Yoav Barnea

Background: Subpectoral implant-based breast reconstruction is associated with complications such as animation deformity, chronic pain, and aesthetic dissatisfaction, significantly affecting patient quality of life (QOL). Prepectoral pocket conversion has emerged as an alternative to address these issues, particularly for patients with complications from prior subpectoral reconstruction. Despite its increasing use, limited data exist on the impact of this technique on patient-reported outcomes, including satisfaction and QOL. This study aimed to evaluate the outcomes of prepectoral pocket conversion, focusing on complications, aesthetic results, and patient-reported QOL improvements, using the BREAST-Q questionnaire. Methods: This is a retrospective cohort study, conducted on 37 patients (60 breasts) who underwent prepectoral pocket conversion between January 2018 and March 2024. Demographic, clinical, surgical, and postoperative data were collected. BREAST-Q scores were compared pre- and post-conversion. Results: Patients had a mean age of 53 years, with a median follow-up of 622 days (1 year and 8 months). Indications for conversion included capsular contracture (21.3%) and animation deformity (17.5%). Complications were minimal, with 1.7% hematoma and 6.7% capsular contracture. Significant improvements were observed in BREAST-Q scores for breast satisfaction ( P = 0.002), physical well-being ( P = 0.037), and sexual well-being ( P = 0.019). Fat grafting was required in 16.7% of cases to enhance aesthetic outcomes. Conclusions: Prepectoral pocket conversion is a safe and effective procedure that alleviates complications of subpectoral reconstruction, improves aesthetic outcomes, and enhances patient satisfaction and QOL. Further prospective studies with larger cohorts are warranted. Level of Evidence: Level III, risk / prognostic study.

Background: Fat grafting is gaining traction in regenerative and aesthetic medicine because of ease of adipose tissue harvesting and potential applications in autologous soft tissue reconstructions. A key challenge remains the limited viability of lipoaspirate-derived adipocytes following the procedures of harvesting, processing, and implantation, which leads to suboptimal outcomes in graft survival. Objectives: The aim of this study was to evaluate whether a hydrogel composed of the amphiphilic and anionic β-sheet peptide Pro-Asp-(Phe-Asp)5-Pro (PFD) enhances fat graft outcomes by improving adipocyte viability, reducing inflammatory response, and facilitating tissue integration compared with conventional fat grafting. Methods: PFD-lipoaspirate mixtures were characterized in vitro, and a lead mixture was tested in porcine models used for initial safety and efficacy assessment of subcutaneous implantation at 1 and 3 months after treatment. A single animal was used for each time point, with multiple treatment sites in each animal and a minimum of 3 sites for each of the treatment and control formulations. Histological and immunohistochemical analyses were performed. Results: PFD hydrogel exhibited superior injectability with smaller extrusion force than hyaluronic acid. The hydrogel could be readily mixed with lipoaspirate to form cohesive, uniform compositions that demonstrated a smoother and more consistent injection force pattern, compared with lipoaspirate only. Hydrogel−lipoaspirate formulations significantly enhanced cell viability compared with lipoaspirate. Within the lipoaspirate, the hydrogel degraded enzymatically. In vivo studies showed the hydrogel−lipoaspirate seamless integration with the surrounding adipose tissue with a 7-fold reduction in inflammatory zones compared with lipoaspirate-only treatment. Macrophage profiling indicated a transition toward predominantly M2 polarization between 1 and 3 months, supported by neovascularization and near-complete resorption by 3 months. Conclusions: PFD hydrogel−lipoaspirate mixture showed favorable outcomes in this preclinical model through improved adipocyte survival, reduced inflammatory response, and seamless tissue integration. These preliminary findings suggest potential utility in fat grafting applications, although clinical validation remains necessary. Level of Evidence: 5 (Therapeutic):

Breast augmentation is among the most frequently performed aesthetic procedures worldwide. Although postoperative infections are uncommon, breast implant-associated infections can be severe and challenging to treat. Nipple piercings, increasingly popular among young women, are a recognized source of local infection, yet their implications in patients with implants remains poorly characterized. This report describes a case of breast infection following nipple piercing in a woman with breast implants and to review the relevant literature. A 23-year-old woman with a history of subpectoral breast augmentation underwent bilateral nipple piercing and subsequently developed rapidly progressive left breast pain, erythema and purulent drainage. Ultrasound revealed a multiloculated abscess. Aspiration cultures grew Streptococcus pyogenes, while intraoperative cultures from both implant pockets were sterile. Despite the absence of direct pocket involvement, her clinical deterioration warranted urgent abscess drainage and bilateral explantation, after which she recovered fully on antibiotic therapy. A targeted literature review identified four published cases of breast or chest implant infections associated with nipple piercing. Reported infections occurred 2–50 weeks after piercing and most involved Staphylococcus or Streptococcus species. Management ranged from antibiotics alone to explantation, though follow-up in most reports was limited. Breast infections following nipple piercing in augmented patients are rare but potentially severe. Significant soft-tissue infections may necessitate explantation, even when pockets appear uninvolved. Patients considering nipple piercing after augmentation should be counseled about these risks, and further systematic reporting is needed to guide prevention and treatment strategies.

The global demand for cosmetic procedures is accelerating, with over 1.6 million aesthetic surgical procedures performed in the US in 2023. Concurrently, AI is transforming surgical practice through advanced analytics, predictive modeling, and computer vision. Cosmetic surgery, characterized by subjective outcomes and limited standardized metrics, presents a unique opportunity for AI integration to enhance precision, objectivity, and patient communication. Following PRISMA 2020 guidelines, we systematically searched MEDLINE/PubMed, Embase, and the Cochrane Library (January 2020−July 2025) for studies applying AI, machine learning, deep learning, computer vision, or large language models to cosmetic or aesthetic procedures. Eligible designs included randomized controlled trials, observational studies, diagnostic accuracy studies, feasibility studies, and prediction model development. Two reviewers independently screened titles/abstracts, assessed full texts, extracted data, and evaluated risk of bias using ROBINS-I for non-randomized studies. Of 3941 records, 38 met the inclusion criteria. AI applications spanned preoperative planning (predictive risk modeling, 3D outcome simulation), intraoperative guidance (augmented reality overlays), and postoperative monitoring (smartphone-based complication detection, objective aesthetic scoring). Benefits included improved patient–surgeon communication, enhanced risk stratification, and standardized outcome measurement. However, most studies were early-phase, with limited external validation, heterogeneous datasets, and inconsistent outcome metrics. Risk of bias was moderate to serious in most studies. AI in cosmetic surgery shows significant potential but remains in early clinical adoption. Progress requires multicenter validation, standardized datasets, explainable algorithms, and clear regulatory frameworks. Large language model—driven tools may accelerate development and integration, provided ethical, equitable, and patient-centered principles guide implementation.

Background: Breast reduction is a common procedure with growing rates in the United States of America, aimed at alleviating the physical and psychological burdens of macromastia. Despite high success rates, it carries a risk of complications, with incidence rates ranging from 6.2% to 43%. Objectives: The authors developed a machine learning model using gradient-boosting decision trees to predict severe breast reduction complications up to 30 days following surgery requiring inpatient care. Methods: This retrospective study included 322 cases of breast reduction surgery performed at the Tel Aviv Medical Center from 2017 to 2024. Model performance was evaluated using 5-fold cross-validation, and key metrics such as area under the receiver operating characteristic curve, accuracy, sensitivity, and specificity were reported. An interpretability tool was also created to visualize complication risks based on clinical features. Results: Severe complications occurred in 7.4% of cases. Key predictive factors included specimen weight, SN-N distance, and liposuction volume. The model achieved an area under the receiver operating characteristic curve (AUC-ROC) of 0.83, with an accuracy of 0.93 and a negative predictive value (NPV) of 0.95. The interpretability tool clearly visualized complication risks, aiding preoperative counseling. Conclusions: This is the first study to use artificial intelligence (AI) to predict severe complications in breast reduction surgery. In this study, the AI model, with an AUC-ROC of 0.83 and NPV of 0.95, offers a reliable tool for surgical planning and patient education. Further validation across diverse populations is recommended to confirm its clinical utility. Level of Evidence: 4 (Risk):

Background/Objectives: Breast cancer-related lymphedema (BCRL) is a chronic complication of breast cancer treatment, leading to physical and psychological morbidity. While widely studied globally, the prevalence and risk factors for BCRL in Israeli patients remain unexplored. This study’s objectives were to determine the prevalence of BCRL in Israeli women treated for breast cancer, validate the Hebrew-translated Norman Questionnaire (NQ) for BCRL screening, and identify risk factors associated with the condition. Methods: A single-center study was conducted at Tel Aviv Sourasky Medical Center, including 181 patients who underwent unilateral axillary lymph node interventions between 2015 and 2018. Participants completed the Hebrew-translated NQ, which was validated through clinical evaluation and circumference-based volume measurements in a subset of 20 patients. Prevalence rates and risk factors were analyzed using multivariate modeling. Results: The prevalence of BCRL was 20%, with rates varying by procedure: 8.9% for sentinel lymph node biopsy, 19.6% for lymph node sampling, and 37.5% for axillary lymph node dissection (ALND). Of the 35 patients with BCRL, only 14% had been previously diagnosed. Risk factors included ALND (OR = 97.31), a higher lymph node excision count (OR = 0.81), and referral to physiotherapy (OR = 133.50). The Hebrew NQ demonstrated strong validity (rs = 0.852; p < 0.001). Conclusions: This is the first study to estimate BCRL prevalence in Israeli women, highlighting underdiagnosis and the need for improved early detection. The Hebrew NQ is a reliable screening tool, enabling timely referral and intervention. Early diagnosis is crucial for optimizing treatment outcomes and improving the quality of life of BCRL patients.

Background: Oncoplastic surgery is an expanding approach for managing breast conservation because it offers improved cosmetic outcomes while maintaining oncological safety. Objectives: This study aimed to assess the oncological and surgical outcomes of patients who underwent oncoplastic procedures at a single institution. Methods: The study population includes all consecutive breast cancer patients who underwent lumpectomy followed by immediate oncoplastic breast reconstruction with contralateral breast adjustment between 2010 and 2021. Following IRB approval, patient demographics, tumor characteristics, surgical details, complications, and follow-up were evaluated for this group. Quality of life (QOL) and patient-reported outcome measures were assessed through questionnaires. Results: Following multidisciplinary tumor board discussion, 77 patients (82 breasts) underwent oncoplastic surgery. Of these, 92.2% underwent breast MRI prior to surgery with mean mass enhancement of 2.35 cm (range, 0-8.5 cm) and non-mass enhancement of 5.77 cm (range, 0-14 cm), and 44% presented with multifocal disease. The final positive surgical margin rate was 2.4%, and all conserved breasts received adjuvant radiation therapy. The 5-year local recurrence rate for invasive tumors was 4.1%. QOL scores were generally high, with most patients reporting good to excellent cosmetic outcomes and high personal satisfaction with breast appearance and softness. Physicians reported breast symmetry in 89.5%. Conclusions: The findings suggest that oncoplastic surgery with contralateral breast adjustment is safe, effective, and an excellent option for breast cancer patients wishing for breast conservation even for large or multifocal masses, with favorable oncologic and cosmetic outcomes. The QOL analysis indicates high patient satisfaction. These results support the use of oncoplastic surgery in the management of breast cancer. Level of Evidence: 4:

Breast implant-associated anaplastic large cell lymphoma (BIA-ALCL) is an uncommon T-cell lymphoma detected in association with textured implants. It presents as a fluid accumulation around the implant, usually years after the implantation. We present our experience in diagnosing and treating four patients with BIA-ALCL, each widely differing from the other. Data on patients’ surgical history, relevant medical information, and findings on pathological slides were retrieved from their medical charts and retrospectively reviewed. Each of the four patients was diagnosed with BIA-ALCL, one after breast augmentation, one after breast reconstruction with an implant, one after breast reconstruction with a latissimus dorsi flap and implant, and the fourth after the removal of breast implants. The cases were presented to a multidisciplinary team and subsequently underwent surgery. All four are currently free of tumors, as established by a negative follow-up via positron emission tomography-computed tomography. Although the incidence of BIA-ALCL is rare, these cases emphasize the need to rule out the diagnosis of BIA-ALCL in patients with textured implants or a history of implanted textured devices who present with symptoms such as late seroma or peri-implant mass. This pathology is typically indolent and slow-growing and heightened awareness for an early diagnosis could lead to quicker intervention and enhanced patient management.