions This study reaffirms the authors' previous findings that the 45:55 ratio has universal appeal in defining the ideal breast. The authors propose that this proportion should be used as a basis for design in aesthetic surgery.

Social media use is growing inexorably, and there is public appetite for evidence-based information. Little is known about engagement by plastic surgeons with social media. The aim of this study was to examine posting about plastic surgery on Twitter, to best inform how board-certified plastic surgeons could use the hashtag #PlasticSurgery as a tool to educate patients and the public.A prospective analysis of 2880 "tweets" containing the words "plastic surgery" was performed. The following were assessed: identity of author, use of the hashtag #PlasticSurgery, subject matter, whether link to study was provided, and whether posts by surgeons were self-promotional or educational.Social media posting about plastic surgery is dominated by the public, accounting for 70.6 percent of posts versus only 6.0 percent by plastic surgeons. Only 5.4 percent of all tweets contained the hashtag #PlasticSurgery, although almost half of those that did were by plastic surgeons. Of these, 61.3 percent of posts by plastic surgeons were about aesthetic surgery; additional posts were about basic science, patient safety, and reconstruction (13.9, 4.0, and 2.3 percent, respectively). Eighteen scientific articles were referenced, with a link to the Journal site posted in two tweets. Of posts by plastic surgeons, 37.0 percent were self-promotional.The American Society of Plastic Surgeons and its Journal have recognized that social media may be used to educate and engage. Board-certified plastic surgeons have a great opportunity to promote evidence-based plastic practice by means of #PlasticSurgery in the interests of supporting patients and the profession.

Body contour surgery is in continuous evolution in an attempt to offer better aesthetic results. With greater understanding of the superficial fascial system of the trunk, various suspension procedures have been devised which use the fascial system as an adjunct to complement traditional abdominoplasty techniques. We present a simple technical refinement to the traditional abdominoplasty which uses the superficial fascial system to tighten the flanks and concomitantly shortens the final scar: the differential fascial glide. In this technique the superficial fascia is dissected as a separate layer from the abdominal flap and suspended in an oblique direction towards the midline whilst the abdominal flap is pulled in a downward and lateral direction, thus creating two opposing vectors of pull. This simple technique results in improved flank contour and a shorter scar in patients undergoing classic abdominoplasty.

There are few objective analyses in the plastic surgical literature to define an aesthetically pleasing template for breast shape and proportion. The authors previously identified key objective parameters that define breast aesthetic ideals in 2 studies: an observational analysis of 100 models with natural breasts, and a population analysis with 1315 respondents. From these data a simple yet reproducible formula for surgical planning in breast augmentation has been developed to consistently achieve beautiful breasts, namely the ICE principle. This article proposes that this principle be used as the basis for design in aesthetic breast surgery.

INTRODUCTION Clinical audit is a requirement of good medical and surgical practice and is central to the UK Government's plans to modernise the NHS. MATERIALS AND METHODS A survey was conducted to assess clinical audit data collection and collation within plastic surgery departments across the UK. The survey identified a variety of different data collection and collation methods, with extensive differences between plastic surgery departments. Those responsible for data collection and its funding were also identified by the survey. RESULTS Results were obtained from 45 plastic surgery departments. Of the 45 departments surveyed, 12 collect data prospectively, whereas 26 units collect data retrospectively. The remaining departments collect data using a combination of methods. Of the units surveyed, 28 collect data on paper-based systems, with only 13 units using electronic applications. The personnel responsible for data collection were identified as being junior doctors. Departments collecting data prospectively do so from a greater number of sources than those collecting data retrospectively. CONCLUSIONS This survey has focused on plastic surgery. The authors believe that similar results would be obtained from a survey of other surgical specialties. A huge variation in all parameters relating to the collection and collation of clinical audit data is seen. There are few standards within this specialty for data collection. Much work must be done in order to reach targets set by the UK Government.

After reading this article, the participant should be able to: 1. Cite the key concepts in the process of breast augmentation that optimize outcomes; 2. Cite key components of tissue-based planning for implant selection; 3. Discuss complications and risks of breast augmentation.Breast augmentation remains one of the top surgical procedures performed by plastic surgeons. Current literature supports the concept that breast augmentation outcomes are optimized using a concept of "the process of breast augmentation." Breast augmentation is often thought of as a surgical procedure; however, the nonsurgical aspects of the procedure are more important for optimizing outcomes and minimizing reoperation and complications. The process of breast augmentation includes patient education, tissue-based preoperative planning, refined surgical technique, and defined postoperative management. This CME article reviews and discusses the current relevant topics and issues surrounding breast implants. There are also supporting videos to enhance the reader's experience. CME questions are present at the end for a self-assessment.

Summary Introduction and aims Tethered scars are a common problem that can have functional and aesthetic consequences. Several approaches which use the dermis have been described for tethered scar correction. The objective of this report is to demonstrate the superior aesthetic outcomes achieved through the introduction of a new, simple dermal technique in scar revision surgery. Materials and methods From August 2002 through to January 2006, 35 patients were operated on by the senior author for revision of tethered, sunken scars. All scars were considered to demonstrate sunken or depressed characteristics based upon clinical examination and photographic evidence. All patients were operated on by the same surgeon and using the same surgical technique. Key results All the patients were women (age range 17–64 years), with tethered scars affecting the breast ( n =10), lower limb ( n =5), upper limb ( n =6), chest wall ( n =4), laparotomy scars ( n =8) and tracheotomy scars ( n =2). Scars ranged in length from 4 to 30cm (mean=12cm). Follow up ranged from 2 to 24 months (median=16 months). At the 12 month follow up, patients were presented with their pre- and postoperative photos and asked to select the overall improvement in aesthetic appearance achieved as either: ‘no improvement', ‘improved' or ‘marked improvement'. These were then ranked to scores of 0, 1 and 2, respectively (0=no improvement; 1=improved and 2=marked improvement). The responses from the questionnaire showed that the median score was 2 with 100% ranking ≥1. Thirty-two patients (91.4%) scored 2. There were no complications reported and the results at 12 months showed that restoration of volume to the scars had been maintained in all patients. To date, no one has had to undergo further revision and there have been no incidences of re-tethering. Conclusion The technique is simple to learn by even junior surgeons. Through following four distinct steps consistent and readily reproducible results are achieved.

EDITOR—Zameel Cader and Winer's lesson of the week highlighted a common error of terminology in describing vascular anomalies.1 The term cavernous haemangioma is a confusing one and should ideally be avoided. The classification of vascular anomalies by Mulliken and Glowacki successfully categorised vascular anomalies in a consistent and …

The healing of an adult skin wound is a complex process involving the collaborative efforts of many different tissues and cell lineages. For simplicity we can consider skin healing to consist of five overlapping phases—clot formation, inflammation, re-epithelialization, granulation tissue formation and contraction, and finally tissue remodeling. Each of these phases is coordinated and regulated by a hierarchy of cell-cell signals, which for the most part are growth factor mediated. This chapter will briefly outline the key events of repair following a skin lesion and then review what is currently known about the roles of vie of the key growth factor families, the EGFs, FGFs, PDGFs, IGFs, and TGFβs, in the wound healing process. We will discuss how growth factor therapy is already being utilized in the clinic to manage problems in wound healing and speculate what more there is to learn about growth factor interactions at the wound site and how this new knowledge might be gathered.

Patients who undergo breast reduction surgery have a low risk of being found to have breast cancer, but they need to be made aware of it—and doctors need to debate whether routine histological examination of tissue specimens is a good idea. We sought the views of Tom Treasure, a surgeon (doi:10.1136/bmj.b759), Jeremy Sugarman, an ethicist (doi:10.1136/bmj.b753), and Tessa Boase, a lay person (10.1136/bmj.b776)