PRS Journal Club: Subfascial Breast Augmentation Implant Selection, Breast Re-Reduction Techniques, and Breast Implant–Associated Anaplastic Large-Cell Lymphoma Trends

With advances in techniques, levels of evidence, and patient-reported outcomes, both aesthetic and reconstructive breast surgery have undergone significant changes over the past decades. The first report of breast reduction surgery in Plastic and Reconstructive Surgery dates back to 1948,1 with breast amputations first predominating over pedicled techniques, followed by the emergence of the inferior pedicle,2 central pedicle,3 superomedial pedicle,4 and even dual-pedicle techniques5,6 from 1970 to 1990. As secondary breast reductions have become more commonplace, the optimal pedicle in secondary cases to avoid nipple-areola complex (NAC) necrosis remains controversial. Over the same timeframe, the landscape of breast augmentation surgery has also evolved, with the preferred plane transitioning from the subglandular and total submuscular 7 to dual-plane approaches,8 and currently to a resurgence of subfascial techniques9 in an era of newer-generation implants. Today, the optimum implant surface texture and plane to maximize aesthetic outcomes while minimizing the incidence of capsular contracture remains undefined, as implant generations and technology progress. Finally, as data emerge surrounding both breast implant–associated anaplastic large-cell lymphoma (BIA-ALCL) and breast implant illness,10,11 counseling of both aesthetic and reconstructive breast patients has become increasingly challenging and important in the preoperative setting. In the April of 2025 edition of PRS Journal Club, we discuss these 3 topics in aesthetic breast surgery with Dr. Elizabeth Hall-Findlay, an internationally renowned plastic surgeon known for breast aesthetics. In the first article, “Modified McKissock Technique for Secondary Breast Reduction: A Prospective Study on Safety and Surgical and Aesthetic Outcomes” by Feldler et al.,12 the authors describe a modified technique for secondary breast reduction involving a tripedicle where the superior, central, and inferior blood supplies to the NAC are maintained, a modification of the McKissock approach first published in 1972.6 The authors report complications and patient-reported outcomes associated with this approach, finding no cases of NAC necrosis with improved BREAST-Q scores, and an overall high patient satisfaction rate in a series of 14 patients undergoing secondary breast reduction.12 In this series, the distance of NAC transposition ranged from 1 to 10 cm, and the pedicle was folded superiorly to allow for nipple transposition. Overall, as secondary breast reduction rates rise, they continue to be associated with a higher risk of complications, including NAC necrosis, compared with primary breast reduction, especially when the primary pedicle is unknown.13,14 Although prior studies have advocated for the use of superior or superomedial techniques in secondary cases, even when the primary pedicle is unknown,15 this tripedicle technique theoretically maintains NAC blood supply more reliably, even in cases where a long nipple transposition distance is required. Future studies are needed to compare this modified McKissock approach to superomedial/superior-pedicle secondary breast reduction techniques. In the second study, “A Comparison of Textured versus Smooth-Surfaced Implants in Subfascial Breast Augmentation,” Tim Brown, MChir, FRCS(Plast),16 reviewed 385 patients who underwent subfascial breast augmentation and compared outcomes between macrotextured and smooth implants before and after implementation of the moratorium on textured breast implants in Australia. At a mean 3-year follow-up, Brown identified no statistically significant differences between textured and smooth implants in complications, patient satisfaction, lower-pole morphometric measurements, and capsular contracture within the follow-up period. Over the past decades, a transition in implant surface texture from macrotextured to smooth has paralleled a transition in preferred plane by some surgeons from submuscular or dual plane to subfascial techniques for breast augmentation. Although subfascial breast augmentation is not a new concept (first introduced by Graf in 20039), controversy persists regarding the utility of this approach compared with subglandular or dual-plane/submuscular techniques with regard to overall outcomes17 and capsular contracture.18 As microtextured devices enter the market in North America, large multicenter studies are still needed to determine the influence of implant texture and plane on overall outcomes, including capsular contracture at long-term follow-up. Finally, in “Estimating the Prevalence of Breast Implant–Associated Anaplastic Large-Cell Lymphoma: A Systematic Review,” Ward et al.19 conducted a systematic review using PubMed and Embase to estimate the overall prevalence of BIA-ALCL, with the goal of generating estimates with accurate numerators and denominators to better counsel patients in the preoperative setting. After pooling 38 studies that met the inclusion criteria, spanning 17,038,371 patients and 1170 BIA-ALCL patients, the authors estimated the overall incidence of BIA-ALCL to be 1 case per 3274 patients among those receiving textured implants, and 1 case per 14,925 patients among those receiving any breast implant. Following the first identified case of BIA-ALCL in 1997,20 reports of BIA-ALCL have surged over the past 2 decades. Now known to be strongly associated with textured implants, the emergence of BIA-ALCL has inspired the transition from textured to smooth implants in both aesthetic and reconstructive breast surgery across North America. Data surrounding BIA-ALCL and breast implant illness have also changed preoperative counseling about the risks and benefits of breast implants for aesthetic and reconstructive indications; generating accurate statistics has become increasingly important when counselling patients in the preoperative setting. As microtextured devices have recently entered the North American market, future studies mirroring this systematic review by Ward et al. will become increasingly important to estimate BIA-ALCL prevalence for smooth and microtextured devices. Overall, these articles highlight and add to current knowledge about 3 important and controversial topics in aesthetic breast surgery today. Moving forward, future studies are needed to define the optimal pedicle in secondary breast reduction, the ideal plane and implant texture in breast augmentation, and the incidence of BIA-ALCL with newer-generation implants. DISCLOSURE The authors have no relevant financial disclosures to report.