Panayotis Patrick Bletsis

SUMMARY Since their introduction in the 1960’s, breast implants have become a cornerstone in plastic surgery, serving both aesthetic and reconstructive purposes. Breast augmentation and breast reconstruction remain among the most frequently performed procedures worldwide, shown to enhance patient satisfaction, self-esteem, and quality of life. The overarching aim of this thesis was to evaluate the contemporary use of breast implants within alloplastic breast surgery. To achieve this, the work was structured into three principal domains: patient safety, breast aesthetics, and operative technique. Collectively, these domains provide a coherent framework for analyzing current practice, identifying challenges, and guiding future directions in the field. PART 1. INTRODUCTION In order to take the reader on our journey, we provide an introduction and overview breast implants in accordance to the three categories around which this thesis has been structured: patient safety, breast aesthetics and operating technique. Subsequently, the aims and outline of this thesis are presented. PART 2. PATIENT SAFETY In Chapter 1, we investigated complication rates of alloplastic and autologous breast reconstruction after prophylactic mastectomy and found the latter to have a lower rate of minor complications, breast seroma and breast infection. Age (≥65), obesity, ASA class (≥3), active smoking, hypertension, and anxiety were risk factors for complications. There was no significant difference between major complications. In Chapter 2, we described the case of a patient with bilateral breast implant-associated chronic lymphocytic leukemia/small lymphocytic lymphoma (CLL/SLL). Similar to BIA-ALCL, explantation of breast-implants in combination with (partial) capsulectomy induced remission of the illness. We believe this interesting and educative case was essential to include in this thesis amongst increasing reports of BIA-ALCL, which is of T-cell lineage. In our case, the lymphoma was of B-cell lineage and bilateral. To our knowledge, this is the first and only case described worldwide. In Chapter 3, evaluation of Dutch-language online resources revealed that most patient-directed materials on breast reconstruction fail to meet recommended readability standards. Given the prevalence of low literacy and its association with poorer psychosocial outcomes, this chapter emphasizes the need for healthcare institutions prioritize readability and to adopt innovative communication strategies, such as spoken animations, to ensure equitable access to comprehensible information. Chapter 4 examined adverse event reporting pathways within the framework of the European Medical Device Regulation (MDR). Findings demonstrated that the Dutch Breast Implant Registry (DBIR) captures substantially more explantations than industry or regulatory bodies, highlighting fragmented surveillance. Integration of registry data across stakeholders is essential to establish a closed-loop system that strengthens post-market vigilance and patient safety. PART 3. BREAST AESTHETICS In Chapter 5, we investigated breast size preference among patients, plastic surgeons and laypeople. Significant differences emerged between cohorts. Patients preferred larger breast sizes than surgeons and non-significantly, than laypersons. Male participants favored larger sizes than females. Among patients, higher age and BMI correlated with preference for greater breast volume, whereas higher educational level was associated with preference for smaller size. The findings underscore the importance of aligning surgical planning with patient expectations while remaining aware of sociocultural norms and surgeon biases that may shape counseling and outcomes. In Chapters 6 and 7, we investigated aesthetic differences between anatomically-shaped and round-shaped breast implants. Queried plastic surgeons and laypeople were able to distinguish between in situ anatomical or round breast implants. Moreover, our cohorts found breasts with a neutral or slightly concave-shaped upper pole slope more attractive and natural looking as upper breast pole fullness; therefore, breasts augmented with anatomical breast implants were rated more attractive and natural as compared to round breast implants. PART 4. OPERATING TECHNIQUE In Chapter 8, survey data revealed widespread use of multiple antiseptic measures among Dutch plastic surgeons during alloplastic breast surgery. Our data showed that plastic surgeons use a median of seven antiseptic measures, despite limited high-quality evidence supporting many of these practices. Chapter 9 documented the shift in implant texture selection and placement following the ban on macrotextured breast implants due to BIA-ALCL. The majority of Dutch plastic surgeons altered implant texture use due to BIA-ALCL and predominantly employ microtextured and smooth/nanotextured in both breast augmentation and reconstruction. The plane, in which breast implants are placed, has not been influenced by BIA-ALCL. Dual-plane placement remained most popular in breast augmentation and submuscular placement in breast reconstruction. In Chapter 10, we reported our experience with the Omega mastopexy technique for the correction of ptosis after breast implant explantation and capsulectomy in a series of nine patients. The Omega mastopexy represents a valuable option when more invasive procedures are undesirable, particularly in older patients and those with an increased risk of complications such as wound healing. While scar burden requires thorough preoperative counseling, the technique offers advantages including auto-augmentation, preserved nipple sensibility, and high patient satisfaction. Chapter 11 emphasized the importance of structured preoperative planning in alloplastic breast surgery. Our revised selection system provides an objective framework that aligns with anatomical parameters while preserving patient preference. By integrating tissue characteristics with individualized goals, the system enhances predictability and supports evidence-based counseling. It offers a reproducible and contemporary patient-centered approach to implant selection that can serve as a model for broader clinical adoption.