Capsular Contracture after Breast Augmentation: An Update for Clinical Practice

Transaxillary Endoscopic Approach to Capsular Contracture Following Previous Breast Augmentation: Operative Technique and Clinical Outcome

BACKGROUND

Capsular contracture (CC) is a complication of breast augmentation that frequently requires revision surgery. The axillary approach reduces the visibility of the postoperative scar. It is unclear whether the previous incision can be used to repair the deformity caused by CC.

METHODS

This study analyzed 21 patients (42 breasts) with grade III-IV CC during 2012-2017. The mean age of the patients was 32 years (range 23-48). Previous axillary scars were used to expose, and CCs were taken out completely or partially. Breast implants were removed. The dissection was performed with endoscopic assistance, using electrocautery under direct visualization.

RESULTS

The mean follow-up period was 13 months (range 6-24 months). The dissection plane was changed to dual plane. Thirty-five CCs were taken out completely. Thirty-eight breast implants taken out remained intact. None of the patients required additional surgery.

CONCLUSION

Endoscopic-assisted treatment may be an effective technique for treating CC and avoiding the additional scar.

LEVEL OF EVIDENCE IV

This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266.

A multi-center, retrospective, preliminary observational study to assess the safety of BellaGel® after augmentation mammaplasty

Background

BellaGel® is the only cohesive silicone gel-filled breast implant from a Korean manufacturer, and it was first developed in 2005. It was approved by the CE in 2008, thus becoming the first Asian breast implant available in the EU. We conducted this study to assess the safety of BellaGel® in patients receiving augmentation mammaplasty.

Methods

We evaluated a consecutive series of 239 patients (478 breasts) who received esthetic augmentation mammaplasty using the BellaGel® (round smooth, round textured, round nanotextured, and anatomical textured types of implant) (HansBiomed Co. Ltd., Seoul, Korea) at three clinics in Korea (JW Plastic Surgery Center, BS The Body Plastic Surgery Clinic and Grace Plastic Surgery Clinic) during a period from December 1, 2015 to January 31, 2018.

Results

A total of 239 patients with a mean age of 33.1 ± 8.5 years old were followed up during a mean period of 399.58 ± 232.71 days, where there were no cases of capsular contracture in our clinical series of the patients. Other complications include one case (0.4%) of seroma, three cases (1.3%) of hematoma, and one case (0.4%) of infection. Moreover, there were no significant differences in the cumulative incidences of complications between the four types of the BellaGel® (χ2 = 2.322, df = 3, P = 0.508). Furthermore, the cumulative Kaplan-Meier survival rate was estimated at 0.979 (95% CI 0.961–0.997).

Conclusions

Our results indicate that the BellaGel® is such a safe breast implant that surgeons might consider using it for esthetic augmentation mammaplasty.

Level of evidence: Level III, risk/prognostic study.

Efficient reduction of fibrous capsule formation around silicone breast implants densely grafted with 2-methacryloyloxyethyl phosphorylcholine (MPC) polymers by heat-induced polymerization

This article presents the efficacy of heat-induced MPC-grafting against excessive fibrous capsule formation and related inflammation in tissues surrounding silicone breast implants inserted in a pig model.

Comparison of inflammatory response and synovial metaplasia in immediate breast reconstruction with a synthetic and a biological mesh: a randomized controlled clinical trial

The aim of this study was to compare inflammatory response and synovial metaplasia in implant-based immediate breast reconstruction with a biological mesh (Veritas^®) with that of a synthetic mesh (TIGR^® Matrix Surgical Mesh). We hypothesize that the inflammatory response and formation of synovial metaplasia might be different and the rate of capsular contracture therefore different. The patients were recruited from the Gothenburg TIGR^®/Veritas^® Study (ClinicalTrials.Gov identifier NCT02985073). All referrals for bilateral immediate breast reconstruction were assessed for inclusions. During the operation, the patients were randomized to which sides the biological and the synthetic mesh were going to be applied. During the implant exchange biopsies were taken. Biopsies were taken from 30 breasts in 15 patients. There seem to be more myofibroblast and neovascularization in the biological meshes than in the synthetic and the collagen fibers seem to be aligned in an irregular pattern with both parallel and vertical fibers. In the synthetic meshes, there were more giant cells and foreign body reaction and the collagen fibers were loosely and well aligned, oriented parallel to the surface of the implant. Synovial metaplasia was seen in the majority of both the biological and the synthetic meshes. The histological patterns in early capsules from biological and synthetic meshes vary considerably. Nonetheless, it is unknown what role different cell types have in capsular formation in the long run and there was no difference in clinical capsular contracture at the clinical follow-up in this study.

Elastic net of polyurethane strands for sustained delivery of triamcinolone around silicone implants of various sizes

We propose an elastic net made of a biocompatible polymer to wrap silicone implants of various sizes, which also allows for the sustained release of an anti-inflammatory drug, triamcinolone, to prevent fibrosis. For this, we first prepared a strand composed of a mixture of polyurethane and triamcinolone via electrospinning, which was then assembled to prepare the elastic drug-delivery net (DDN). The DDN was prepared to just fit for wrapping the small silicone implant sample herein, but was also able to wrap a sample 7 times as large at 72% strain due to the elastic property of polyurethane. The DDN exhibited sustained drug release for 4 weeks, the profile of which was not very different between the intact and strained DDNs. When implanted in a subcutaneous pocket in living rats, the DDN-wrapped silicone implant samples showed an obvious antifibrotic effect due to the sustained release of triamcinolone. Importantly, this effect was similar for the small and large silicone samples, both wrapped with the same DDN. Therefore, we conclude that this drug-loaded net made of an elastic, biocompatible polymer has high potential for sustained drug delivery around silicone implants manufactured in various sizes.

Roxatidine inhibits fibrosis by inhibiting NF‑κB and MAPK signaling in macrophages sensing breast implant surface materials

Capsular contracture is an important complication after silicone mammary implant surgery. Fibroblasts and macrophages play critical roles in the pathogenesis of capsular contracture, making these two cell types therapeutic targets. It has been reported that inhibiting histamine receptors results attenuates fibrosis, but the role of roxatidine (a histamine receptor 2 inhibitor) in preventing fibrosis caused by breast implant materials remains unknown. The aim of the present study was to assess the hypothesis that roxatidine might have a prophylactic effect in capsular contracture induced by implant material. Inflammation induced by breast implant materials was mimicked by co-culturing macrophages or fibroblasts with these materials in vitro. Capsular contracture was modeled in mice by planting breast implant materials in a subcutaneous pocket. Roxatidine was added in the culture medium or administered to mice bearing breast implant materials. By co-culturing macrophages or fibroblasts with common breast implant materials (micro-textured or smooth breast implants), the present study demonstrated that macrophages respond to these materials by producing pro-inflammatory cytokines, a process that was abolished by addition of roxatidine to the culture medium. Although fibroblasts did not respond to implant surface materials in the same way as macrophages, the conditioned media of macrophages induced proliferation of fibroblasts. Mechanistically, administration of roxatidine inhibited activation of NF-κB and p38/mitogen-activated protein kinase (MAPK) signaling in macrophages. Furthermore, treatment with roxatidine in implant-bearing mice reduced serum concentrations of transforming growth factor-β and the abundance of fibroblasts around the implant. The present study concluded that roxatidine plays an important role in preventing fibrosis by inhibiting activation of NF-κB and p38/MAPK signaling in macrophages.

Modulation of Foreign Body Reaction against PDMS Implant by Grafting Topographically Different Poly(acrylic acid) Micropatterns

The surface of poly(dimethylsiloxane) (PDMS) is grafted with poly(acrylic acid) (PAA) layers via surface-initiated photopolymerization to suppress the capsular contracture resulting from a foreign body reaction. Owing to the nature of photo-induced polymerization, various PAA micropatterns can be fabricated using photolithography. Hole and stripe micropatterns ≈100-µm wide and 3-µm thick are grafted onto the PDMS surface without delamination. The incorporation of PAA micropatterns provides not only chemical cues by hydrophilic PAA microdomains but also topographical cues by hole or stripe micropatterns. In vitro studies reveal that a PAA-grafted PDMS surface has a lower proliferation of both macrophages (Raw 264.7) and fibroblasts (NIH 3T3) regardless of the pattern presence. However, PDMS with PAA micropatterns, especially stripe micropatterns, minimizes the aggregation of fibroblasts and their subsequent differentiation into myofibroblasts. An in vivo study also shows that PDMS samples with stripe micropatterns polarized macrophages into anti-inflammatory M2 macrophages and most effectively inhibits capsular contracture, which is demonstrated by investigation of inflammation score, transforming-growth-factor-β expression, number of macrophages, and myofibroblasts as well as the collagen density and capsule thickness.

A Step Forward Toward the Understanding of the Long-Term Pathogenesis of Double Capsule Formation in Macrotextured Implants: A Prospective Histological Analysis

BACKGROUND

Although increasingly reported in the literature, most plastic surgeons cannot define the etiology of double capsules. Often an incidental finding at implant exchange, double capsules are frequently associated with macrotextured devices. Several mechanisms have been proposed, including at the forefront that shearing causes a delamination of the periprosthetic capsule into a double capsule.

OBJECTIVES

This study was designed to confirm the hypothesis that mechanical forces are involved in formation of double capsules by histological analysis.

METHODS

A prospective analysis of consecutive implants with double capsules removed over 2 years was performed. Data collected at the time of surgery included Baker classification, reason for explant, implant manufacturer and style, and any presence of a seroma associated with the capsule. Specimens were sent for analysis by histology utilizing hematoxylin and eosin and alpha-smooth muscle actin staining techniques.

RESULTS

Eight double capsules were collected for specimen analysis. All capsules demonstrated evidence of granulation tissue, alpha-smooth muscle actin positive myofibroblasts, and folds with embedded texture. Fibrosis surrounded weak areas with presence of layering and splitting, creating a potential space that is prone to separation. Tears and folds from granulomatous reaction are also present within the outer layer of the double capsule, which can only be explained by a mechanical shearing force as a pathogenic mechanism.

CONCLUSIONS

Understanding the pathogenesis of double capsules may allow plastic surgeons to refine their indications for macrotextured implants while providing guidance to patients on avoidance of activities that produce shear-forces. The findings support the hypothesis that shearing forces delaminate the capsule into 2 separate distinct capsules.

LEVEL OF EVIDENCE: 5

Management of Capsular Contracture in Cases of Silicone Gel Breast Implant Rupture with Use of Pulse Lavage and Open Capsulotomy

INTRODUCTION

Pulse lavage (PL) irrigation of prosthesis pockets has prior been described for breast implant salvages. However, PL for removal of leaked silicone from prosthesis pockets after implant ruptures has not been studied yet. Since open capsulotomies are regarded as equal treatment of capsular contracture (CC) than capsulectomies, this study analyzed the clinical outcome of PL for silicone removal and subsequent capsulotomy in cases of concurrent CC and breast implant rupture.

METHODS

Between 2012 and 2017, 55 patients (75 breasts) with suspected silicone implant rupture and CC (Baker grade III/IV), after primary breast augmentation or implant-based breast reconstruction, were included in a retrospective, observational study. Mean patient follow-up was 12.2 ± 3.6 months.

RESULTS

In all preoperatively suspected ruptured silicone breast implants, around a quarter were intact. In contrast to previously published data, implant exchanges in cases of implant ruptures did not lead to significantly higher CC recurrence rates (27.6% vs. 22.2% in cases of intact implants, p = 0.682), if the prosthesis pockets were treated with PL irrigation followed by open capsulotomy. PL reduced the amount of encapsulated silicone remnants histologically. The age of patients with CC after failed implant-based reconstruction was significant lower for salvage surgeries with flap reconstruction than for implant exchanges, p < 0.05.

CONCLUSIONS

PL irrigation of prosthesis pockets prior to open capsulotomy is a safe and effective treatment of CC with concurrent silicone leakage. Remaining silicone remnants in breast capsules may affect the development of a recurrent CC. To avoid CC recurrences, patients should consider conversion to autologous tissue.

LEVEL OF EVIDENCE IV

This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

A comparative assessment of three planes of implant placement in breast augmentation: A Bayesian analysis

BACKGROUND

Techniques based on three planes of implant placement, including the subglandular (SG), subpectoral (SP), and subfascial (SF) planes are used for breast augmentation. The placement that offers the greatest balance of risks and benefits is unclear. This study presents a systematic review with a Bayesian network meta-analysis to compare different implant placement techniques for augmentation mammaplasty.

METHODS

A systematic literature search was performed. We estimated the odds ratios (ORs) for capsular contractures, hematomas, seromas, infections, reoperation rates, rippling, nipple numbness, malplacements, ruptures, and asymmetry among the different interventions. Muscle movement events and satisfaction rates were also evaluated.

RESULTS

A total of 19 studies (25,744 cases) were included. SG placement significantly increased the incidence of capsular contractures (SP vs. SG: OR 0.42; 95% credible interval [CrI] 0.28-0.63; SF vs. SG: OR 0.41; 95% CrI 0.17-0.97), hematomas (SF vs. SG: OR 0.22; 95% CrI 0.06-0.63), and seromas (SF vs. SG: OR 0.04; 95% CrI 0.00-0.81) compared to other placement techniques. Muscle movement only occurred in the SP group, but it did not increase the risk of subsequent malplacements, asymmetries, or ruptures. Most patients were highly satisfied with their surgical results. Comparisons did not show significant differences in the remaining results.

CONCLUSIONS

Our evidence suggests that SG placement increases the risk of capsular contractures, hematomas, and seromas. The SP and SF planes were safe and effective for controlling total complication rates and achieving high satisfaction rates; however, the long-term benefits of the SF technique require further research.

Oncological Risk in Autologous Stem Cell Donation for Novel Tissue-Engineering Approaches to Postmastectomy Breast Regeneration

Adipose tissue engineering using adipose-derived stem cells (ADSCs) has emerged as an opportunity to develop novel approaches to postmastectomy breast reconstruction with the potential for an autologous tissue source with a natural appearance and texture. As of yet, the role of ADSCs in breast cancer development and metastasis is not completely understood; therefore, we must consider the oncological safety of employing an autologous source of ADSCs for use in breast regeneration. This study investigated the regenerative properties of ADSCs isolated from breast cancer patients, including those who had received neoadjuvant chemotherapy, and noncancer controls. The ADSCs were characterised for several parameters central to tissue regeneration, including cell viability, proliferation, differentiation potential, and cytokine secretion. A stem cell population was isolated and confirmed by flow cytometry and multilineage differentiation. There was no difference in cell phenotype or surface antigen expression between ADSCs from different sources. Adipose-derived stem cells isolated from the breast of cancer patients exhibited reduced adipogenic differentiation potential compared with ADSCs from other sources. The greatest degree of adipogenic differentiation was observed in ADSCs isolated from the subcutaneous abdominal fat of noncancer controls. The proliferation rate of ADSCs isolated from the breast of cancer patients was increased compared with other sources; however, it was decreased in ADSCs isolated from breast cancer patients who had recently been treated with neoadjuvant chemotherapy. A number of cytokines were detected in the cell conditioned media of ADSCs from different sources, including matrix metalloproteinase-2 (MMP-2), which was detected at higher levels in the secretome of ADSCs from breast cancer patients compared with noncancer controls. This study provides important information relating to the suitability of ADSCs as an autologous cell source for adipose tissue engineering in postcancer reconstruction. Results indicate that while the surface phenotype does not differ, the differentiation capacity, proliferative rate, and secreted cytokine profile are affected by the presence or treatment of breast cancer. These findings support further investigation into the regenerative potential of these ADSCs, if they are to be considered in clinical reconstructive strategies.

Hypoxia-induced epithelial-mesenchymal transition and fibrosis for the development of breast capsular contracture

Fibrosis has been considered as a major cause of capsular contracture. Hypoxia has widely emerged as one of the driving factors for fibrotic diseases. The aim of this study was to examine the association between hypoxia-induced fibrosis and breast capsular contracture formation. Fibrosis, epithelial-mesenchymal transition (EMT), expression levels of hypoxia-inducible factor-1α (HIF-1α), vimentin, fibronectin, and matrix metalloproteinase-9 (MMP-9) in tissues from patients with capsular contracture were determined according to the Baker classification system. Normal breast skin cells in patients with capsular contracture after implant-based breast surgery and NIH3T3 mouse fibroblasts were cultured with cobalt chloride (CoCl₂) to mimic hypoxic conditions. Treatment responses were determined by detecting the expression of HIF-1α, vimentin, fibronectin, N-cadherin, snail, twist, occludin, MMP-9, tissue inhibitor of metalloproteinase-1 (TIMP-1) and -2, as well as phosphorylated ERK. The expression levels of HIF-1α, vimentin, fibronectin, and fibrosis as well as EMT were positively correlated with the severity of capsular contracture. MMP-9 expression was negatively correlated the Baker score. Hypoxia up-regulated the expression of HIF-1α, vimentin, fibronectin, N-cadherin, snail, twist, TIMP-1 and -2, as well as phosphorylated ERK in normal breast skin cells and NIH3T3. Nonetheless, the expression levels of MMP-9 and occludin were down-regulated in response to CoCl₂ treatment. This study is the first to demonstrate the association of hypoxia-induced fibrosis and capsular contracture.

Acellular Dermal Matrix Reduces Myofibroblast Presence in the Breast Capsule

Background

Capsular contracture remains a common complication after implant-based breast reconstruction. Previous work has suggested that the use of acellular dermal matrix (ADM) reduces the rate of capsular contracture, though little is understood about the underlying mechanism. As myofibroblasts are believed to be the key cells implicated in contracture formation, we hypothesized that ADM would result in a reduction in periprosthetic myofibroblast concentration.

Methods

Five patients who underwent immediate prepectoral tissue expander placement with anterior ADM coverage and an inferior cuff were included. At the second stage, tissue samples were obtained of both ADM and capsule from each reconstructed breast. Samples were then prepared for hematoxylin and eosin staining and immunohistochemistry for myofibroblast identification (alpha smooth muscle actin and vimentin positive and desmin negative) and analysis. Experimental values are presented as mean ± SD unless otherwise stated. Statistical significance was determined using unpaired t test.

Results

Successful incorporation of ADM was noted in all cases. A significant reduction in myofibroblast concentration was noted in the ADM versus the capsule (P = 0.0018). This was paralleled by significantly thicker periprosthetic capsule formation overlying the formerly raw pectoralis major muscle, that is, not covered by ADM (P < 0.0001).

Conclusions

In the presence of ADM, there are significantly fewer myofibroblasts in breast capsules and thinner capsules on histology. Given the central role of myofibroblasts in the development of clinically significant capsular contracture, this study unmasks a possible mechanism for the protective effect of ADM with respect to capsular contracture development.

Biological acellular pericardial mesh regulated tissue integration and remodeling in a rat model of breast prosthetic implantation

The use of biological meshes has proven beneficial in surgical restriction and periprosthetic capsular contracture following breast prosthetic-reconstruction. Three different types (smooth, texturized, and polyurethane) of silicone round mini prostheses were implanted under rat skin with or without two different bovine acellular pericardial biological meshes (APMs, BioRipar, and Tutomesh). One hundred eighty-six female rats were divided into 12 groups, sacrificed after 3, 6, and 24 weeks and tissue samples investigated by histology and immunohistochemistry. Implantation of both APMs, with or without prostheses, reduced capsular α-SMA expression and CD3⁺ inflammatory cell infiltration, increasing capillary density and cell proliferation, with some differences. In particular, Tutomesh was associated with higher peri-APM CD3⁺ inflammation, prosthetic capsular dermal α-SMA expression and less CD31⁺ vessels and cell proliferation compared with BioRipar. None differences were observed in tissue integration and remodeling following the APM + prostheses implantation; the different prostheses did not influence tissue remodeling. The aim of our study was to investigate if/how the use of different APMs, with peculiar intrinsic characteristics, may influence tissue integration. The structure of APMs critically influenced tissue remodeling after implantation. Further studies are needed to develop new APMs able to optimize tissue integration and neoangiogenesis minimizing periprosthetic inflammation and fibrosis.

Ten-Year Safety Data for Eurosilicone's Round and Anatomical Silicone Gel Breast Implants

Background

Although silicone breast implants have been available for over 60 years, their safety and efficacy continue to be assessed via long-term clinical and vigilance studies. Complications often associated with breast implant surgery include but are not limited to capsular contracture and rupture.

Objective

The authors investigate and evaluate the safety and performance of Eurosilicone’s (Eurosilicone S.A.S, Apt Cedex, France) Cristalline Paragel breast implants at least 10 years postimplantation.

Methods

Nine hundred and ninety-five of Eurosilicone’s textured mammary implants were implanted in 526 women undergoing primary (423 patients) and revision surgery (103 patients) at 17 centers throughout France. Complications were recorded at 3 months and annually thereafter for 10 years. Descriptive statistics were used and the Kaplan-Meier method was utilized to analyze key complications.

Results

Seventy-four women (98 implants) experienced capsular contracture across all cohorts. The Kaplan-Meier 10-year cumulative risk of capsular contracture (Baker Grade III/IV) per implant was 11.5% in the primary augmentation cohort and 25.2% in the primary reconstruction cohort. Sixteen implant ruptures were observed by surgeon examination giving a Kaplan-Meier risk of 3.8% per patient and 3.5% per implant. Surgical re-intervention (explantation/exchange) was reported 80 times resulting in a Kaplan-Meier cumulative risk of 13.3% and 31.6% for primary augmentation and primary reconstruction, respectively, per patient. Local complication rates including infection and seroma were low with risk rates of 0.6% and 0.2% by subject.

Conclusions

This multicenter clinical study demonstrates the long-term safety and efficacy profile through 10 years for Eurosilicone round and anatomical silicone gel breast implants.

Level of Evidence: 3

Periprosthetic Capsule Formation and Contracture in a Rodent Model of Implant-Based Breast Reconstruction With Delayed Radiotherapy

INTRODUCTION

Capsular contracture (CC) is the most common complication of breast implantation, with an incidence of nearly 50% in patients undergoing breast reconstruction with subsequent radiotherapy. Although the move toward submuscular (SM) device placement led to a decreased incidence of CC, subcutaneous (SQ) implantation has seen a resurgence. The purpose of this study was to use a rodent model of breast reconstruction with smooth silicone implants and delayed radiotherapy to assess the occurrence of CC in SQ versus SM implantation.

METHODS

Custom 2 mL smooth round silicone implants were placed bilaterally into 12 female Sprague Dawley rats that were randomized into 4 groups of 3, with each group differing by implantation plane (SQ vs SM) and irradiation status (irradiated vs nonirradiated). Rats from the SQ group received implants bilaterally underlying the skin on the flank. Rats in the SM groups received implants bilaterally under the latissimus dorsi muscle. Irradiated rats received 20 Gy localized to each implant on postoperative day 10. One rat from each group was imaged with a micro-computed tomography scanner at baseline and at explant 3 months later, whereupon capsules from all rats were examined histologically.

RESULTS

Rats in the SQ group showed evidence of contracture on gross examination and greater evidence of morphologic disruption per micro-computed tomography scan. There was no evidence of contracture or morphologic disruption in either SM group. Mean ± SD capsule thickness was 39.0 ± 9.0 μm in the SQ versus 37.6 ± 9.8 μm in the SM nonirradiated groups and 43.9 ± 14.9 μm in the SQ versus 34.3 ± 8.3 μm in the SM irradiated groups (all P > 0.05).

CONCLUSIONS

In a rodent model of smooth silicone breast implantation and delayed radiotherapy, although there did not appear to be differences in capsule thickness regardless of device placement plane, SQ implants demonstrated gross evidence of CC. These data indicate that capsule thickness is only part of a larger pathogenetic picture, which should take into consideration the contribution from all peri-implant tissue.

Silicone Implant Coated with Tranilast-Loaded Polymer in a Pattern for Fibrosis Suppression

Pathologic fibrosis around silicone implants is problematic, and thus, these implants have been coated with a mixture of a biocompatible polymer and antifibrotic drug for sustained drug release to prevent fibrosis. However, a coating applied over an entire surface would be subject to mechanical instability as the implant would be severely crumpled for implant insertion. Therefore, in this work, we proposed localized, patterned coating dots, each composed of poly(lactic-co-glycolic acid) (PLGA) and tranilast, to be applied on the surface of silicone implants. The drug loaded in the pattern-coated implant herein was well retained after a cyclic tensile test. Due to the presence of PLGA in each coating dot, the tranilast could be released in a sustained manner for more than 14 days. When implanted in a subcutaneous pocket in living rats for 12 weeks, compared with the intact implant, the pattern-coated implant showed a decreased capsule thickness and collagen density, as well as less transforming growth factor-β (TGF-β) expression and fewer fibroblasts; importantly, these changes were similar between the surfaces with and without the coating dots. Therefore, we conclude that the pattern-coating strategy proposed in this study can still effectively prevent fibrosis by maintaining the physical stability of the coatings.

The Evolving Role of Pre-pectoral ADM-assisted Approach in Implant-based Immediate Breast Reconstruction Following Conservative Mastectomy: An Overview of the Literature and Description of Technique

BACKGROUND/AIM

The recent development of acellular dermal matrix (ADM) devices has enhanced implant-based breast reconstruction surgery following conservative mastectomy for therapeutic and risk-reducing purposes leading to improved aesthetics. In the traditional sub-pectoral approach, coverage of the implant is provided by the pectoral muscles superiorly and the ADM inferiorly. The need to eliminate breast animation, reduce post-operative dysfunctional pain and the risk of capsular contracture, have stimulated surgeons to investigate the feasibility of placing the implant over the pectoralis major muscle with complete coverage with ADM thus inventing a novel pre-pectoral approach.

MATERIALS AND METHODS

We reviewed the literature regarding this evolving technique of muscle sparing ADM-assisted implant-based immediate breast reconstruction. Also, we describe our technique, and present pictures of the post-operative result.

RESULTS AND CONCLUSION

The early reported results of the pre-pectoral breast reconstruction approach are encouraging and confirmed the potential benefits of eliminating breast animation and reducing postoperative pain. However, most of these studies had a small sample size (<100 patients) and were retrospective in nature with a limited follow-up duration and lack of data regarding the objective aesthetic assessment and oncological outcome. Nevertheless, suitable patients undergoing conservative mastectomy and implant-based reconstruction should be offered this option while further evaluation is being performed.

A Different Perspective on Breast Implant Surface Texturization and Anaplastic Large Cell Lymphoma (ALCL)

Anaplastic large cell lymphoma (ALCL) is a rare form of lymphoma involving cells of the immune system. It is currently gaining interest because of an association between the development of ALCL and an increased risk in women who have had breast implant surgery. Although not confirmed, many theories exist as to the etiology of this association in women, and there is growing concern that ALCL is more prevalent in women with textured breast implants. In particular, the risk of developing ALCL appears to be related to increasing implant texturization or "surface roughness." This paper examines the current manner of defining and characterizing breast implant surface texture and challenges the appropriateness of applying this technology and linking it to ALCL. It is not a comprehensive review of the etiology of capsular contracture and ALCL, but it proposes an alternative perspective on surface texture measurements from that currently employed and its role in researching the etiology of ALCL. The authors hope that their article will provoke thought and reflection when considering the issues currently being highlighted with regard to texturing of breast implants.

Silicone breast implant modification review: overcoming capsular contracture

Background

Silicone implants are biomaterials that are frequently used in the medical industry due to their physiological inertness and low toxicity. However, capsular contracture remains a concern in long-term transplantation. To date, several studies have been conducted to overcome this problem. This review summarizes and explores these trends.

Main body

First, we examined the overall foreign body response from initial inflammation to fibrosis capsule formation in detail and introduced various studies to overcome capsular contracture. Secondly, we introduced that the main research approaches are to inhibit fibrosis with anti-inflammatory drugs or antibiotics, to control the topography of the surface of silicone implants, and to administer plasma treatment. Each study examined aspects of the various mechanisms by which capsular contracture could occur, and addressed the effects of inhibiting fibrosis.

Conclusion

This review introduces various silicone surface modification methods to date and examines their limitations. This review will help identify new directions in inhibiting the fibrosis of silicone implants.

Capsular fibrosis in aesthetic and reconstructive-cancer patients: A retrospective analysis of 319 cases

BACKGROUND

Implant-based breast augmentation is one of the most frequently performed operations in plastic surgery worldwide, for aesthetic and reconstructive reasons. Capsular fibrosis is the most common long-term foreign body response after breast implant augmentation.

OBJECTIVE

To compare the occurrence of capsular contracture in aesthetic and reconstructive-cancer patients, including those patients who received radiotherapy prior to breast reconstruction with implants.

METHODS

We conducted a retrospective evaluation of 319 patients who underwent breast implant revision between Jan 2000 and Oct 2016. The patient group was comprised of 175 reconstructive-cancer patients and 144 patients who underwent operation for aesthetic reasons. The occurrence of capsular fibrosis, other complications and the time-period between implantation of breast implants and revision surgery (TP) was analyzed.

RESULTS

For all 319 patients the mean TP was 7.9 years (7.86±0.45). The most common complication in all revisions was capsular fibrosis (65.1% of all revisions). In aesthetic patients with capsular fibrosis the mean TP was 11.9 years (11.89±0.95, p < 0.001). This mean TP was significantly higher than the mean TP of 6.1 years (6.13±0.56, p < 0.001) in breast cancer patients with capsular fibrosis. Preoperatively irradiated cancer patients had a mean TP of 6.2 years (6.17±0.95), compared to a mean TP of 5.1 years (5.07±0.19, p = 0.051) in non-irradiated cancer patients, which was not significantly different.

CONCLUSIONS

We found that aesthetic patients exhibit a significantly higher mean TP compared to breast cancer patients, suggesting that reconstructive-cancer patients in general develop capsular fibrosis earlier. Despite the literature, we did not find a significant influence of preoperative radiotherapy on the occurrence of capsular fibrosis in reconstructive-cancer patients. Further clinical studies need to be conducted to identify methods to decrease the risk of developing capsular fibrosis.

Jumping Breast Phenomenon Following Subcutaneous Mastectomy: First Description and Grading of a Well-Known Breast Deformity

Introduction

One of the goals of breast cancer surgery is to preserve the breast. However, where this is not possible, various breast reconstructive procedures are available. The most common procedure is the immediate insertion of a subpectoral implant after removing the breast tissue. A significant challenge involving subpectoral implants is the deformation of the breast upon contraction of the pectoral muscle causing elevation of the breast and development of wrinkles or ripples in the caudal and cranial quadrants (jumping breast), especially in slim patients with a thin subcutaneous fat layer.

Methods

While the jumping breast phenomenon after augmentation is well-known in cosmetic breast surgery, it has never been systematically described. In oncologic breast surgery, this deformity, which at times can be quite severe, has been ignored thus far.

Results and Conclusion

In this paper, we present an initial distinction of grades for the so-called jumping breast, show examples for the different grades of severity of breast deformity in response to tensing of the pectoral muscle, and further describe different primary and secondary procedures for the prevention of the jumping breast phenomenon. By means of a 2-stage procedure, we can prevent this complication and reduce the risk of breast deformity after implant-based breast reconstruction.

Optimise not compromise: The importance of a multidisciplinary breast cancer patient pathway in the era of oncoplastic and reconstructive surgery

Modern breast cancer care is a complex multidisciplinary undertaking in which the integrated function of multiple constituent parts is critical, and where changes to one therapeutic component may profoundly influence the delivery and outcomes of another. Oncoplastic and reconstructive breast surgery has evolved in the era of longer survival rates for women with breast cancer and aims to enhance oncological and cosmetic outcomes. However, concurrently there has been an expansion in the indications for post-mastectomy radiation therapy (Abdulkarim et al., 2011; Early Breast Cancer Trialists' Collaborative Group (EBCTCG), 2014; Poortmans et al., 2015; Wang et al., 2011), the recognition of several biologically distinct breast cancer subtypes (Perou et al., 2000; Sørlie et al., 2001, 2003; Cheang et al., 2008, 2009; Sotiriou et al., 2003; Millar et al., 2011; Blows et al., 2010; Schnitt, 2010; Haque et al., 2012; Dai et al., 2015) and the development of recommendations for prophylactic surgery for high-risk women, including BRCA-mutation carriers (James et al., 2006; Domchek et al., 2010). Primary systemic therapy is increasingly utilised yet has varying efficacy depending on tumour biology (Cortazar et al., 2014). In this paper we review the evidence which informs the multidisciplinary team opinion in the era of oncoplastic and reconstructive breast surgery. We aim to describe an optimal multidisciplinary approach which balances competing risks of multimodal therapies to optimise oncological and cosmetic outcomes.

The A, B and C's of Silicone Breast Implants: Anaplastic Large Cell Lymphoma, Biofilm and Capsular Contracture

Breast implantation either for cosmetic or reconstructive e purposes is one of the most common procedures performed in plastic surgery. Biofilm infection is hypothesised to be involved in the development of both capsular contracture and anaplastic large cell lymphoma (ALCL). Capsular contracture is one of the principal reasons for breast revision surgery and is characterised by the tightening and hardening of the capsule surrounding the implant, and ALCL is an indolent lymphoma found only in women with textured implants. We describe the types of breast implants available with regard to their surface characteristics of surface area and roughness and how this might contribute to capsular contracture and/or biofilm formation. The pathogenesis of capsular contracture is thought to be due to biofilm formation on the implant, which results in on-going inflammation. We describe the current research into breast implant associated ALCL and how implant properties may affect its pathogenesis, with ALCL only occurring in women with textured implants.

Breast Implant Texturization Does Not Affect the Crosstalk Between MSC and ALCL Cells

In the last decade, there has been a growing interest about the possible association between anaplastic large cell lymphoma (ALCL) and breast implants (BIA-ALCL). Many variables, such as breast implants texturization, have been investigated. Breast implants often lead to the formation of a periprosthetic capsule, characterized by inflammation. The presence of the inflamed capsule has been found in the majority of patients with BIA-ALCL. Inflammation may be sustained or counteracted by mesenchymal stem cells (MSCs) by the secretion of pro- or anti-inflammatory cytokines. MSCs were isolated from three capsules surrounding micro-textured (micro-MSCs) and from three capsules surrounding macro-textured (macro-MSCs) implants; after characterization, MSCs were co-cultured with KI-JK cells (a cell line derived from the cutaneous form of ALCL). The secretion of cytokines related to inflammation, the proliferation rate, and the expression of genes referred to pro-tumoral mechanisms were evaluated. Co-cultures of KI-JK cells with micro- or macro-MSCs gave the same results about the secretion of cytokines (increase of IL10, G-CSF, and TGF-β1 and decrease of IL4, IL5, IL12, IL13, IL17A, IFN-γ (p < 0.05) with respect to mock sample), expression of selected genes (increase for ACVR1, VEGF, TGF-βR2, CXCL12, and MKi67 (p < 0.05) with respect to control sample), and the proliferation rate (no variation between mock and co-cultured samples). Our results suggest that MSCs derived from capsules surrounding micro- and macro-textured implants display the same effects on the ALCL cells.

The Role of Antibiotics in Breast Pocket Irrigation and Implant Immersion: A Systematic Review

Background:

The usage of antibiotics and antiseptics to washout the breast pocket, or to soak the breast implant during surgery, has come under scrutiny in recent times. Guidelines from the Centers for Disease Control and Prevention give no recommendation for or against the usage of antibiotics in this regard. They do however offer a weak recommendation for washing tissues with iodophor. This systematic review aims to investigate the efficacy and impact of such topical antibiotic or antiseptic usage in reducing infection rates.

Methods:

A systematic electronic search was performed on the PreMEDLINE, MEDLINE, EMBASE, and CENTRAL (Cochrane) databases from inception to April 2017. Reference search was performed manually through Scopus. Results of the searches were independently screened by 2 reviewers (A.F. and P.H.). Studies involving an implant or tissue expander, with appropriate controls were included. Meta-analyses were performed where possible and data summarized when not.

Results:

Three retrospective cohort studies were found to fit the review requirements. No randomized control trials were found. These studies covered a period of 1996–2010 for a total of 3,768 women undergoing augmentative surgery. The usage of antibiotics in pocket washout or implant immersion resulted in lower infection rates (RR = 0.52; P = 0.004; 95% CI = 0.34–0.81).

Conclusions:

There is a clinical benefit in using antibiotics for breast pocket irrigation and implant immersion. However, the quality of the evidence obtained in this review is low; hence, we recommend a randomized control trial for a higher level of evidence on this important issue.

Dual surface modification of PDMS-based silicone implants to suppress capsular contracture

In this study, we report a new physicochemical surface on poly(dimethylsiloxane) (PDMS)-based silicone implants in an effort to minimize capsular contracture. Two different surface modification strategies, namely, microtexturing as a physical cue and multilayer coating as a chemical cue, were combined to achieve synergistic effects. The deposition of uniformly sized microparticles onto uncured PDMS surfaces and the subsequent removal after curing generated microtextured surfaces with concave hemisphere micropatterns. The size of the individual micropattern was controlled by the microparticle size. Micropatterns of three different sizes (37.16, 70.22, and 97.64 μm) smaller than 100 μm were produced for potential application to smooth and round-shaped breast implants. The PDMS surface was further chemically modified by layer-by-layer (LbL) deposition of poly-l-lysine and hyaluronic acid. Short-term in vitro experiments demonstrated that all the PDMS samples were cytocompatible. However, lower expression of TGF-β and α-SMA, the major profibrotic cytokine and myofibroblast marker, respectively, was observed in only multilayer-coated PDMS samples with larger size micropatterns (70.22 and 97.64 μm), thereby confirming the synergistic effects of physical and chemical cues. An in vivo study conducted for 8 weeks after implantation in rats also indicated that PDMS samples with larger size micropatterns and multilayer coating most effectively inhibited capsular contracture based on analyses of tissue inflammation, number of macrophage, fibroblast and myofibroblast, TGF-β expression, collagen density, and capsule thickness.

STATEMENT OF SIGNIFICANCE

Although poly(dimethylsiloxane) (PDMS)-based silicone implants have been widely used for various applications including breast implants, they usually cause typical side effects called as capsular contracture. Prior studies have shown that microtexturing and surface coating could reduce capsular contracture. However, previous methods are limited in their scope for application, and it is difficult to obtain FDA approval because of the large and nonuniform size of the microtexture as well as the use of toxic chemical components. Herein, those issues could be addressed by creating a microtexture of size less than 100 m, with a narrow size distribution and using layer-by-layer deposition of a biocompatible polymer without using any toxic compounds. Furthermore, this is the first attempt to combine microtexture with multilayer coating to obtain synergetic effects in minimizing the capsular contracture.

Effect of Keller Funnel on the Rate of Capsular Contracture in Periareolar Breast Augmentation

Background

Capsular contracture is 1 of the most common complications after breast implant surgery and is a major indication for reoperation. Capsular contracture is believed to be a multifactorial process that is affected by implant texture, incision type, and ultimately pocket contamination. This contamination causes a biofilm that leads to capsular contracture. The intraoperative use of a Keller funnel is a mechanical way to decrease the implant's contact with the skin and ducts, reducing bacterial contamination that can cause these biofilms. For this reason, periareolar breast augmentation has been less popular among surgeons. The purpose of this study was to examine if there was a significant difference between the rates of capsular contracture in patients having periareolar breast augmentations with the use of a Keller funnel for insertion and those having periareolar breast augmentations without Funnel use.

Methods

This level 3 retrospective study followed 2 groups of patients, the first having periareolar breast augmentations without the use of a funnel for insertion (group A; patients n = 15; implants n = 30) and the second having periareolar breast augmentations with the use of a funnel for insertion (group B; patients n = 151; implants n = 300).

Results

The rate of capsular contracture in group A was found to be 10% compared with a rate of capsular contracture of 1.3% for patients in group B, an 87% reduction (P = 0.0019).

Conclusions

According to the results found in this study, the rate of capsular contracture in patients having periareolar breast augmentations after insertion with a Keller funnel was statistically significantly lower than the rate in patients having implants inserted without the assistance of a funnel, making the device useful in reducing the occurrence of postoperative capsular contracture.

Risk factors for developing capsular contracture in women after breast implant surgery: A systematic review of the literature

BACKGROUND

Capsular contracture is the most frequent complication in breast augmentation or reconstruction with breast implants. The exact mechanism for this complication is not completely understood. Yet, it is most likely to be a multifactorial condition. Several patient-, surgery-, and implant-specific risk factors have been related to cause capsular contracture. This review aims to provide a clear overview of all risk factors for capsular contracture.

METHODS

A systematic literature review was performed focusing on patient-, surgery-, and/or implant-related factors related to capsular contracture in breast implants. PubMed, Embase, and Wiley/Cochrane Library databases were searched for relevant articles published from inception up to October 20, 2016. The included studies were assessed for the following main variables: study characteristics, patient characteristics, indication for surgery, type of surgery, implant characteristics, and other characteristics.

RESULTS

Data on the risk factors for the development of capsular contracture were retrieved from 40 studies. A presumptive increased risk in the development of capsular contracture is shown for the following variables: longer duration of follow-up, breast reconstructive surgery in patients with a history of breast cancer, subglandular implant placement, postoperative hematoma, and a textured implant surface. There is little, weak, or no evidence for the association of other factors with capsular contracture. This review also shows a large heterogeneity between studies and within the definition of capsular contracture.

CONCLUSION

This review provides an overview of the relationship between patient-, surgery-, and implant-specific risk factors in the development of capsular contracture.

Non-linear optical microscopy and histological analysis of collagen, elastin and lysyl oxidase expression in breast capsular contracture

Background

Capsular contracture is one of the most common complications in surgical interventions for aesthetic breast augmentation or post-mastectomy breast reconstruction involving the use of silicone prostheses. Although the precise cause of capsular contracture is yet unknown, the leading hypothesis is that it is caused by long-term unresolved foreign body reaction towards the silicone breast implant. To authors’ best knowledge, this is the first study that elucidates the presence of lysyl oxidase (LOX)—an enzyme that is involved in collagen and elastin crosslinking within fibrous capsules harvested from patients with severe capsular contracture. It was hypothesized that over-expression of LOX plays a role in the irreversible crosslinking of collagen and elastin which, in turn, stabilizes the fibrous proteins and contributes to the progression of capsular contracture.

Methods

Eight fibrous capsules were collected from patients undergoing capsulectomy procedure, biomechanical testing was performed for compressive Young’s moduli and evaluated for Type I and II collagen, elastin and LOX by means of non-linear optical microscopy and immunohistology techniques.

Results

Observations revealed the heterogeneity of tissue structure within and among the collected fibrous capsules. Regardless of the tissue structure, it has been shown that LOX expression was intensified at the implant-to-tissue interface.

Conclusion

Our results indicate the involvement of LOX in the initiation of fibrous capsule formation which ultimately contributes towards the progression of capsular contracture.

Electronic supplementary material

The online version of this article (10.1186/s40001-018-0322-0) contains supplementary material, which is available to authorized users.

Postoperative radiotherapy after nipple- or skin-sparing mastectomy: a review of recent institutional and pooled data

The increasing use of nipple-sparing mastectomy (NSM) and skin-sparing mastectomy (SSM) in the treatment of nonmetastatic breast cancer is justified by considerations linked to their therapeutic index. In selected patients, efficacy results tend to be similar to those observed after radical modified mastectomy and at the same time, subcutaneous mastectomies preserve the patient’s body image. Yet the oncologic safety of the two former surgical approaches is still a matter of debate, also in consideration of the almost complete absence of clinical studies directed to prospective, controlled comparisons between subcutaneous and radical modified mastectomies. In addition, no clear statement—and consequently no consensus—emerges from the rather rare reports addressing the issue of whether or not there exist robust algorithms for guiding decision-making in delivering postoperative radiotherapy after NSM or SSM. The objective of the present review article is to revisit the dataset recently provided by the literature, which might help oncology teams optimise local treatment in this patient population.

Surface Areas of Textured Breast Implants: Implications for the Biofilm Theory of Capsule Formation

Supplemental Digital Content is available in the text.

Background:

Increased surface area of mammary implants is suggested as a causative agent for the development of biofilms, which may lead to capsular contraction. The aim of this study was to quantify the surface areas of round implants of different textures and examine how these data can be interpreted with regard to clinical observation.

Methods:

Surface areas of textured round breast implants were calculated from previously reported confocal scanning microscopic assessment, and dimensions sourced from 3 breast implant manufacturers (McGhan, Mentor, and Silimed). Statistical comparisons were made between manufacturers for different implant volumes, profiles, and texturing.

Results:

There was a difference in surface area between manufacturers for all implant profiles and between manufacturers for equivalent volume implants (F (3, 253) = 2,828.87; P < 0.001). Silimed polyurethane implants (mean area = 6.12 × 10⁶ mm²) was the highest. Natrelle (mean area = 1.2 × 10⁶ mm²) was the next highest, followed by Siltex (mean area = 4.8 × 10⁵ mm²). Mentor smooth implants (mean area = 4 × 10⁴ mm²) had the lowest mean surface area. There were no differences in surface area between the different profiles for Siltex, Silimed polyurethane, and Mentor smooth implants of the same volume.

Conclusions:

The increased surface area produced by texturing, although different between manufacturers, seems to provide protection against capsular contraction. Correlation with clinical data indicates that the surface area alone cannot account for these differences. Smooth implants, which have the smallest surface area have the highest incidence of capsular contraction. These data are at odds with the biofilm theory of capsular contraction.

Comparing the Outcome of Different Biologically Derived Acellular Dermal Matrices in Implant-based Immediate Breast Reconstruction: A Meta-analysis of the Literatures

Background:

Acellular dermal matrices (ADMs) have been used extensively in implant-based breast reconstruction. It was reported that due to the different sources and processing methods, the outcomes of ADMs in implant-based breast reconstructions are expected to differ. We designed this study to statistically analyze and discuss the outcome of 3 commonly used ADMs, Alloderm, Strattice, and Surgimend in implant-based breast reconstruction.

Methods:

Comprehensive review of the literatures searched on electronic databases was done to identify studies published between 2006 and 2017 comparing the outcome of ADMs. Pooled random effect estimates for each complication and 95% confidence interval (CI) were calculated. One-way analysis of variance and Bonferroni test were used to compare statistical significance between and within groups, respectively. Multiple linear regression was done to include confounding factors and R statistic program for forest plot.

Results:

Twenty-one studies met the inclusion with a total of 1,659, 999, and 912 breasts reconstructions in Alloderm, Strattice, and Surgimend, respectively. Seven complications extracted including major and minor infection, seroma, implant loss, hematoma, capsular contracture, and localized erythema. Pooled total complication rates were 23.82% (95% CI, 21.18–26.47%) in Strattice, 17.98% (95% CI, 15.49–20.47%) in Surgimend, 16.21% (95% CI, 14.44–17.99%) in Alloderm. Seroma rate was the highest in Strattice group (8.61%; 95% CI, 6.87–10.35%). There was no statistical significance between and within groups.

Conclusion:

Although Strattice exhibited a higher overall pooled complication rate compared with Alloderm and Surgimend, the incidence of individual complication varies between studies. A cost analysis of different ADMs may aid in choosing the type of ADMs to be used.

Eight-Year Safety Data for Round and Anatomical Silicone Gel Breast Implants

BACKGROUND

The safety and efficacy of all medical devices, including breast implants, is important and consistent performance is best shown by undertaking long-term clinical and vigilance studies. Local complications such as capsular contracture and rupture are risks often associated with breast implant surgery.

OBJECTIVES

The authors investigate and evaluate the safety and performance of Eurosilicone's (Eurosilicone S.A.S, Apt Cedex, France) Cristalline Paragel breast implants at 8 years postimplantation.

METHODS

In this prospective clinical study, 995 Eurosilicone textured cohesive Cristalline Paragel mammary implants were implanted in 526 women undergoing augmentation and reconstructive surgery at 17 centers across France. Complications were recorded at 3 months and annually thereafter for 8 years. Descriptive statistics were used and key complications were analysed using the Kaplan-Meier method.

RESULTS

Capsular contracture was reported in 8.5% of implants across all cohorts through 8 years. The Kaplan-Meier risk of capsular contracture (Baker Grade III/IV) per implant was 8.4% in the primary augmentation cohort and 18.0% in the primary reconstruction cohort. Eight implant ruptures were identified by surgeon examination during this follow-up period. The Kaplan-Meier risk of rupture occurring within 8 years postimplantation, across all cohorts, was 1.4% per patient and 0.9% per implant. Actual implant removal rate (explantation/exchange) was 6.0% and 13.8% for primary augmentation and primary reconstruction, respectively. Actual rates of local complications including infection and seroma were low with risk rates of 0.6% and 0.2% by subject.

CONCLUSIONS

This multicenter clinical study involving Eurosilicone's silicone gel breast implants in both round and shaped profiles demonstrates an excellent safety and efficacy profile through 8 years.

Immunophenotypic characterization of human T cells after in vitro exposure to different silicone breast implant surfaces

The most common complication of silicone breast implants is capsular contracture (massive scar formation around the implant). We postulate that capsular contracture is always a sequel to inflammatory processes, with both innate and adaptive immune mechanisms participating. In general, fibroblasts and macrophages have been used as cell types to evaluate in vitro the biocompatibility of breast implant surfaces. Moreover, also T cells have been found at the implant site at the initial stage of fibrous capsule formation. However, only few studies have addressed the influence of surfaces with different textures on T-cell responses. The aim of the present study was to investigate the immune response of human peripheral blood mononuclear cells (PBMC) to commercially available silicone breast implants in vitro. PBMC from healthy female blood donors were cultured on each silicone surface for 4 days. Proliferation and phenotype of cultured cells were assessed by flow cytometry. Cytokine levels were determined by multiplex and real-time assay. We found that silicone surfaces do not induce T-cell proliferation, nor do they extensively alter the proportion of T cell subsets (CD4, CD8, naïve, effector memory). Interestingly, cytokine profiling identified matrix specific differences, especially for IL-6 and TNF-α on certain surface topographies that could lead to increased fibrosis.

A 10-Year Prospective Study of Implant-Based Breast Augmentation and Reconstruction

Objective: Observational studies are essential for ensuring patient safety, decreasing complications, and developing better surgical techniques and implants. The primary objective of this study is to demonstrate the safety and efficacy of Sebbin breast implants in both augmentation and reconstruction cohorts. Methods: This prospective, multicenter, observational 10-year study conducted in France included 205 patients (385 implants) who underwent breast augmentation (n = 166) or reconstruction (n = 39) with Sebbin round silicone gel implants. Data on patient demographics, surgical details, and complications were collected. Results: Median patient age was 39 years; 20.5% of patients were smokers. The augmentation cohort included 166 patients (81.0%); the reconstruction cohort, 39 patients (19.0%). Median implant volume was 280 ml; 91.2% of implants were textured, and 8.8% were smooth. Average patient follow-up was 63 months. The most frequent surgical approach in the Augmentation Cohort was periareolar (72.4%), with 45.5% submuscular and 51.5% subglandular placements. All patients received antibiotic prophylaxis, and postoperative antibiotic therapy was given to 39.5% of patients (average 4.8 days). Drainage was performed in 59.5% of patients (average 2.9 days). Of the reconstruction cohort, 64.1% had preoperative radiotherapy. Nine patients had Baker III/IV capsular contracture (3 bilateral; 4 had a history of radiotherapy) and 7 patients had implant rupture; 41 patients underwent explantation. No cases of double capsule, late seroma, or anaplastic large cell lymphoma occurred. Conclusions: This study found an excellent safety profile and very low capsular contracture rate with breast augmentation and reconstruction using Sebbin round silicone gel implants.

The evolving role of pre-pectoral ADM-assisted implant-based immediate breast reconstruction following skin-sparing mastectomy

INTRODUCTION

The increasing use of acellular dermal matrix (ADM) and fat transfer in the context of breast reconstruction, following skin sparing mastectomy (SSM) for therapeutic and risk reducing purposes, combined with the need to eliminate animation deformities, reduce post-operative dysfunctional pain and the risk of capsular contracture, has prompted surgeons to investigate the possibility of placing the mammary implant over the pectoralis major muscle with complete coverage with ADM thus reviving the pre-pectoral approach which was previously abandoned due to high complications rates and poor aesthetics in the pre-ADM era.

METHODS

We reviewed the literature regarding this evolving technique of muscle sparing ADM-assisted implant-based immediate breast reconstruction.

RESULTS AND CONCLUSIONS

Several authors have recently reported positive early results confirming the potential benefits of eliminating breast animation and reducing postoperative pain, however, most of these reports contain insufficient numbers of patients (<100) and were retrospective in nature with a very short-term follow-up and lack of data regarding objective aesthetic assessment. Prospective data are required for more definitive recommendations.