A novel, survey-based validated grading system for implant rippling in breast reconstruction

Implant rippling remains a common esthetic complication in implant-based breast reconstruction (IBBR), adversely affecting patient satisfaction and quality of life. Current grading systems lack standardization, granularity, and rigorous validation. This study presents and validates a novel, photograph-based grading scale for rippling severity and evaluates clinical predictors associated with its occurrence.

A retrospective analysis of 62 patients undergoing IBBR was conducted using standardized postoperative photographs (frontal and bilateral oblique views). Thirty-five plastic surgeons and residents independently graded rippling severity on a 5-point scale incorporating "social" and "nonsocial" breast regions. Interrater reliability was assessed using a two-way random effects intraclass correlation coefficient for absolute agreement (ICC [2,1]), and Cronbach's alpha was calculated to evaluate internal consistency among the raters. Lasso regression with cross-validation identified key clinical predictors, followed by multivariable modeling to assess interactions, particularly between fat grafting and preoperative chemotherapy.

Interrater reliability analysis demonstrated moderate agreement across raters using the intraclass correlation coefficient (ICC [2,1] = 0.47; 95% CI, 0.39-0.54), and Cronbach's alpha indicated strong internal consistency among the evaluators (α = 0.96). Lasso regression identified infection and preoperative chemotherapy as key predictors of rippling severity (Table 2, Figure 5). In adjusted regression models, fat grafting, although not retained in Lasso feature selection, demonstrated a protective association with rippling. Infection was consistently associated with higher rippling scores across modeling approaches. Interaction modeling suggested a potential interaction between fat grafting and preoperative chemotherapy, with a stronger protective association observed among patients receiving preoperative chemotherapy in exploratory analyses. Stratified analyses confirmed infection as the only consistent predictor across the chemotherapy subgroups.

This validated, photograph-based grading system provides an objective, reproducible method for assessing implant rippling in IBBR. Moderate interrater agreement and identification of clinically relevant predictors support its utility for surgical planning, patient counseling, and outcome evaluation. Future work should integrate patient-reported outcomes and longitudinal follow-up to broaden clinical applicability.