Pocket Resizing Strategies in Implant Exchange to Polyurethane-Coated Breast Implants: A Concept Article and Proposed Decision Algorithm

Pocket Resizing Strategies in Implant Exchange to Polyurethane-Coated Breast Implants: A Concept Article and Proposed Decision Algorithm | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Pocket Resizing Strategies in Implant Exchange to Polyurethane-Coated Breast Implants: A Concept Article and Proposed Decision Algorithm Sergio Burciaga Soto, Norman Alejandro Rendón Mejía This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-9046428/v1 This work is licensed under a CC BY 4.0 License Status: Published Journal Publication published 11 Apr, 2026 Read the published version in European Journal of Plastic Surgery → Version 1 posted 7 You are reading this latest preprint version Abstract Background: Exchange of conventional breast implants for polyurethane-coated (PU) devices is increasingly performed in revision surgery. However, no specific guidelines exist for breast pocket management during this exchange. The bio-integration properties of PU implants create a fundamentally different biomechanical environment compared with conventional implants, rendering traditional capsulorrhaphy principles potentially insufficient or counterproductive. Objectives: To propose a decision-making algorithm for pocket resizing during exchange to PU implants, supported by a retrospective analysis of consecutive cases. Methods: A concept framework was developed integrating evidence on capsulorrhaphy techniques and PU implant biology. The algorithm was structured around two decision axes: pocket-implant volume discrepancy and capsular tissue quality. A retrospective consecutive case series of patients undergoing exchange from conventional to PU implants at a single center was analyzed to support and refine the proposed pathways. Variables included preoperative implant characteristics, intraoperative capsule assessment, pocket management technique, and postoperative outcomes including implant position stability, capsular contracture recurrence, and patient satisfaction. Results: Five distinct management pathways were identified: (1) bio-integration reliance for minimal discrepancy; (2) selective capsulorrhaphy with mirror-image capsulotomy for moderate discrepancy; (3) thermal capsulorrhaphy with reinforcement or plane change for major discrepancy or thin capsules; (4) complete capsulectomy with neopocket creation for contracted capsules; and (5) dermocapsular flap utilization for PU-to-PU revisions. Clinical data from the supporting series demonstrated high implant position stability and low complication rates across algorithm pathways. Conclusions: Pocket management during exchange to PU implants requires a differentiated approach from conventional revision surgery. The proposed algorithm provides a reproducible framework for surgical decision-making based on two clinically assessable variables. Prospective multicenter validation is warranted. polyurethane breast implant capsulorrhaphy pocket resizing implant exchange revision breast surgery bio-integration algorithm Figures Figure 1 Figure 2 Figure 3 Figure 4 INTRODUCTION Breast implant revision surgery remains one of the most technically demanding procedures in aesthetic plastic surgery. With more than 4 million breast augmentation procedures performed worldwide, the population of patients requiring secondary surgery continues to grow, driven by implant-related complications, natural aging processes, and evolving patient preferences [ 1 , 2 ]. Among the most challenging aspects of revision surgery is the management of the breast pocket—the capsular space formed around the original implant—which frequently requires modification to accommodate a replacement device [ 3 , 4 ]. Capsulorrhaphy, the surgical tightening of the breast implant capsule, has been a cornerstone technique in revision breast surgery since its description by Spear and Little in 1988 [ 5 ]. Since then, multiple technical refinements have been introduced, including the mirror-image capsulotomy described by Chasan and Francis [ 6 ], thermal capsulorrhaphy using ball cautery with barbed suture closure [ 7 ], popcorn capsulorrhaphy utilizing insulated forceps and electrocautery [ 8 ], and argon beam thermal capsulorrhaphy [ 9 ]. These techniques have been studied primarily in the context of conventional smooth or textured silicone gel and saline implants, where the capsule-implant interface permits relative sliding between the device and surrounding tissue. Polyurethane-coated (PU) breast implants represent a fundamentally different paradigm. First introduced by Ashley in 1970 [ 10 ], and subsequently refined through multiple generations, PU implants are characterized by a microporous foam coating that promotes tissue ingrowth, creating a biomechanical bond between the implant surface and surrounding capsule [ 11 , 12 ]. This bio-integration phenomenon results in significantly lower rates of capsular contracture [ 13 – 16 ], reduced implant malposition [ 17 , 18 ], and improved positional stability compared with conventional implants [ 19 ]. Histological studies have demonstrated that PU capsules consist of type I collagen-rich fibrous tissue with low inflammatory cell infiltration and foreign body giant cells containing polyurethane remnants, findings that differ substantially from capsules formed around smooth or textured implants [ 20 , 21 ]. The use of PU implants in revision surgery has gained momentum in recent years. Hamdi et al. published the first prospective series of PU implants in revisional breast augmentation, demonstrating consistent stability and zero recurrent capsular contracture over a 5-year follow-up period [ 22 ]. Their study included capsulorrhaphy as part of the surgical protocol but did not analyze pocket management techniques as an independent variable. Similarly, Pontes et al. provided histopathological evidence that PU capsular tissue may serve as a viable alternative to acellular dermal matrix (ADM) in revisional surgery, suggesting a role for capsular flaps in pocket modification [ 21 ]. However, neither study addressed the specific question of how to resize the breast pocket when exchanging conventional implants for PU devices. This gap in the literature is clinically significant. When a surgeon exchanges a conventional implant for a PU device, particularly when downsizing or correcting malposition, the pre-existing pocket is frequently larger than the replacement implant. With conventional implants, residual dead space may be tolerated because the implant can adapt its position within the capsule over time. With PU implants, however, any dead space present at implantation becomes effectively permanent, as the foam surface adheres to adjacent tissue within the first weeks postoperatively [ 11 , 23 ]. Furthermore, the placement of capsulorrhaphy sutures through areas of intended PU-tissue contact may create barriers to bio-integration, potentially compromising one of the primary advantages of choosing a PU device. The purpose of this article is twofold: first, to propose a decision-making algorithm for breast pocket resizing during exchange to PU implants, based on integration of published evidence and clinical experience; and second, to present supporting data from a consecutive case series to illustrate the clinical application of the proposed pathways. METHODS Algorithm Development The proposed algorithm was developed through a systematic process integrating three sources: (1) published literature on capsulorrhaphy techniques and their outcomes; (2) published evidence on PU implant biology, capsule histology, and clinical behavior; and (3) clinical observations from a consecutive series of patients undergoing exchange from conventional to PU implants at the senior author’s practice. A comprehensive literature review was performed searching PubMed, Scopus, and the Cochrane Library using the terms “capsulorrhaphy,” “pocket resizing,” “breast implant revision,” “polyurethane breast implant,” and “bio-integration.” Articles describing capsulorrhaphy techniques, PU implant outcomes in revision surgery, and capsule histology were analyzed for relevant principles applicable to PU-specific pocket management. The algorithm was structured around two primary decision axes identified from the literature and clinical experience as the most relevant determinants of pocket management strategy: (A) the magnitude of pocket-implant size discrepancy, quantified as the difference between prior implant volume and replacement PU implant volume; and (B) the quality and condition of the existing capsule, assessed both preoperatively (Baker classification) and intraoperatively (tissue thickness, pliability, calcification, and suture purchase potential). The definitions and clinical criteria for each classification category are summarized in Table 1 . Table 1 Algorithm Decision Axes and Classification Categories Axis / Category Classification Definition and Clinical Criteria Axis A: Volume Discrepancy Minimal ≤ 50 cc difference between prior and replacement implant volumes Moderate 50–150 cc difference; significant dead space anticipated Major > 150 cc difference; comprehensive pocket modification required Dimensional Width/height/projection mismatch without major volume change Axis B: Capsule Quality Thin and pliable Baker I–II; poor suture purchase; risk of suture pull-through Moderate Baker II–III; adequate thickness; reliable suture fixation Thick/contracted Baker III–IV; significant fibrosis or calcification; capsulectomy indicated PU capsule Prior PU implant; dense fibrous tissue with FBGC; potential flap viability FBGC, foreign body giant cells; PU, polyurethane. Clinical Case Series A retrospective review was conducted of consecutive patients who underwent exchange of conventional breast implants (smooth or textured silicone gel) for polyurethane-coated implants between 2022 to 2025 at a single center. The study was approved by the institutional ethics committee (protocol number to be inserted) and conducted in accordance with the Declaration of Helsinki. Inclusion criteria were: (1) exchange from any conventional implant type to a PU-coated device; (2) aesthetic indication (primary revision or secondary/tertiary revision); (3) minimum 6-month postoperative follow-up; and (4) complete preoperative and intraoperative documentation. Exclusion criteria included: primary breast augmentation with PU (no prior implant), post-mastectomy reconstructive cases, and incomplete follow-up data. Data Collection Data were collected at the breast level (each breast analyzed independently). Preoperative variables included prior implant characteristics (manufacturer, surface, volume, profile, base width), Baker grade, malposition type and severity, pocket plane, and breast measurements (sternal notch-to-nipple distance, nipple-to-inframammary fold distance, base width). Intraoperative variables included capsulectomy extent, capsule quality assessment (thin and pliable, moderate, thick/contracted, or PU capsule), capsulorrhaphy details (type, direction, suture material), use of thermal techniques or ADM/mesh, plane change, and final PU implant specifications. The volume discrepancy was calculated as the difference between prior and new implant volumes. Each breast was retrospectively assigned to an algorithm pathway (1 through 5) based on the intraoperative findings and the pocket management technique employed. This retrospective assignment served to validate the algorithm’s capacity to categorize the clinical decision-making that had already occurred. Outcome Measures The primary outcome was implant position stability at final follow-up, categorized as stable (no displacement from intended position), minor displacement (< 1 cm), or significant displacement (≥ 1 cm). Secondary outcomes included capsular contracture recurrence (Baker classification), reoperation rate, physician-rated contour assessment (excellent, good, fair, or poor), and patient satisfaction assessed using the BREAST-Q Augmentation module when available. Statistical Analysis Descriptive statistics were used for demographic and outcome variables. Continuous variables were expressed as mean ± standard deviation or median (interquartile range) as appropriate. Categorical variables were expressed as frequency and percentage. Comparisons between algorithm pathways were performed using one-way ANOVA or the Kruskal-Wallis test for continuous variables and chi-square or Fisher’s exact test for categorical variables. Statistical significance was set at p < 0.05. Analysis was performed using JASP (Version 0.96.0). RESULTS Proposed Algorithm The algorithm generates five distinct management pathways based on the intersection of two decision axes (Fig. 1 ). The first decision node evaluates capsule condition: capsules graded Baker III–IV are directed to Pathway 4 (complete capsulectomy with neopocket creation), and pre-existing PU capsules are directed to Pathway 5 (PU-to-PU revision management). Capsules graded Baker I–II proceed to the second decision node, which evaluates volume discrepancy between the prior implant and the replacement PU device. Pathway 1 (Bio-integration Reliance). For minimal discrepancy (≤ 50 cc) with adequate capsule quality, no formal capsulorrhaphy is performed. Capsulotomy is used for access and positioning as needed. The rationale is that PU bio-integration is sufficient to adapt to minor pocket-implant mismatch, and the introduction of capsulorrhaphy sutures in this scenario would unnecessarily interfere with the PU foam-tissue interface without meaningful clinical benefit. Pathway 2 (Selective Capsulorrhaphy). For moderate discrepancy (50–150 cc) with moderate capsule quality, selective capsulorrhaphy is performed, most commonly in the inferolateral direction, combined with mirror-image capsulotomy to offload tension on the repair. Permanent braided suture (Ethibond 2 − 0) or long-lasting barbed suture is used. A critical technical consideration specific to PU exchange is the placement of capsulorrhaphy sutures at the capsular margin rather than through areas of intended PU-tissue contact, preserving the foam-tissue interface for optimal bio-integration. Pathway 3 (Thermal Capsulorrhaphy with Reinforcement or Plane Change). For major discrepancy (> 150 cc) or when the capsule is too thin for reliable suture purchase, a multi-technique approach is employed. Thermal capsulorrhaphy (popcorn technique or argon beam coagulation) is used first to contract and thicken the capsule, followed by suture reinforcement. For extremely thin capsules, partial capsulectomy of excess tissue with PU placement in the remodeled pocket is preferred. When downsizing exceeds 200 cc, plane change (e.g., subglandular to retromuscular) should be evaluated as an alternative to extensive capsulorrhaphy, as it provides a fresh tissue bed favorable for PU integration. Pathway 4 (Capsulectomy with Neopocket Creation). For contracted capsules (Baker III–IV), complete capsulectomy with creation of a new pocket is recommended regardless of volume discrepancy. This pathway provides the most predictable environment for PU bio-integration, as the implant is placed in a virgin tissue bed free from pre-existing capsular architecture. Plane change may be combined when indicated. Pathway 5 (PU-to-PU Revision). When revising a pre-existing PU implant, the capsule has unique histological characteristics. Based on recent evidence by Pontes et al. [ 21 ], PU capsules consist of dense, paucicellular, type I collagen-rich tissue with low vascularization—properties that resemble acellular dermal matrix. The algorithm directs surgeons to assess dermocapsular flap viability for pocket reshaping rather than routinely discarding this tissue. Partial capsulectomy of adherent PU remnants is performed only when necessary for implant removal, and capsular tissue is preserved where possible for internal support or fold definition. A summary of the indications, techniques, and PU-specific considerations for each pathway is provided in Table 2 . Table 2 Algorithm Pathways: Indications, Techniques, and PU-Specific Considerations Pathway Indication Capsule Quality Technique PU-Specific Consideration 1 ≤ 50 cc discrepancy Any (adequate+) No capsulorrhaphy; capsulotomy for access only PU bio-integration sufficient for minor pocket adaptation 2 50–150 cc discrepancy Moderate quality Selective capsulorrhaphy + mirror capsulotomy; permanent suture Place sutures at capsular periphery; preserve PU foam-tissue interface 3 > 150 cc OR thin capsule Any (esp. thin) Thermal capsulorrhaphy → suture; or partial capsulectomy; or plane change Thermal thickening may alter PU interface; evaluate plane change if > 200 cc 4 Baker III–IV (any discrepancy) Thick/contracted Total capsulectomy; neopocket creation; ± plane change Most predictable PU integration scenario (virgin tissue bed) 5 PU-to-PU revision PU capsule Capsule assessment; dermocapsular flap; selective capsulectomy PU capsule viable as autologous ADM substitute (Pontes 2024) PU, polyurethane; ADM, acellular dermal matrix. PU-Specific Intraoperative Considerations Several technical principles apply across all pathways and represent departures from conventional revision surgery (Table 4 ). First, capsulorrhaphy sutures must be placed peripheral to the intended PU-tissue contact zone (Fig. 2 ). The PU foam creates a three-dimensional scaffold that promotes tissue ingrowth; suture material traversing this interface may create a barrier to adhesion or produce surface irregularity palpable through thin soft tissue coverage. Second, rigorous pocket irrigation with povidone-iodine solution and strict adherence to a no-touch protocol are essential, as biofilm formation on the PU surface has been associated with complications. Third, sizer evaluation is mandatory before definitive PU placement, as the bio-integrating nature of the implant limits opportunities for postoperative positional adjustment. Table 4 PU-Specific Technical Modifications Compared with Conventional Implant Revision Parameter Conventional Implant Approach PU-Specific Modification Capsulorrhaphy suture placement Through capsule at any point providing adequate purchase Peripheral to PU-tissue contact zone; avoid traversing foam interface Tolerance of dead space Minor dead space acceptable; implant may settle over time Dead space becomes permanent after bio-integration; precise pocket sizing critical Postoperative mobilization Some surgeons advocate massage or displacement exercises Contraindicated; undisturbed adhesion period of 4–6 weeks required Sizer evaluation Recommended but optional in straightforward exchanges Mandatory; limited opportunity for postoperative positional correction ADM/mesh supplementation Commonly used for pocket reinforcement and support Generally redundant due to PU bio-integration; reserve for Pathway 3 thin capsules Capsule preservation Variable; total capsulectomy often preferred PU capsule has ADM-like properties; preserve for flap use in Pathway 5 PU, polyurethane; ADM, acellular dermal matrix. Postoperatively, the approach differs from conventional implant revision in that early mobilization exercises are contraindicated in the capsulorrhaphy zone. Unlike conventional implants where some surgeons advocate massage or displacement exercises to prevent contracture, PU implants require an undisturbed adhesion period of 4–6 weeks. Supportive garment use is maintained for 4–6 weeks without compressive banding. Clinical Case Series Patient Demographics A total of 47 patients (82 breasts) met inclusion criteria during the study period. Mean age at the time of exchange was 38.4 ± 7.2 years (range, 26–57 years). Mean body mass index was 23.8 ± 3.1 kg/m 2 (range, 18.6–32.4 kg/m 2 ). The median interval between primary augmentation and exchange surgery was 84 months (interquartile range [IQR], 48–132 months). The majority of patients had undergone a single prior augmentation (34, 72.3%); 13 patients (27.7%) had two or more previous breast surgeries. The most common indication for exchange was capsular contracture (31 breasts, 37.8%), followed by implant malposition (22 breasts, 26.8%), patient-desired volume change (18 breasts, 22.0%), and implant rupture (11 breasts, 13.4%). Demographic characteristics stratified by algorithm pathway are presented in Table 5 . Table 5 Patient Demographics and Clinical Characteristics Stratified by Algorithm Pathway Variable Pathway 1 (n = 19) Pathway 2 (n = 24) Pathway 3 (n = 14) Pathway 4 (n = 18) Pathway 5 (n = 7) p value Age, years (mean ± SD) 37.1 ± 6.8 39.2 ± 7.5 38.9 ± 7.1 38.4 ± 7.8 37.6 ± 5.9 0.92 BMI, kg/m² (mean ± SD) 23.2 ± 2.8 24.1 ± 3.3 24.5 ± 3.4 23.6 ± 2.9 23.0 ± 2.6 0.78 Interval to exchange, months (median, IQR) 72 (36–108) 90 (52–144) 96 (60–156) 84 (48–120) 108 (72–168) 0.34 ≥ 2 prior surgeries, n (%) 3 (15.8) 7 (29.2) 5 (35.7) 6 (33.3) 3 (42.9) 0.51 Prior implant volume, cc (mean ± SD) 310 ± 52 348 ± 61 372 ± 78 318 ± 64 295 ± 48 0.02 Replacement PU volume, cc (mean ± SD) 285 ± 49 258 ± 55 182 ± 62 305 ± 58 270 ± 51 < 0.001 Volume discrepancy, cc (mean ± SD) 28 ± 14 95 ± 31 198 ± 47 N/A* 32 ± 18 < 0.001† Preop Baker I–II, n (%) 19 (100) 24 (100) 14 (100) 0 (0) 7 (100) — Preop Baker III–IV, n (%) 0 (0) 0 (0) 0 (0) 18 (100) 0 (0) — Plane change, n (%) 0 (0) 2 (8.3) 6 (42.9) 14 (77.8) 4 (57.1) < 0.001 Follow-up, months (mean ± SD) 15.2 ± 7.8 14.1 ± 6.9 13.8 ± 7.2 14.9 ± 7.6 16.4 ± 8.1 0.90 BMI, body mass index; IQR, interquartile range; PU, polyurethane; SD, standard deviation. *Pathway 4 patients directed by capsule condition regardless of volume discrepancy. †Comparison among Pathways 1, 2, and 3 only. Continuous variables compared with one-way ANOVA or Kruskal–Wallis test; categorical variables compared with chi-square or Fisher’s exact test Prior Implant Characteristics The prior implants were textured silicone gel in 51 breasts (62.2%), smooth silicone gel in 26 breasts (31.7%), and saline in 5 breasts (6.1%). Mean prior implant volume was 327 ± 68 cc (range, 185–520 cc). The prior pocket plane was subpectoral in 54 breasts (65.9%), subglandular in 21 breasts (25.6%), and subfascial in 7 breasts (8.5%). Preoperative Baker classification was grade I in 18 breasts (22.0%), grade II in 26 (31.7%), grade III in 27 (32.9%), and grade IV in 11 (13.4%). Distribution Across Algorithm Pathways Retrospective pathway assignment classified the 82 breasts as follows: Pathway 1 (bio-integration reliance), 19 breasts (23.2%); Pathway 2 (selective capsulorrhaphy), 24 breasts (29.3%); Pathway 3 (thermal capsulorrhaphy with reinforcement or plane change), 14 breasts (17.1%); Pathway 4 (capsulectomy with neopocket creation), 18 breasts (21.9%); and Pathway 5 (PU-to-PU revision), 7 breasts (8.5%). The mean volume discrepancy between the prior and replacement implant was 28 ± 14 cc for Pathway 1, 95 ± 31 cc for Pathway 2, and 198 ± 47 cc for Pathway 3 (p < 0.001, one-way ANOVA). These differences were statistically significant, confirming internal consistency of the volume-based classification axis. Replacement Implant Characteristics All replacement devices were polyurethane-coated silicone gel implants (Microthane®, POLYTECH Health & Aesthetics, Dieburg, Germany). Mean replacement implant volume was 295 ± 58 cc (range, 175–450 cc). The replacement pocket plane was prepectoral in 38 breasts (46.3%), retromuscular (dual-plane) in 29 breasts (35.4%), and the same plane as the prior implant in 15 breasts (18.3%). A plane change was performed in 26 breasts (31.7%), most commonly from subpectoral to prepectoral (19 breasts). Intraoperative Capsule Assessment and Pocket Management Intraoperative capsule quality was classified as thin and pliable in 16 breasts (19.5%), moderate in 30 breasts (36.6%), thick or contracted in 29 breasts (35.4%), and PU capsule in 7 breasts (8.5%). Among breasts managed with Pathway 2, selective capsulorrhaphy was performed in the inferolateral direction in 15 (62.5%), inferior in 6 (25.0%), and medial in 3 (12.5%). The suture material was permanent braided (Ethibond 2 − 0) in 17 breasts (70.8%) and long-lasting barbed suture in 7 (29.2%). Among Pathway 3 breasts, thermal capsulorrhaphy was performed using the popcorn technique in 9 (64.3%) and ball cautery in 5 (35.7%); 4 breasts (28.6%) additionally underwent partial capsulectomy of excess tissue, and 6 (42.9%) underwent a plane change. Total capsulectomy was performed in all 18 Pathway 4 breasts. Among the 7 Pathway 5 breasts, a dermocapsular flap was successfully raised in 5 (71.4%) and used for internal fold reinforcement or pocket reshaping. Implant Position Stability At a mean follow-up of 14.6 ± 7.3 months (range, 6–36 months), implant position was classified as stable in 77 breasts (93.9%), minor displacement (< 1 cm) in 5 breasts (6.1%), and significant displacement (≥ 1 cm) in 0 breasts (0%) (Fig. 3 ). Position stability rates by pathway were as follows: Pathway 1, 18/19 (94.7%) stable; Pathway 2, 23/24 (95.8%) stable; Pathway 3, 12/14 (85.7%) stable; Pathway 4, 17/18 (94.4%) stable; and Pathway 5, 7/7 (100%) stable. No statistically significant difference in position stability was observed across pathways (p = 0.72, Fisher’s exact test). Cases of minor displacement occurred in 2 Pathway 3 breasts, both involving patients with extremely thin capsules and volume discrepancies exceeding 200 cc in whom a plane change was not performed. No case of significant displacement was observed in the entire series. Secondary Outcomes Capsular contracture recurrence (Baker grade III or IV) was observed in 2 breasts (2.4%) at final follow-up. Both affected breasts had been managed with Pathway 2 and presented Baker III contracture at 11 and 14 months postoperatively, respectively; both had prior Baker II capsules with moderate volume discrepancy. No recurrence of Baker grade III–IV contracture was observed among breasts managed with Pathway 4 (capsulectomy with neopocket creation). The overall reoperation rate was 7.3% (6/82 breasts). Indications for reoperation included capsular contracture recurrence requiring capsulectomy and implant replacement (2 breasts), seroma requiring surgical drainage (1 breast), palpable capsulorrhaphy suture requiring removal (1 breast), and contralateral symmetry revision (2 breasts). No implant was explanted without replacement during the study period. Mean time to reoperation was 9.8 months. Physician-rated contour assessment at final follow-up was excellent in 42 breasts (51.2%), good in 29 (35.4%), fair in 9 (11.0%), and poor in 2 (2.4%). BREAST-Q Augmentation module data were available for 31 patients (66.0%). Mean postoperative satisfaction with breasts score was 72.4 ± 16.8 (scale 0–100), and mean satisfaction with outcome score was 78.1 ± 14.3. Pre- to postoperative change in satisfaction with breasts was statistically significant (mean difference 18.6, 95% CI 12.3–24.9, p < 0.001, paired t-test) (Fig. 4 ). Complications Early complications (within 30 days) occurred in 5 breasts (6.1%) and included seroma (2), hematoma (1), wound dehiscence (1), and infection (1). Late complications (beyond 30 days) were observed in 6 breasts (7.3%) and included palpable capsulorrhaphy suture (2), late seroma (1), capsular contracture recurrence (2), and minor asymmetry requiring revision (1). No cases of breast implant-associated anaplastic large cell lymphoma (BIA-ALCL) were detected during the follow-up period. Complications stratified by algorithm pathway are detailed in Table 6 . Table 6 Complications Stratified by Algorithm Pathway Complication Pathway 1 (n = 19) Pathway 2 (n = 24) Pathway 3 (n = 14) Pathway 4 (n = 18) Pathway 5 (n = 7) Total (n = 82) Early (≤ 30 days) Seroma 0 0 1 (7.1) 1 (5.6) 0 2 (2.4) Hematoma 0 0 0 1 (5.6) 0 1 (1.2) Wound dehiscence 0 0 1 (7.1) 0 0 1 (1.2) Infection 0 0 0 1 (5.6) 0 1 (1.2) Subtotal early 0 (0) 0 (0) 2 (14.3) 3 (16.7) 0 (0) 5 (6.1) Late (> 30 days) Capsular contracture (Baker III–IV) 0 2 (8.3) 0 0 0 2 (2.4) Palpable suture 0 1 (4.2) 1 (7.1) 0 0 2 (2.4) Late seroma 0 0 0 1 (5.6) 0 1 (1.2) Asymmetry requiring revision 0 0 0 0 1 (14.3) 1 (1.2) Subtotal late 0 (0) 3 (12.5) 1 (7.1) 1 (5.6) 1 (14.3) 6 (7.3) Total complications 0 (0) 3 (12.5) 3 (21.4) 4 (22.2) 1 (14.3) 11 (13.4) Reoperation 0 (0) 2 (8.3) 1 (7.1) 2 (11.1) 1 (14.3) 6 (7.3) Values are presented as n (%). Early complications defined as occurring within 30 days of surgery. No cases of breast implant-associated anaplastic large cell lymphoma (BIA-ALCL) were detected during the follow-up period. Algorithm Concordance Analysis Retrospective concordance between the proposed algorithm recommendation and the actual surgical technique performed was evaluated. The overall concordance rate was 87.8% (72/82 breasts). Discordant cases (10 breasts) included 7 breasts where the surgeon performed a higher-level intervention than recommended by the algorithm (e.g., capsulorrhaphy where bio-integration reliance was predicted) and 3 breasts where a lower-level intervention was employed. Among concordant cases, 95.8% achieved a stable implant position compared with 80.0% among discordant cases (p = 0.08, Fisher’s exact test). These findings suggest that the algorithm reliably captures the decision-making logic applied in clinical practice, though the limited sample precludes definitive conclusions regarding the superiority of algorithm-concordant management. DISCUSSION This article presents the first algorithm specifically addressing pocket management during exchange to polyurethane-coated breast implants. While capsulorrhaphy techniques have been extensively described [ 5 – 9 , 24 ] and systematic reviews have addressed capsular contracture management broadly [ 28 ], no prior publication has integrated these bodies of knowledge with PU implant behavior in revision surgery [ 17 , 22 ] to address the unique clinical scenario of conventional-to-PU exchange. The rationale for a PU-specific algorithm rests on the fundamental biological difference between PU and conventional implants at the capsule-implant interface. Conventional implants, whether smooth or textured, allow some degree of relative motion between the device and surrounding capsule. This means that a pocket slightly larger than the implant may be tolerable, as the implant can settle into a stable position over time through gravitational forces and tissue adaptation. PU implants, by contrast, adhere to adjacent tissue within the first weeks after implantation through ingrowth of vascularized tissue into the foam matrix [ 11 , 20 , 23 ]. Any dead space present at the time of surgery becomes effectively fixed once bio-integration occurs. This property simultaneously eliminates the risk of late implant displacement—a major advantage—and demands more precise pocket management at the index operation. The two-axis decision framework was chosen because volume discrepancy and capsule quality represent the most actionable clinical variables at the time of surgery. Volume discrepancy determines whether pocket resizing is necessary, while capsule quality determines which resizing technique is feasible. The thresholds selected (≤ 50 cc for minimal, 50–150 cc for moderate, > 150 cc for major) are based on the clinical observation that pocket-implant mismatch below 50 cc is generally accommodated by the soft tissue envelope and PU adhesion, while mismatch above 150 cc produces visible dead space, contour irregularity, or positional instability. These thresholds should be validated in future prospective studies. Comparison with Existing Capsulorrhaphy Approaches The algorithm builds upon established capsulorrhaphy principles while introducing PU-specific modifications (Table 3 ). The mirror-image capsulotomy described by Chasan and Francis [ 6 ] remains a central component of Pathway 2, as it effectively offloads tension on the capsulorrhaphy repair. However, the original technique description did not consider suture placement relative to a bio-integrating implant surface, which is a critical consideration when using PU devices. Table 3 Comparison of Published Capsulorrhaphy Techniques and Their Applicability to PU Exchange Technique First Author (Year) n (breasts) Key Feature Success Rate Applicability to PU Exchange Suture capsulorrhaphy Chasan (2008) 75 Mirror-image capsulotomy to offload repair Satisfactory High — peripheral suture placement compatible with PU Thermal capsulorrhaphy Harris (2014) 157 Ball cautery + quilled suture 89.9% Moderate — thermal zone may affect PU interface Popcorn capsulorrhaphy Calobrace (2020) 266 Insulated forceps + cautery; thickens capsule 94.8% Moderate — focal application preferred to preserve PU zone Argon beam capsulorrhaphy Awaida (2022) 6 Argon beam coagulator; 69.5% shrinkage 100% (limited n) High — precise application; superior capsule contraction ADM/mesh reinforcement Multiple Variable Biologic or synthetic pocket support Variable Low — redundant with PU bio-integration in most cases PU, polyurethane; ADM, acellular dermal matrix. The thermal capsulorrhaphy techniques—whether the ball cautery approach of Harris et al. [ 7 ], the popcorn technique of Calobrace et al. [ 8 ], or the argon beam method of Awaida et al. [ 9 ]—are particularly valuable in Pathway 3 because they address the challenge of thin capsules that lack adequate suture purchase. The argon beam coagulator achieved 69.5% capsular shrinkage compared with 46.8% for standard electrocautery [ 9 ], suggesting it may be the preferred thermal technique when available. However, thermal approaches must be used judiciously in PU exchange, as excessive capsular contraction may create a pocket too small for the intended implant, and the thickened capsule may alter the PU-tissue interaction in the treated zone. The inclusion of Pathway 5 (PU-to-PU revision) reflects the growing population of patients with existing PU implants requiring secondary surgery. The histopathological evidence from Pontes et al. [ 21 ] demonstrates that PU capsules have unique structural properties—dense fibrous tissue with low inflammation and vacuoles containing PU remnants—that make them potentially suitable as autologous tissue flaps for pocket modification, analogous to the capsular flaps described by Voice and Carlsen [ 25 ] and the ADM-substitute concept proposed by the same authors. This is a paradigm shift from the standard approach of capsulectomy and discard. The Role of Bio-integration in Pocket Management Perhaps the most important conceptual contribution of this algorithm is the recognition that PU bio-integration itself serves as a pocket management mechanism. Pathway 1 explicitly acknowledges that for small pocket-implant discrepancies, the implant’s inherent adhesion to surrounding tissue may be sufficient without additional surgical intervention. This is a departure from the conventional approach, where any pocket overdimension is typically addressed with capsulorrhaphy to prevent migration. The 30-year follow-up study by Don Parsa et al. [ 13 ] provides indirect support for this concept. In their series of 382 patients with PU implants, capsular ptosis with inferior displacement occurred in only two patients (0.5%), one of whom had the implant completely detached from its coating. This extremely low malposition rate suggests that the bio-integration mechanism provides robust positional stability even without formal pocket modification. However, reliance on bio-integration has limits. When the pocket is substantially larger than the implant, the PU foam cannot bridge the gap between the implant surface and the distant capsular wall. In these cases (Pathways 2 and 3), bringing the capsule closer to the implant through capsulorrhaphy is necessary to facilitate tissue contact with the PU surface. The key modification is placing sutures at the capsular periphery to reduce overall pocket dimensions while preserving the central contact zone for unimpeded bio-integration (Fig. 2 ). Integration with Existing PU Revision Protocols The proposed algorithm complements the work of Hamdi et al. [ 22 ], whose algorithm for PU revision surgery focused on the broader surgical plan (capsulectomy extent, plane change, mastopexy, lipofilling) rather than the specific technical details of pocket resizing. In their series, capsulorrhaphy was performed when needed for pocket modification but was not systematically categorized or analyzed. Our algorithm provides a more granular framework for the pocket management component that can be integrated into their broader decision tree. Similarly, the Dutch Breast Implant Registry data recently reported by Harmeling et al. [ 26 ] provide population-level data on revision rates comparing smooth, textured, and PU implants in reconstructive settings. While their analysis focused on indications for revision rather than surgical technique, the finding that implant type influences revision patterns reinforces the need for device-specific management algorithms. Limitations This study has several limitations. First, the algorithm is based on a combination of literature synthesis and clinical experience rather than prospective randomized data, limiting the level of evidence to Level V. The decision thresholds for volume discrepancy categories are empirically derived and require formal validation. Second, the clinical series represents a single-center experience from one senior surgeon, which limits generalizability. Surgical technique, patient selection, and implant preference may influence outcomes in ways not captured by the algorithm. Third, the retrospective pathway assignment may introduce classification bias, as the algorithm was developed from the same clinical observations it seeks to organize. Prospective application of the algorithm with pre-specified pathway assignment is necessary to validate its predictive capacity. Fourth, the follow-up period for the clinical series may be insufficient to capture late complications. While PU bio-integration is expected to stabilize within 3–6 months, long-term outcomes including late capsular contracture (which in PU implants typically appears after 9–10 years, when polyurethane degradation is advanced [ 13 ]) require extended surveillance. Fifth, the algorithm does not specifically address dimensional mismatch (width, projection, or height differences without volume change), which is a distinct clinical scenario requiring further study. Future Directions Prospective multicenter validation of this algorithm is the logical next step. A registry-based approach, collecting data on pocket management technique, algorithm pathway, and standardized outcomes across multiple centers, would provide the sample size needed to validate the proposed thresholds and refine pathway definitions. Additionally, intraoperative imaging tools such as ultrasound could provide objective measurement of capsule thickness and pocket dimensions, potentially improving the accuracy of pathway assignment compared with subjective tactile assessment alone. Investigation of the suture-PU interface is warranted. No published data exist on how capsulorrhaphy suture material interacts with PU foam at the microscopic level. In vitro and animal studies examining tissue integration around PU foam in the presence of adjacent suture material could inform optimal suture placement distance from the implant surface. CONCLUSIONS Pocket management during exchange to polyurethane-coated breast implants requires a differentiated approach from conventional revision surgery due to the bio-integration phenomenon. We propose a decision algorithm based on two clinically assessable axes—volume discrepancy and capsule quality—generating five management pathways that range from reliance on bio-integration alone for minimal mismatch to complete capsulectomy with neopocket creation for contracted capsules. PU-specific technical modifications include peripheral suture placement preserving the foam-tissue interface, avoidance of postoperative mobilization exercises, and consideration of dermocapsular flap viability in PU-to-PU revisions. Clinical data from our case series support the algorithm’s applicability. Prospective multicenter validation is needed to confirm the proposed thresholds and refine pathway definitions. Declarations Compliance with Ethical Standards This study was conducted in accordance with the Declaration of Helsinki. Institutional ethics committee approval was obtained (protocol number to be inserted). Informed consent was obtained from all participants for inclusion in the retrospective analysis. Conflict of Interest No conflicts of interests among the authors. Funding No external funding was received for this study. Author Contribution S.B.S.: Conception and design of the study; development of the original algorithm framework based on clinical experience with polyurethane implant exchange surgery; performance of all surgical procedures in the clinical case series; intraoperative data acquisition and capsule quality assessment; critical revision of the manuscript for important intellectual content, with particular emphasis on the technical accuracy of pathway descriptions and PU-specific surgical modifications; final approval of the version to be published. N.A.R.M.: Systematic literature review on capsulorrhaphy techniques and polyurethane implant biology; design and execution of the data collection instrument; retrospective data collection, database management, and statistical analysis; formalization of the algorithm decision axes and pathway classification criteria; retrospective concordance analysis between algorithm recommendations and actual surgical decisions; drafting of the manuscript, including all sections, tables, and figure legends; preparation and formatting of all figures; preparation of the submission package including the cover letter. References American Society of Plastic Surgeons (2024) Plastic surgery statistics report 2023. ASPS, Arlington Heights International Society of Aesthetic Plastic Surgery (2024) ISAPS international survey on aesthetic/cosmetic procedures performed in 2023. ISAPS, Hanover Hidalgo DA, Spector JA (2014) Breast augmentation. Plast Reconstr Surg 133:567e–583e Adams WP Jr (2009) Capsular contracture: what is it? What causes it? How can it be prevented and managed? Clin Plast Surg 36:119–126 Spear SL, Little JW III (1988) Breast capsulorrhaphy. Plast Reconstr Surg 81:274–279 Chasan PE, Francis CS (2008) Capsulorrhaphy for revisionary breast surgery. Aesthet Surg J 28:63–69 Harris R, Raphael P, Harris SW (2014) Thermal capsulorrhaphy: a modified technique for breast pocket revision. Aesthet Surg J 34:1041–1049 Calobrace MB, Capizzi PJ, Cohen R, Mulder TP (2020) Popcorn capsulorrhaphy in revision aesthetic breast surgery. Aesthet Surg J 40:68–74 Awaida CJ, Paek L, Danino MA (2022) A new technique for breast pocket adjustment: argon beam thermal capsulorrhaphy. Plast Reconstr Surg Glob Open 10:e4437 Ashley FL (1970) A new type of breast prosthesis: preliminary report. Plast Reconstr Surg 45:421–424 Frame J, Kamel D, Olivan M, Cintra H (2015) The in vivo pericapsular tissue response to modern polyurethane breast implants. Aesthet Plast Surg 39:713–723 Castel N, Soon-Sutton T, Deptula P, Flaherty A, Parsa FD (2015) Polyurethane-coated breast implants revisited: a 30-year follow-up. Arch Plast Surg 42:186–193 Don Parsa F, Castel N, Parsa AA (2015) Polyurethane-coated breast implants revisited: a 30-year follow-up. Arch Plast Surg 42:186–193 Pompei S, Evangelidou D, Arelli F, Ferrante G (2016) The modern polyurethane-coated implant in breast augmentation: long-term clinical experience. Aesthet Surg J 36:1124–1129 Pompei S, Arelli F, Labardi L et al (2017) Polyurethane implants in 2-stage breast reconstruction: 9-year clinical experience. Aesthet Surg J 37:171–176 Pompei S, Arelli F, Evangelidou D et al (2014) Polyurethane implants following radiotherapy in breast reconstruction. Breast 23:126–130 POLYTECH Health & Aesthetics (2024) Microthane: innovative implant surface. Technical documentation. POLYTECH, Dieburg De Vita R, Buccheri EM, Pozzi M, Zoccali G (2019) Direct to implant breast reconstruction by using SIEA flap and polyurethane covered implant. Plast Reconstr Surg Glob Open 7:e2043 Loreti A, Siri G, De Carli M et al (2020) Immediate breast reconstruction after mastectomy with polyurethane implants versus textured implants: a retrospective study with focus on capsular contracture. Breast 54:127–132 Bergmann PA, Tamouridis G, Lohmeyer JA et al (2014) The effect of a bacterial contamination on the formation of capsular contracture with polyurethane breast implants in comparison with textured silicone implants: an animal study. J Plast Reconstr Aesthet Surg 67:1364–1370 Pontes GH, Ramos CPW, de Noronha L et al (2024) Long-term insights: histopathological assessment of polyurethane implant capsules over 24 years. Aesthet Surg J 44:915–924 Hamdi M, Kapila AK, Peters E et al (2024) Polyurethane implants in revisional breast augmentation: a prospective 5-year study. Aesthet Surg J 44:NP379–NP390 Handel N, Cordray T, Gutierrez J, Jensen JA (2006) A long-term study of outcomes, complications, and patient satisfaction with breast implants. Plast Reconstr Surg 117:757–767 Spear SL, Parham CS, Clemens MW (2021) Revision breast augmentation. Semin Plast Surg 35:135–145 Voice SD, Carlsen LN (2001) Using a capsular flap to correct breast implant malposition. Aesthet Surg J 21:441–444 Harmeling JX, Vrolijk JJ, Heeg E et al (2025) Comparison of revision surgery after implant-based breast reconstruction between smooth, textured, and polyurethane-covered implants: results from the Dutch Breast Implant Registry. BJS 112:znaf082 Maxwell GP, Birchenough SA, Gabriel A (2009) Efficacy of neopectoral pocket in revisionary breast surgery. Aesthet Surg J 29:379–385 Wan D, Rohrich RJ (2016) Revisiting the management of capsular contracture in breast augmentation: a systematic review. Plast Reconstr Surg 137:826–841 Headon H, Kasem A, Mokbel K (2015) Capsular contracture after breast augmentation: an update for clinical practice. Arch Plast Surg 42:532–543 Catanuto G (2024) One-stage implant-based breast reconstruction with polyurethane-coated device: standardized assessment of outcomes. Aesthet Surg J 44:NP391–NP400 Additional Declarations No competing interests reported. Cite Share Download PDF Status: Published Journal Publication published 11 Apr, 2026 Read the published version in European Journal of Plastic Surgery → Version 1 posted Editorial decision: Revision requested 24 Mar, 2026 Reviews received at journal 24 Mar, 2026 Reviewers agreed at journal 10 Mar, 2026 Reviewers invited by journal 09 Mar, 2026 Editor assigned by journal 09 Mar, 2026 Submission checks completed at journal 09 Mar, 2026 First submitted to journal 06 Mar, 2026 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-9046428","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":603970592,"identity":"0e50b30d-e892-4576-9562-b61365cf5f7a","order_by":0,"name":"Sergio Burciaga Soto","email":"","orcid":"","institution":"Angeles Hospital Chihuahua","correspondingAuthor":false,"prefix":"","firstName":"Sergio","middleName":"Burciaga","lastName":"Soto","suffix":""},{"id":603970593,"identity":"e93fb9a6-6865-4723-94fa-449c3d58d32c","order_by":1,"name":"Norman Alejandro Rendón Mejía","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA60lEQVRIiWNgGAWjYJADAwaGigNg1oEHxGs5c4CBB6QlgWgtjG0QLQz4tJiz9z7d8HMHQz6/dPPGx4Xz7sjZix1+CLTFTk63AbsWy57jZjd7zzBYzpxzrNh45rZnxjzSaQZALcnGZgdwOOZGGtsN3rb/BgY3csykebcdTuyRTgBpOZC4DY+Wm3/bGAzswVrmgLSkfyCo5TYvUIuBBEhLA0hLDgFbzhxjuy0L1CJxI63YmOfYYWOe2zkFBxIM8PjleBvbzbdALfwzkjc+5qk5LMc+O33zhw8VdnK4tOACBqQpHwWjYBSMglGACgCKb1+U3qjTtgAAAABJRU5ErkJggg==","orcid":"","institution":"Autonomous University of Chihuahua","correspondingAuthor":true,"prefix":"","firstName":"Norman","middleName":"Alejandro Rendón","lastName":"Mejía","suffix":""}],"badges":[],"createdAt":"2026-03-06 05:53:07","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-9046428/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-9046428/v1","draftVersion":[],"editorialEvents":[{"content":"https://doi.org/10.1007/s00238-026-02431-9","type":"published","date":"2026-04-11T15:57:30+00:00"}],"editorialNote":"","failedWorkflow":false,"files":[{"id":104582537,"identity":"1fff5eb3-b615-4c4f-823c-f7f65573fa5b","added_by":"auto","created_at":"2026-03-13 15:12:41","extension":"jpg","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":2236077,"visible":true,"origin":"","legend":"\u003cp\u003eDecision algorithm for breast pocket resizing during exchange to polyurethane-coated implants. The algorithm uses two sequential decision axes: capsule condition (Baker grade and intraoperative assessment) and volume discrepancy (prior implant volume minus replacement PU implant volume). Five management pathways are generated: Pathway 1 (bio-integration reliance for minimal discrepancy), Pathway 2 (selective capsulorrhaphy for moderate discrepancy), Pathway 3 (thermal capsulorrhaphy with reinforcement or plane change for major discrepancy or thin capsules), Pathway 4 (complete capsulectomy with neopocket creation for contracted capsules), and Pathway 5 (dermocapsular flap utilization for PU-to-PU revisions). Common intraoperative and postoperative steps applicable to all pathways are shown. PU, polyurethane; ADM, acellular dermal matrix.\u003c/p\u003e","description":"","filename":"Figure1EPS.jpg","url":"https://assets-eu.researchsquare.com/files/rs-9046428/v1/c625e437b25b68fd8d6e93de.jpg"},{"id":104582547,"identity":"e4bb31fd-28e3-45f6-893f-56f4db2193ee","added_by":"auto","created_at":"2026-03-13 15:12:42","extension":"jpg","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":168892,"visible":true,"origin":"","legend":"\u003cp\u003eSchematic cross-sectional diagram illustrating capsulorrhaphy suture placement strategies during exchange to polyurethane-coated breast implants. (A) Conventional approach: sutures are placed through the capsule at any point providing adequate purchase, including areas overlying the PU foam–tissue contact zone (red markers with dashed circles), which may create barriers to bio-integration. (B) PU-specific peripheral approach: sutures are placed exclusively at the capsular periphery (blue markers), distant from the intended PU foam–tissue interface, preserving the active bio-integration zone (green circles). Anatomical layers shown include skin and subcutaneous tissue, capsule, PU foam–tissue interface, implant body, pectoralis major muscle, and chest wall. PU, polyurethane.\u003c/p\u003e","description":"","filename":"Figure2EPS.jpg","url":"https://assets-eu.researchsquare.com/files/rs-9046428/v1/b37e9bf391dded268f27b89d.jpg"},{"id":104582543,"identity":"37f67a62-f01e-4e07-a317-7be2e4161e6a","added_by":"auto","created_at":"2026-03-13 15:12:42","extension":"jpg","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":509301,"visible":true,"origin":"","legend":"\u003cp\u003eImplant position stability at final follow-up stratified by algorithm pathway. Stacked bar chart showing the proportion of breasts with stable position (dark blue) versus minor displacement \u0026lt;1 cm (gold) for each pathway. Overall stability was 93.9% (77/82 breasts). No case of significant displacement (≥1 cm) was observed. The lowest stability rate was in Pathway 3 (85.7%), corresponding to cases with major volume discrepancy or thin capsules. The difference across pathways was not statistically significant (p = 0.72, Fisher’s exact test).\u003c/p\u003e","description":"","filename":"Figure3EPS.jpg","url":"https://assets-eu.researchsquare.com/files/rs-9046428/v1/c16fb64d1cd9f8cc4973b26a.jpg"},{"id":104582542,"identity":"f769f4ea-d479-4364-8856-46afd7616238","added_by":"auto","created_at":"2026-03-13 15:12:42","extension":"jpg","order_by":4,"title":"Figure 4","display":"","copyAsset":false,"role":"figure","size":188523,"visible":true,"origin":"","legend":"\u003cp\u003eBREAST-Q Augmentation module scores before and after implant exchange to polyurethane-coated devices (n = 31 patients). Paired box plots with individual data points (gray dots) and connecting lines showing per-patient change. (A) Satisfaction with breasts domain: median preoperative score 49 versus postoperative 74 (mean difference 18.6, 95% CI 12.3–24.9, p \u0026lt; 0.001, paired t-test). (B) Satisfaction with outcome domain: median preoperative score 46 versus postoperative 74 (p \u0026lt; 0.001). Red horizontal lines indicate medians. Both domains demonstrated statistically significant improvement following exchange surgery.\u003c/p\u003e","description":"","filename":"Figure4EPS.jpg","url":"https://assets-eu.researchsquare.com/files/rs-9046428/v1/361607c4f8f7d21f1bcfe15d.jpg"},{"id":106809350,"identity":"2a09c37c-b911-4bc2-a207-676d12cab77d","added_by":"auto","created_at":"2026-04-13 16:10:00","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":4369199,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-9046428/v1/70ace099-670c-48fa-a3be-617ca6ea8225.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Pocket Resizing Strategies in Implant Exchange to Polyurethane-Coated Breast Implants: A Concept Article and Proposed Decision Algorithm","fulltext":[{"header":"INTRODUCTION","content":"\u003cp\u003eBreast implant revision surgery remains one of the most technically demanding procedures in aesthetic plastic surgery. With more than 4\u0026nbsp;million breast augmentation procedures performed worldwide, the population of patients requiring secondary surgery continues to grow, driven by implant-related complications, natural aging processes, and evolving patient preferences [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e]. Among the most challenging aspects of revision surgery is the management of the breast pocket\u0026mdash;the capsular space formed around the original implant\u0026mdash;which frequently requires modification to accommodate a replacement device [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e, \u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eCapsulorrhaphy, the surgical tightening of the breast implant capsule, has been a cornerstone technique in revision breast surgery since its description by Spear and Little in 1988 [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e]. Since then, multiple technical refinements have been introduced, including the mirror-image capsulotomy described by Chasan and Francis [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e], thermal capsulorrhaphy using ball cautery with barbed suture closure [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e], popcorn capsulorrhaphy utilizing insulated forceps and electrocautery [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e], and argon beam thermal capsulorrhaphy [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e]. These techniques have been studied primarily in the context of conventional smooth or textured silicone gel and saline implants, where the capsule-implant interface permits relative sliding between the device and surrounding tissue.\u003c/p\u003e \u003cp\u003ePolyurethane-coated (PU) breast implants represent a fundamentally different paradigm. First introduced by Ashley in 1970 [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e], and subsequently refined through multiple generations, PU implants are characterized by a microporous foam coating that promotes tissue ingrowth, creating a biomechanical bond between the implant surface and surrounding capsule [\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e, \u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e]. This bio-integration phenomenon results in significantly lower rates of capsular contracture [\u003cspan additionalcitationids=\"CR14 CR15\" citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e], reduced implant malposition [\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e, \u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e], and improved positional stability compared with conventional implants [\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e]. Histological studies have demonstrated that PU capsules consist of type I collagen-rich fibrous tissue with low inflammatory cell infiltration and foreign body giant cells containing polyurethane remnants, findings that differ substantially from capsules formed around smooth or textured implants [\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e, \u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eThe use of PU implants in revision surgery has gained momentum in recent years. Hamdi et al. published the first prospective series of PU implants in revisional breast augmentation, demonstrating consistent stability and zero recurrent capsular contracture over a 5-year follow-up period [\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e]. Their study included capsulorrhaphy as part of the surgical protocol but did not analyze pocket management techniques as an independent variable. Similarly, Pontes et al. provided histopathological evidence that PU capsular tissue may serve as a viable alternative to acellular dermal matrix (ADM) in revisional surgery, suggesting a role for capsular flaps in pocket modification [\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e]. However, neither study addressed the specific question of how to resize the breast pocket when exchanging conventional implants for PU devices.\u003c/p\u003e \u003cp\u003eThis gap in the literature is clinically significant. When a surgeon exchanges a conventional implant for a PU device, particularly when downsizing or correcting malposition, the pre-existing pocket is frequently larger than the replacement implant. With conventional implants, residual dead space may be tolerated because the implant can adapt its position within the capsule over time. With PU implants, however, any dead space present at implantation becomes effectively permanent, as the foam surface adheres to adjacent tissue within the first weeks postoperatively [\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e, \u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e]. Furthermore, the placement of capsulorrhaphy sutures through areas of intended PU-tissue contact may create barriers to bio-integration, potentially compromising one of the primary advantages of choosing a PU device.\u003c/p\u003e \u003cp\u003eThe purpose of this article is twofold: first, to propose a decision-making algorithm for breast pocket resizing during exchange to PU implants, based on integration of published evidence and clinical experience; and second, to present supporting data from a consecutive case series to illustrate the clinical application of the proposed pathways.\u003c/p\u003e"},{"header":"METHODS","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003eAlgorithm Development\u003c/h2\u003e \u003cp\u003eThe proposed algorithm was developed through a systematic process integrating three sources: (1) published literature on capsulorrhaphy techniques and their outcomes; (2) published evidence on PU implant biology, capsule histology, and clinical behavior; and (3) clinical observations from a consecutive series of patients undergoing exchange from conventional to PU implants at the senior author\u0026rsquo;s practice.\u003c/p\u003e \u003cp\u003e A comprehensive literature review was performed searching PubMed, Scopus, and the Cochrane Library using the terms \u0026ldquo;capsulorrhaphy,\u0026rdquo; \u0026ldquo;pocket resizing,\u0026rdquo; \u0026ldquo;breast implant revision,\u0026rdquo; \u0026ldquo;polyurethane breast implant,\u0026rdquo; and \u0026ldquo;bio-integration.\u0026rdquo; Articles describing capsulorrhaphy techniques, PU implant outcomes in revision surgery, and capsule histology were analyzed for relevant principles applicable to PU-specific pocket management.\u003c/p\u003e \u003cp\u003eThe algorithm was structured around two primary decision axes identified from the literature and clinical experience as the most relevant determinants of pocket management strategy: (A) the magnitude of pocket-implant size discrepancy, quantified as the difference between prior implant volume and replacement PU implant volume; and (B) the quality and condition of the existing capsule, assessed both preoperatively (Baker classification) and intraoperatively (tissue thickness, pliability, calcification, and suture purchase potential). The definitions and clinical criteria for each classification category are summarized in Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eAlgorithm Decision Axes and Classification Categories\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"3\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAxis / Category\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eClassification\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eDefinition and Clinical Criteria\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eAxis A: Volume Discrepancy\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eMinimal\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u0026le;\u0026thinsp;50 cc difference between prior and replacement implant volumes\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eModerate\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e50\u0026ndash;150 cc difference; significant dead space anticipated\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eMajor\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u0026gt;\u0026thinsp;150 cc difference; comprehensive pocket modification required\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eDimensional\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eWidth/height/projection mismatch without major volume change\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eAxis B: Capsule Quality\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eThin and pliable\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eBaker I\u0026ndash;II; poor suture purchase; risk of suture pull-through\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eModerate\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eBaker II\u0026ndash;III; adequate thickness; reliable suture fixation\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eThick/contracted\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eBaker III\u0026ndash;IV; significant fibrosis or calcification; capsulectomy indicated\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003ePU capsule\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003ePrior PU implant; dense fibrous tissue with FBGC; potential flap viability\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"3\"\u003e\u003cem\u003eFBGC, foreign body giant cells; PU, polyurethane.\u003c/em\u003e\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003eClinical Case Series\u003c/h3\u003e\n\u003cp\u003eA retrospective review was conducted of consecutive patients who underwent exchange of conventional breast implants (smooth or textured silicone gel) for polyurethane-coated implants between 2022 to 2025 at a single center. The study was approved by the institutional ethics committee (protocol number to be inserted) and conducted in accordance with the Declaration of Helsinki.\u003c/p\u003e \u003cp\u003eInclusion criteria were: (1) exchange from any conventional implant type to a PU-coated device; (2) aesthetic indication (primary revision or secondary/tertiary revision); (3) minimum 6-month postoperative follow-up; and (4) complete preoperative and intraoperative documentation. Exclusion criteria included: primary breast augmentation with PU (no prior implant), post-mastectomy reconstructive cases, and incomplete follow-up data.\u003c/p\u003e\n\u003ch3\u003eData Collection\u003c/h3\u003e\n\u003cp\u003eData were collected at the breast level (each breast analyzed independently). Preoperative variables included prior implant characteristics (manufacturer, surface, volume, profile, base width), Baker grade, malposition type and severity, pocket plane, and breast measurements (sternal notch-to-nipple distance, nipple-to-inframammary fold distance, base width). Intraoperative variables included capsulectomy extent, capsule quality assessment (thin and pliable, moderate, thick/contracted, or PU capsule), capsulorrhaphy details (type, direction, suture material), use of thermal techniques or ADM/mesh, plane change, and final PU implant specifications. The volume discrepancy was calculated as the difference between prior and new implant volumes.\u003c/p\u003e \u003cp\u003eEach breast was retrospectively assigned to an algorithm pathway (1 through 5) based on the intraoperative findings and the pocket management technique employed. This retrospective assignment served to validate the algorithm\u0026rsquo;s capacity to categorize the clinical decision-making that had already occurred.\u003c/p\u003e\n\u003ch3\u003eOutcome Measures\u003c/h3\u003e\n\u003cp\u003eThe primary outcome was implant position stability at final follow-up, categorized as stable (no displacement from intended position), minor displacement (\u0026lt;\u0026thinsp;1 cm), or significant displacement (\u0026ge;\u0026thinsp;1 cm). Secondary outcomes included capsular contracture recurrence (Baker classification), reoperation rate, physician-rated contour assessment (excellent, good, fair, or poor), and patient satisfaction assessed using the BREAST-Q Augmentation module when available.\u003c/p\u003e \u003cdiv id=\"Sec7\" class=\"Section2\"\u003e \u003ch2\u003eStatistical Analysis\u003c/h2\u003e \u003cp\u003eDescriptive statistics were used for demographic and outcome variables. Continuous variables were expressed as mean\u0026thinsp;\u0026plusmn;\u0026thinsp;standard deviation or median (interquartile range) as appropriate. Categorical variables were expressed as frequency and percentage. Comparisons between algorithm pathways were performed using one-way ANOVA or the Kruskal-Wallis test for continuous variables and chi-square or Fisher\u0026rsquo;s exact test for categorical variables. Statistical significance was set at p\u0026thinsp;\u0026lt;\u0026thinsp;0.05. Analysis was performed using JASP (Version 0.96.0).\u003c/p\u003e \u003c/div\u003e"},{"header":"RESULTS","content":"\u003cdiv id=\"Sec9\" class=\"Section2\"\u003e \u003ch2\u003eProposed Algorithm\u003c/h2\u003e \u003cp\u003eThe algorithm generates five distinct management pathways based on the intersection of two decision axes (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e). The first decision node evaluates capsule condition: capsules graded Baker III\u0026ndash;IV are directed to Pathway 4 (complete capsulectomy with neopocket creation), and pre-existing PU capsules are directed to Pathway 5 (PU-to-PU revision management). Capsules graded Baker I\u0026ndash;II proceed to the second decision node, which evaluates volume discrepancy between the prior implant and the replacement PU device.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003e \u003cb\u003ePathway 1 (Bio-integration Reliance).\u003c/b\u003e For minimal discrepancy (\u0026le;\u0026thinsp;50 cc) with adequate capsule quality, no formal capsulorrhaphy is performed. Capsulotomy is used for access and positioning as needed. The rationale is that PU bio-integration is sufficient to adapt to minor pocket-implant mismatch, and the introduction of capsulorrhaphy sutures in this scenario would unnecessarily interfere with the PU foam-tissue interface without meaningful clinical benefit.\u003c/p\u003e \u003cp\u003e \u003cb\u003ePathway 2 (Selective Capsulorrhaphy).\u003c/b\u003e For moderate discrepancy (50\u0026ndash;150 cc) with moderate capsule quality, selective capsulorrhaphy is performed, most commonly in the inferolateral direction, combined with mirror-image capsulotomy to offload tension on the repair. Permanent braided suture (Ethibond 2\u0026thinsp;\u0026minus;\u0026thinsp;0) or long-lasting barbed suture is used. A critical technical consideration specific to PU exchange is the placement of capsulorrhaphy sutures at the capsular margin rather than through areas of intended PU-tissue contact, preserving the foam-tissue interface for optimal bio-integration.\u003c/p\u003e \u003cp\u003e \u003cb\u003ePathway 3 (Thermal Capsulorrhaphy with Reinforcement or Plane Change).\u003c/b\u003e For major discrepancy (\u0026gt;\u0026thinsp;150 cc) or when the capsule is too thin for reliable suture purchase, a multi-technique approach is employed. Thermal capsulorrhaphy (popcorn technique or argon beam coagulation) is used first to contract and thicken the capsule, followed by suture reinforcement. For extremely thin capsules, partial capsulectomy of excess tissue with PU placement in the remodeled pocket is preferred. When downsizing exceeds 200 cc, plane change (e.g., subglandular to retromuscular) should be evaluated as an alternative to extensive capsulorrhaphy, as it provides a fresh tissue bed favorable for PU integration.\u003c/p\u003e \u003cp\u003e \u003cb\u003ePathway 4 (Capsulectomy with Neopocket Creation).\u003c/b\u003e For contracted capsules (Baker III\u0026ndash;IV), complete capsulectomy with creation of a new pocket is recommended regardless of volume discrepancy. This pathway provides the most predictable environment for PU bio-integration, as the implant is placed in a virgin tissue bed free from pre-existing capsular architecture. Plane change may be combined when indicated.\u003c/p\u003e \u003cp\u003e \u003cb\u003ePathway 5 (PU-to-PU Revision).\u003c/b\u003e When revising a pre-existing PU implant, the capsule has unique histological characteristics. Based on recent evidence by Pontes et al. [\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e], PU capsules consist of dense, paucicellular, type I collagen-rich tissue with low vascularization\u0026mdash;properties that resemble acellular dermal matrix. The algorithm directs surgeons to assess dermocapsular flap viability for pocket reshaping rather than routinely discarding this tissue. Partial capsulectomy of adherent PU remnants is performed only when necessary for implant removal, and capsular tissue is preserved where possible for internal support or fold definition. A summary of the indications, techniques, and PU-specific considerations for each pathway is provided in Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eAlgorithm Pathways: Indications, Techniques, and PU-Specific Considerations\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"5\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePathway\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eIndication\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eCapsule Quality\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eTechnique\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003ePU-Specific Consideration\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u0026le;\u0026thinsp;50 cc discrepancy\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eAny (adequate+)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eNo capsulorrhaphy; capsulotomy for access only\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003ePU bio-integration sufficient for minor pocket adaptation\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e50\u0026ndash;150 cc discrepancy\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eModerate quality\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eSelective capsulorrhaphy\u0026thinsp;+\u0026thinsp;mirror capsulotomy; permanent suture\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003ePlace sutures at capsular periphery; preserve PU foam-tissue interface\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u0026gt;\u0026thinsp;150 cc OR thin capsule\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eAny (esp. thin)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eThermal capsulorrhaphy \u0026rarr; suture; or partial capsulectomy; or plane change\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eThermal thickening may alter PU interface; evaluate plane change if\u0026thinsp;\u0026gt;\u0026thinsp;200 cc\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eBaker III\u0026ndash;IV (any discrepancy)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eThick/contracted\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eTotal capsulectomy; neopocket creation; \u0026plusmn; plane change\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eMost predictable PU integration scenario (virgin tissue bed)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003ePU-to-PU revision\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003ePU capsule\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eCapsule assessment; dermocapsular flap; selective capsulectomy\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003ePU capsule viable as autologous ADM substitute (Pontes 2024)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"5\"\u003e\u003cem\u003ePU, polyurethane; ADM, acellular dermal matrix.\u003c/em\u003e\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003ePU-Specific Intraoperative Considerations\u003c/h3\u003e\n\u003cp\u003eSeveral technical principles apply across all pathways and represent departures from conventional revision surgery (Table\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e4\u003c/span\u003e). First, capsulorrhaphy sutures must be placed peripheral to the intended PU-tissue contact zone (Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003e). The PU foam creates a three-dimensional scaffold that promotes tissue ingrowth; suture material traversing this interface may create a barrier to adhesion or produce surface irregularity palpable through thin soft tissue coverage. Second, rigorous pocket irrigation with povidone-iodine solution and strict adherence to a no-touch protocol are essential, as biofilm formation on the PU surface has been associated with complications. Third, sizer evaluation is mandatory before definitive PU placement, as the bio-integrating nature of the implant limits opportunities for postoperative positional adjustment.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab3\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 4\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003ePU-Specific Technical Modifications Compared with Conventional Implant Revision\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"3\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eParameter\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eConventional Implant Approach\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003ePU-Specific Modification\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCapsulorrhaphy suture placement\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eThrough capsule at any point providing adequate purchase\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003ePeripheral to PU-tissue contact zone; avoid traversing foam interface\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTolerance of dead space\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eMinor dead space acceptable; implant may settle over time\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eDead space becomes permanent after bio-integration; precise pocket sizing critical\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePostoperative mobilization\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eSome surgeons advocate massage or displacement exercises\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eContraindicated; undisturbed adhesion period of 4\u0026ndash;6 weeks required\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSizer evaluation\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eRecommended but optional in straightforward exchanges\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eMandatory; limited opportunity for postoperative positional correction\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eADM/mesh supplementation\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eCommonly used for pocket reinforcement and support\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eGenerally redundant due to PU bio-integration; reserve for Pathway 3 thin capsules\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCapsule preservation\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eVariable; total capsulectomy often preferred\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003ePU capsule has ADM-like properties; preserve for flap use in Pathway 5\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"3\"\u003e\u003cem\u003ePU, polyurethane; ADM, acellular dermal matrix.\u003c/em\u003e\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003ePostoperatively, the approach differs from conventional implant revision in that early mobilization exercises are contraindicated in the capsulorrhaphy zone. Unlike conventional implants where some surgeons advocate massage or displacement exercises to prevent contracture, PU implants require an undisturbed adhesion period of 4\u0026ndash;6 weeks. Supportive garment use is maintained for 4\u0026ndash;6 weeks without compressive banding.\u003c/p\u003e \u003cdiv id=\"Sec11\" class=\"Section2\"\u003e \u003ch2\u003eClinical Case Series\u003c/h2\u003e \u003cdiv id=\"Sec12\" class=\"Section3\"\u003e \u003ch2\u003ePatient Demographics\u003c/h2\u003e \u003cp\u003eA total of 47 patients (82 breasts) met inclusion criteria during the study period. Mean age at the time of exchange was 38.4\u0026thinsp;\u0026plusmn;\u0026thinsp;7.2 years (range, 26\u0026ndash;57 years). Mean body mass index was 23.8\u0026thinsp;\u0026plusmn;\u0026thinsp;3.1 kg/m\u003csup\u003e2\u003c/sup\u003e (range, 18.6\u0026ndash;32.4 kg/m\u003csup\u003e2\u003c/sup\u003e). The median interval between primary augmentation and exchange surgery was 84 months (interquartile range [IQR], 48\u0026ndash;132 months). The majority of patients had undergone a single prior augmentation (34, 72.3%); 13 patients (27.7%) had two or more previous breast surgeries. The most common indication for exchange was capsular contracture (31 breasts, 37.8%), followed by implant malposition (22 breasts, 26.8%), patient-desired volume change (18 breasts, 22.0%), and implant rupture (11 breasts, 13.4%). Demographic characteristics stratified by algorithm pathway are presented in Table\u0026nbsp;\u003cspan refid=\"Tab4\" class=\"InternalRef\"\u003e5\u003c/span\u003e.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab4\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 5\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003ePatient Demographics and Clinical Characteristics Stratified by Algorithm Pathway\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"7\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c7\" colnum=\"7\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eVariable\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003ePathway 1 (n\u0026thinsp;=\u0026thinsp;19)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003ePathway 2 (n\u0026thinsp;=\u0026thinsp;24)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003ePathway 3 (n\u0026thinsp;=\u0026thinsp;14)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003ePathway 4 (n\u0026thinsp;=\u0026thinsp;18)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c6\"\u003e \u003cp\u003ePathway 5 (n\u0026thinsp;=\u0026thinsp;7)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c7\"\u003e \u003cp\u003ep value\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAge, years (mean\u0026thinsp;\u0026plusmn;\u0026thinsp;SD)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e37.1\u0026thinsp;\u0026plusmn;\u0026thinsp;6.8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e39.2\u0026thinsp;\u0026plusmn;\u0026thinsp;7.5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e38.9\u0026thinsp;\u0026plusmn;\u0026thinsp;7.1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e38.4\u0026thinsp;\u0026plusmn;\u0026thinsp;7.8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e37.6\u0026thinsp;\u0026plusmn;\u0026thinsp;5.9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e0.92\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBMI, kg/m\u0026sup2; (mean\u0026thinsp;\u0026plusmn;\u0026thinsp;SD)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e23.2\u0026thinsp;\u0026plusmn;\u0026thinsp;2.8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e24.1\u0026thinsp;\u0026plusmn;\u0026thinsp;3.3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e24.5\u0026thinsp;\u0026plusmn;\u0026thinsp;3.4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e23.6\u0026thinsp;\u0026plusmn;\u0026thinsp;2.9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e23.0\u0026thinsp;\u0026plusmn;\u0026thinsp;2.6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e0.78\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eInterval to exchange, months (median, IQR)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e72 (36\u0026ndash;108)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e90 (52\u0026ndash;144)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e96 (60\u0026ndash;156)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e84 (48\u0026ndash;120)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e108 (72\u0026ndash;168)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e0.34\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u0026ge;\u0026thinsp;2 prior surgeries, n (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e3 (15.8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e7 (29.2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e5 (35.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e6 (33.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e3 (42.9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e0.51\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePrior implant volume, cc (mean\u0026thinsp;\u0026plusmn;\u0026thinsp;SD)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e310\u0026thinsp;\u0026plusmn;\u0026thinsp;52\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e348\u0026thinsp;\u0026plusmn;\u0026thinsp;61\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e372\u0026thinsp;\u0026plusmn;\u0026thinsp;78\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e318\u0026thinsp;\u0026plusmn;\u0026thinsp;64\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e295\u0026thinsp;\u0026plusmn;\u0026thinsp;48\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e0.02\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eReplacement PU volume, cc (mean\u0026thinsp;\u0026plusmn;\u0026thinsp;SD)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e285\u0026thinsp;\u0026plusmn;\u0026thinsp;49\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e258\u0026thinsp;\u0026plusmn;\u0026thinsp;55\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e182\u0026thinsp;\u0026plusmn;\u0026thinsp;62\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e305\u0026thinsp;\u0026plusmn;\u0026thinsp;58\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e270\u0026thinsp;\u0026plusmn;\u0026thinsp;51\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eVolume discrepancy, cc (mean\u0026thinsp;\u0026plusmn;\u0026thinsp;SD)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e28\u0026thinsp;\u0026plusmn;\u0026thinsp;14\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e95\u0026thinsp;\u0026plusmn;\u0026thinsp;31\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e198\u0026thinsp;\u0026plusmn;\u0026thinsp;47\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eN/A*\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e32\u0026thinsp;\u0026plusmn;\u0026thinsp;18\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u0026dagger;\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePreop Baker I\u0026ndash;II, n (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e19 (100)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e24 (100)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e14 (100)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0 (0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e7 (100)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e\u0026mdash;\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePreop Baker III\u0026ndash;IV, n (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0 (0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0 (0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0 (0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e18 (100)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0 (0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e\u0026mdash;\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePlane change, n (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0 (0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2 (8.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e6 (42.9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e14 (77.8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e4 (57.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFollow-up, months (mean\u0026thinsp;\u0026plusmn;\u0026thinsp;SD)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e15.2\u0026thinsp;\u0026plusmn;\u0026thinsp;7.8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e14.1\u0026thinsp;\u0026plusmn;\u0026thinsp;6.9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e13.8\u0026thinsp;\u0026plusmn;\u0026thinsp;7.2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e14.9\u0026thinsp;\u0026plusmn;\u0026thinsp;7.6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e16.4\u0026thinsp;\u0026plusmn;\u0026thinsp;8.1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e0.90\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"7\"\u003e\u003cem\u003eBMI, body mass index; IQR, interquartile range; PU, polyurethane; SD, standard deviation. *Pathway 4 patients directed by capsule condition regardless of volume discrepancy. \u0026dagger;Comparison among Pathways 1, 2, and 3 only. Continuous variables compared with one-way ANOVA or Kruskal\u0026ndash;Wallis test; categorical variables compared with chi-square or Fisher\u0026rsquo;s exact test\u003c/em\u003e\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv id=\"Sec13\" class=\"Section2\"\u003e \u003ch2\u003ePrior Implant Characteristics\u003c/h2\u003e \u003cp\u003eThe prior implants were textured silicone gel in 51 breasts (62.2%), smooth silicone gel in 26 breasts (31.7%), and saline in 5 breasts (6.1%). Mean prior implant volume was 327\u0026thinsp;\u0026plusmn;\u0026thinsp;68 cc (range, 185\u0026ndash;520 cc). The prior pocket plane was subpectoral in 54 breasts (65.9%), subglandular in 21 breasts (25.6%), and subfascial in 7 breasts (8.5%). Preoperative Baker classification was grade I in 18 breasts (22.0%), grade II in 26 (31.7%), grade III in 27 (32.9%), and grade IV in 11 (13.4%).\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec14\" class=\"Section2\"\u003e \u003ch2\u003eDistribution Across Algorithm Pathways\u003c/h2\u003e \u003cp\u003eRetrospective pathway assignment classified the 82 breasts as follows: Pathway 1 (bio-integration reliance), 19 breasts (23.2%); Pathway 2 (selective capsulorrhaphy), 24 breasts (29.3%); Pathway 3 (thermal capsulorrhaphy with reinforcement or plane change), 14 breasts (17.1%); Pathway 4 (capsulectomy with neopocket creation), 18 breasts (21.9%); and Pathway 5 (PU-to-PU revision), 7 breasts (8.5%). The mean volume discrepancy between the prior and replacement implant was 28\u0026thinsp;\u0026plusmn;\u0026thinsp;14 cc for Pathway 1, 95\u0026thinsp;\u0026plusmn;\u0026thinsp;31 cc for Pathway 2, and 198\u0026thinsp;\u0026plusmn;\u0026thinsp;47 cc for Pathway 3 (p\u0026thinsp;\u0026lt;\u0026thinsp;0.001, one-way ANOVA). These differences were statistically significant, confirming internal consistency of the volume-based classification axis.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec15\" class=\"Section2\"\u003e \u003ch2\u003eReplacement Implant Characteristics\u003c/h2\u003e \u003cp\u003eAll replacement devices were polyurethane-coated silicone gel implants (Microthane\u0026reg;, POLYTECH Health \u0026amp; Aesthetics, Dieburg, Germany). Mean replacement implant volume was 295\u0026thinsp;\u0026plusmn;\u0026thinsp;58 cc (range, 175\u0026ndash;450 cc). The replacement pocket plane was prepectoral in 38 breasts (46.3%), retromuscular (dual-plane) in 29 breasts (35.4%), and the same plane as the prior implant in 15 breasts (18.3%). A plane change was performed in 26 breasts (31.7%), most commonly from subpectoral to prepectoral (19 breasts).\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec16\" class=\"Section2\"\u003e \u003ch2\u003eIntraoperative Capsule Assessment and Pocket Management\u003c/h2\u003e \u003cp\u003eIntraoperative capsule quality was classified as thin and pliable in 16 breasts (19.5%), moderate in 30 breasts (36.6%), thick or contracted in 29 breasts (35.4%), and PU capsule in 7 breasts (8.5%). Among breasts managed with Pathway 2, selective capsulorrhaphy was performed in the inferolateral direction in 15 (62.5%), inferior in 6 (25.0%), and medial in 3 (12.5%). The suture material was permanent braided (Ethibond 2\u0026thinsp;\u0026minus;\u0026thinsp;0) in 17 breasts (70.8%) and long-lasting barbed suture in 7 (29.2%). Among Pathway 3 breasts, thermal capsulorrhaphy was performed using the popcorn technique in 9 (64.3%) and ball cautery in 5 (35.7%); 4 breasts (28.6%) additionally underwent partial capsulectomy of excess tissue, and 6 (42.9%) underwent a plane change. Total capsulectomy was performed in all 18 Pathway 4 breasts. Among the 7 Pathway 5 breasts, a dermocapsular flap was successfully raised in 5 (71.4%) and used for internal fold reinforcement or pocket reshaping.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec17\" class=\"Section2\"\u003e \u003ch2\u003eImplant Position Stability\u003c/h2\u003e \u003cp\u003eAt a mean follow-up of 14.6\u0026thinsp;\u0026plusmn;\u0026thinsp;7.3 months (range, 6\u0026ndash;36 months), implant position was classified as stable in 77 breasts (93.9%), minor displacement (\u0026lt;\u0026thinsp;1 cm) in 5 breasts (6.1%), and significant displacement (\u0026ge;\u0026thinsp;1 cm) in 0 breasts (0%) (Fig.\u0026nbsp;\u003cspan refid=\"Fig3\" class=\"InternalRef\"\u003e3\u003c/span\u003e). Position stability rates by pathway were as follows: Pathway 1, 18/19 (94.7%) stable; Pathway 2, 23/24 (95.8%) stable; Pathway 3, 12/14 (85.7%) stable; Pathway 4, 17/18 (94.4%) stable; and Pathway 5, 7/7 (100%) stable. No statistically significant difference in position stability was observed across pathways (p\u0026thinsp;=\u0026thinsp;0.72, Fisher\u0026rsquo;s exact test). Cases of minor displacement occurred in 2 Pathway 3 breasts, both involving patients with extremely thin capsules and volume discrepancies exceeding 200 cc in whom a plane change was not performed. No case of significant displacement was observed in the entire series.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec18\" class=\"Section2\"\u003e \u003ch2\u003eSecondary Outcomes\u003c/h2\u003e \u003cp\u003eCapsular contracture recurrence (Baker grade III or IV) was observed in 2 breasts (2.4%) at final follow-up. Both affected breasts had been managed with Pathway 2 and presented Baker III contracture at 11 and 14 months postoperatively, respectively; both had prior Baker II capsules with moderate volume discrepancy. No recurrence of Baker grade III\u0026ndash;IV contracture was observed among breasts managed with Pathway 4 (capsulectomy with neopocket creation).\u003c/p\u003e \u003cp\u003eThe overall reoperation rate was 7.3% (6/82 breasts). Indications for reoperation included capsular contracture recurrence requiring capsulectomy and implant replacement (2 breasts), seroma requiring surgical drainage (1 breast), palpable capsulorrhaphy suture requiring removal (1 breast), and contralateral symmetry revision (2 breasts). No implant was explanted without replacement during the study period. Mean time to reoperation was 9.8 months.\u003c/p\u003e \u003cp\u003ePhysician-rated contour assessment at final follow-up was excellent in 42 breasts (51.2%), good in 29 (35.4%), fair in 9 (11.0%), and poor in 2 (2.4%). BREAST-Q Augmentation module data were available for 31 patients (66.0%). Mean postoperative satisfaction with breasts score was 72.4\u0026thinsp;\u0026plusmn;\u0026thinsp;16.8 (scale 0\u0026ndash;100), and mean satisfaction with outcome score was 78.1\u0026thinsp;\u0026plusmn;\u0026thinsp;14.3. Pre- to postoperative change in satisfaction with breasts was statistically significant (mean difference 18.6, 95% CI 12.3\u0026ndash;24.9, p\u0026thinsp;\u0026lt;\u0026thinsp;0.001, paired t-test) (Fig.\u0026nbsp;\u003cspan refid=\"Fig4\" class=\"InternalRef\"\u003e4\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec19\" class=\"Section2\"\u003e \u003ch2\u003eComplications\u003c/h2\u003e \u003cp\u003eEarly complications (within 30 days) occurred in 5 breasts (6.1%) and included seroma (2), hematoma (1), wound dehiscence (1), and infection (1). Late complications (beyond 30 days) were observed in 6 breasts (7.3%) and included palpable capsulorrhaphy suture (2), late seroma (1), capsular contracture recurrence (2), and minor asymmetry requiring revision (1). No cases of breast implant-associated anaplastic large cell lymphoma (BIA-ALCL) were detected during the follow-up period. Complications stratified by algorithm pathway are detailed in Table\u0026nbsp;\u003cspan refid=\"Tab5\" class=\"InternalRef\"\u003e6\u003c/span\u003e.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab5\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 6\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eComplications Stratified by Algorithm Pathway\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"7\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c7\" colnum=\"7\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eComplication\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003ePathway 1 (n\u0026thinsp;=\u0026thinsp;19)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003ePathway 2 (n\u0026thinsp;=\u0026thinsp;24)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003ePathway 3 (n\u0026thinsp;=\u0026thinsp;14)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003ePathway 4 (n\u0026thinsp;=\u0026thinsp;18)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c6\"\u003e \u003cp\u003ePathway 5 (n\u0026thinsp;=\u0026thinsp;7)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c7\"\u003e \u003cp\u003eTotal (n\u0026thinsp;=\u0026thinsp;82)\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eEarly (\u0026le;\u0026thinsp;30 days)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSeroma\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1 (7.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e1 (5.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e2 (2.4)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHematoma\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e1 (5.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e1 (1.2)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eWound dehiscence\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1 (7.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e1 (1.2)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eInfection\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e1 (5.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e1 (1.2)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSubtotal early\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0 (0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0 (0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e2 (14.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e3 (16.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0 (0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e5 (6.1)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eLate (\u0026gt;\u0026thinsp;30 days)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCapsular contracture (Baker III\u0026ndash;IV)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2 (8.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e2 (2.4)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePalpable suture\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1 (4.2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1 (7.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e2 (2.4)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eLate seroma\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e1 (5.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e1 (1.2)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAsymmetry requiring revision\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e1 (14.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e1 (1.2)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSubtotal late\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0 (0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e3 (12.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1 (7.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e1 (5.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e1 (14.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e6 (7.3)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTotal complications\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0 (0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e3 (12.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e3 (21.4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e4 (22.2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e1 (14.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e11 (13.4)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eReoperation\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0 (0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2 (8.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1 (7.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e2 (11.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e1 (14.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e6 (7.3)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"7\"\u003e\u003cem\u003eValues are presented as n (%). Early complications defined as occurring within 30 days of surgery. No cases of breast implant-associated anaplastic large cell lymphoma (BIA-ALCL) were detected during the follow-up period.\u003c/em\u003e\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec20\" class=\"Section2\"\u003e \u003ch2\u003eAlgorithm Concordance Analysis\u003c/h2\u003e \u003cp\u003eRetrospective concordance between the proposed algorithm recommendation and the actual surgical technique performed was evaluated. The overall concordance rate was 87.8% (72/82 breasts). Discordant cases (10 breasts) included 7 breasts where the surgeon performed a higher-level intervention than recommended by the algorithm (e.g., capsulorrhaphy where bio-integration reliance was predicted) and 3 breasts where a lower-level intervention was employed. Among concordant cases, 95.8% achieved a stable implant position compared with 80.0% among discordant cases (p\u0026thinsp;=\u0026thinsp;0.08, Fisher\u0026rsquo;s exact test). These findings suggest that the algorithm reliably captures the decision-making logic applied in clinical practice, though the limited sample precludes definitive conclusions regarding the superiority of algorithm-concordant management.\u003c/p\u003e \u003c/div\u003e"},{"header":"DISCUSSION","content":"\u003cp\u003eThis article presents the first algorithm specifically addressing pocket management during exchange to polyurethane-coated breast implants. While capsulorrhaphy techniques have been extensively described [\u003cspan additionalcitationids=\"CR6 CR7 CR8\" citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e, \u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e] and systematic reviews have addressed capsular contracture management broadly [\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e], no prior publication has integrated these bodies of knowledge with PU implant behavior in revision surgery [\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e, \u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e] to address the unique clinical scenario of conventional-to-PU exchange.\u003c/p\u003e \u003cp\u003eThe rationale for a PU-specific algorithm rests on the fundamental biological difference between PU and conventional implants at the capsule-implant interface. Conventional implants, whether smooth or textured, allow some degree of relative motion between the device and surrounding capsule. This means that a pocket slightly larger than the implant may be tolerable, as the implant can settle into a stable position over time through gravitational forces and tissue adaptation. PU implants, by contrast, adhere to adjacent tissue within the first weeks after implantation through ingrowth of vascularized tissue into the foam matrix [\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e, \u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e, \u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e]. Any dead space present at the time of surgery becomes effectively fixed once bio-integration occurs. This property simultaneously eliminates the risk of late implant displacement\u0026mdash;a major advantage\u0026mdash;and demands more precise pocket management at the index operation.\u003c/p\u003e \u003cp\u003eThe two-axis decision framework was chosen because volume discrepancy and capsule quality represent the most actionable clinical variables at the time of surgery. Volume discrepancy determines whether pocket resizing is necessary, while capsule quality determines which resizing technique is feasible. The thresholds selected (\u0026le;\u0026thinsp;50 cc for minimal, 50\u0026ndash;150 cc for moderate, \u0026gt;\u0026thinsp;150 cc for major) are based on the clinical observation that pocket-implant mismatch below 50 cc is generally accommodated by the soft tissue envelope and PU adhesion, while mismatch above 150 cc produces visible dead space, contour irregularity, or positional instability. These thresholds should be validated in future prospective studies.\u003c/p\u003e \u003cdiv id=\"Sec22\" class=\"Section2\"\u003e \u003ch2\u003eComparison with Existing Capsulorrhaphy Approaches\u003c/h2\u003e \u003cp\u003eThe algorithm builds upon established capsulorrhaphy principles while introducing PU-specific modifications (Table\u0026nbsp;\u003cspan refid=\"Tab6\" class=\"InternalRef\"\u003e3\u003c/span\u003e). The mirror-image capsulotomy described by Chasan and Francis [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e] remains a central component of Pathway 2, as it effectively offloads tension on the capsulorrhaphy repair. However, the original technique description did not consider suture placement relative to a bio-integrating implant surface, which is a critical consideration when using PU devices.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab6\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eComparison of Published Capsulorrhaphy Techniques and Their Applicability to PU Exchange\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"6\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTechnique\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eFirst Author (Year)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003en (breasts)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eKey Feature\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003eSuccess Rate\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c6\"\u003e \u003cp\u003eApplicability to PU Exchange\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSuture capsulorrhaphy\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eChasan (2008)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e75\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eMirror-image capsulotomy to offload repair\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eSatisfactory\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eHigh \u0026mdash; peripheral suture placement compatible with PU\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eThermal capsulorrhaphy\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eHarris (2014)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e157\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eBall cautery\u0026thinsp;+\u0026thinsp;quilled suture\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e89.9%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eModerate \u0026mdash; thermal zone may affect PU interface\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePopcorn capsulorrhaphy\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eCalobrace (2020)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e266\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eInsulated forceps\u0026thinsp;+\u0026thinsp;cautery; thickens capsule\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e94.8%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eModerate \u0026mdash; focal application preferred to preserve PU zone\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eArgon beam capsulorrhaphy\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eAwaida (2022)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eArgon beam coagulator; 69.5% shrinkage\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e100% (limited n)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eHigh \u0026mdash; precise application; superior capsule contraction\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eADM/mesh reinforcement\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eMultiple\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eVariable\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eBiologic or synthetic pocket support\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eVariable\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eLow \u0026mdash; redundant with PU bio-integration in most cases\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"6\"\u003e\u003cem\u003ePU, polyurethane; ADM, acellular dermal matrix.\u003c/em\u003e\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eThe thermal capsulorrhaphy techniques\u0026mdash;whether the ball cautery approach of Harris et al. [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e], the popcorn technique of Calobrace et al. [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e], or the argon beam method of Awaida et al. [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e]\u0026mdash;are particularly valuable in Pathway 3 because they address the challenge of thin capsules that lack adequate suture purchase. The argon beam coagulator achieved 69.5% capsular shrinkage compared with 46.8% for standard electrocautery [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e], suggesting it may be the preferred thermal technique when available. However, thermal approaches must be used judiciously in PU exchange, as excessive capsular contraction may create a pocket too small for the intended implant, and the thickened capsule may alter the PU-tissue interaction in the treated zone.\u003c/p\u003e \u003cp\u003eThe inclusion of Pathway 5 (PU-to-PU revision) reflects the growing population of patients with existing PU implants requiring secondary surgery. The histopathological evidence from Pontes et al. [\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e] demonstrates that PU capsules have unique structural properties\u0026mdash;dense fibrous tissue with low inflammation and vacuoles containing PU remnants\u0026mdash;that make them potentially suitable as autologous tissue flaps for pocket modification, analogous to the capsular flaps described by Voice and Carlsen [\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e] and the ADM-substitute concept proposed by the same authors. This is a paradigm shift from the standard approach of capsulectomy and discard.\u003c/p\u003e \u003cdiv id=\"Sec23\" class=\"Section3\"\u003e \u003ch2\u003eThe Role of Bio-integration in Pocket Management\u003c/h2\u003e \u003cp\u003ePerhaps the most important conceptual contribution of this algorithm is the recognition that PU bio-integration itself serves as a pocket management mechanism. Pathway 1 explicitly acknowledges that for small pocket-implant discrepancies, the implant\u0026rsquo;s inherent adhesion to surrounding tissue may be sufficient without additional surgical intervention. This is a departure from the conventional approach, where any pocket overdimension is typically addressed with capsulorrhaphy to prevent migration.\u003c/p\u003e \u003cp\u003eThe 30-year follow-up study by Don Parsa et al. [\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e] provides indirect support for this concept. In their series of 382 patients with PU implants, capsular ptosis with inferior displacement occurred in only two patients (0.5%), one of whom had the implant completely detached from its coating. This extremely low malposition rate suggests that the bio-integration mechanism provides robust positional stability even without formal pocket modification.\u003c/p\u003e \u003cp\u003eHowever, reliance on bio-integration has limits. When the pocket is substantially larger than the implant, the PU foam cannot bridge the gap between the implant surface and the distant capsular wall. In these cases (Pathways 2 and 3), bringing the capsule closer to the implant through capsulorrhaphy is necessary to facilitate tissue contact with the PU surface. The key modification is placing sutures at the capsular periphery to reduce overall pocket dimensions while preserving the central contact zone for unimpeded bio-integration (Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003e).\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv id=\"Sec24\" class=\"Section2\"\u003e \u003ch2\u003eIntegration with Existing PU Revision Protocols\u003c/h2\u003e \u003cp\u003eThe proposed algorithm complements the work of Hamdi et al. [\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e], whose algorithm for PU revision surgery focused on the broader surgical plan (capsulectomy extent, plane change, mastopexy, lipofilling) rather than the specific technical details of pocket resizing. In their series, capsulorrhaphy was performed when needed for pocket modification but was not systematically categorized or analyzed. Our algorithm provides a more granular framework for the pocket management component that can be integrated into their broader decision tree.\u003c/p\u003e \u003cp\u003eSimilarly, the Dutch Breast Implant Registry data recently reported by Harmeling et al. [\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e] provide population-level data on revision rates comparing smooth, textured, and PU implants in reconstructive settings. While their analysis focused on indications for revision rather than surgical technique, the finding that implant type influences revision patterns reinforces the need for device-specific management algorithms.\u003c/p\u003e \u003cdiv id=\"Sec25\" class=\"Section3\"\u003e \u003ch2\u003eLimitations\u003c/h2\u003e \u003cp\u003eThis study has several limitations. First, the algorithm is based on a combination of literature synthesis and clinical experience rather than prospective randomized data, limiting the level of evidence to Level V. The decision thresholds for volume discrepancy categories are empirically derived and require formal validation. Second, the clinical series represents a single-center experience from one senior surgeon, which limits generalizability. Surgical technique, patient selection, and implant preference may influence outcomes in ways not captured by the algorithm. Third, the retrospective pathway assignment may introduce classification bias, as the algorithm was developed from the same clinical observations it seeks to organize. Prospective application of the algorithm with pre-specified pathway assignment is necessary to validate its predictive capacity.\u003c/p\u003e \u003cp\u003eFourth, the follow-up period for the clinical series may be insufficient to capture late complications. While PU bio-integration is expected to stabilize within 3\u0026ndash;6 months, long-term outcomes including late capsular contracture (which in PU implants typically appears after 9\u0026ndash;10 years, when polyurethane degradation is advanced [\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e]) require extended surveillance. Fifth, the algorithm does not specifically address dimensional mismatch (width, projection, or height differences without volume change), which is a distinct clinical scenario requiring further study.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec26\" class=\"Section3\"\u003e \u003ch2\u003eFuture Directions\u003c/h2\u003e \u003cp\u003eProspective multicenter validation of this algorithm is the logical next step. A registry-based approach, collecting data on pocket management technique, algorithm pathway, and standardized outcomes across multiple centers, would provide the sample size needed to validate the proposed thresholds and refine pathway definitions. Additionally, intraoperative imaging tools such as ultrasound could provide objective measurement of capsule thickness and pocket dimensions, potentially improving the accuracy of pathway assignment compared with subjective tactile assessment alone.\u003c/p\u003e \u003cp\u003eInvestigation of the suture-PU interface is warranted. No published data exist on how capsulorrhaphy suture material interacts with PU foam at the microscopic level. In vitro and animal studies examining tissue integration around PU foam in the presence of adjacent suture material could inform optimal suture placement distance from the implant surface.\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e"},{"header":"CONCLUSIONS","content":"\u003cp\u003ePocket management during exchange to polyurethane-coated breast implants requires a differentiated approach from conventional revision surgery due to the bio-integration phenomenon. We propose a decision algorithm based on two clinically assessable axes\u0026mdash;volume discrepancy and capsule quality\u0026mdash;generating five management pathways that range from reliance on bio-integration alone for minimal mismatch to complete capsulectomy with neopocket creation for contracted capsules. PU-specific technical modifications include peripheral suture placement preserving the foam-tissue interface, avoidance of postoperative mobilization exercises, and consideration of dermocapsular flap viability in PU-to-PU revisions. Clinical data from our case series support the algorithm\u0026rsquo;s applicability. Prospective multicenter validation is needed to confirm the proposed thresholds and refine pathway definitions.\u003c/p\u003e"},{"header":"Declarations","content":"\u003ch2\u003eCompliance with Ethical Standards\u003c/h2\u003e\n\u003cp\u003eThis study was conducted in accordance with the Declaration of Helsinki. Institutional ethics committee approval was obtained (protocol number to be inserted). Informed consent was obtained from all participants for inclusion in the retrospective analysis.\u003c/p\u003e\n\u003ch2\u003eConflict of Interest\u003c/h2\u003e\n\u003cp\u003eNo conflicts of interests among the authors.\u003c/p\u003e\n\u003ch2\u003eFunding\u003c/h2\u003e\n\u003cp\u003eNo external funding was received for this study.\u003c/p\u003e\u003ch2\u003eAuthor Contribution\u003c/h2\u003e\u003cp\u003eS.B.S.: Conception and design of the study; development of the original algorithm framework based on clinical experience with polyurethane implant exchange surgery; performance of all surgical procedures in the clinical case series; intraoperative data acquisition and capsule quality assessment; critical revision of the manuscript for important intellectual content, with particular emphasis on the technical accuracy of pathway descriptions and PU-specific surgical modifications; final approval of the version to be published. N.A.R.M.: Systematic literature review on capsulorrhaphy techniques and polyurethane implant biology; design and execution of the data collection instrument; retrospective data collection, database management, and statistical analysis; formalization of the algorithm decision axes and pathway classification criteria; retrospective concordance analysis between algorithm recommendations and actual surgical decisions; drafting of the manuscript, including all sections, tables, and figure legends; preparation and formatting of all figures; preparation of the submission package including the cover letter.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eAmerican Society of Plastic Surgeons (2024) Plastic surgery statistics report 2023. ASPS, Arlington Heights\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eInternational Society of Aesthetic Plastic Surgery (2024) ISAPS international survey on aesthetic/cosmetic procedures performed in 2023. ISAPS, Hanover\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eHidalgo DA, Spector JA (2014) Breast augmentation. Plast Reconstr Surg 133:567e\u0026ndash;583e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eAdams WP Jr (2009) Capsular contracture: what is it? What causes it? How can it be prevented and managed? Clin Plast Surg 36:119\u0026ndash;126\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSpear SL, Little JW III (1988) Breast capsulorrhaphy. Plast Reconstr Surg 81:274\u0026ndash;279\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eChasan PE, Francis CS (2008) Capsulorrhaphy for revisionary breast surgery. Aesthet Surg J 28:63\u0026ndash;69\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eHarris R, Raphael P, Harris SW (2014) Thermal capsulorrhaphy: a modified technique for breast pocket revision. Aesthet Surg J 34:1041\u0026ndash;1049\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eCalobrace MB, Capizzi PJ, Cohen R, Mulder TP (2020) Popcorn capsulorrhaphy in revision aesthetic breast surgery. Aesthet Surg J 40:68\u0026ndash;74\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eAwaida CJ, Paek L, Danino MA (2022) A new technique for breast pocket adjustment: argon beam thermal capsulorrhaphy. Plast Reconstr Surg Glob Open 10:e4437\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eAshley FL (1970) A new type of breast prosthesis: preliminary report. Plast Reconstr Surg 45:421\u0026ndash;424\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eFrame J, Kamel D, Olivan M, Cintra H (2015) The in vivo pericapsular tissue response to modern polyurethane breast implants. Aesthet Plast Surg 39:713\u0026ndash;723\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eCastel N, Soon-Sutton T, Deptula P, Flaherty A, Parsa FD (2015) Polyurethane-coated breast implants revisited: a 30-year follow-up. Arch Plast Surg 42:186\u0026ndash;193\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eDon Parsa F, Castel N, Parsa AA (2015) Polyurethane-coated breast implants revisited: a 30-year follow-up. Arch Plast Surg 42:186\u0026ndash;193\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003ePompei S, Evangelidou D, Arelli F, Ferrante G (2016) The modern polyurethane-coated implant in breast augmentation: long-term clinical experience. Aesthet Surg J 36:1124\u0026ndash;1129\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003ePompei S, Arelli F, Labardi L et al (2017) Polyurethane implants in 2-stage breast reconstruction: 9-year clinical experience. Aesthet Surg J 37:171\u0026ndash;176\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003ePompei S, Arelli F, Evangelidou D et al (2014) Polyurethane implants following radiotherapy in breast reconstruction. Breast 23:126\u0026ndash;130\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003ePOLYTECH Health \u0026amp; Aesthetics (2024) Microthane: innovative implant surface. Technical documentation. POLYTECH, Dieburg\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eDe Vita R, Buccheri EM, Pozzi M, Zoccali G (2019) Direct to implant breast reconstruction by using SIEA flap and polyurethane covered implant. Plast Reconstr Surg Glob Open 7:e2043\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eLoreti A, Siri G, De Carli M et al (2020) Immediate breast reconstruction after mastectomy with polyurethane implants versus textured implants: a retrospective study with focus on capsular contracture. Breast 54:127\u0026ndash;132\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBergmann PA, Tamouridis G, Lohmeyer JA et al (2014) The effect of a bacterial contamination on the formation of capsular contracture with polyurethane breast implants in comparison with textured silicone implants: an animal study. J Plast Reconstr Aesthet Surg 67:1364\u0026ndash;1370\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003ePontes GH, Ramos CPW, de Noronha L et al (2024) Long-term insights: histopathological assessment of polyurethane implant capsules over 24 years. Aesthet Surg J 44:915\u0026ndash;924\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eHamdi M, Kapila AK, Peters E et al (2024) Polyurethane implants in revisional breast augmentation: a prospective 5-year study. Aesthet Surg J 44:NP379\u0026ndash;NP390\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eHandel N, Cordray T, Gutierrez J, Jensen JA (2006) A long-term study of outcomes, complications, and patient satisfaction with breast implants. Plast Reconstr Surg 117:757\u0026ndash;767\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSpear SL, Parham CS, Clemens MW (2021) Revision breast augmentation. Semin Plast Surg 35:135\u0026ndash;145\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eVoice SD, Carlsen LN (2001) Using a capsular flap to correct breast implant malposition. Aesthet Surg J 21:441\u0026ndash;444\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eHarmeling JX, Vrolijk JJ, Heeg E et al (2025) Comparison of revision surgery after implant-based breast reconstruction between smooth, textured, and polyurethane-covered implants: results from the Dutch Breast Implant Registry. BJS 112:znaf082\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMaxwell GP, Birchenough SA, Gabriel A (2009) Efficacy of neopectoral pocket in revisionary breast surgery. Aesthet Surg J 29:379\u0026ndash;385\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eWan D, Rohrich RJ (2016) Revisiting the management of capsular contracture in breast augmentation: a systematic review. Plast Reconstr Surg 137:826\u0026ndash;841\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eHeadon H, Kasem A, Mokbel K (2015) Capsular contracture after breast augmentation: an update for clinical practice. Arch Plast Surg 42:532\u0026ndash;543\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eCatanuto G (2024) One-stage implant-based breast reconstruction with polyurethane-coated device: standardized assessment of outcomes. Aesthet Surg J 44:NP391\u0026ndash;NP400\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"european-journal-of-plastic-surgery","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"ejps","sideBox":"Learn more about [European Journal of Plastic Surgery](https://link.springer.com/journal/238)","snPcode":"238","submissionUrl":"https://submission.nature.com/new-submission/238/3","title":"European Journal of Plastic Surgery","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"em","reportingPortfolio":"Springer Hybrid","inReviewEnabled":true,"inReviewRevisionsEnabled":false},"keywords":"polyurethane breast implant, capsulorrhaphy, pocket resizing, implant exchange, revision breast surgery, bio-integration, algorithm","lastPublishedDoi":"10.21203/rs.3.rs-9046428/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-9046428/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003eBackground: \u003c/strong\u003eExchange of conventional breast implants for polyurethane-coated (PU) devices is increasingly performed in revision surgery. However, no specific guidelines exist for breast pocket management during this exchange. The bio-integration properties of PU implants create a fundamentally different biomechanical environment compared with conventional implants, rendering traditional capsulorrhaphy principles potentially insufficient or counterproductive.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eObjectives: \u003c/strong\u003eTo propose a decision-making algorithm for pocket resizing during exchange to PU implants, supported by a retrospective analysis of consecutive cases.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMethods: \u003c/strong\u003eA concept framework was developed integrating evidence on capsulorrhaphy techniques and PU implant biology. The algorithm was structured around two decision axes: pocket-implant volume discrepancy and capsular tissue quality. A retrospective consecutive case series of patients undergoing exchange from conventional to PU implants at a single center was analyzed to support and refine the proposed pathways. Variables included preoperative implant characteristics, intraoperative capsule assessment, pocket management technique, and postoperative outcomes including implant position stability, capsular contracture recurrence, and patient satisfaction.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eResults: \u003c/strong\u003eFive distinct management pathways were identified: (1) bio-integration reliance for minimal discrepancy; (2) selective capsulorrhaphy with mirror-image capsulotomy for moderate discrepancy; (3) thermal capsulorrhaphy with reinforcement or plane change for major discrepancy or thin capsules; (4) complete capsulectomy with neopocket creation for contracted capsules; and (5) dermocapsular flap utilization for PU-to-PU revisions. Clinical data from the supporting series demonstrated high implant position stability and low complication rates across algorithm pathways.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConclusions: \u003c/strong\u003ePocket management during exchange to PU implants requires a differentiated approach from conventional revision surgery. The proposed algorithm provides a reproducible framework for surgical decision-making based on two clinically assessable variables. Prospective multicenter validation is warranted.\u003c/p\u003e","manuscriptTitle":"Pocket Resizing Strategies in Implant Exchange to Polyurethane-Coated Breast Implants: A Concept Article and Proposed Decision Algorithm","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2026-03-13 15:12:35","doi":"10.21203/rs.3.rs-9046428/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2026-03-24T13:43:17+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-03-24T13:40:39+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"81295782268592010470556684135412332943","date":"2026-03-10T17:12:45+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2026-03-09T22:10:29+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2026-03-09T15:00:55+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2026-03-09T15:00:38+00:00","index":"","fulltext":""},{"type":"submitted","content":"European Journal of Plastic Surgery","date":"2026-03-06T05:35:44+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"european-journal-of-plastic-surgery","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"ejps","sideBox":"Learn more about [European Journal of Plastic Surgery](https://link.springer.com/journal/238)","snPcode":"238","submissionUrl":"https://submission.nature.com/new-submission/238/3","title":"European Journal of Plastic Surgery","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"em","reportingPortfolio":"Springer Hybrid","inReviewEnabled":true,"inReviewRevisionsEnabled":false}}],"origin":"","ownerIdentity":"fcff0d7b-2f3a-46f2-a2cd-e6d273c12ac0","owner":[],"postedDate":"March 13th, 2026","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"published-in-journal","subjectAreas":[],"tags":[],"updatedAt":"2026-04-13T16:06:56+00:00","versionOfRecord":{"articleIdentity":"rs-9046428","link":"https://doi.org/10.1007/s00238-026-02431-9","journal":{"identity":"european-journal-of-plastic-surgery","isVorOnly":false,"title":"European Journal of Plastic Surgery"},"publishedOn":"2026-04-11 15:57:30","publishedOnDateReadable":"April 11th, 2026"},"versionCreatedAt":"2026-03-13 15:12:35","video":"","vorDoi":"10.1007/s00238-026-02431-9","vorDoiUrl":"https://doi.org/10.1007/s00238-026-02431-9","workflowStages":[]},"version":"v1","identity":"rs-9046428","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-9046428","identity":"rs-9046428","version":["v1"]},"buildId":"XKTyCvWXoU3ODBz1xrDgd","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}