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

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.