A factor that facilitates the decision to undergo a preventive mastectomy is that results of breast reconstructive surgery have improved. [ 15 ]  A 2004 Canadian study found that 70% of women were satisfied or extremely satisfied with the reconstruction after bilateral prophylactic mastectomy. [ 12 ]  In the United States preventive mastectomy is gaining increased acceptance. [ 15 ] [ 16 ]  The decision of famous actresses such as  Christina Applegate  and  Angelina Jolie [ 13 ]  to undergo preventive mastectomy has given the procedure wider media attention. [ 15 ]   The trend towards prophylactic mastectomy appears to be less pronounced in Europe [ 15 ]  and India. [ 17 ]


Radiation lobectomy  is a form of  radiation therapy  used in  interventional radiology  to treat  liver cancer . It is performed in patients that would be surgical candidates for resection, but cannot undergo surgery due to insufficient remaining liver tissue. It consists of injecting small radioactive beads loaded with  yttrium-90  into the hepatic artery feeding the hepatic lobe in which the tumor is located. This is done with the intent of inducing growth in the contralateral hepatic lobe, not dissimilarly from  portal vein embolization  (PVE).


RL is performed in people with liver cancer, both primary such as  hepatocellular carcinoma  and metastatic such as from  colon adenocarcinoma . Surgical resection is considered the only curative treatment for liver cancer (other than liver transplantation for hepatocellular carcinoma) but it can only be performed in patients with sufficient remnant liver after resection (amongst other criteria). Both PVE and RL are performed in patients who are not surgical candidates due to insufficient future liver remnant (FLR), which is advised to be between 20-30% and 30-40% of the native liver volume in healthy and cirrhotic livers, respectively. [ 1 ]


Radiation lobectomy is a relatively new application of  radioembolization  and results are mainly reported in the form of retrospective chart review studies and case reports, without any prospective validation. Most authors report a comparable future liver remnant hypertrophy between portal vein embolization and RL, ranging between 10 and 47% [ 2 ] [ 3 ] [ 4 ] [ 5 ]  with cases reaching up to 119% with RL. [ 6 ]  The main difference between the two is the time interval necessary for appropriate hypertrophy, greater for RL. PVE requires a shorter time frame to achieve comparable results, ranging between 2–6 weeks, [ 7 ] [ 8 ]  while the hypertrophy kinetics of RL are slower but more constant, without significant plateau (some studies report continued hypertrophy up to 9 months). [ 2 ]  Some authors have even raised concerns regarding PVE and the potential interval disease progression in the embolized and treatment naive lobes while allowing hypertrophy, which is of less concern with RL due to its added tumoricidal effect. [ 9 ]  Additionally, RL has been demonstrated to aid surgical resection in some cases by inducing a “vascular shift” of tumor masses via necrosis and contraction away from major vascular pedicles, converting patients to resectable status. [ 4 ]  One study has shown preliminary 600-day survival in 12 out of 13 patients who received RL and subsequent resection. [ 4 ]  Ultimately, further studies are needed to prospectively compare survival and recurrence outcomes in patients receiving RL versus PVE. [ citation needed ]


Common side effects include fatigue, abdominal pain, nausea and anorexia, usually self-limiting. Post-radioembolization syndrome occurs in 20-70% of patients that undergo traditional radioembolization, presenting with shakes, chills, fatigue, nausea/vomiting, abdominal pain/discomfort, and/or cachexia and possibly hemodynamic changes, rarely requiring admission. Unfortunately, most data, if not all, is derived from traditional radioembolization outcomes studies and more will be needed to assess the actual incidence and risk of post-radioembolization syndrome in RL. [ 10 ] [ 11 ]


Complications are abscess formation, biliary complications (biloma, radiation induced cholecystitis and cholangitis, biliary necrosis), gastrointestinal complications (diarrhea, radiation induced gastritis and gastrointestinal ulceration), radiation induced pancreatitis, dermatitis, pneumonitis and lymphopenia. [ 10 ] [ 11 ] [ 2 ]


RL is performed by an interventional radiologist in the  angiography  suite, in a fashion similar to radioembolization. The procedure is composed of two different portions, a planning phase and the actual radiation lobectomy, usually performed in two different sessions: [ 10 ]


Patients undergo cross-sectional imaging at approximately 30–60 days from the procedure for evaluation of the degree of  hypertrophy  undergone by the contralateral side (as assessed by future liver remnant) and to assess tumor burden. At this time, the surgeons and/or a multi-specialty tumor board will convene to determine if the patient can/should undergo safe surgical resection.


Radical mastectomy  is a surgical procedure that treats  breast cancer  by removing the breast and its underlying chest muscle (including  pectoralis major  and  pectoralis minor ), and  lymph nodes  of the  axilla  (armpit). Breast cancer is the most common cancer among women. During the early twentieth century it was primarily treated by surgery, when the mastectomy was developed. [ 1 ]  However, with the advancement of technology and surgical skills in recent years, mastectomies have become less invasive. [ 2 ]  As of 2016 [update] , a combination of  radiotherapy  and breast conserving mastectomy are considered optimal treatment.


Halsted  and Meyer were the first to achieve successful results with the radical mastectomy, thus ushering in the modern era of surgical treatment for breast cancer. In 1894,  William Halsted  published his work with radical mastectomy from the 50 cases operated at Johns Hopkins between 1889 and 1894. [ 3 ]  Willy Meyer also published research on radical mastectomy from his interactions with New York patients in December 1894. [ 4 ]  The  en bloc  removal of the breast tissue became known as the Halsted mastectomy before adopting the title "the complete operation" and eventually, "the radical mastectomy" as it is known today. [ 5 ]


Radical mastectomy was based on the medical belief at the time that breast cancer spread locally at first, invading nearby tissue and then spreading to surrounding lymph ducts where the cells were "trapped". It was thought that hematic spread of tumor cells occurred at a much later stage. [ 1 ]  Halsted himself believed that cancer spread in a "centrifugal spiral", solidifying this opinion in the medical community at the time. [ 6 ]


Radical mastectomy involves removing all the breast tissue, overlying skin, the pectoralis muscles, and all the axillary lymph nodes. Skin was removed because the disease involved the skin, which was often ulcerated. [ 3 ] [ 7 ]  The pectoralis muscles were removed not only because the chest wall was involved, but also because it was thought that removal of the transpectoral lymphatic pathways were necessary. It was also thought, at that time, that it was anatomically impossible to do a complete axillary dissection without removing the pectoralis muscle. [ 3 ] [ 4 ]


William Halsted  accomplished a three-year recurrence rate of 3% and a locoregional recurrence rate of 20% with no  perioperative mortality . The five-year survival rate was 40%, which was twice that of untreated patients. [ 3 ]  However, post-operation morbidity rates were high as the large wounds were left to heal by  granulation ,  lymphedema  was  ubiquitous, and arm movement was highly restricted. Thus, chronic pain became a prevalent  sequela . Because surgeons were faced with such large breast cancers that seemed to need drastic treatment methods, the quality of patient life was not taken into consideration. [ 7 ] [ 8 ] [ 9 ] [ 10 ] [ 11 ] [ 12 ] [ 13 ] [ excessive citations ]


Nonetheless, due to  Halsted  and Meyer's work, it was possible to cure some cases of breast cancer and knowledge of the disease began to increase. Standardized treatments were created, and controlled long-term studies were conducted. Soon, it became apparent that some women with advanced stages of the disease did not benefit from surgery. In 1943, Haagensen and Stout reviewed over 500 patients who had radical mastectomy for breast cancer and identified a group of patients who could not be cured by radical mastectomy thus developing the concepts of operability and inoperability. [ 14 ]  The signs of inoperability included ulceration of the skin, fixation to the chest wall, satellite nodules, edema of the skin (peau d'orange), supraclavicular lymph node enlargement, axillary lymph nodes greater than 2.5 cm, or matted, fixed lymph nodes. [ 14 ]  This contribution of Haagensen and his colleagues would eventually lead to the development of a clinical staging system for breast cancer, the Columbia Clinical Classification, which is a landmark in the study of biology and treatment of breast cancer. [ citation needed ]


Today, surgeons rarely perform radical mastectomies, as a 1977 study by the National Surgical Adjuvant Breast and Bowel Project (NSABP), led by  Bernard Fisher , showed that there was no statistical difference in survival or recurrence between radical mastectomies and less invasive surgeries. [ 15 ] [ 16 ]


According to the Halsted-Meyer theory, the major pathway for breast cancer dissemination was through the  lymphatic ducts . Therefore, it was thought that performing wider and more mutilating surgeries that removed a greater number of lymph nodes would result in greater chances of cure. [ 17 ]  From 1920 onwards, many surgeons performed surgeries more invasive than the original procedure by  Halsted .  Sampson Handley  noted  Halsted 's observation of the existence of malignant metastasis to the chest wall and breast bone via the chain of internal mammary nodes under the sternum and employed an "extended" radical mastectomy that included the removal of the lymph nodes located there and the implantation of radium needles into the anterior intercostal spaces. [ 18 ]  This line of study was extended by his son, Richard S. Handley, who studied internal mammary chain nodal involvement in breast cancer and demonstrated that 33% of 150 breast cancer patients had internal mammary chain involvement at the time of surgery. [ 19 ]  The radical mastectomy was subsequently extended by a number of surgeons such as Sugarbaker and Urban to include removal of internal mammary lymph nodes. [ 20 ] [ 21 ]  Eventually, this "extended" radical mastectomy was extended even further to include removal of the supraclavicular lymph nodes at the time of mastectomy by Dahl-Iversen and Tobiassen. [ 22 ]  Some surgeons like Prudente even went as far as amputating the upper arm  en bloc  with the mastectomy specimen in an attempt to cure relatively advanced local disease. [ 23 ]  This increasingly radical progression culminated in the ‘super-radical’ mastectomy which consisted of complete excision of all breast tissue, axillary content, removal of the latissimus dorsi, pectoralis major and minor muscles and dissection of the internal mammary lymph nodes. [ 24 ]  After retrospective analysis, the extended radical mastectomies were abandoned as these massive and disabling operations proved to be not superior to those of the standard radical mastectomies. [ citation needed ]


Radiofrequency ablation  ( RFA ), also called  fulguration , [ 1 ]  is a medical procedure in which part of the  electrical conduction system of the heart ,  tumor ,  sensory nerves  or a dysfunctional  tissue  is  ablated  using the heat generated from  medium frequency   alternating current  (in the range of 350–500 kHz). [ 2 ] [ 3 ]  RFA is generally conducted in the  outpatient  setting, using either a  local anesthetic [ 3 ]  or  twilight anesthesia . When it is delivered via  catheter , it is called radiofrequency  catheter ablation .


Two advantages of  radio frequency  current (over previously used low frequency AC or pulses of DC) are that it does not directly stimulate nerves or heart muscle, and therefore can often be used without the need for  general anesthesia , and that it is specific for treating the desired tissue without significant collateral damage. [ 3 ] [ 4 ]  Due to this, RFA is an alternative for eligible patients who have  comorbities  or do not want to undergo surgery. [ 3 ] [ 5 ] [ 6 ]


Documented benefits have led to RFA becoming widely used during the 21st century. [ 3 ] [ 5 ] [ 7 ] [ 8 ] [ 9 ]  RFA procedures are performed under image guidance (such as X-ray screening,  CT scan  or  ultrasound ) by an interventional pain specialist (such as an anesthesiologist),  interventional radiologist ,  otolaryngologists , a gastrointestinal or surgical endoscopist, or a  cardiac electrophysiologist , a subspecialty of  cardiologists .


RFA may be performed to treat tumors in the lung, [ 10 ] [ 11 ] [ 12 ]  liver, [ 13 ]  kidney, and bone, as well as other body organs less commonly. Once the diagnosis of tumor is confirmed, a needle-like RFA probe is placed inside the tumor. The radiofrequency waves passing through the probe increase the temperature within tumor tissue, which results in destruction of the tumor. RFA can be used with small tumors, whether these arose within the organ (primary tumors) or spread to the organ ( metastases ). The suitability of RFA for a particular tumor depends on multiple factors. [ citation needed ]


RFA can usually be administered as an outpatient procedure, though may at times require a brief hospital stay. RFA may be combined with locally delivered chemotherapy to treat hepatocellular carcinoma (primary liver cancer). A method currently in phase III trials uses the low-level heat (hyperthermia) created by the RFA probe to trigger release of concentrated chemotherapeutic drugs from heat-sensitive liposomes in the margins around the ablated tissue as a treatment for  hepatocellular carcinoma  (HCC). [ 14 ]
Radiofrequency ablation is also used in pancreatic cancer and bile duct cancer. [ 15 ]


RFA has become increasingly important in the care of benign bone tumors, most notably  osteoid osteomas . Since the procedure was first introduced for the treatment of osteoid osteomas in the 1990s, [ 16 ]  it has been shown in numerous studies to be less invasive and expensive, to result in less bone destruction and to have equivalent safety and efficacy to surgical techniques, with 66 to 95% of people reporting freedom from symptoms. [ 17 ] [ 18 ] [ 19 ]  While initial success rates with RFA are high, symptom recurrence after RFA treatment has been reported, with some studies demonstrating a recurrence rate similar to that of surgical treatment. [ 20 ]  RFA is also increasingly used in the palliative treatment of painful  metastatic bone disease  in people who are not eligible or do not respond to traditional therapies ( i.e.  radiation therapy ,  chemotherapy , palliative surgery,  bisphosphonates  or analgesic medications). [ 21 ]


Radiofrequency energy is used in heart tissue or normal parts to destroy abnormal electrical pathways that are contributing to a  cardiac arrhythmia . It is used in recurrent  atrial flutter  (Afl),  atrial fibrillation  (AF),  supraventricular tachycardia  (SVT),  atrial tachycardia ,  Multifocal Atrial Tachycardia  (MAT) and some types of  ventricular arrhythmia . The energy-emitting probe (electrode) is at the tip of a catheter which is placed into the heart, usually through a vein. This catheter is called the  ablator . The practitioner first "maps" an area of the heart to locate the abnormal electrical activity ( electrophysiology study ) before the responsible tissue is eliminated. Radiofrequency ablation technique can be used in AF, either to block the  atrioventricular node  after implantation of a pacemaker or to block conduction within the  left atrium , especially around the  pulmonary veins . Radiofrequency ablation for AF can be unipolar (one electrode) or bipolar (two electrodes). [ 22 ]  Although bipolar can be more successful, it is technically more difficult, resulting in unipolar being used more often. [ 22 ]  But bipolar is more effective in preventing recurrent atrial arrhythmias. [ 23 ]


Ablation is now the standard treatment for SVT and typical atrial flutter, In some conditions, especially forms of intra-nodal re-entry (the most common type of SVT), also called atrioventricular nodal reentrant tachycardia or AVNRT, ablation can also be accomplished by cryoablation (tissue freezing using a coolant which flows through the catheter) which avoids the risk of complete heart block – a potential complication of radiofrequency ablation in this condition. Recurrence rates with cryoablation are higher, though. [ 24 ]  Microwave ablation, where tissue is ablated by the microwave energy "cooking" the adjacent tissue, and ultrasonic ablation, creating a heating effect by mechanical vibration, or laser ablation have also been developed but are not in widespread use. [ citation needed ]


A new indication for the use of radiofrequency technology has made news in the last few years.  Hypertension  is a very common condition, with about 1 billion people over the world, nearly 75 million in the US alone. Complications of inadequately controlled hypertension are many and have both individual and global impact. Treatment options include medications, diet, exercise, weight reduction and meditation. Inhibition of the neural impulses that are believed to cause or worsen hypertension has been tried for a few decades. Surgical sympathectomy has helped but not without significant side effects. Therefore, the introduction of non-surgical means of renal denervation using a radiofrequency ablation catheter was enthusiastically welcomed. Although the initial use of radiofrequency-generated heat to ablate nerve endings in the renal arteries to aid in management of 'resistant hypertension' were encouraging, the most recent phase 3 studying looking at catheter-based renal denervation for the treatment of resistant hypertension failed to show any significant reduction in systolic blood pressure. [ 25 ]


Radiofrequency  ablation [ 26 ]  is a dermatosurgical procedure by using various forms of alternating current. Types of radiofrequency are electrosection, electrocoagulation, electrodessication and fulguration. The use of radiofrequency ablation has obtained importance as it can be used to treat most of the skin lesions with minimal side effects and complications. [ citation needed ]


Radiofrequency ablation is a minimally invasive procedure used in the treatment of  varicose veins . It is an alternative to the traditional stripping operation. Under ultrasound guidance, a radiofrequency catheter is inserted into the abnormal vein and the vessel treated with radio-energy, resulting in closure of the involved vein. Radiofrequency ablation is used to treat the  great saphenous vein , the  small saphenous vein , and the  perforator veins . The latter are connecting veins that transport blood from the superficial veins to the deep veins. Branch varicose veins are then usually treated with other minimally invasive procedures, such as  ambulatory phlebectomy ,  sclerotherapy , or  foam sclerotherapy . Currently, the VNUS ClosureRFS stylet is the only device specifically cleared by FDA for endovenous ablation of perforator veins. [ 27 ]


The possibility of skin burn during the procedure is very small, because the large volumes (500 cc) of dilute Lidocaine (0.1%) tumescent anesthesia injected along the entire vein prior to the application of radiofrequency provide a heat sink that absorbs the heat created by the device. Early studies have shown a high success rate with low rates of complications. [ 28 ]


RFA was first studied in  obstructive sleep apnea  (OSA) in a pig model. [ 29 ]  RFA has been recognized as a  somnoplasty  treatment option in selected situations by the  American Academy of Otolaryngology [ 29 ]  but was not endorsed for general use in the  American College of Physicians  guidelines. [ 30 ]


The clinical application of  RFA in obstructive sleep apnea  is reviewed in that main article, including controversies and potential advantages in selected  medical situations .
Unlike other electrosurgical devices, [ 31 ]  RFA allows very specific treatment targeting of the desired tissue with a precise  line of demarcation  that avoids collateral damage, which is crucial in the head and neck region due to its high density of major nerves and blood vessels. RFA also does not require high temperatures. However, overheating from misapplication of RFA can cause harmful effects such as coagulation on the surface of the electrode, boiling within tissue that can leave "a gaping hole", tears, or even charring. [ 32 ]


RFA, or  rhizotomy , was developed by  Nikolai Bogduk  to treat chronic pain arising from the  facet joints  in the lower ( lumbar ) back.  Radiofrequency waves  are used to produce heat on specifically identified nerves surrounding the  facet joints  called the lumbar medial branches of the  dorsal ramus of the spinal nerves . [ 33 ]   By generating heat around the nerve, the nerve is ablated, thus destroying its ability to transmit signals to the brain.


The nerves to be ablated are identified through injections of local anesthesia (such as  lidocaine ) around the medial branches prior to the RFA procedure to first confirm the diagnosis. If the  local anesthesia  injections provide temporary pain relief, the injection is repeated a second time to confirm the diagnosis. Then RFA is performed on the nerve(s) that responded well to the injections.


RFA is a minimally invasive procedure which can usually be done in day-surgery clinics, going home shortly after completion of the procedure. The person is awake during the procedure, so risks associated with general anesthesia are avoided. Whether for back or knee pain, a drawback for this procedure is that nerves recover function over time, so the pain relief achieved lasts only temporarily (3–15 months) in most people. [ 9 ]


Radiofrequency ablation of sensory nerves in the knee, also called  genicular neurotomy  or  genicular RFA , is clinically preceded by confirming pain reduction upon anesthetizing the main knee sensory nerves in a test procedure called  genicular nerve block . [ 3 ] [ 34 ] [ 35 ]  Genicular nerve block is a short (10-30 minutes), outpatient procedure usually performed weeks before genicular RFA. [ 3 ] [ 36 ] [ 37 ]  The extent of pain reduction by injecting a local anesthetic, such as  bupivacaine , at specific locations of the target genicular nerves, is self-assessed by the person for hours after the procedure, leading to confirmation with the physician of the need for RFA. [ 3 ] [ 37 ]


In the procedure for genicular RFA, a guide cannula is first directed under local anesthesia and imaging ( ultrasound  or  fluoroscopy ) to each target genicular nerve, then the radiofrequency electrode is passed through the cannula, and the electrode tip is heated to about 80 °C (176 °F) for one minute to  cauterize  a small segment of the nerve. [ 3 ] [ 34 ]  The heat destroys that segment of the nerve, which is prevented from sending pain signals to the brain. [ 3 ] [ 34 ]


As of 2019, several hundred publications showed promise for substantial, long-term (6 months or longer) reduction of knee pain following genicular RFA. [ 3 ] [ 38 ]


The US  Food and Drug Administration  had approved in 2017 a commercial device using cooled RFA, with effects lasting for up to a year of pain relief from  knee arthritis . [ 9 ] [ 39 ]  As of 2023, reviews of clinical outcomes indicated that efficacy for reducing knee pain was achieved by ablating three or more branches of the genicular nerve (one of the  articular  branches of the  tibial nerve ). [ 36 ] [ 38 ] [ 40 ] [ 41 ]  Other sources indicate 4-5 genicular nerve targets may be justified for ablation to optimize pain relief, [ 35 ] [ 36 ]  while a 2022 analysis indicated that as many as 10 genicular nerve targets for RFA would produce better long-term relief of knee pain. [ 42 ]


Knee pain relief of 50% or more following genicular RFA may last from several months to two years, [ 3 ] [ 40 ] [ 41 ]  and can be repeated by the same outpatient procedure when pain recurs. [ 3 ]


An anatomical study of  cadaver  knees indicated that ultrasound-guided bony landmarks could be used to effectively target the superior medial geniculate nerve, superior lateral geniculate nerve, and inferior medial geniculate nerve – the three nerves commonly targeted for knee RFA [ 3 ]  – with average nerve-to-needle distances of 1.7, 3.2, and 1.8 mm, respectively. [ 43 ]


Radiofrequency ablation has been shown to be a safe and effective treatment for  Barrett's esophagus . The balloon-based radiofrequency procedure was invented by Robert A. Ganz, Roger Stern and Brian Zelickson in 1999 (System and Method for Treating Abnormal Tissue in the Human Esophagus). While the person is sedated, a catheter is inserted into the esophagus and radiofrequency energy is delivered to the diseased tissue. This outpatient procedure typically lasts from fifteen to thirty minutes. Two months after the procedure, the physician performs an upper endoscopic examination to assess the esophagus for residual Barrett's esophagus. If any Barrett's esophagus is found, the disease can be treated with a focal RFA device. Between 80 and 90% or greater of people in numerous clinical trials have shown complete eradication of Barrett's esophagus in approximately two to three treatments with a favorable safety profile. The treatment of Barrett's esophagus by RFA is durable for up to 5 years. [ 44 ] [ 45 ] [ 46 ] [ 47 ] [ 48 ]


Radiofrequency ablation has been used successfully on benign thyroid nodules for decades, most notably in Europe, South America and Korea. [ citation needed ]  In the United States, the FDA approved the use of RFA techniques for thyroid nodules in 2018. Since then, professional guidelines reflect its use as a viable treatment modality for thyroid nodules, and the procedure is increasingly applied. [ citation needed ]


- 2023: the  American Thyroid Association  issued the position statement "Thyroid ablative procedures provide valid alternative treatment strategies to conventional surgical management for a subset of patients with symptomatic benign thyroid nodules. [ 49 ]


- 2022: the  American Association of Clinical Endocrinologists  published an update in Endocrine Practice, stating that the "new image-guided minimally invasive approaches appear safe and effective alternatives when used appropriately and by trained professionals to treat symptomatic or enlarging thyroid masses". [ 50 ]


- 2018: FDA approved the RFA procedure for treatment of benign thyroid nodules. [ citation needed ]


The procedure is similar to a thyroid biopsy, although instead of using a needle to remove cells from the nodule, a probe delivers heat to the interior of the nodule that effectively  cauterizess  the tissue. [ medical citation needed ]  Over the course of 3-6 months, the nodule will continue to shrink, typically achieving a 50-80% reduction total size. [ medical citation needed ]


In order to qualify for an RFA procedure, a person must have a clearly benign thyroid nodule, usually proven by two fine needle aspiration biopsies. [ medical citation needed ]


As of 2020, RFA is not recommended for the treatment of  malignant  thyroid nodules, although research into this topic is ongoing. [ 51 ]


RFA is also used in radiofrequency lesioning for vein closure in areas where intrusive surgery is contraindicated by trauma, and in liver resection to control bleeding (hemostasis) and facilitate the transection process. [ citation needed ]


This process has also been used to treat  TRAP sequence  in multiple gestation pregnancies. This has an acceptable success rate for saving the 'pump' twin in recent studies compared to previous methods including laser photocoagulation. [ citation needed ]


RFA is used to treat  uterine fibroids  using the heat energy of radio frequency waves to ablate the fibroid tissue. The Acessa device [ 52 ]  obtained FDA approval in 2012. [ 53 ]  The device is inserted via a laparoscopic probe and guided inside the fibroid tissue using an ultrasound probe. The heat shrinks the fibroids. Clinical data on the procedure show an average of 45% shrinkage.


RFA is also used in the treatment of  Morton's neuroma [ 54 ]  where the outcome appears to be more reliable than alcohol injections. [ 55 ]


A  resection margin  or  surgical margin  is the margin of apparently non-tumorous tissue around a tumor that has been surgically removed, called " resected ", in  surgical oncology .  The resection is an attempt to remove a  cancer   tumor  so that no portion of the malignant growth extends past the edges or margin of the removed tumor and surrounding tissue.  These are retained after the surgery and examined microscopically by a  pathologist  to see if the margin is indeed free from tumor cells (called "negative"). If cancerous cells are found at the edges (called "positive") the operation is much less likely to achieve the desired results. [ 1 ] : sections 1-2


The size of the margin is an important issue in areas that are functionally important (i.e., large vessels like the  aorta  or vital organs) or in areas for which the extent of surgery is minimized due to aesthetic concerns (i.e.,  melanoma  of the face or  squamous cell carcinoma  of the  penis ). [ 2 ]  The desired size of margin around the tumour can vary. In resections for  breast cancer , there appears to be a difference between European and American radiation oncologists, with the former preferring larger margins of over 5 mm. [ 1 ] : section 2


Residual tumour at the primary site after treatment (it does not address the surgical margin as commonly believed) is classified by the pathologist as (AJCC 8th Edition):


The Margin Status following tumour resection (AJCC 8th Edition):


Apart from traditional methods looking at stained "shaves" (thin slices of tissue removed from the edge of the margin) or smeared and stained imprints, more recent techniques used to assess margins include x-rays with compression, frozen specimens, and new techniques such as intraoperative fluorescence imaging,  Raman spectroscopy ,  optical coherence tomography  and quantitative diffuse reflectance  spectroscopy . [ 3 ] [ 1 ] : sections 5-6


Surgical margin in a surgery report defines the visible margin or free edge of "normal" tissue seen by the  surgeon  with the naked eye.  Surgical margin as read in a  pathology  report defines the histological measurement of normal or unaffected tissue surrounding the visible  tumor  under a  microscope  on a glass mounted histology section. [ 4 ] [ 5 ]   A "narrow" surgical margin implies that the tumor exists very close to the surgical margin, and a "wide" surgical margin implies the tumor exists far from the cut edge or the surgical margin.  Narrow surgical margin using the  bread loafing  technique suggests that residual cancer might be left due to  false negative  error.  A surgeon often will perform a second surgery if a narrow surgical margin is noted on a pathology report.


This determination is made with the full understanding of " false negative  error" intrinsic in the  bread loafing  technique of histology (also known as POMA - a term used by the NCCN). [ 6 ]   The higher the false negative error is, the higher the recurrence rate of a cancer or tumor at the surgical margin. This is due to the misreading of a pathology specimen as being clear of residual tumor when there is actually residual tumor left where the specimen was not cut and mounted on the histology slide. The " false negative  error" is very low in the  CCPDMA  method of histology processing, and can be very high in the  bread loafing  (POMA) method of histology processing. [ 6 ]   In the bread loafing method of processing, one will note a high  false negative  error rate with narrow surgical margin; and one will note a low  false negative  error with a wide surgical margin [ 7 ]   Surgical margin has a much less significant effect on the  false negative  error rate of  CCPDMA  methods, allowing the surgeon to routinely use very narrow surgical margins (1 to 2 mm for non-melanoma skin cancer). [ 7 ]  The worldwide extent of  inadequate resection of the tumor is illustrated in following Table showing the percentage of positive surgical margins for the most common cancer types.


Retroperitoneal lymph node dissection  (RPLND) is a  surgical procedure  to remove abdominal  lymph nodes . It is used to treat  testicular cancer , as well as to help establish the exact  stage  and type of the cancer.


Testicular cancer  metastasizes  in a predictable pattern, and lymph nodes in the  retroperitoneum  are typically the first place it lands. [ 1 ] [ 2 ]  By examining the removed lymphatic tissue, a  pathologist  can determine whether the disease has spread. If no malignant tissue is found, the cancer can be labeled Stage I, limited to the  testicle . [ 3 ]


The procedure is common in the treatment of Stage I and II  non-seminomatous germ cell tumors . [ 2 ]  In  seminomas , another form of testicular cancer,  radiation therapy  is generally preferred to the invasive RPLND procedure. [ 4 ]


Whether RPLND is needed after  orchiectomy  depends on the type of tumor and its stage. RPLND may be performed to remove tumor remnants that persist after chemotherapy, because these remnants might otherwise spread and become resistant to the chemotherapy agents previously used. [ 5 ]


Chemotherapy may be administered before RPLND and, if successful, may render surgery unnecessary. However, if the cancer does recur, surgery is much more difficult in a patient previously treated with chemotherapy. [ 2 ]


RPLND is usually performed using an incision that extends from the  sternum  to several inches below the  navel . A less invasive procedure (L-RPLND) can be performed  laparoscopically , but this is more costly and time-consuming, and requires specialized equipment that not every hospital has. Additionally, it is unclear whether L-RPLND is as effective as the standard, open procedure. [ 6 ]


Potential complications of RPLND include damage to the  sympathetic nerves  running parallel to the  spinal cord , which can result in  retrograde ejaculation  and  infertility . [ 6 ]  In most cases nerve sparing is feasible leading to reduced rates of retrograde ejaculation. However, prior chemotherapy or very large residual masses may make nerve sparing challenging. [ 7 ]  Contrary to popular belief,  erectile function  is not compromised by RPLND because the nerves responsible for erection are located elsewhere. [ 6 ]


As with any major surgery,  infection  is a possibility, as are  bowel obstructions  and  adhesions . [ 6 ]


Stereotactic injection  is a procedure in which a  computer  and a  3-dimensional   scanning device  are used to  inject   anticancer drugs  directly into a  tumor .


Stereotactic injection may also refer to the use of injections during  stereotactic surgery  to precisely target specific sites, such as brain regions, during experimental research. [ 1 ] [ 2 ]


Vulvectomy  refers to a  gynecological  procedure in which the  vulva  is partly or completely removed.  The procedure is usually performed as a last resort in certain cases of  cancer , [ 1 ]   vulvar dysplasia ,  vulvar intraepithelial neoplasia , [ 2 ]  or as part of  female genital mutilation . Although there may be severe pain in the groin area after the procedure, for a number of weeks, sexual function is generally still possible but limited. [ 3 ]


A  simple vulvectomy  can be either complete (more than 80% of the vulvar area) or partial (less than 80% of vulvar area).  It removes the skin and superficial subcutaneous tissues.  A  radical vulvectomy  is the same with regard to complete or partial, however, includes removal of skin and deep subcutaneous tissue.  An  inguinofemoral lymphadenectomy  may be performed along with a radical vulvectomy (whether partial or complete) on one or both sides if spread of a cancer is suspected. [ 4 ]


A  simple partial vulvectomy  is the least severe, only removing the affected portion of the vulva.


A "skinning vulvectomy" is the removal of the top layer of vulvar skin (the external female genital organs, including the clitoris, vaginal lips and the opening of the vagina). In this case  skin grafts  from other parts of the body may be needed to cover the area. There are two types of skinning vulvectomy, the "partial" and the "total". The objective of the first is the preservation of the cosmetic and functional integrity of the vulva in younger and sexually active patients, in whom a steady increase in the incidence of  vulvar intraepithelial neoplasia  has been observed in the last decade. [ when? ]  The objective of the latter is the removal of the entire vulva with total skin graft replacement in patients with an entire  vulvar cancer  involvement. "Modified radical vulvectomy" involves the removal of vulva containing cancer and some of the normal tissue around it.


Wedge resection  is a  surgical procedure  to remove a triangle-shaped slice of tissue. It may be used to remove a  tumor  or some other type of tissue that requires removal and typically includes a small amount of normal tissue around it.
It is easy to repair, does not greatly distort the shape of the underlying organ and leaves just a single stitch line as a residual.


Wedge resection of the lung  is a  surgical  operation where a part of a  lung  is removed. It is done to remove a localized portion of diseased lung, such as early  stage   lung cancer . [ 1 ]


The  Wertheim–Meigs operation  (named after  Ernst Wertheim  and  Joe Vincent Meigs ) is a surgical procedure for the treatment of  cervical cancer  performed by way of an abdominal incision.


The German surgeon  Wilhelm Alexander Freund  undertook the first ever abdominal  extirpation  of a cancerous uterus on January 30, 1878. [ 1 ]  The first radical hysterectomy operation was described by John G. Clark, resident  gynecologist  under  Howard Kelly  at the  Johns Hopkins Hospital  in 1895. [ 2 ] [ 3 ]  In 1898, Ernst Wertheim, a Viennese physician, developed the radical total hysterectomy with removal of the pelvic lymph nodes and the parametrium. In 1905, he reported the outcomes of his first 270 patients. The operative  mortality rate  was 18%, and the major morbidity rate was 31%. [ 4 ]  In 1912, Wertheim reported on his first 500 operations and had his name assigned to the operation. In 1944, Meigs repopularized the surgical approach when he developed a modified Wertheim operation with removal of all pelvic nodes. [ 2 ] [ 4 ]  Meigs reported a survival rate of 75% for patients with stage I disease and demonstrated an operative mortality rate of 1% when these procedures were performed by a specially trained gynecologist. [ 4 ]


The Wertheim–Meigs operation is used to treat  stage IA2, IB1, IB2 and IIA cervical cancers , stage II  adenocarcinomas  of the  endometrium , upper vaginal carcinomas, uterine or cervical sarcomas, and other rare malignancies confined to the area of the cervix, uterus, and/or upper vagina. [ 5 ]  It is one of the most comprehensive gynecological interventions. It consists of the following measures: [ citation needed ]


The  ovaries  and  fallopian tubes  are typically left intact, although this decision is made on an individual basis.


The morbidity associated with the Wertheim–Meigs operation is substantial. The most important complications are  ureteral , ureterovaginal, and  vesicovaginal fistulae , appearing during the immediate postoperative  convalescence  period or later mainly in patients who received subsequent  radiotherapy . Other complications are described: intraoperative  hemorrhage  due to pelvic large vessel lesion, ureter or  bladder  accidental section,  abdominal wall dehiscence , ureteral obstruction causing  hydronephrosis  and  renal exclusion , disorders such as  urinary incontinence ,  pollakiuria ,  vesical atony , often accompanied by  urinary tract infection  and  hematuria . [ 6 ]


Aesthetic medicine  is a branch of modern medicine that focuses on altering natural or acquired unwanted appearance through the treatment of conditions including  scars , skin laxity, wrinkles, moles,  liver spots , excess fat,  cellulite , unwanted hair, skin discoloration,  spider veins [ 1 ]  and or any unwanted externally visible appearance. Traditionally, it includes  dermatology ,  oral and maxillofacial surgery ,  reconstructive surgery  and  plastic surgery , [ 2 ]  surgical procedures ( liposuction ,  facelifts ,  breast implants ,  Radio frequency ablation ), non-surgical procedures ( radio frequency skin tightening ,  non- surgical liposuction ,  chemical peel ,  high-intensity focused electromagnetic field , radio frequency fat removal), and a combination of both. [ 3 ]  Aesthetic medicine procedures are usually elective. [ 4 ]  There is a long history of aesthetic medicine procedures, dating back to many notable cases in the 19th century, [ 5 ]  though techniques have developed much since then.


Physical beauty  has been a consistently coveted notion. [ 6 ]   Efforts to improve and enhance beauty through aesthetic medical practices can be seen as early as 2000 years ago, in India, where the 'forehead flap' was used to reconstruct the noses and faces of soldiers injured in war and criminal punishments. [ 7 ]  This technique, though thoroughly developed and modified, is still used today as a common method to repair nasal defects. [ 8 ]  Although Greek and Roman medical practices have been considered the foundation for European and modern-day medicine for a long time, ancient Egyptian texts have revealed that Egyptian medicine produced many key medical discoveries and the basis for many modern practices. [ 9 ]  The Egyptians recorded their use of oils, waxes,  Cyperus , [ 9 ]  and other plant materials to reduce the signs of aging, like wrinkles and spots, and to restore youthful skin. [ 10 ]  They studied bodily functions, like inflammatory processes, and were able to make discoveries that allowed them to treat cosmetic wounds and burns using therapies and medicines. This included the initial application of fresh meat to the wound, followed by the use of oil/lipids, honey, and fibers, generally woven linen, until the wound had healed. [ 11 ]  As physicians have discovered more about medicine throughout history, these practices have been developed to be more efficient and sanitary and can be seen today in common skin reparation remedies. [ 9 ]


In more recent history, within the past 30 years, the industry of aesthetic medicine has been developing rapidly with the addition of and growing demand for "injectables," [ 12 ]  a form of transcutaneous treatment used to rejuvenate and restore the skin of a patient. [ 13 ]  These medical injectables have become well established due to their associated low risk, especially compared to other aesthetic surgical practices, as well as the practically non-existent recovery time needed after the procedures are performed. [ 14 ]  Within the past ten years, the  U.S. Food and Drug Administration  has reviewed and approved [ 15 ]  over 20 injectable products used for medical aesthetics, in response to the growing demand. [ 12 ]  The most commonly used injectables in the industry today are  botulinum neurotoxin , commonly referred to as botox, and hyaluronic acid fillers. [ 16 ]  According to statistics from an annual survey conducted by the  American Society for Aesthetic Plastic Surgery , from 1997 to 2011 the number of nonsurgical procedures performed by aesthetic physicians increased by 356%. [ 12 ]


Aesthetic medicine specializes in altering the cosmetic appearance.  It has diverse applications for dermatological and surgical conditions.  It includes indications related to minimizing signs of aging, such as skin laxity, wrinkles, and  liver spots .  Aesthetic medicine also plays a role in the treatment of excess fat,  cellulite , and obesity.  Laser based therapies can be indicated for the treatment of  scars , unwanted hair, skin discoloration, and  spider veins . [ 26 ]


Overall health is assessed by a physician to ensure that the symptom being treated (for example, weight gain and  excessive hair ) is not a sign of an underlying medical condition (like hypothyroidism) that should be stabilized with medical therapies.
It is also very important for the medical aesthetician to be inclusive in providing a team approach for minimally invasive facial aesthetic procedures.


A career in aesthetic medicine can be approached from a number of professions.  A multidisciplinary or team based approach is often necessary to adequately address an aesthetic need.  To perform certain procedures, one must be a  surgeon ,  medical doctor  (Dermatologist/plastic surgeon/ENT surgeon/Oculoplastic surgeon) or  maxillofacial surgeon /Cosmetic Dentist . [ 27 ]  Medical Aesthetics requires specialized training and certification beyond a nurse license / aesthetic license.  Counselors ,  psychologists  or  psychiatrists  can help people determine if their reasons for pursuing aesthetic procedures are healthy and help to identify psychiatric disorders such as  compulsive eating ,  anorexia , and  body dysmorphic disorder .  Reconstructive surgeons  can help correct appearance after accidents, burns, surgery for  cancer  (such as  breast reconstruction  after  mastectomy  for cancer), or for  congenital deformities  like correction of  cleft lip .  Orthodontists  work to improve alignment of teeth, often partially for aesthetic reasons, and  oral and maxillofacial surgeons  can perform cosmetic facial surgery & correct deformities of the mouth and jaw.  Both orthodontists and maxillofacial surgeons can be assisted by  dental technicians .


Anthropometric cosmetology  ( Anthropometry  from Greek Ανθρωπος, "man") is the medical practice to correct or modify deformities in the upper and lower extremities of the body. This is done in order to attain an aesthetically pleasing appearance or to eliminate physical and psychological discomforts.


Anthropometric (orthopedic) cosmetology appeared in the 1990s based on  traumatology ,  orthopedic , and  aesthetic surgery [ citation needed ] . In 1965,  Gavriil Ilizarov  determined that  bone  fragments could be carefully pulled apart without disrupting their alignment. These bone fragments could then grow back to a complete form. This discovery was groundbreaking for the fields of traumatology orthopedics. In complex cases of comminuted fractures, the  Ilizarov apparatus  method makes it possible to avoid squeezing the remnant fragments together, which otherwise might result in shortened  limbs . Traumatic injuries, as well as congenital and acquired deformities, may be treated with this technique.


Chondrodysplasia  is a disease where a child's growth stops abruptly, resulting in an adult dwarf, with shortened and often deformed arms and legs and is regarded as a congenital deformity. Ilizarov began to solve the problems associated with such diseases using his own apparatus. The apparatus he initially used was modified to support the lengthening of finger ( phalanx ) bones. The first experiments involved stretching the bones in the arms and legs of people with chondrodysplasia. New techniques, involving artificial fractures, have been developed.


Ilizarov's followers, Kaplunov and Yegorov, first used anthropometric cosmetology in  Volgograd , Russia in 1992, on a healthy patient for strictly cosmetic purposes. [ 1 ]  The surgical operation was a success: the tibia was lengthened 6 cm over 11 months. Later, this technique was used elsewhere. Yegorov, Chernov, and Nekrasov subsequently wrote a book  Orthopedic Cosmetology , the first scientific publication in this field.


Surgical intervention:


Anthropometric cosmetology can be used when the patient has: [ 2 ]


Types of anthropometric cosmetology:


Breast augmentation  and  augmentation mammoplasty  is a cosmetic surgery procedure, which uses  breast-implants  and/ or fat-graft  mammoplasty  technique to increase the size, change the shape, and alter the texture of the breasts. Although in some cases augmentation mammoplasty is applied to correct  congenital defects  of the breasts and the chest wall [ 1 ]  in other cases it is performed purely for cosmetic reasons.


The surgical implantation approach creates a  spherical  augmentation of the breast hemisphere, using a breast implant filled with either  saline  solution or  silicone gel ; the fat-graft transfer approach augments the size and corrects contour defects of the breast hemisphere with grafts of the  adipocyte fat tissue , drawn from the person's body.


In a breast reconstruction procedure, a  tissue expander  (a temporary breast implant device) is sometimes put in place and inflated with saline to prepare (shape and enlarge) the recipient site (implant pocket) to receive and accommodate the breast implant prosthesis.


In most instances of fat-graft breast augmentation, the increase is of modest volume, usually only one  bra  cup size or less, [ 2 ]  which is thought to be the physiological limit allowed by the metabolism of the human body. [ 3 ]


There are four types of implant:


The saline breast implant, filled with  saline solution , was first manufactured by the Laboratoires Arion company, in France, and introduced for use as a prosthetic  medical device  in 1964. Modern-day versions of saline breast implants are manufactured with thicker, room-temperature  vulcanized  (RTV) shells made of a  silicone   elastomer . The study  In vitro Deflation of Pre-filled Saline Breast Implants  (2006) reported that the rates of deflation (filler leakage) of the pre-filled saline breast implant made it a second-choice prosthesis for "corrective breast surgery". [ clarification needed ] [ 5 ]  Nonetheless, in the 1990s, the saline breast implant was mandated to be the prosthesis usual for breast augmentation surgery, the result of the U.S.   Food and Drug Administration 's (FDA) temporary restriction against the importation of silicone-filled breast implants. [ citation needed ]


The technical goal of saline-implant technique was a less-invasive surgical technique, by inserting an empty, rolled-up breast implant through a smaller surgical incision. [ 6 ]  In surgical practice, after having installed the empty breast implants in the implant pockets, the plastic surgeon would then fill each device with saline solution through a  one-way valve  and, because the required insertion incisions were short and small, the resultant incision scars would be smaller and shorter than the surgical scars typical of the pre-filled, silicone-gel implant surgical technique. [ 7 ]


When compared with the results achieved with a silicone-gel breast implant, the saline implant can yield "good-to-excellent" results of increased breast size, a smoother hemisphere-contour, and realistic consistency; yet it is likelier to cause cosmetic problems, such as the rippling and the wrinkling of the breast-envelope skin, and technical problems, such as the implant's presence being noticeable to the eye and to the touch. The occurrence of such cosmetic problems is likelier in the case of a person with very little breast tissue; in the case of a person who requires  post-mastectomy  breast reconstruction, the silicone-gel implant is the technically superior  prosthetic  device for  breast reconstruction . In the case of the person with much breast tissue, for whom sub-muscular placement is the recommended surgical approach, saline breast implants can give an aesthetic result much like that produced by silicone breast implants: an appearance of proportionate breast size, smooth contour, and realistic consistency. [ 8 ]


The modern  prosthetic breast  was invented in 1961, by the American  plastic surgeons  Thomas Cronin and Frank Gerow, and manufactured by the  Dow Corning Corporation ; in due course, the first augmentation mammoplasty was performed in 1962. [ 9 ]  There are five generations of  medical device   technology  for the breast-implant models filled with silicone gel; each generation of breast prosthesis is defined by common model-manufacturing techniques.


The Cronin–Gerow implant, prosthesis model 1963, was a silicone rubber envelope-sack, shaped like a teardrop, which was filled with viscous silicone-gel. [ 10 ]  To reduce the rotation of the emplaced breast-implant upon the chest wall, the model 1963 prosthesis was affixed to the implant pocket with a fastener-patch, made of Dacron material ( polyethylene terephthalate ), which was attached to the rear of the breast implant shell. [ 11 ]


In the 1970s, manufacturers offered the second generation of breast implant prostheses


In the 1980s, the third- and fourth-generation implants were stepwise advances in manufacturing technology, such as  elastomer -coated shells that decreased gel bleed (filler leakage), and a thicker, increased-cohesion filler gel. The manufacturers of implantable breast prostheses then designed and made anatomic models (like the natural breast) and "shaped" models, which realistically corresponded with the breast and body types of actual women. The tapered models of breast implant have a uniformly textured surface, to reduce rotation of the prosthesis within the implant pocket; round models of breast implant are available in both smooth-surface and textured-surface models, as rotation is not an issue.


Since the mid-1990s, the fifth generation of silicone gel breast implant is made of a semi-solid gel, which mostly eliminates the occurrences of filler leakage ("silicone-gel bleed") and of the migration of the silicone filler from the implant-pocket to other areas of the person's body. The studies  Experience with Anatomical Soft Cohesive Silicone gel Prosthesis in Cosmetic and Reconstructive Breast Implant Surgery  (2004) and  Cohesive Silicone gel Breast Implants in Aesthetic and Reconstructive Breast Surgery  (2005) reported relatively lower rates of  capsular contracture  and of device-shell rupture, and relatively  greater rates of "medical safety" and "technical efficacy" than those of early-generation breast implants. [ 15 ] [ 16 ] [ 17 ]


Saline and silicone gel are the most common types of breast implant used in the world today. [ 18 ]  Alternative-composition implants have largely been discontinued. These implants featured fillers such as soy oil and polypropylene string. Other discontinued materials include ox  cartilage ,  Terylene  "wool", ground  rubber ,  silastic  rubber, and  Teflon -silicone prostheses. [ 18 ]


Structured implants were approved by the FDA and Health Canada in 2014 as a fourth category of breast implant. [ 4 ]  These implants incorporate both saline and silicone gel implant technology. The filler is saline solution, in case of rupture, and has a natural feel, like silicone gel implants. [ 19 ]  This implant type uses an internal structure consisting of three nested silicone rubber "shells" that support the upper half of the breast, with the two spaces between the three shells filled with saline. The implant is inserted, empty, then filled once in place, which requires a smaller incision than a pre-filled implant. [ 4 ]


The breasts are  apocrine glands  which produce  milk  for the feeding of infant children, [ 20 ]


Digestive tract contamination and systemic toxicity due to the leakage of breast implant filler to the breast milk are the principal infant-health concerns with breast implants. Breast implant fillers are biologically inert:  silicone  filler is  indigestible  and saline filler is mostly salt and water. Each of these substances should be chemically inert and present in the environment. [ citation needed ]  Moreover, "proponent" physicians have stated that there "should be no absolute contraindication to breast-feeding by women with silicone breast implants." [ 21 ]  In the early 1990s, at the beginning of the silicone gel breast implant illness panic, small-scale, non-randomized studies indicated possible breast-feeding complications from silicone implants; no one study was able to demonstrate disease causality due to implants. [ 22 ]


A person with breast implants is usually able to  breastfeed  an infant; yet implants can cause functional breastfeeding difficulties, especially with  mammoplasty  procedures that involve cutting around the areola, and implant placement directly beneath the breast, which tend to cause greater breast-feeding difficulties. Patients are advised to select a procedure which causes the least damage to the  lactiferous ducts  and the nerves of the nipple-areola complex (NAC). [ 23 ] [ 24 ] [ 25 ]


Functional breastfeeding difficulties arise if the surgeon cuts the milk ducts or the major nerves innervating the breast, or if the milk glands are otherwise damaged. Some surgical approaches, including IMF (inframammary fold), TABA (trans-axillary breast augmentation), and TUBA ( trans-umbilical breast augmentation ), avoid the tissue of the nipple-areola complex; if the person is concerned about possible breast-feeding difficulties, the periareolar incisions can sometimes be made so as to reduce damage to the milk ducts and to the nerves of the NAC. The milk glands are affected most by subglandular implants (under the gland), and by large-sized breast implants, which pinch the lactiferous ducts and impede milk flow. Small-sized breast implants, and submuscular implantation, cause fewer breast function problems; however, some women have managed to successfully breastfeed after undergoing periareolar incisions and subglandular emplacement. [ 25 ]


The studies  Body Image Concerns of Breast Augmentation Patients  (2003) and  Body Dysmorphic Disorder and Cosmetic Surgery  (2006) reported that the woman who underwent breast augmentation surgery also had undergone  psychotherapy , had low  self-esteem , presented frequent occurrences of  psychological depression , had attempted  suicide , and had  body dysmorphia  – a type of mental illness wherein she perceives non-existent physical defects. Post-operative patient surveys about the mental health and the quality of life of the women, reported improved physical health, physical appearance, social life, self-confidence, self-esteem, and satisfactory  sexual functioning . Furthermore, most of the women reported long-term satisfaction with their breast implants; some despite having had medical complications that required surgical revision, either corrective or aesthetic. Likewise, in Denmark, 8.0 percent of breast augmentation patients had a pre-operative history of psychiatric hospitalization. [ 26 ] [ 27 ] [ 28 ] [ 29 ] [ 30 ] [ 31 ] [ 32 ] [ 33 ] [ 34 ] [ 35 ] [ excessive citations ]


The Cosmeticsurgery.com article  They Need Bosoms, too – Women Weight Lifters  (2013) reported that women weight-lifters have resorted to breast augmentation surgery to maintain a feminine physique, and so compensate for the loss of breast mass consequent to the increased lean-body mass and decreased body-fat consequent to  lifting weights . [ 36 ]


The  longitudinal study   Excess Mortality from Suicide and other External Causes of Death Among Women with Cosmetic Breast Implants  (2007), reported that women who sought breast implants are almost 3.0 times as likely to commit suicide as are women who have not sought breast implants. Compared to the standard suicide-rate for women of the general populace, the suicide-rate for women with augmented breasts remained alike until 10-years post-implantation, yet it increased to 4.5 times greater at the 11-year mark, and so remained until the 19-year mark, when it increased to 6.0 times greater at 20-years post-implantation. Moreover, additional to the suicide risk, women with  breast implants  also faced a trebled death risk from  alcoholism  and drugs abuse (prescription and recreational). [ 37 ] [ 38 ]  Although seven studies have statistically connected a woman's undergoing a breast augmentation procedure to a greater suicide rate, the research indicates that augmentation [ 39 ] [ 40 ]  surgery does not increase the suicide rate; and that, in the first instance, it is the  psychopathologically  inclined woman who is likelier to undergo breast augmentation. [ 41 ] [ 42 ] [ 43 ] [ 44 ] [ 45 ] [ 46 ]


Moreover, the study  Effect of Breast Augmentation Mammoplasty on Self-Esteem and Sexuality: A Quantitative Analysis  (2007), reported that the women attributed their improved self-esteem, self-image, and increased, satisfactory sexual functioning to having undergone breast augmentation; the cohort, aged 21–57 years, averaged post-operative self-esteem increases ranging from 20.7 to 24.9 points on the 30-point  Rosenberg self-esteem scale , which data supported the 78.6 percent increase in the woman's  libido , relative to her pre-operative level of libido. Therefore, before agreeing to any surgical procedure, the plastic surgeon evaluates and considers the woman's  mental health  to determine if breast implants can positively affect her self-esteem and  sexual functioning . [ 47 ]


An augmentation mammoplasty for emplacing  breast implants  has three therapeutic purposes:


The  operating room  time of post– mastectomy   breast reconstruction , and of breast augmentation surgery is determined by the emplacement procedure employed, the type of incisional technique, the breast implant (type and materials), and the pectoral locale of the implant pocket. [ citation needed ]


The emplacement of a breast implant device is performed with five types of  surgical  incisions: [ 48 ]


The four surgical approaches to emplacing a breast implant to the implant pocket are described in  anatomical  relation to the  pectoralis major muscle .


The  surgical   scars  of a breast augmentation  mammoplasty  heal at 6-weeks post-operative, and fade within several months, according to the skin type of the woman. Depending upon the daily physical activity the woman might require, the augmentation mammoplasty patient usually resumes her normal life activities at about 1-week post-operative. The woman who underwent submuscular implantation (beneath the  pectoralis major  muscles) usually has a longer post–operative convalescence, and experiences more pain, because of the healing of the deep-tissue cuts into the chest muscles for the breast augmentation. The patient usually does not exercise or engage in strenuous physical activities for about six weeks. Moreover, during the initial convalescence, the patient is encouraged to regularly exercise (flex and move) her arms to alleviate pain and discomfort; and, as required,  analgesic  medication catheters for alleviating pain. [ 57 ] [ 58 ]


The plastic surgical emplacement of breast-implant devices, either for  breast reconstruction  or for  aesthetic purpose , presents the same health risks common to  surgery , such as adverse reaction to  anesthesia ,  hematoma  (post-operative bleeding),  seroma  (fluid accumulation), incision-site breakdown (wound infection). [ 59 ]  Complications specific to breast augmentation include breast pain, altered sensation, impeded breast-feeding function, visible wrinkling, asymmetry, thinning of the breast tissue, and  symmastia , the "bread loafing" of the bust that interrupts the natural plane between the breasts. Specific treatments for the complications of indwelling breast implants –  capsular contracture  and capsular rupture – are periodic  MRI  monitoring and physical examinations. Furthermore,  complications  and re-operations related to the implantation surgery, and to  tissue expanders  (implant placeholders during surgery) can cause unfavorable  scarring  in approximately 6–7% of the patients.
 [ 34 ] [ 60 ] [ 61 ]  Statistically, 20% of women who underwent cosmetic implantation, and 50% of women who underwent breast reconstruction implantation, required their explantation at the 10-year mark. [ 62 ]  In 2019, a direct link was identified between Allergan BIOCELL textured breast implants of Allergan and the breast implant-associated anaplastic large cell lymphoma (BIA-ALCL), a cancer of the immune system. FDA recalled all Allergan BIOCELL implants. [ 63 ]


Because a breast implant is a  Class III medical device  of limited product-life, the principal rupture-rate factors are its age and design; Nonetheless, a breast implant device can retain its mechanical integrity for decades in a woman's body. [ 64 ]  When a saline breast implant ruptures, leaks, and empties, it quickly deflates, and thus can be readily explanted (surgically removed). The follow-up report,  Natrelle Saline-filled Breast Implants: a Prospective 10-year Study  (2009) indicated rupture-deflation rates of 3–5 percent at 3-years post-implantation, and 7–10 percent rupture-deflation rates at 10-years post-implantation. [ 65 ]  In a study of his 4761 augmentation mammaplasty patients, Eisenberg reported that overfilling saline breast implants 10-13% significantly reduced the rupture-deflation rate to 1.83% at 8-years post-implantation. [ 66 ]


When a silicone breast implant ruptures it usually does not deflate, yet the filler gel does leak from it, which can migrate to the implant pocket; therefore, an intracapsular rupture (in-capsule leak) can become an extracapsular rupture (out-of-capsule leak), and each occurrence is resolved by explantation. Although the leaked silicone filler-gel can migrate from the chest tissues to elsewhere in the woman's body, most clinical  complications  are limited to the breast and  armpit  areas, usually manifested as  granulomas  (inflammatory nodules) and axillary  lymphadenopathy  (enlarged  lymph glands  in the armpit area). [ 67 ] [ 68 ] [ 69 ]


Silicone implant rupture can be evaluated using magnetic resonance imaging; from the long-term  MRI  data for single-lumen  breast implants, the European literature about second generation silicone-gel breast implants (1970s design), reported silent device-rupture rates of 8–15 percent at 10-years post-implantation (15–30% of the patients). [ 71 ] [ 72 ] [ 73 ] [ 74 ]


The study  Safety and Effectiveness of Mentor's MemoryGel Implants at 6 Years  (2009), which was a branch study of the U.S. FDA's core  clinical trials  for primary breast augmentation surgery patients, reported low device-rupture rates of 1.1 percent at 6-years post-implantation. [ 75 ]  The first series of MRI evaluations of the silicone breast implants with thick filler-gel reported a device-rupture rate of 1.0 percent, or less, at the median 6-year device-age. [ 76 ]  Statistically, the manual examination (palpation) of the woman is inadequate for accurately evaluating if a breast implant has ruptured. The study,  The Diagnosis of Silicone Breast-implant Rupture: Clinical Findings Compared with Findings at Magnetic Resonance Imaging  (2005), reported that, in asymptomatic patients, only 30 percent of the ruptured breast implants is accurately palpated and detected by an experienced plastic surgeon, whereas MRI examinations accurately detected 86 percent of breast-implant ruptures. [ 77 ]  Therefore, the U.S. FDA recommended scheduled MRI examinations, as silent-rupture screenings, beginning at the 3-year-mark post-implantation, and then every two years, thereafter. [ 34 ]  Nonetheless, beyond the U.S., the medical establishments of other nations have not endorsed routine MRI screening, and, in its stead, proposed that such a  radiologic  examination be reserved for two purposes: (i) for the woman with a suspected breast-implant rupture; and (ii) for the confirmation of  mammographic  and  ultrasonic  studies that indicate the presence of a ruptured breast implant. [ 78 ]


Furthermore,  The Effect of Study design Biases on the Diagnostic Accuracy of Magnetic Resonance Imaging for Detecting Silicone Breast Implant Ruptures: a Meta-analysis  (2011) reported that the breast-screening MRIs of asymptomatic women might overestimate the incidence of breast-implant rupture. [ 79 ]  In the event, the U.S. Food and Drug Administration emphasised that "breast implants are not lifetime devices. The longer a woman has silicone gel-filled breast implants, the more likely she is to experience complications." [ 80 ]


When one lumen of a structured implant ruptures, it leaks and empties. The other lumen remain intact and the implant only partially deflates, allowing for ease of explant and replacement. [ 4 ]


The human body's  immune response  to a surgically installed foreign object – breast implant, cardiac  pacemaker ,  orthopedic   prosthesis  – is to encapsulate it with  scar tissue  capsules of tightly woven  collagen  fibers, in order to maintain the integrity of the body by isolating the foreign object, and so tolerate its presence.  Capsular contracture  – which should be distinguished from normal capsular tissue – occurs when the collagen-fiber capsule thickens and compresses the breast implant; it is a painful  complication  that might distort either the breast implant, or the breast, or both. [ citation needed ]


The cause of capsular contracture is unknown, but the common incidence factors include bacterial contamination, device-shell rupture, filler leakage, and  hematoma . The surgical implantation procedures that have reduced the incidence of capsular contracture include submuscular emplacement, the use of breast implants with a textured surface (polyurethane-coated); [ 81 ] [ 82 ] [ 83 ]  limited pre-operative handling of the implants, limited contact with the chest skin of the implant pocket before the emplacement of the breast implant, and irrigation of the recipient site with triple-antibiotic solutions. [ 84 ] [ 85 ]  The use of a funnel device for implant insertion has also been shown to reduce the rate of capsular contracture. [ 86 ]


The correction of capsular contracture might require an open capsulotomy (surgical release) of the collagen-fiber capsule, or the removal, and possible replacement, of the breast implant. Furthermore, in treating capsular contracture, the closed capsulotomy (disruption via external manipulation) once was a common maneuver for treating hard capsules, but now is a discouraged technique, because it can rupture the breast implant. Non-surgical treatments for collagen-fiber capsules include massage, external  ultrasonic  therapy,  leukotriene pathway inhibitors  such as  zafirlukast  (Accolate) or  montelukast  (Singulair), and  pulsed electromagnetic field therapy  (PEMFT). [ 87 ] [ 88 ] [ 89 ] [ 90 ]


When the woman is unsatisfied with the outcome of the augmentation mammoplasty; or when technical or medical complications occur; or because of the breast implants' limited product life ( Class III medical device , in the U.S.), it is likely she might require replacing the breast implants. The common revision surgery indications include major and minor medical complications, capsular contracture, shell rupture, and device deflation. [ 70 ]  Revision incidence rates were greater for breast reconstruction patients, because of the post-mastectomy changes to the soft-tissues and to the skin envelope of the breast, and to the  anatomical  borders of the breast, especially in women who received adjuvant external  radiation therapy . [ 70 ]  Moreover, besides breast reconstruction,  breast cancer  patients usually undergo revision surgery of the nipple-areola complex (NAC), and symmetry procedures upon the opposite breast, to create a bust of natural appearance, size, form, and feel. Carefully matching the type and size of the breast implants to the patient's pectoral soft-tissue characteristics reduces the incidence of revision surgery. Appropriate tissue matching, implant selection, and proper implantation technique, the re-operation rate was 3.0% at the 7-year-mark, compared with the re-operation rate of 20% at the 3-year-mark, as reported by the U.S. Food and Drug Administration. [ 91 ] [ 92 ]


Since the 1990s, reviews of the studies that sought causal links between silicone-gel breast implants and  systemic disease  reported no link between the implants and subsequent systemic and autoimmune diseases. [ 78 ] [ 93 ] [ 94 ] [ 95 ]  Nonetheless, during the 1990s, thousands of women claimed sicknesses they believed were caused by their breast implants, including  neurological  and  rheumatological  health problems.


In the study  Long-term Health Status of Danish Women with Silicone Breast Implants  (2004), the national healthcare system of Denmark reported that women with implants did not risk a greater incidence and diagnosis of  autoimmune disease , when compared to same-age women in the general population; that the incidence of musculoskeletal disease was lower among women with breast implants than among women who had undergone other types of cosmetic surgery; and that they had a lower incidence rate than like women in the general population. [ 96 ] [ 97 ]


Follow-up  longitudinal studies  of these breast implant patients confirmed the previous findings on the matter. [ 98 ]  European and North American studies reported that women who underwent augmentation mammoplasty, and any plastic surgery procedure, tended to be healthier and wealthier than the general population, before and after implantation; that plastic surgery patients had a lower  standardized mortality ratio  than did patients for other surgeries; yet faced an increased risk of death by  lung cancer  than other plastic surgery patients. Moreover, because only one study, the Swedish  Long-term Cancer Risk Among Swedish Women with Cosmetic Breast Implants: an Update of a Nationwide Study  (2006), controlled for  tobacco smoking  information, the data were insufficient to establish verifiable statistical differences between smokers and non-smokers that might contribute to the higher  lung cancer  mortality rate of women with breast implants. [ 99 ] [ 100 ]  The long-term study of 25,000 women,  Mortality among Canadian Women with Cosmetic Breast Implants  (2006), reported that the "findings suggest that breast implants do not directly increase mortality in women." [ 44 ]


The study  Silicone gel Breast Implant Rupture, Extracapsular Silicone, and Health Status in a Population of Women  (2001), reported increased incidences of  fibromyalgia  among women who had  extracapsular silicone-gel leakage  than among women whose breast implants neither ruptured nor leaked. [ 101 ]  The study later was criticized as significantly methodologically flawed, and a number of large subsequent follow-up studies have not shown any evidence of a causal device–disease association. After investigating, the U.S. FDA has concluded "the weight of the  epidemiological  evidence published in the literature does not support an association between fibromyalgia and breast implants." [ 102 ] [ 103 ]  The systemic review study,  Silicone Breast implants and Connective tissue Disease: No Association  (2011) reported the investigational conclusion that "any claims that remain regarding an association between cosmetic breast implants and CTDs are not supported by the scientific literature". [ 104 ]


The manufacture of silicone breast implants requires the  metallic element   platinum  (Pt, 78) as a  catalyst  to accelerate the transformation of  silicone oil  into silicone gel for making the  elastomer  silicone shells, and for making other medical-silicone devices. [ 105 ]  The literature indicates that trace quantities of platinum leak from such types of silicone breast implant; therefore, platinum is present in the surrounding pectoral tissue(s). The rare pathogenic consequence is an accumulation of platinum in the  bone marrow , from where blood cells might deliver it to  nerve endings , thus causing  nervous system  disorders such as blindness, deafness, and  nervous tics  (involuntary muscle contractions). [ 105 ]


In 2002, the U.S. Food and Drug Administration (U.S. FDA) reviewed the studies on the human biological effects of breast-implant platinum, and reported little causal evidence of platinum toxicity to women with breast implants. [ 106 ]  Furthermore, in the journal  Analytical Chemistry , the study "Total Platinum Concentration and Platinum Oxidation States in Body Fluids, Tissue, and Explants from Women Exposed to Silicone and Saline Breast Implants by IC-ICPMS" (2006) proved controversial for claiming to have identified previously undocumented toxic platinum oxidative states  in vivo . [ 107 ]  Later, in a letter to the readers, the editors of  Analytical Chemistry  published their concerns about the faulty  experimental design  of the study, and warned readers to "use caution in evaluating the conclusions drawn in the paper". [ 108 ]


Furthermore, after reviewing the research data of the study "Total Platinum Concentration and Platinum Oxidation States in Body Fluids, Tissue, and Explants from Women Exposed to Silicone and Saline Breast Implants by IC-ICPMS", and other pertinent literature, the U.S. FDA reported that the data do not support the findings presented; that the platinum used in new-model breast implant devices likely is not  ionized , and therefore is not a significant risk to the health of the women. [ 109 ]


Non-implant breast augmentation with injections of autologous fat grafts (adipocyte tissue) is indicated for women requiring  breast reconstruction ,  defect correction , and the æsthetic enhancement of the bust.


The  operating room  time of breast reconstruction, congenital defect correction, and primary breast augmentation procedures is determined by the indications to be treated.


The advent of  liposuction  technology facilitated medical applications of the liposuction-harvested fat tissue as autologous filler for injection to correct bodily defects, and for breast augmentation. Melvin Bircoll introduced the practice of contouring the breast and for correcting bodily defects with autologous fat grafts harvested by liposuction; and he presented the fat-injection method used for emplacing the fat grafts. [ 110 ] [ 111 ]  In 1987, the Venezuelan plastic surgeon Eduardo Krulig emplaced fat grafts with a syringe and blunt needle (lipo-injection), and later used a disposable fat trap to facilitate the collection and to ensure the sterility of the harvested adipocyte tissue. [ 112 ] [ 113 ]


To emplace the grafts of autologous fat-tissue, doctors J. Newman and J. Levin designed a lipo-injector gun with a gear-driven plunger, which allowed the even injection of autologous fat-tissue to the desired recipient sites. The control afforded by the lipo-injector gun assisted the plastic surgeon in controlling excessive pressure to the fat in the barrel of the syringe, thus avoiding over-filling the recipient site. [ 114 ]  The later-design lipo-injector gun featured a ratchet-gear operation that afforded the surgeon greater control in accurately emplacing grafts of autologous fat to the recipient site; a trigger action injected 0.1 cm 3  of filler. [ 115 ]  Since 1989, most non-surgical, fat-graft augmentations of the breast employ adipocyte fat from sites other than the breast, up to 300 ml of fat in three equal injections, is placed into the subpectoral space and the intrapectoral space of the  pectoralis major muscle , as well as the submammary space, to achieve a breast outcome of natural appearance and contour. [ 116 ]


The technique of autologous fat-graft injection to the  breast  is applied for the correction of breast asymmetry or deformities, for  post-mastectomy   breast reconstruction  (as a primary and as an adjunct technique), for the improvement of soft-tissue coverage of breast implants, and for the aesthetic enhancement of the bust. The careful harvesting and  centrifugal  refinement of the mature adipocyte tissue (injected in small aliquots) allows the transplanted fat tissue to remain viable in the breast, where it provides the anatomical structure and the hemispheric contour that cannot be achieved solely with breast implants or with corrective plastic surgery. [ citation needed ]


In fat-graft breast augmentation procedures, there is the risk that the  adipocyte tissue  grafted to the breast(s) can undergo  necrosis ,  metastatic calcification , develop cysts, and agglomerate into palpable lumps. Although the cause of metastatic calcification is unknown, the post-procedure biological changes occurred to the fat-graft tissue resemble the tissue changes usual to breast surgery procedures such as  reduction mammoplasty . The French study  Radiological Evaluation of Breasts Reconstructed with Lipo-modeling  (2005) indicates the therapeutic efficacy of fat-graft breast reconstruction in the treatment of  radiation therapy  damage to the chest, the incidental reduction of  capsular contracture , and the improved soft-tissue coverage of breast implants. [ 117 ] [ 118 ] [ 119 ]


The study  Fat Grafting to the Breast Revisited: Safety and Efficacy  (2007) reported successful transfers of body fat to the  breast , and proposed the fat-graft injection technique as an alternative (i.e., non-implant) augmentation mammoplasty procedure instead of the surgical procedures usual for effecting breast augmentation, breast defect correction, and breast reconstruction. [ citation needed ]


Structural fat-grafting was performed either to one breast or to both breasts of the 17 women; the age range of the women was 25–55 years; the mean age was 38.2 years; the average volume of a tissue-graft was 278.6 cm 3  of fat per operation, per breast. [ citation needed ]


The pre-procedure mammograms were negative for  malignant neoplasms . In the 17-patient cohort, it was noted that two women developed  breast cancer  (diagnosed by  mammogram ) post-procedure: one at 12 months, and the other at 92 months. [ 120 ]  Further, the study  Cell-assisted Lipotransfer for Cosmetic Breast Augmentation: Supportive Use of Adipose-Derived Stem/Stromal Cells  (2007), an approximately 40-woman cohort indicated that the inclusion of adipose  stem cells  in the grafts of adipocyte fat increased the rate of corrective success of the autologous fat-grafting procedure. [ 121 ]


The centrifugal refinement of the liposuction-harvested adipocyte tissues removes blood products and free  lipids  to produce autologous breast filler. The injectable filler-fat is obtained by centrifuging (spinning) the fat-filled syringes for sufficient time to allow the serum, blood, and oil (liquid fat) components to collect, by density, apart from the refined, injection-quality fat. [ 122 ]  To refine the fat for facial injection quality, the fat-filled syringes are centrifuged for 1.0 minute at 2,000 RPM, which separates the unnecessary solution, leaving refined filler-fat. [ 123 ]  Moreover, centrifugation at 10,000 RPM for 10 minutes produces a "collagen graft"; the  histologic  composition of which is  cell  residues,  collagen  fibres, and 5.0 percent intact fat cells. Furthermore, because the patient's body naturally absorbs some of the fat grafts, the breasts maintain their contours and volumes for 18–24 months. [ 124 ] [ 125 ]


In the study  Fat Grafting to the Breast Revisited: Safety and Efficacy  (2007), the investigators reported that the autologous fat was harvested by liposuction, using a 10-ml syringe attached to a two-hole Coleman harvesting  cannula ; after centrifugation, the refined breast filler fat was transferred to 3-ml syringes. Blunt infiltration cannulas were used to emplace the fat through 2-mm incisions; the blunt cannula injection method allowed greater dispersion of small aliquots (equal measures) of fat, and reduced the possibility of intravascular fat injection; no sharp needles are used for fat-graft injection to the breasts. The 2-mm incisions were positioned to allow the infiltration (emplacement) of fat grafts from at least two directions; a 0.2 ml fat volume was emplaced with each withdrawal of the cannula. [ 126 ]


The breasts were contoured by layering the fat grafts into different levels within the breast, until achieving the desired breast form. The fat-graft injection technique allows the plastic surgeon precise control in accurately contouring the breast – from the chest wall to the breast skin envelope – with subcutaneous fat grafts to the superficial planes of the breast. This greater degree of breast sculpting is unlike the global augmentation realised with a breast implant emplaced below the breast or below the pectoralis major muscle, respectively expanding the  retromammary space  and the retropectoral space. The greatest proportion of the grafted fat usually is infiltrated to the pectoralis major muscle, then to the retropectoral space, and to the prepectoral space, (before and behind the pectoralis major muscle). Moreover, although fat grafting to the breast  parenchyma  usually is minimal, it is performed to increase the degree of projection of the  bust . [ 120 ]


The biologic survival of autologous fat  tissue  depends upon the correct handling of the fat graft, of its careful washing (refinement) to remove extraneous blood cells, and of the controlled, blunt-cannula injection (emplacement) of the refined fat-tissue grafts to an adequately  vascularized  recipient site. Because the body resorbs some of the injected fat grafts (volume loss), compensative over-filling aids in obtaining a satisfactory breast outcome for the patient; thus the transplantation of large-volume fat grafts greater than required, because only 25–50 percent of the fat graft survives at 1-year post-transplantation. [ 127 ]


The correct technique maximizes fat graft survival by minimizing  cellular  trauma during the liposuction harvesting and the centrifugal refinement, and by injecting the fat in small aliquots (equal measures), not clumps (too-large measures). Injecting minimal-volume aliquots with each pass of the  cannula  maximizes the surface area contact, between the grafted fat-tissue and the recipient breast-tissue, because proximity to a vascular system ( blood supply ) encourages  histologic  survival and minimizes the potential for fat necrosis. [ 120 ]  Transplanted autologous fat tissue undergoes histologic changes like those undergone by a bone transplant; if the body accepts the fat-tissue graft, it is replaced with new fat tissue, if the fat-graft dies it is replaced by  fibrous tissue . New fat tissue is generated by the activity of a large, wandering  histocyte -type  cell , which ingests fat and then becomes a fat cell. [ 128 ]  When the breast-filler fat is injected to the breasts in clumps (too-large measures), fat cells emplaced too distant from blood vessels might die, which can lead to fat tissue necrosis, causing lumps, calcifications, and the eventual formation of liponecrotic cysts.


The operating room time required to harvest, refine, and emplace fat to the breasts is greater than the usual 2-hour OR time; the usual infiltration time was approximately 2 hours for the first 100 cm 3  volume, and approximately 45 minutes for injecting each additional 100 cm 3  volume of breast-filler fat. The technique for injecting fat grafts for breast augmentation allows the plastic surgeon great control in sculpting the breasts to the required contour, especially in the correction of  tuberous breast deformity . In which case, no fat-graft is emplaced beneath the nipple-areola complex (NAC), and the skin envelope of the breast is selectively expanded (contoured) with subcutaneously emplaced body-fat, immediately beneath the skin. Such controlled contouring selectively increased the proportional volume of the breast in relation to the size of the nipple-areola complex, and thus created a breast of natural form and appearance; greater verisimilitude than is achieved solely with breast implants. The fat-corrected, breast-implant deformities, were inadequate soft-tissue coverage of the implant(s) and  capsular contracture , achieved with subcutaneous fat-grafts that hid the implant-device edges and wrinkles, and decreased the palpability of the underlying breast implant. Furthermore, grafting autologous fat around the breast implant can result in softening the breast capsule. [ 129 ]


The successful outcome of fat-graft breast augmentation is enhanced by achieving a pre-expanded recipient site to create the breast-tissue  matrix  that will receive grafts of autologous adipocyte fat. The recipient site is expanded with an external vacuum tissue-expander applied upon each breast. The biological effect of negative pressure ( vacuum ) expansion upon  soft tissues  derives from the ability of soft tissues to grow when subjected to controlled, distractive, mechanical forces. (see  distraction osteogenesis ) The study reported the technical effectiveness of recipient-site pre-expansion. In a single-group study, 17 healthy women (aged 18–40 years) wore a brassiere-like vacuum system that applied a 20-mmHg vacuum (controlled, mechanical, distraction force) to each breast for 10–12 hours daily for 10 weeks. Pre- and post-procedure, the breast volume (size) was periodically measured; likewise, a magnetic resonance image ( MRI ) of the breast-tissue architecture and water density was taken during the same phase of the patient's  menstrual cycle ; of the 17-woman study group, 12 completed the study, and 5 withdrew, because of non-compliance with the  clinical trial protocol . [ 130 ]


The breast volume (size) of all 17 women increased throughout the 10-week treatment period, the greatest increment was at week 10 (final treatment) – the average volume increase was 98+/–67 percent over the initial breast-size measures. Incidences of partial recoil occurred at 1-week post-procedure, with no further, significant, breast volume decrease afterwards, nor at the follow-up treatment at 30-weeks post-procedure. The stable, long-term increase in breast size was 55 percent (range 15–115%). The MRI visualizations of the breasts showed no  edema , and confirmed the proportionate enlargement of the adipose and glandular components of the breast-tissue  matrices . Furthermore, a statistically significant decrease in body weight occurred during the study, and  self-esteem  questionnaire scores improved from the initial-measure scores. [ 130 ]


Because external vacuum expansion of the recipient-site tissues permits injecting large-volume fat grafts (+300 cc) to correct defects and enhance the bust, the  histologic  viability of the breast filler (adipocyte fat) and its volume must be monitored and maintained. The long-term, volume maintenance data reported in  Breast Augmentation using Pre-expansion and Autologous Fat Transplantation: a Clinical Radiological Study  (2010) indicate the technical effectiveness of external tissue expansion of the recipient site for a 25-patient study group, who had 46 breasts augmented with fat grafts. The indications included  micromastia  (underdevelopment), explantation deformity (empty implant pocket), and congenital defects ( tuberous breast deformity ,  Poland's syndrome ). [ 131 ]


Pre-procedure, every patient used external vacuum expansion of the recipient-site tissues to create a breast tissue matrix to be injected with autologous fat grafts of adipocyte tissue, refined via low G-force centrifugation. Pre- and post-procedure, the breast volumes were measured; the patients underwent pre-procedure and 6-month post-procedure MRI and  3D volumetric imaging  examinations. At six months post-procedure, each woman had a significant increase in breast volume, ranging 60–200 percent, per the MRI (n=12) examinations. The size, form, and feel of the breasts was natural; post-procedure MRI examinations revealed no oil  cysts  or  abnormality  ( neoplasm ) in the fat-augmented breasts. Moreover, given the sensitive, biologic nature of breast tissue, periodic MRI and 3-D volumetric imaging examinations are required to monitor the breast-tissue viability and the maintenance of the large volume (+300 cc) fat grafts. [ 131 ]


Surgical post-mastectomy  breast reconstruction  requires general anaesthesia, cuts the chest muscles, produces new scars, and requires a long post-surgical recovery for the patient. The surgical emplacement of breast implant devices (saline or silicone) introduces a foreign object to the patient's body (see  capsular contracture ). The  TRAM flap  (Transverse Rectus Abdominis Myocutaneous flap) procedure reconstructs the breast using an autologous flap of abdominal, cutaneous, and muscle tissues. The latissimus myocutaneous flap employs skin fat and muscle harvested from the back, and a breast implant. The  DIEP flap  (Deep Inferior Epigastric Perforators) procedure uses an autologous flap of abdominal skin and fat tissue. [ 132 ] [ full citation needed ]


The reconstruction of the breast(s) with grafts of autologous fat is a non-implant alternative to further surgery after a breast cancer surgery, be it a  lumpectomy  or a breast removal – simple (total) mastectomy, radical mastectomy, modified radical mastectomy, skin-sparing mastectomy, and  subcutaneous (nipple sparing) mastectomy . The breast is reconstructed by first applying external tissue expansion to the recipient-site tissues ( adipose ,  glandular ) to create a breast-tissue matrix that can be injected with autologous fat grafts (adipocyte tissue); the reconstructed breast has a natural form, look, and feel, and is generally sensate throughout and in the nipple-areola complex (NAC). [ 132 ]  The reconstruction of breasts with fat grafts requires a three-month treatment period – begun after 3–5 weeks of external vacuum expansion of the recipient-site tissues. The autologous breast-filler fat is harvested by liposuction from the patient's body (buttocks, thighs, abdomen), is refined and then is injected (grafted) to the breast-tissue matrices (recipient sites), where the fat will thrive.


One method of non-implant breast reconstruction is initiated at the concluding steps of the breast cancer surgery, wherein the  oncological  surgeon is joined by the reconstructive plastic surgeon, who immediately begins harvesting, refining, and seeding (injecting) fat grafts to the post-mastectomy recipient site. After that initial post-mastectomy fat-graft seeding in the operating room, the patient leaves hospital with a slight breast mound that has been seeded to become the foundation tissue matrix for the breast reconstruction. Then, after 3–5 weeks of continual external vacuum expansion of the breast mound (seeded recipient-site) – to promote the  histologic  regeneration of the extant tissues ( fat ,  glandular ) via increased blood circulation to the mastectomy scar (suture site) – the patient formally undergoes the first fat-grafting session for the reconstruction of her breasts. The external vacuum expansion of the breast mound created an adequate,  vascularised , breast-tissue matrix to which the autologous fat is injected; and, per the patient, such reconstruction affords almost-normal sensation throughout the breast and the nipple-areola complex. Patient recovery from non-surgical fat graft breast reconstruction permits her to resume normal life activities at 3-days post-procedure. [ 132 ]


The breast-tissue matrix consists of engineered tissues of complex, implanted, biocompatible scaffolds seeded with the appropriate cells. The  in-situ  creation of a tissue matrix in the breast mound is begun with the external vacuum expansion of the mastectomy defect tissues (recipient site), for subsequent seeding (injecting) with autologous fat grafts of adipocyte tissue. A 2010 study, reported that serial fat-grafting to a pre-expanded recipient site achieved (with a few 2-mm incisions and minimally invasive blunt-cannula injection procedures), a non-implant outcome equivalent to a surgical breast reconstruction by  autologous-flap  procedure. Technically, the external vacuum expansion of the recipient-site tissues created a skin envelope as it stretched the mastectomy scar, and so generated a fertile breast-tissue matrix to which were injected large-volume fat grafts (150–600 ml) to create a breast of natural form, look, and feel. [ 133 ]


The fat graft breast reconstructions for 33 women (47 breasts, 14 irradiated), whose clinical statuses ranged from zero days to 30 years post-mastectomy, began with the pre-expansion of the breast mound (recipient site) with an external vacuum tissue-expander for 10 hours daily, for 10–30 days before the first grafting of autologous fat. The breast mound expansion was adequate when the mastectomy scar tissues stretched to create a 200–300 ml recipient matrix (skin envelope), that received a fat-suspension volume of 150–600 ml in each grafting session. [ 133 ]


At one week post-procedure, the patients resumed using the external vacuum tissue-expander for 10 hours daily, until the next fat grafting session; 2–5 outpatient procedures, 6–16 weeks apart, were required until the plastic surgeon and the patient were satisfied with the volume, form, and feel of the reconstructed breasts. The follow-up mammogram and  MRI  examinations found neither defects (necrosis) nor abnormalities ( neoplasms ). At six months post-procedure, the reconstructed breasts had a natural form, look, and feel, and the stable breast-volumes ranged 300–600 ml per breast. The post-procedure mammographies indicated normal, fatty breasts with well-vascularized fat, and few, scattered, benign oil cysts. The occurred complications included  pneumothorax  and transient cysts. [ 133 ]


The autologous fat graft replacement of breast implants (saline and silicone) resolves  medical complications  such as:  capsular contracture , implant shell rupture, filler leakage (silent rupture), device deflation, and silicone-induced  granulomas , which are medical conditions usually requiring re-operation and explantation (breast implant removal). The patient then has the option of surgical or non-implant breast corrections, either replacement of the explanted breast implants or fat-graft breast augmentation. Moreover, because fat-grafts are biologically sensitive, they cannot survive in the empty implantation pocket, instead, they are injected to and diffused within the breast-tissue matrix (recipient site), replacing approximately 50% of the volume of the removed implant – as permanent breast augmentation. The outcome of the explantation correction is a bust of natural appearance; breasts of volume, form, and feel, that – although approximately 50% smaller than the explanted breast size – are larger than the original breast size, pre-procedure.