A National Survey to Assess the Population’s Perception of B… : Plastic and Reconstructive Surgery

We read with interest the article by Azzi et al. reporting the results of a national survey to assess the population’s general perception of breast implant–associated anaplastic large-cell lymphoma (BIA-ALCL) and breast implant illness (BII).1 The authors reported that 91 percent and 49.1 percent of participants had never heard the terms BIA-ALCL and BII, respectively. They concluded these findings to support the need for further targeted awareness to fill the knowledge gaps relating to BII and BIA-ALCL. They also underlined the need to remedy existing misperceptions regarding BIA-ALCL and BII, highlighting how 71 percent of respondents were not aware that, to date, only textured implants/expanders were associated with BIA-ALCL.

We totally agree with the authors when underlining how awareness campaigns are strongly awaited and needed in order to disseminate knowledge on BIA-ALCL and BII to the general population. On the other side, we would like to highlight that balanced and evidence-based knowledge should be disseminated, in order not to increase instead of remedying misperceptions.

The first step toward general population information is a full and balanced consciousness of the scientific community that any communication should be based on evidence-based data and not on personal views and “a priori” beliefs. An evidence-based demonstration that BIA-ALCL is only associated with textured implants/expanders is not actually available.2 The strong association between textured implants and BIA-ALCL reported in some case series3 is not generalizable to the whole population, as we recently demonstrated.4

Moreover, the U.S. Food and Drug Administration’s medical device reports, as of January of 2020, show 28 cases of BIA-ALCL developed around smooth implants. If we state that BIA-ALCL is only associated with textured implants, this would imply that all 10 patients reported by the Food and Drug Administration who developed BIA-ALCL around smooth implants with unknown prior history of implants had indeed a history of textured implants, as the 10 patients with a history of prior implants with an unknown texture. Moreover, having a history of prior textured implants does not change the evidence that the BIA-ALCL developed on a smooth implant. The “cancerogenic” effect of the texturization would be so long term that the patient developed the BIA-ALCL on the subsequent smooth implant only because she was exposed to a textured implant in the past.

We think that while waiting for the demonstration of the exclusive association of BIA-ALCL development with textured implants, we should also investigate the previous history of implants for all patients who developed BIA-ALCL around textured implants, as they could have a history of smooth devices. This would be the only way to carry out a correct and balanced evaluation.

As the traditional aphorism says, “The absence of evidence is not evidence of absence.”5 As followers of Galileo Galilei, we must look for “needed demonstration” of any scientific assertion. As the authors themselves correctly conclude, “it is imperative for plastic surgeons to harness the power of social media to educate the public with evidence-based information,”1


None of the authors has a financial interest to declare in relation to the content of this article.

Maurizio Bruno Nava, M.D.
G.RE.T.A. Group for Reconstructive and Therapeutic Advancements
Milan, Italy

Giuseppe Catanuto, M.D., Ph.D.
G.RE.T.A. Group for Reconstructive and Therapeutic Advancements
Catania, Italy
Multidisciplinary Breast Unit
Azienda Ospedaliera Cannizzaro
Catania, Italy

Christoph Andree, M.D.
Department of Plastic and Aesthetic Surgery
Sana Hospital Düsseldorf
Düsseldorf, Germany

Yoav Barnea, M.D.
Plastic and Reconstructive Breast Surgery Unit
Tel Aviv Medical Center
Tel Aviv, Israel

Roy De Vita, M.D.
Department of Plastic Surgery
National Cancer Institute “Regina Elena”
Rome, Italy

Moustapha Hamdi, M.D.
Plastic Surgery Department and Lymph Clinic
Brussels University Hospital
Brussels, Belgium

Paolo Montemurro, M.D.
Plastic and Reconstructive Surgery
Stockholm, Sweden

Alberto Rancati, M.D.
Instituto Oncologico Henry Moore
Universidad de Buenos Aires
Buenos Aires, Argentina

Nicola Rocco, M.D., Ph.D.
G.RE.T.A. Group for Reconstructive and Therapeutic Advancements
Naples, Italy


1. Azzi AJ, Almadani Y, Davison P. A national survey to assess the population’s perception of breast implant–associated anaplastic large cell lymphoma and breast implant illness. Plast Reconstr Surg. 2021;147:795–803.

2. Nava MB, Adams WP Jr, Botti G, et al. MBN 2016 Aesthetic Breast Meeting BIA-ALCL Consensus Conference report. Plast Reconstr Surg. 2018;141:40–48.

3. Loch-Wilkinson A, Beath KJ, Magnusson MR, et al. Breast implant–associated anaplastic large cell lymphoma in Australia: A longitudinal study of implant and other related risk factors. Aesthet Surg J. 2020;40:838–846.

4. Nava MB, Chiodini P, Catanuto G, Rocco N. Is breast implant associated–anaplastic large cell lymphoma linked to textured implants? Aesthet Plast Surg. 2021;45:2593–2601. E-published ahead of print April 9, 2021.

5. Alderson P. Absence of evidence is not evidence of absence. BMJ 2004;328:476–477.


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