Textured or smooth implants for breast augmentation? Three year follow-up of a prospective randomised controlled trial

Effect of tissue inhibitors of metalloproteinases and matrix metalloproteinases on capsular formation around smooth and textured silicone gel implants

BACKGROUND

Capsular contracture is one of the most distressing complications after cosmetic breast augmentation. Evidence suggests that matrix metalloproteinases (MMPs) and tissue inhibitors of metalloproteinases (TIMPs) may play a key role in the onset or progression of several fibrotic disorders. In this study we used quantitative reverse-transcription PCR methodology to profile the expression of TIMP-1, TIMP-2, MMP-2, and MMP-9 in the tissue of patients with capsular contracture after breast augmentation with smooth and textured silicone breast implants.

METHODS

The study included 20 female patients (average age = 37 +/- 15 years) with capsular contracture after bilateral subglandular cosmetic breast augmentation with smooth silicone implants. Ten patients developed grade II capsule contracture, 8 grade III contracture, and 1 grade IV contracture. Twenty other female patients (average age = 41 +/- 9 years) with capsular contracture after breast augmentation with textured silicone implants were also included (Baker grade II = 10 patients, grade III = 8, grade IV = 2). Expression of mRNA in capsular tissue was calculated using a relative quantification method (Pfaffl). Statistical analysis was performed using the Mann-Whitney test. The level of significance was considered to be p < 0.05.

RESULTS

The expression of MMP-2 was significantly increased in tissue of patients with textured implants and capsular contracture grades II and III/IV in comparison to grade I (p < 0.05). In comparison to grade I, the capsular tissue from patients with Baker II and III/IV fibrosis showed a significant increase for TIMP-1 and TIMP-2 (p < 0.05) in both smooth and textured silicone implants. The expression was significantly higher in tissue from patients with severe contracture (Baker III/IV) and smooth silicone implants compared with that in tissue from patients with textured implants (p < 0.05).

CONCLUSION

The decrease in MMP-to-TIMP expression can cause increased synthesis and deposition of collagen surrounding alloplastic breast implants, leading to a profibrotic state. The higher expression of TIMPs in capsular tissue of patients with smooth silicone gel implants might be a reason for the observed higher rates of capsular contracture. In the future, a nonoperative treatment that decreases TIMPs but increases the activity of MMPs may be an appropriate therapy for patients with capsular contracture.

Possible future development of implants and breast augmentation

Since the introduction of the silicone gel prosthesis in 1962, breast augmentation has become one of the most frequently performed operations in plastic surgery. As we strive for perfect results, it is important to continue to gather and review data evaluating innovative techniques and devices. Now we even have more options available for breast augmentation, whether we use them in combination or alone. By combining all of the available options (acellular dermal matrix products, silicone implant, fat grafting), we have been able to create "bioengineered breasts" with high patient and surgeon satisfaction. As always in plastic surgery, our concern is with safety; as newer technology and products are introduced to us, patient education, consent, and follow-up remain important.

Augmentation mammaplasty: retrospective analysis of 210 cases

Since its introduction in 1895, augmentation mammaplasty has gained widespread acceptance. The choice of breast augmentation procedure is determined almost entirely by three variables: the selection of incision location, the pocket plane for implant placement (either subpectoral or completely subglandular), and the appropriate implant. The current study evaluated 210 cases of augmentation mammaplasty retrospectively. A capsular contracture rate of 8% was found. Rupture and gel bleeding were observed in eight cases (4%). For various reasons, such as capsular contracture or implant rupture, the prostheses were renewed once in 16 patients (8%) and twice in 5 patients (2%). Submammary incision was used in 42 cases (20%). The patients in 23 cases responded that they had implant folds or edges they could feel (11%). Only 4 of these 23 patients stated that feeling the edge of the implant was a concern for them. Of the 210 augmented breasts, 5 had diminished sensation postoperatively (2%), as interpreted by the patient.

Capsular Contracture in Subglandular Breast Augmentation with Textured versus Smooth Breast Implants: A Systematic Review

BACKGROUND

There are conflicting recommendations in the literature regarding the use of textured implants to reduce capsular contracture in subglandular breast augmentation. The authors reviewed the literature to evaluate the effectiveness of surface texturization in reducing capsular contracture.

METHODS

The electronic databases MEDLINE, EMBASE and the Cochrane Central Register of Controlled Trials were searched for randomized controlled trials comparing textured with smooth implants for subglandular breast augmentation. Study quality was evaluated, and data were extracted from the relevant studies by two reviewers. Outcome measures were reduction in capsular contracture as defined by Baker grade, applanation tonometry, and patient self-assessment. Overall, the treatment effects were expressed as relative risk for dichotomous data and as weighted mean differences for continuous data.

RESULTS

Six randomized controlled trials were identified with a total of 235 patients (470 breasts). Textured implants were associated with less capsular contracture as evaluated by Baker grade at 1 year (relative risk, 4.16; 95% CI, 1.58 to 10.96), 3 years (relative risk, 7.25; 95% CI, 2.42 to 21.69), and 7 years (relative risk, 2.98; 95% CI, 0.86 to 10.37) of follow-up. Applanation tonometry used as an objective measure of firmness, however, was not sensitive enough to detect any significant difference in contractures in the two groups (weighted mean differences, -1.54; 95% CI, -6.83 to -3.75). Interestingly, the self-assessment questionnaire revealed that capsular contracture or firmness is one (albeit a very important factor) of many facets in patient overall satisfaction.

CONCLUSIONS

This systematic review suggests that implant texturization reduces the incidence of early capsular contracture in subglandular breast augmentation. However, further studies are needed to evaluate the long-term effect of texturization and confirm the long-term benefits noted in this study.

The Composition and Behavior of Capsules around Smooth and Textured Breast Implants in Pigs

BACKGROUND

The surface of the implant is one of the many factors often associated with the occurrence of capsular contracture, the etiopathogeny of which remains unclear. The purpose of this study was to analyze the behavior of capsular contracture by means of applanation tonometry and histology using a midsized animal model.

METHODS

Silicone breast implants were implanted into 33 pigs and observed at 30, 60, 180, and 270 postoperative days.

RESULTS

Capsular contracture in smooth implants showed significantly greater pressure values of tonometry, and the smooth implant capsule was significantly thicker than the textured implant capsule. Both pressure and thickness of the capsules increased at each period. The collagenous layer did not show any difference considering the periods of time in which the total thickness was analyzed; on the other hand, the increase in total capsular thickness occurred by thickening of the noncollagenous layer in both smooth and textured implants. Taking into consideration both kinds of implants, histomorphometric analysis showed that thin fibers were replaced by thick fibers in later postoperatives periods (180 and 270 days).

CONCLUSIONS

The greater incidence of capsular contracture in smooth implants was correlated with the progressive increase in total capsule thickness, due to a higher concentration of collagenous fibers, when compared with textured implants (p = 0.011; mean difference, 6.61), and a higher concentration of thick fibers (p = 0.034; average, >5.51 percentage points per field of thick fibers than the textured implants in all periods). Pigs are good animal models for studying the healing process after breast augmentation with implants.

Textured Surface Breast Implants in the Prevention of Capsular Contracture among Breast Augmentation Patients: A Meta-Analysis of Randomized Controlled Trials

BACKGROUND

Capsular contracture is a common complication associated with the use of breast implants. Numerous randomized controlled trials addressing the efficacy of textured surface breast implants in reducing capsular contracture have yielded nonuniform results. This meta-analysis addresses the use of textured breast implants in the prevention of capsular contracture.

METHODS

MEDLINE, EMBASE, and the Cochrane Central Register of Controlled Trials databases were searched to identify all randomized controlled trials involving the use of textured versus smooth breast implants. The results of these trials were meta-analyzed to obtain a pooled odds ratio of the effect of textured surfacing on capsular contracture rates. In addition, subgroup analyses were performed based on implant type (saline or silicone gel), type of surface texturing (Siltex or Biocell), placement (subglandular or submuscular), and length of follow-up.

RESULTS

Eleven trials were reviewed. Four were excluded because they failed to meet a priori inclusion criteria. The remaining seven trials were meta-analyzed. Only three of these studies found significantly lower rates of capsular contracture with the use of textured implants. However, when all seven studies were pooled, the odds ratio was found to be 0.19 (95 percent confidence interval, 0.07 to 0.52), indicating a protective effect for surface texturing on the rate of capsular contracture. Submuscular placement was the only subgroup in which significance was not achieved. However, this subgroup consisted of a single study, which was dramatically underpowered.

CONCLUSION

The results of this meta-analysis demonstrate the superiority of textured over smooth breast implants in decreasing the rate of capsular contracture.

Capsular contracture around saline-filled and textured subcutaneously-placed implants in irradiated and non-irradiated breast cancer patients: Five years of monitoring of a prospective trial

One hundred and seven breast cancer patients underwent subcutaneous mastectomy and immediate reconstruction with a subcutaneously-placed, round, saline-filled prosthesis with a textured surface. The primary aim of this prospective study was to determine the frequency of capsular contracture in both irradiated and non-irradiated breasts after this operation. Two different types of round implants with different pore sizes on their textured surfaces, Siltex and Microcell, were randomly chosen. Twenty-four patients received radiotherapy within the first year following the operation. Capsular contracture was measured by the Baker/Palmer classification and by applanation tonometry at regular intervals for 5 years or as long as the patients lived (median 60 months). Twenty-two patients (20.6%) developed capsular contracture, defined as Baker three or four. Sixteen of those were reoperated, 15 with open capsulotomy with or without implant exchange, one with closed compression capsulotomy, and monitored thereafter for 5 years or until death (median 60 months). All 107 patients could be monitored for 2 years, while 87 reported for the 5-year follow-up. The rate of capsular contracture was significantly higher (p=0.01) for irradiated breasts than for non-irradiated ones, 41.7 and 14.5%, respectively. It was slightly higher (p<0.05) for large-pore implants than for those with smaller (and more numerous) pores. There was a good correlation between the two different methods for measuring capsular contracture. None of the 16 reoperated patients had a recurrence of capsular contracture within 5 years. The results indicate a high rate of capsular contracture after this operation, especially when followed by radiation. However, a fairly simple procedure to treat capsular contracture seems to give good long-term results.

Critères intervenant dans le choix entre prothèse préremplie au gel de silicone et prothèse remplie au sérum physiologique en chirurgie mammaire d'augmentation

The use is to oppose silicone and saline implants. Both are used in regular practice. What are the arguments to choose in between the two types? We separated three different criteria groups: prosthesis characteristics, surgical procedures and complications. For each criterion we made a review of literature looking for arguments in favour or against silicone or saline implants. The number of criteria to choose the correct type of prosthesis is very important. We conclude that surgeon experience; desires of the patient and evolution of prosthesis are the most important criteria.

Les complications postopératoires en chirurgie d'augmentation mammaire

Augmentation mammoplasty is one of the most popular and frequently performed aesthetic operations. The implants are not, however, without complications; and many have been reported in order to this surgical procedure: hematoma, infection, seroma, capsular contracture, rupture ... Current surgical practices and modern implants used for breast augmentation produce fewer complications than procedures and devices of the past. The aim of this work is to index most common post operative breast complications. The prevention and the treatment procedure of these complications are also reported. A good knowledge of all these points seems to be essential to improve the quality of the final results and patients satisfaction.

Prothèses lisses ou texturées : que choisir ?

Envelope structure has evolved since the seventies. Indeed, low-bleed implants allow an important reduction of capsular contracture for silicone filled implants. Later, textured implants permit an additional reduction of capsular contracture, especially when positioned in a retroglandular pocket. Whereas many studies confirm these findings, the interest of textured implants in the retromuscular plane is not really clear, even if some authors recommend it. Due to the need of a tissular anchorage, anatomical implants are not manufactured with smooth envelopes.

Electrostimulation: uses and applications for periprosthetic capsular contracture: experimental model

BACKGROUND

Studies have documented an increase in collagen production and acceleration of the scarring process when galvanic electrostimulation of less than 300 mV is used, but the effects of electrostimulation with characteristics different from those usually studied are unknown.

METHODS

Electrostimulators were designed and manufactured specifically for the study. A total of 40 rats were divided into 10 groups, with 4 randomly selected rats in each group. Five groups received smooth implants, and the remaining five groups received textured implants. The first group was designated as the control group, and the remaining four groups received electrostimulation in differing amounts from the 3rd to the 15th postoperative day.

RESULTS

The type of implant used was not a determining factor in the degree of capsular contracture encountered. In the groups that received less than 300 mV, showed greater capsule thickness than the control group. The group that received 600 mV, had a thinner periprosthetic capsule than the control group and all the other groups. All the results were statistically significant.

CONCLUSIONS

Electrostimulation using direct galvanic current with reversal of polarity on postoperative day 3 at intensities of 600 mV inhibits the process of periprosthetic capsular formation in rats.

Early experience with an anatomical soft cohesive silicone gel prosthesis in cosmetic and reconstructive breast implant surgery

Recently, an anatomic breast implant filled with soft cohesive silicone gel was introduced by Mentor Medical Systems onto the European market. This study reports the early experience of a single surgeon with this implant. All patients who received a Contour Profile Gel (CPG) implant from March 2001 to October 2002 were studied. Patient satisfaction with breast shape and consistency was assessed using linear analogue scales with a maximum score of 10. Thirty-five patients received CPG implants for cosmetic (10 patients, 20 breasts) and reconstructive (25 patients, 31 breasts) surgery purposes. Patients were satisfied with their breast shape (mean score: 8.3). Eighty-five percent of the breasts were rated as soft (score >/=6). No serious esthetic complications such as implant malposition or significant capsular contracture were observed. Anatomic soft cohesive gel implants provide excellent results in selected cases. They are well accepted by patients and not associated with an increased rate of complications.

The correction of capsular contracture by conversion to "dual-plane" positioning: technique and outcomes

Little has been published regarding the treatment of patients with long-established capsular contracture after previous submuscular or subglandular breast augmentation. This study reviews 7 years of experience in treating established capsular contracture after augmentation mammaplasty by relocating implants to the "dual-plane" or partly subpectoral position. A retrospective chart review was performed on all patients who were treated for capsular contracture using this technique between 1993 and 1999. Data collected included the date of the original augmentation, the original implant location, date of revision and type of implant used, length of follow-up, outcome, and any ensuing complications. Different surgical techniques were used, depending on whether the prior implant was located in a subglandular or submuscular plane. All patients had revisions such that their implants were relocated to a dual plane, with the superior two thirds or so of the implant located beneath the pectoralis major muscle and the inferior one third located subglandularly. Of 85 patients reviewed, 54 had their original implants in a submuscular position and 31 had their initial augmentation in a subglandular position. Of the 54 patients whose implants were initially submuscular, 23 patients (43 percent) had silicone gel implants, 15 patients (28 percent) had double-lumen implants, and the remaining 16 patients (30 percent) had saline implants. Of the 31 patients whose implants were initially subglandular, 20 patients (65 percent) had silicone gel implants, three patients (10 percent) had double-lumen implants, and the remaining eight patients (26 percent) had saline implants. Fifty-one patients (60 percent) had replacement with saline implants (37 smooth saline, 14 textured saline), whereas 34 (40 percent) had silicone gel implants (seven smooth gel, 27 textured gel). The average time from previous augmentation to revision was 9 years 9 months. The average follow-up time after conversion to the dual-plane position was 11.5 months. Only three of 85 patients required reoperation for complications, all of which involved some degree of implant malposition. Of patients converted to the dual plane, 98 percent were free of capsular contracture and were Baker class I at follow-up, whereas 2 percent were judged as Baker class II. There were no Baker level III or IV contractures at follow-up. The dual-plane method of breast augmentation has proved to be an effective technique for correcting established capsular contracture after previous augmentation mammaplasty. This technique appears to be effective when performed with either silicone or saline-filled implants.

Comparison of the capsular response to the Biocell RTV and Mentor 1600 Siltex breast implant surface texturing: a scanning electron microscopic study

The utility of mammary prosthesis texturing in the prevention of capsular contracture was established some 20 years ago. Various models of implant texturing are currently on the market. We decided to study two of the most popular implants with two different surface texturings: the Biocell RTV and the Mentor 1600 Siltex. An observation at the electron microscopic level of the implants' surfaces was achieved. At the time of a prospective survey on 10 patients, the capsule fragments corresponding to these two prostheses have been analyzed at the electron microscopic level. All prostheses were removed from the patients because of asymmetry or bad positioning. The aim of our study was to establish a correlation between these two frequent texturing surfaces and their corresponding capsules. Our results showed that only the Biocell's capsules present a mirror image with correspondence of the depressions on the prosthesis and contacts on the capsule. This phenomenon seems linked to the existence of a critical size of the pores constituting the implant surface. This observation leads us to the hypothesis of an adhesive effect between the prosthesis and its capsule. If this last is not directly linked to the prevention of capsular contracture, it can have an effect on implant stabilization in the primary mammary reconstruction and in the secondary corrections of asymmetry or bad position.

Capsular contracture around saline-filled fine textured and smooth mammary implants: a prospective 7.5-year follow-up

In a previous prospective randomized clinical study comparing in the same patient textured and smooth saline-filled mammary implants (Biocell) with large pore size (300 to 600 microm), we saw no difference in capsular contracture. This study was undertaken in a similar way to compare capsular contracture around smooth and textured saline-filled prostheses with pores of small size. During a period of 7.5 years, the breast hardness was followed up, and at the end of the study patient satisfaction was evaluated. Twenty healthy women with a mean age of 30 years were operated on for breast augmentation. Two surgeons performed all operations in a standardized way. Each patient received subglandularly a Siltex textured saline-filled prosthesis with a pore size of 30 to 70 microm in one breast, and a smooth saline-filled prosthesis in the other. The hardness of the breasts was evaluated after 0.5, 1, and 7.5 years using Baker grading and applanation tonometry. Eighteen patients completed 1-year and 7.5-year follow-up. Two breasts with smooth prostheses were contracted after 6 months (Baker III or IV). After 1 year, four patients with smooth prostheses and one with a textured prosthesis had capsular contracture (p = 0.34). Seven and one-half years after surgery, six patents with smooth and four with textured implants had contracture (p = 0.66). On two patients with smooth prostheses and one patient with a textured prosthesis, the capsule around the implant hardened between 6 and 12 months. Between 1 year and 7.5 years, three breasts with smooth and textured implants contracted and one with a textured implant softened.The patients reported on a Visual Analogue Scale (1 to 10) the impact of the augmentation on their quality of life to be 9 +/- 1. Four patients preferred the breast with the smooth prosthesis, three preferred the breast with the textured prosthesis, and the others found both breasts equal. This study showed no significant difference of contracture with smooth versus fine textured implants. The majority of the patients preferred the smooth implants. The patients reported that the breast augmentation had had an extremely high impact on their quality of life.

Innovation and regulation in human implant technologies: developing comparative approaches

Human implant technologies are subject to continual innovation and proliferation, raising important issues for technology testing, healthcare sciences, clinical performance and risk assessment, and regulation. The regulatory environment of medical devices is being shaped by harmonisation of standards in the European Union. The aim of this paper is to compare the histories and current regulatory environment of two technologies, breast implants and artificial hips, and to consider the implications of this comparison for a sociological healthcare research agenda to investigate the issues raised. The main focus is upon developments in the United Kingdom. Major points of contrast between the two technologies include the institutional contexts in which clinical evidence has been marshalled for government attention; the relative importance of strategic alliances between clinicians and manufacturers in the innovation process; the degree of public controversy evident; the varying definitions of an 'adverse incident' within medical device vigilance systems; and in the UK the presence of a national register for breast implants but not for hip implants. Inter-national contrasts in these dimensions are noted. The analysis suggests that improved understanding is required of the institutional, organisational and professional processes involved in implant technology innovation and regulation. A comparative research agenda is proposed, focusing upon: innovativeness and proliferation; safety and technological standards; clinical and social outcomes; and consumer/user information and choice. It is concluded that research in these areas will enhance the 'evidence-base' for the evaluation of human implant technologies in the context of their innovatory and regulatory environments.

Capsular contracture after cosmetic breast implant surgery in Denmark

The authors investigated the association between the occurrence of capsular contracture and implant and patient characteristics. All women with breast implants from 1977 to 1997 were identified from the files of two private plastic surgery clinics in Denmark. Information on implant and patient characteristics, surgical procedure, and complications was obtained through medical records and self-administered questionnaires. Of 754 women (1,572 implants), average age at implantation was 32 years. Implant types were silicone double lumen, textured, 31.2%; silicone single lumen, textured, 27.8%; silicone single lumen, smooth, 24.5%; silicone double lumen, smooth, 0.8%; and other or missing, 15.7%. Placement was submuscular for more than 90% of implants. Capsular contracture occurred in 7.9% of implanted breasts, on an average of 621 days postoperatively, with 51.6% being bilateral. Overall, 66.1% of capsular contractures were recorded within the first 12 months postoperatively, and 79.0% were recorded within 24 months. Double-lumen implants were associated with a significantly (p < 0.01) reduced occurrence of capsular contracture. In summary, capsular contracture typically occurs within the first 2 years of implantation. Host factors may be important because more than half the capsular contractures in the current study were bilateral. Occurrence of capsular contracture did not appear to be associated with implant surface or placement, occurrence of local complications, or patient characteristics, although these findings should be interpreted cautiously.

Immediate breast reconstruction after mastectomy for cancer

BACKGROUND

Immediate breast reconstruction after mastectomy has increased over the past decade following the unequivocal demonstration of its oncological safety and the availability of reliable methods of reconstruction. Broadly, it is undertaken in the treatment of breast cancer, after prophylactic mastectomy in high-risk patients, and in the management of treatment failure after breast-conserving surgery and radiotherapy. Immediate breast reconstruction can be achieved reliably with a variety of autogenous tissue techniques or prosthetic devices. Careful discussion and evaluation remain vital in choosing the correct technique for the individual patient.

METHODS

This review is based primarily on an English language Medline search with secondary references obtained from key articles.

RESULTS AND CONCLUSION

Immediate breast reconstruction is a safe and acceptable procedure after mastectomy for cancer; there is no evidence that it has untoward oncological consequences. In the appropriate patient it can be achieved effectively with either prosthetic or autogenous tissue reconstruction. Patient selection is important in order to optimize results, minimize complications and improve quality of life, while simultaneously treating the malignancy. Close cooperation and collaboration between the oncological breast and reconstructive surgeons is desirable in order to achieve these objectives.

Morbidity of immediate breast reconstruction (IBR) after mastectomy by a subpectorally placed silicone prosthesis: the adverse effect of radiotherapy

AIMS

This study evaluates the incidence of local complications after immediate breast reconstruction (IBR) following mastectomy with a subpectorally placed silicone prosthesis, with emphasis on the effect of radiation treatment on IBR.

METHODS

The medical records of 100 women, who underwent a mastectomy followed by IBR with a subpectorally placed silicone prosthesis at the University Hospital Rotterdam/Daniel den Hoed Cancer Center, between March 1990 and March 1995, were reviewed. Thirteen prostheses were implanted prior to radiation treatment, and 15 prostheses were implanted after irradiation of the chest wall.

RESULTS

Early complications were seen in 15% of the IBR and were more often in irradiated women. At long-term follow-up, the most common complication was capsular contracture (21%). This occurred significantly more around prostheses placed in a previously irradiated area (P<0.0005), or which were irradiated after IBR (P=0.001). Loss of prosthesis was seen in 11 cases, and was significantly (P<0.005) more in irradiated women (n=5; 18%) compared to women who were not irradiated (n=6; 7%).

CONCLUSIONS

Complications after IBR with a silicone prosthesis were more common in women who were treated with radiotherapy prior to or after IBR following mastectomy than in women who were not irradiated. In particular, capsular contracture around a prosthesis placed in a previously irradiated area was significantly increased. The use of musculocutaneous flaps, such as the transverse rectus abdominis muscle or latissimus dorsi flap, is preferable for reconstruction of previously irradiated breasts. There is no indication to remove the prosthesis before radiation therapy of the chest wall.

Silicone gel-filled breast implant integrity: a retrospective review of 478 consecutively explanted implants

Concern has been expressed over the long-term integrity of silicone gel breast implants. There are no large series representing experience with these implants outside of the United States. A retrospective case note review of explanted silicone breast implants was performed; 478 implants have been explanted during the past 11 years and relate to the use of these devices since 1971. Loss of implant integrity was not simply related to its age in vivo. Failure was more likely with implants of the late 1970s and early 1980s (second generation) and with subpectoral placement. Implant failure was independent of capsular contracture as the indication for removal (p = 0.09). There is no evidence that the currently used textured silicone gel breast implants are subject to the same loss of integrity as previous examples of these devices. The life span of these implants, the first of which are approaching 10 years in vivo, is at present unknown. Information concerning the integrity of silicone gel breast implants is essential in the current climate for counseling of both new and old implant recipients.

Reduction of potential contamination of breast implants by the use of 'nipple shields'

Forty-three breast implant operations in 25 patients were studied prospectively to determine the effectiveness of covering the nipple-areolar complex with an adhesive film dressing in preventing perioperative expression of bacteria from nipple ducts contaminating the operative field. One swab from the nipple after skin preparation and none of the swabs taken from the outer surface of the film dressing postoperatively yielded any bacterial growth. Fourteen breasts (33%) in 11 patients (44%) yielded bacterial growth from swabs under the film postoperatively. Six of 9 breasts (67%) in 5 patients who had capsulectomies had bacteria isolated from under the film postoperatively. Ten of 14 (71%) control breasts (no shields) in 6 of 7 patients (86%) had positive postoperative swabs. This study confirms the potential risk of bacterial contamination arising from nipple duct flora during intra-operative breast manipulation, and the effectiveness of a perioperative adhesive film placed over the nipple-areolar complex in preventing subclinical bacterial contamination of implanted breast prostheses.