Influence of local complications on capsule formation around model implants in a rat model

The aetiopathogenesis of capsular contracture: A systematic review of the literature

BACKGROUND

Capsular contracture is the most frequent complication after breast augmentation or reconstruction with breast implants. The immune system plays a prominent role in capsular contracture formation, albeit to an unknown extent. Bacterial contamination in situ has been hypothesized to be causative for capsular contracture. How this relates to the immunological processes involved is unknown. This article aims to provide an overview of immunological and bacterial factors involved in development of capsular contracture.

MATERIALS AND METHODS

We undertook a systematic literature review focused on immunological factors and microbiota in relation to capsular contraction around implants. This systematic review was performed in accordance with the PRISMA guidelines. PubMed, EMBASE, and the Cochrane databases were searched from inception up to October 2016. Included studies were assessed for the following variables: subject characteristics, number of capsules, primary indication for surgery, surgical procedure, follow-up or implant duration, study methods, type of antibiotics or medical therapies and outcomes related to microbiota and immunological factors.

RESULTS

Data on immunological factors and bacterial contamination were retrieved from 64 included studies. Notably the presence of macrophages and Staphylococcus epidermidis within capsules was often associated with capsular contracture.

CONCLUSION

This review provides a clear overview of the immunological factors associated with capsular contracture and provides a hypothetical immunological model for development of the disease. Furthermore, an overview of bacterial contamination and associations with capsular contracture has been provided. Follow-up research may result in clinical recommendations to prevent capsular contracture.

Identification of hub genes related to silicone-induced immune response in rats

Silicone implants are used widely in the field of plastic surgery and are used in a large population. However, their safety profile, especially the silicone-induced immune response, has been a major concern for plastic surgeons for decades. It has been hypothesized that there is a cause and effect relation between silicone and immunity, but this is controversial. The objective of the present study was to determine the hub genes and key pathways related to silicone implant–induced immune responses in a rat model. In addition to cluster and enrichment analyses, we used weighted gene co-expression network analysis (WGCNA) to examine the gene expression profiles in a systematic context. A total five genes (Fes, Aif1, Gata3, Tlr6, Tlr2) were identified as hub genes that are most likely related to the silicone-induced immune response, four of which (Aif1, Gata3, Tlr6, Tlr2) have been associated with autoimmunity as target genes or disease markers. The Toll-like receptor signaling pathway (p < 0.01, fold enrichment: 7.01) and systemic lupus erythematosus signaling pathway (p < 0.05, fold enrichment: 5.01), which are considered strongly associated with autoimmunity, were significantly enriched in the silicone-implanted skin samples. The results indicate that silicone implants might trigger the localized immune response, as various immune reaction genes were detected after silicone implantation. The identified five hub genes will hopefully serve as novel therapeutic targets for silicone-related complications and the associated autoimmune diseases.

Carbon Ion Implantation: A Good Method to Enhance the Biocompatibility of Silicone Rubber

BACKGROUND

Silicone rubber and silicone rubber-based materials have been used as medical tissue implants in the field of plastic surgery for many years, but there are still some reports of adverse reactions to long-term implants. Earlier studies have shown that ion implantation could enhance the biocompatibility of biomaterials. However, whether ion implantation has a good effect on silicone rubber is unknown.

METHODS

Three types of carbon ion silicone rubber were obtained by implanting three doses of carbon ions. Then, the antibacterial adhesion properties and the in vivo host responses were evaluated. The antibacterial adhesion properties were examined by plate colony counting, fluorescence staining, and scanning electron microscopic observation. The host responses were evaluated by surveying inflammation and fiber capsule formation that developed after subcutaneous implantation in Sprague-Dawley rats for 7, 30, 90, and 180 days. In addition, the possible mechanism by which ion implantation enhanced the biocompatibility of the biomaterial was investigated and discussed.

RESULTS

Carbon ion silicone rubber exhibits less bacterial adhesion, less collagen deposition, and thinner and weaker tissue capsules. Immunohistochemical staining results for CD4, tumor necrosis factor-α, α-smooth muscle actin, and elastin showed the possible mechanism enhancing the biocompatibility of silicone rubber. These data indicate that carbon ion silicone rubber exhibits good antibacterial adhesion properties and triggers thinner and weaker tissue capsules. In addition, high surface roughness and high zeta potential may be the main factors that induce the unique biocompatibility of carbon ion silicone rubber.

CONCLUSION

Ion implantation should be considered for further investigation and application, and carbon ion silicone rubber could be a better biomaterial to decrease silicone rubber-initiated complications.

Comparative study of membranes induced by PMMA or silicone in rats, and influence of external radiotherapy

The induced membrane technique has been used for long bone defect reconstruction after traumatism. One of the major drawbacks of this method is the difficult removal of the polymethyl methacrylate spacer after membrane formation. We therefore replaced the stiff PMMA spacer with a semi-flexible medical grade silicone spacer. This study aimed to compare subcutaneously formed membranes, induced by PMMA and silicone, in the irradiated or not irradiated areas within 28 rats that received the spacers. Histological analysis was performed to evaluate the composition of the membrane and to quantify the amount of vessels. Histomorphometric measurements were used to evaluate membranes' thickness, while fibrosis and inflammation were scored. The expression of VEGF and BMP-2 in lysates of the crushed membranes was determined by Western blotting. ALP expression was analyzed in HBMSC cultures in contact with the same lysates. Non-irradiated membranes induced by the two spacer types were non-inflammatory, fibrous and organized in layers. Irradiation did not change the macroscopic properties of membranes that were induced by silicone, while PMMA induced membranes were sensitive to the radiotherapy, resulting in thicker, strongly inflammatory membranes. Irradiated membranes showed an overall reduced osteogenic potential. Medical grade silicone is safe for the use in radiotherapy and might therefore be of great advantage for patients in need of cancer treatment.

Biomedical implant capsule formation: lessons learned and the road ahead

Clinicians and investigators have been implanting biomedical devices into patients and experimental animals for centuries. There is a characteristic complex inflammatory response to the presence of the biomedical device with diverse cell signaling, followed by migration of fibroblasts to the implant surface and the eventual walling off of the implant in a collagen capsule. If the device is to interact with the surrounding tissues, the collagen envelope will eventually incapacitate the device or myofibroblasts can cause capsular contracture with resulting distortion, migration, or firmness. This review analyzes the various tactics used in the past to modify or control capsule formation with suggestions for future investigative approaches.

Multiple extracorporeal shock wave therapy degrades capsular fibrosis after insertion of silicone implants

Capsular fibrosis is the most frequent long-term complication after insertion of silicone devices. Today, mainly direct immunostimulation and subclinical infection are held responsible for inducing and maintaining inflammatory reactions, which lead to overwhelming extracellular matrix formation. Extracorporeal shock waves (ESWs) are capable of inhibiting inflammatory processes and revealing antibacterial capacity. In our previous study, we observed decelerated capsule development after application of a single shock wave immediately after surgery. The purpose of this study was to evaluate the effects of multiple ESWT after insertion of silicone implants in the same rodent model. Therefore, silicone prostheses were inserted into a submuscular pocket in 12 additional male Lewis rats, and shock waves were administered over a 14-d interval. At 35 d (n = 6) and 100 d (n = 6) after insertion, silicone implants and surrounding capsule tissue were removed and prepared for histologic and immunohistochemical analysis, as well as polymerase chain reaction (Ccl2, CD68, transforming growth factor β1, matrix metalloproteinase 2). Compared with the control group, multiple ESWT had no effect on day 35, but resulted in a significantly thinner capsule on day 100 (825.8 ± 313.2 vs. 813.3 ± 47.9, p = 0.759, and 1062.3 ± 151.9 vs. 495.4 ± 220.4, p < 0.001, respectively). The capsule was even thinner than after a single shock wave application, which had been found to result in thinner capsules at every time point in our previous study. This active degradation of the fibrous envelope caused by multiple ESWs was accompanied by synergistic alterations in pro- and anti-fibrotic proteins (transforming growth factor β1 and matrix metalloproteinase 2, respectively). In conclusion, after insertion of silicone devices, single ESWT is capable of decelerating capsule formation in contrast to multiple ESWT, which degrades fibrotic tissue. These findings seem to be associated with inhibition of inflammation and beneficial effects on pro- and anti-fibrotic proteins.

Local Delivery of Nicotine does not Mitigate Fibrosis but may Lead to Angiogenesis

As with most implanted biomaterials, the wound healing response following implantation of a silicone breast implant leads to the formation of a fibrotic capsule. This can result in capsular contracture, a painful complication that often necessitates the removal of implant. It is well established that nicotine and nicotinic agonists inhibit inflammatory signaling. Based on the link between the inflammatory response and capsule formation, we hypothesized that local delivery of nicotine from the implant may lead to the reduction in inflammation and capsule thickness, which may ultimately reduce the incidence of capsular contracture. Nicotine was loaded into PDMS membranes using a previously established method. The loaded materials were implanted into the submammary pockets between the third and fourth mammary glands of rats. To confirm that the nicotine was acting locally and not systemically, serum cotinine, the primary metabolite of nicotine, was measured by ELISA at 3 days. Thirty days post implantation, the animals were euthanized and the tissue samples were fixed for histological analysis. Blood vessel density was measured immunohistochemically, while the capsule thickness was evaluated microscopically. While the presence of the nicotine metabolite, cotinine, in the serum at the early time points demonstrated that the nicotine was released locally from the devices, there were no significant differences in the capsule thickness between the control and experimental implants. However, the results indicated that there were differences in angiogenesis with the local delivery of nicotine, which may have other implications for the development of biomaterials.

Quantitative measurement of telomerase activity and localization of its catalytic subunit (hTERT) in chronic inflammation of capsule formation around various model implants and in sarcomas in a rat model

Telomerase is upregulated in some preneoplastic lesions and overexpressed in the majority of malignant tumors, but absent in most nonneoplastic somatic tissues. We analyzed telomerase activity using TRAP-assay in capsule tissues in a rat model with chronic inflammation and in tumor, and visualized the catalytic subunit of telomerase (hTERT) by immunhistochemistry. Significant elevated telomerase activity was found in tumor tissue compared with nonneoplastic tissue (p = 0.047). Cases with a strong inflammation in capsule tissue showed a specific telomerase activity. In these cases, there were no significant differences in telomerase activities compared with malignant tumor tissue. We demonstrate elevated telomerase activity and its diagnostic limits around model implants in a rat model, and visualize its expression not only in malignant tissue but also in inflammatory cells. So the quantitative measurement of telomerase activity should not be applied in general as a marker for malignancy in capsule tissue.

Pirfenidone prevents capsular contracture after mammary implantation

BACKGROUND

Pirfenidone (PFD), a new antifibrotic and antiinflammatory agent, prevents and resolves fibrous tissue. This study evaluated the effect of PFD on adverse events in mammary implants using an animal model. Mammary implantation, the most frequent aesthetic surgery, may present several complications after surgery such as swelling, capsule contracture, hardness, and pain.

METHODS

Wistar rats underwent submammary implantation with either smooth or textured silicone gel implants and were administrated 200 mg/kg of PFD daily. The control group received saline. The animals were killed at 8 weeks. The capsular tissue of both implants was removed for histologic and molecular analyses.

RESULTS

Typical postaugmentation periimplant capsules with opacity on adjacent tissues developed 8 weeks after silicone implantation. No significant differences were observed between the textured and smooth implants in any analyzed parameter. Clearly, PFD reduced capsule thickness around submmamary tissue, fibroblast-like cell proliferation, and recruitment of inflammatory cells. The total cell numbers per field were reduced as well. In contrast, the control group presented abundant mononuclear cell infiltration and fibroblast-like cell proliferation. The total content of collagen in the PFD group was 50% less than in the control group. Fibroblast cells displayed 45% less activated phenotype in the PFD group than in the control group, as determined by immunohistochemistry techniques. In the PFD animals, transforming growth factor-beta (TGF-beta) decreased 85% and collagen 1 gene expression 60%, compared with the control group.

CONCLUSION

The findings show a positive effect of PFD on mammary contracture in 10 rats. Despite the small number of animals, the differences found in 10 control rats encourage the authors to propose a larger study later and to suggest PFD as a potential preventive strategy in human mammary implantation surgery.

Allograft inflammatory factor-1 and its immune regulation

The allograft inflammatory factor-1 (AIF-1) is a 17 kDa interferon-gamma (IFN-gamma) inducible Ca(2+)-binding EF-hand protein that is encoded within the HLA class III genomic region. Three proteins including ionized Ca(2+)-binding adaptor 1, microglia response factor-1, and daintain are identical with AIF-1. The expression of AIF-1 was mostly limited to the monocyte/macrophage lineage, and augmented by cytokines such as IFN-gamma. It was assumed that AIF-1 was a novel molecule involved in inflammatory responses, allograft rejection, as well as the activation and function of macrophages. However, it has been reported that AIF-1 is also expressed in macrophages and microglial cells in autoimmune diseases such as experimental autoimmune encephalomyelitis, neuritis and uveitis models, suggesting that AIF-1 may play a pivotal role in autoimmunity. In the present manuscript, the genomic and functional characteristics of AIF-1 family proteins as well as their immune regulatory effects are reviewed.

Radiation-induced capsule tissue reactions around textured breast implants in a rat model

Capsule fibrosis and other complications around various filled breast implants were evaluated in a rat radiation model after 12 months of implantation. Model implants, one per rat, were implanted subcutaneously. One month after subcutaneous implantation, high voltage radiation followed one half each group. A higher rate of capsule fibrosis occurred in radiated animals. Malignant tumors at the implantation site developed in 40% of radiated and 24% of non-radiated animals, with a much higher rate of mitosis in the radiated group (Mann-Whitney, P=0.008). The presence of an implant is a cofactor for tumor development in rats (chi2-test, chi2=6.927; P=0.008) as well as radiation, since none of the control animals developed tumors. Applied to humans, capsule contracture (fibrosis) is a common complication of radiation, while development of radiation-induced sarcoma is a rare complication after postoperative radiotherapy by all account. Still further long-term follow-up human studies are necessary.

The effect of seprafilm and interceed on capsule formation around silicone discs in a rat model

The insertion of a foreign substance, such as a breast implant into mammalian soft tissues, evokes a wound healing response that culminates in a dense connective-tissue envelope or capsule surrounding the implant. Several biodegradable products, such as Seprafilm (carboxymethylcellulose and hyaluronic acid) and Interceed (oxidized regenerated cellulose), have been demonstrated to inhibit adhesions in abdominal and gynecologic surgery. The ability of these cellulose compounds to inhibit capsule formation was addressed in this investigation. Twenty-eight rats were implanted intermuscularly with either plain silicone discs (10 animals), discs wrapped in Seprafilm (10 animals), or discs covered with Interceed (8 animals). Additional control animals (6 animals) consisted of two that had sham operations, two animals implanted with Seprafilm only, and two more implanted with Interceed only. Animals were sacrificed in pairs at varying time intervals after implantation (2, 4, 8, 12, and 16 wk), and the tissues around the silicone discs were analyzed with light microscopy. Control animals were sacrificed at 8 wk. Both Interceed and Seprafilm slowed the formation of a capsule around the implanted silicone discs as both products were degraded. Evidence of residual material, presumably Seprafilm and Interceed, was seen intracellularly in animals 3 to 4 mo, respectively, after implantation. However, neither material prevented the eventual formation of a fibrous capsule around the silicone discs. The results of this study suggest that encapsulating foreign substances with these types of biodegradable materials will not significantly hinder capsule formation. A more direct attack on the wound healing mechanism may provide a definitive solution for capsule problems with implanted materials.