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BackgroundNipple-areola complex reconstruction (NAR) most commonly represents the finishing touch to breast reconstruction (BR). Nipple presence is particularly relevant to the patient’s psyche, beyond any shadow of doubt. Many reconstructive options have been described in time. Surgery is easy, but final result is often disappointing on the long run.MethodsThe goal of this manuscript is to analyze and classify knowledge concerning NAR techniques and the factors that influence success, and then to elaborate a practical evidence-based algorithm. Out of the 3136 available articles as of August 8th, 2020, we selected 172 manuscripts that met inclusion criteria, which we subdivided into 5 main topics of discussion, being the various NAR techniques; patient factors (including patient selection, timing and ideal position); dressings; potential complications and finally, outcomes/patient satisfaction.ResultsWe found 92 articles describing NAR techniques, 41 addressing patient factors (out of which 17 discussed patient selection, 14 described ideal NAC location, 10 described appropriate timing), 10 comparing dressings, 7 studying NAR complications, and 22 addressing outcomes and patient satisfaction. We elaborated a comprehensive decision-making algorithm to help narrow down the choice among NAR techniques, and choose the correct strategy according to the various scenarios, and particularly the BR technique and skin envelope.ConclusionsNo single NAR technique provides definitive results, which is why we believe there is no “end-all be-all solution”. NAR must be approached as a case-by-case situation. Furthermore, despite NAR being such a widely discussed topic in scientific literature, we still found a lack of clinical trials to allow for more thorough recommendations to be elaborated.Level of Evidence IIIThis journal requires that authors assign a level of evidence to each submission to which Evidence-Based Medicine rankings are applicable. This excludes Review Articles, Book Reviews, and manuscripts that concern Basic Science, Animal Studies, Cadaver Studies, and Experimental Studies. 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

: Breast implant-associated anaplastic large cell lymphoma (BIA-ALCL) is a mature T-cell lymphoma linked to textured breast implants. A leading hypothesis suggests that chronic inflammation, combined with immunological and genetic factors, drives its pathogenesis. Two previous studies investigating bacterial biofilms on breast implant capsules have produced conflicting results, particularly regarding the enrichment of spp. : We analyzed the microbiota profiles in seroma samples from 10 BIA-ALCL patients and 12 patients with non-neoplastic effusion, subclassified into acute-, mixed-, and chronic-type based on cellular composition. We used two metagenomic approaches: 16S rRNA gene sequencing and Nanopore sequencing with the \"What's in My Pot?\" (WIMP) taxonomic classifier. Our analyses included alpha and beta diversity metrics, as well as comparisons of Gram status and oxygen requirements. : Both sequencing methods identified , , and as the most prevalent bacterial families in both BIA-ALCL and benign seroma samples. Notably, the family was more abundant in some of the benign seromas according to the 16S rRNA sequencing, but spp. were not detected. BIA-ALCL showed higher richness (based on Nanopore data) and higher evenness (based on 16S rRNA data) compared to acute-type seromas, indicating a more homogenous representation of the different taxa identified. BIA-ALCL seromas did not cluster together based on Nanopore data, but they did form a distinct cluster with 16S rRNA data. This cluster was differentiated from the other two clusters by a relatively balanced presence of multiple families without overt dominance. We observed no significant differences in Gram staining between BIA-ALCL and benign samples using either method. However, non-aerobic bacterial families were enriched in BIA-ALCL cases only when analyzed with the Nanopore pipeline. : Overall, our findings did not identify a distinctive microbial signature specifically associated with BIA-ALCL.

BackgroundThe aim of the study was to describe details of surgical techniques and objectively evaluate nipple–areola (NAC) sensibility and viability of septum-based mammaplasties compared to not septum-based reduction techniques.MethodsData regarding NAC sensibility for static and moving one- and two-point discrimination were prospectively collected from 63 active group hypertrophic-breasted patients undergoing septum-based reduction mammaplasty preoperatively, at 6 and 12 months postoperatively, and from a control group of 60 patients who underwent not septum-based techniques. Fixed and mixed effect models were used for statistical analysis.ResultsComparison of complications showed no significant differences between groups (p = 0.07). After adjusting the results of the active group according to type of sensory testing, it emerged that the threshold decreases by 10% (p = 0.0003) at 6 months and even reaches 43% (p < 0.0001) at 12 months. The results have been modulated according to age, since the variation is less marked when age increased, by 0.6% at 6 months and 0.8% at 12 months (p = 0.019). The effects of the BMI can only be seen at 12 months, with an increase by 1.3% per year (p = 0.033). Among septum-based techniques, the inferior-central pedicle showed better sensibility outcomes even if not significantly (p = 0.06). Comparison of NAC sensibility outcomes showed that active group had thresholds that were 48% lower when compared to those of the control group at 12 months postoperatively (p < 0.001).ConclusionSeptum-based mammaplasty gives optimal results in terms of NAC viability with a significant improvement of sensibility postoperatively. Comparative outcomes on sensibility were also significantly better than not septum-based techniques.Level of Evidence IIThis 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.

IntroductionThis study aims to analyze whether there is any patient- or treatment-related factor that can influence patients’ body perception after mastectomy and autologous or implant-based breast reconstruction.Materials and MethodsThis retrospective cohort study included patients who underwent immediate implant-based or DIEP flap breast reconstruction. Predictive factors analyzed included chemotherapy, radiotherapy, hormone therapy, body mass index, age, type of mastectomy, and follow-up length. The BREAST-Q was administered postoperatively almost 2 years from the last surgical procedure. Mean BREAST-Q scores were reported for the overall cohort and by modality for the postoperative period. A linear regression model was applied to all BREAST-Q scores with all predictor factors.ResultsIn total, 325 patients were enrolled in this study (133 DIEP flap and 192 implant-based reconstructions). The DIEP flap reconstruction group with a previous nipple sparing mastectomy showed the highest scores. Patients with a longer follow-up were less satisfied than the ones with a shorter follow-up, which could be considered as an assessment of the outcome. No significant difference was reported between patients who underwent radiotherapy, chemotherapy or hormone therapy and those who did not. Furthermore, age and BMI had no influence on patient satisfaction.ConclusionThis study is the first that groups a large number of patients and analyzes predictive factors of long-term satisfaction of patients undergoing breast reconstruction. This can be regarded as a pilot study to raise the awareness of everyone's clinical practice to predict the attitude that patients have after surgery and to prepare them in the best possible way.Level of Evidence IVThis 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.

Suction drains are widely used in surgical practice, but a consensus is yet to be found around their use in plastic surgery. Nowadays, patients are frequently discharged from hospitals with drains still in place. Soft drains are easier to manage at home because of the reduced weight and size. The content can be disposed of when the container is full, but volume assessment is only possible when the reservoir is inflated. Evaluating the total drained volume alone is a flawed assessment method, as it might lead to erroneously decide whether a drain should be kept or removed. What we should use as a reference instead is the output quantity from the last 24 h. We can precisely determine the amount of collected material on a daily basis by closing the clip of the tubing, opening the exit valve to inflate the container, measuring and then emptying the container. However, this whole process can be complicated and put the sterile environment at risk of contamination, which is why it cannot be performed by the patient at home. We ask our patients to weigh the container daily using a kitchen scale and to write down the obtained values. When the patient returns for a postoperative checkup, they can report their measurements, thus making it easier for the surgeon to decide whether to remove the drain or not. We believe that this simple method can be safely implemented to track drains in the postoperative period after the patient is discharged.Level of Evidence VThis 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 Breast implants (BI) are widely used in plastic surgery, though they are not lifetime devices. Average life before rupture is reported to be around 10–15 years. No consensus exists regarding which factors are involved. Objectives Following FDA recommendations, this study aims at identifying potential risk factors by evaluating their effect on BI rupture cases. Methods In this observational study, 763 BI patients were operated between 2003 and 2019, with a mean implant indwelling of 12.2 years. Patients that returned for follow-up were administered a questionnaire regarding postoperative lifestyle and habits. Implant rupture rate was 15.1%, while BI lifespan was 10.1 years. We obtained complete data from 191 breast implant patients (288 implants). Twenty-three potential risk factors were evaluated and divided in four categories: patient-related, surgery-related, postoperative complications/symptoms, and postoperative care/lifestyle habits. Odds Ratio (OR) for each factor was calculated. Linear regression analysis was calculated for those with a significant OR. Results We report 120 patients (195 implants) with intact and 71 (93 implants) with ruptured devices. BIs were macrotextured in 95.1% of cases (86.8% Allergan BIOCELL). OR was significant for underwire bra use (OR: 2.708), car seat belts (OR: 3.066), mammographic imaging (OR: 2.196), weightlifting (OR: 0.407) and carry-on heavy purses and backpacks (OR: 0.347). Conclusion Wearing underwire bras, seat belts and undergoing mammography increases the risk of rupture. Weightlifting and carry heavy bags do not increase that risk. Implant rupture is directly linked with time of indwelling. Postoperative recommendations in BI patients should consider findings from our study, though larger multicenter studies should be encouraged. 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 .

Background Because of poor knowledge of risks and benefits, prophylactic explantation of high BIA-ALCL risk breast implant (BI) is not indicated. Several surgical risks have been associated with BI surgery, with mortality being the most frightening. Primary aim of this study is to assess mortality rate in patients undergoing breast implant surgery for aesthetic or reconstructive indication. Materials and Methods In this retrospective observational cohort study, Breast Implant Surgery Mortality rate (BISM) was calculated as the perioperative mortality rate among 99,690 patients who underwent BI surgery for oncologic and non-oncologic indications. Mean age at first implant placement (A1P), implant lifespan (IL), and women’s life expectancy (WLE) were obtained from a literature review and population database. Results BISM rate was 0, and mean A1P was 34 years for breast augmentation, and 50 years for breast reconstruction. Regardless of indication, overall mean A1P can be presumed to be 39 years, while mean BIL was estimated as 9 years and WLE as 85 years. Conclusion This study first showed that the BISM risk is 0. This information, and the knowledge that BI patients will undergo one or more revisional procedures if not explantation during their lifetime, may help surgeons in the decision-making process of a pre-emptive substitution or explant in patients at high risk of BIA-ALCL. Our recommendation is that patients with existing macrotextured implants do have a relative indication for explantation and total capsulectomy. The final decision should be shared between patient and surgeon following an evaluation of benefits, surgical risks and comorbidities. 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 .

Background High incidence of epidermolysis and full thickness necrosis of Wise-pattern skin-sparing mastectomy (WPM) skin flaps to almost 30 % represent the Achilles’ heel of this procedure. Our purpose was to investigate potential predictors of skin flap ischemic complications (SFIC) in WPM. Methods A total of 75 immediate prosthetic reconstructions following Wise-pattern mastectomy on 63 patients were retrospectively analyzed to assess risk factors for SFIC and their impact on aesthetic outcomes and patient satisfaction. There were 2 clusters of hypothetic predictors investigated: patient-related (age, body mass index, smoking, neoadjuvant chemotherapy) and procedure-related (implant weight, breast weight, curative-prophylactic procedure, axillary lymph nodes dissection). Significant predictors from univariate and mixed-effects multivariate logistic regression analyses were considered to be important selection criteria that expose the patients to higher risk of SFIC. Moreover, patients were divided into 3 subgroups according to postoperative outcome: (A) group healed uneventfully, (B) with partial thickness, and (C) with full thickness necrosis. Aesthetic evaluations scores of subgroups were analyzed and compared using a Kruskal–Wallis analysis of variance, and Dunn’s test for multiple comparisons between subgroups. Results Smoking and weight of prosthesis >468 g showed significant association with SFIC, additionally analysis of aesthetic evaluations confirmed differences between subgroups ( p  = 0.001), and multiple testing showed significance between subgroup A and C ( p  < 0.05). Conclusions Patients with clinically significant predictors are at higher risk of postoperative SFIC and consequently less satisfied of their aesthetic outcomes. The surgeon should consider alternative procedures for such patients, and prostheses heavier than 468 g should be avoided.

We here present a few comments on the invited discussion of Dr. van Heijningen on the paper “Assessment of Risk Factors for Rupture in Breast Reconstruction Patients with Macrotextured Breast Implants”. Dr. van Heijningen made some reservations regarding paper conclusions due to the high dropout rate, the adopted exclusion criteria and the location and mechanism of implant rupture. First of all, a high dropout rate is not unbeknown to researchers in surveys-based studies and may be expected when recalling in 6 months a population observed during last 20 years. In our study data are missing at random not affecting the risk of bias, while the population accurately depicts the people we care, mainly but not only reconstructive. Patients who did not respond to the questionnaire could not participate to the survey, while those who did not hold recent imaging were excluded because of the risk of false negative due to possible silent rupture, accounting to 10% in some reports. MRI imaging often shows that implants fold back on their selves when capsular contracture reduces implant pocket. As the use of the underwire bra prevents implant inferior displacement, repeated muscular contraction may worsen implant folds and the chronic wear-and-tear mechanism may be responsible for the rupture. Finally, folding is presumably easier to occur at the upper quadrants where anatomical implant shell is thinnest and gel concentration reduced than the opposite, therefore is not surprising that the higher percentage of ruptures is located in the upper implant quadrants. Level of evidence V 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 .

IntroductionThe purpose of this study is to determine if there is a better quality of life with one of the two techniques and if the results are in line with those already present in the literature. The hypothesis from which we started is to demonstrate that cancer patients who undergo a deep inferior epigastric perforator flap (DIEP) breast reconstruction surgery are more satisfied and have a higher level of quality of life compared to those subjected to an intervention of reconstruction with prosthesis.Materials and MethodsAll patients undergoing reconstruction from January 2010 to July 2018 were eligible for inclusion. This is a retrospective cohort study carried out using the patients of two plastic surgery departments who have undergone monolateral or bilateral implant-based or DIEP flap breast reconstruction. We administered BREAST-Q questionnaire electronically almost 2 year after surgery. Patients were divided into two groups: implant-based and autologous breast reconstruction with DIEP flaps. Baseline demographics and patient characteristics were analyzed using a Students t-test (continuous variables) or Chi-square/Fisher’s exact test (categorical variables). Mean standard deviation BREAST-Q scores were reported for the overall cohort and by modality for the postoperative period. The linear regression model was applied to all BREAST-Q score with all predictor factors.ResultsOf the 1125 patients involved, only 325 met the inclusion criteria and were enrolled in this study; specifically, 133 (41%) DIEP and 192 (59%) prosthetic reconstructions. We summarized the results of the principal scales of BREAST-Q module: satisfaction with breast, psychosocial well-being, satisfaction with outcome, and sexual well-being in which the autologous group was always more satisfied. We reported results of all linear regression models with higher values for the DIEP group independently from predictors.ConclusionThis is the first study performed on the Italian population that compares autologous surgical techniques with the implantation of breast implants. In this population, DIEP is considered the technique that leads to the highest satisfaction in all BREAST-Q scores.Level of Evidence IVThis 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.