Mammary compliance: an objective measurement of capsular contracture

Is It All about Surface Topography? An Intra-Individual Clinical Outcome Analysis of Two Different Implant Surfaces in Breast Reconstruction

The most common long-term complication of silicone breast implants (SMI) remains capsular fibrosis. The etiology of this exaggerated implant encapsulation is multifactorial but primarily induced by the host response towards the foreign material silicone. Identified risk factors include specific implant topographies. Of note, breast implant-associated anaplastic large cell lymphoma (BIA-ALCL) has only been observed in response to textured surface implants. We hypothesize that reduction of SMI surface roughness causes less host response and, hence, better cosmetic outcomes with fewer complications for the patient. A total of 7 patients received the routinely used CPX^®4 breast expander (~60 µM Ra) and the novel SmoothSilk^® (~4 µM Ra), fixed prepectoral with a titanized mesh pocket and randomized to the left or right breast after bilateral prophylactic NSME (nipple-sparing mastectomy). We aimed to compare the postoperative outcome regarding capsule thickness, seroma formation, rippling, implant dislocation as well as comfortability and practicability. Our analysis shows that surface roughness is an influential parameter in controlling fibrotic implant encapsulation. Compared intra-individually for the first time in patients, our data confirm an improved biocompatibility with minor capsule formation around SmoothSilk^® implants with an average shell roughness of 4 µM and in addition an amplification of host response by titanized implant pockets.

Defining the Relationship Between Pocket and Breast Implant Surface Area as the Basis for a New Classification System for Capsular Contracture

BACKGROUND

The precise etiology and treatment for capsular contracture remains uncertain at least partially due to the fact that there is no reliable quantitative measurement tool. To address this, it is postulated that the surface area of an implant as defined by the surrounding pocket may provide a quantifiable variable that can be measured to evaluate the degree of capsular contracture.

METHODS

A bench model for capsular contracture was developed. The surface area of a series of spherical test objects and non-contracted and contracted breast implants was measured using a wax coating technique as well as three-dimensional reconstructions created from CT scan images.

RESULTS

Comparison of the mathematically calculated surface areas to the wax and CT results for spheres of known dimension provided nearly identical values documenting the accuracy of the two experimental methods. Comparison of the surface area measurements between the test groups showed that the average decrease in surface area for all implants was 20%, ranging from a high of 30.9% for a low profile implant to a low of 14.1 % for a high profile implant. The anatomically shaped devices demonstrated nearly uniform degrees of surface area change over three different heights with volume and projection held relatively constant.

CONCLUSIONS

The described bench model provides a useful tool for the study of capsular contracture. Surface area is a descriptive variable that can assess the degree of capsular contracture that is present. A classification system based on surface area is presented.

Effects of Prophylactic Lipofilling After Radiotherapy Compared to Non-Fat Injected Breasts: A Randomized, Objective Study

BACKGROUND

Patients who are suffering from invasive breast cancer may require post-mastectomy radiation therapy (PMRT). PMRT improves outcomes in breast cancer patients in terms of locoregional recurrence. Preliminary studies indicate that fat injections reduce post-radiation damage of soft tissue and implants.

OBJECTIVES

The aim of this study was to demonstrate the safety and effectiveness of prophylactic fat injections on radiated implanted breasts.

METHODS

The authors randomly assigned 60 female patients to either Group A or B. Group A patients received 3 breast fat injections, according to Coleman's technique, after radiotherapy and before expander removal with definitive implant insertion. Group B patients underwent surgery without lipofilling. At each surgical operation, skin biopsies were performed in a specific breast area to evaluate adipose tissue thickness, and a statistical analysis of the thickness variations was performed with the Wilcoxon's sum test. Disability was assessed according to the Late Effects of Normal Tissues-Subjective Objective Management Analytic scale.

RESULTS

The study demonstrates a qualitative and quantitative improvement about tissues after fat injection. This is highlighted by the significant increase in thickness after lipofilling.

CONCLUSIONS

The study, which is based on both clinical and histological findings and is supported by the comparison of a control group with a 1-year follow-up, demonstrates that fat injections reduce tissue radio damage, improving reconstructive surgery outcomes and quality of life.

LEVEL OF EVIDENCE: 2

One-stage muscle-sparing breast reconstruction in elderly patients: A new tool for retaining excellent quality of life

More than 50% of breast cancer care occurs in elderly but women aged 65 and over generally have lower breast reconstruction (BR) rates. In medical literature, few papers focused on BR in elderly patients and usually the reported techniques are multisteps such as expander-implant reconstruction, local, and free flaps. We present a one-stage reconstruction technique employed in elderly patients: muscle-sparing immediate BR with subcutaneous implant and Braxon acellular dermal matrix. We prove the feasibility and safety of the technique and believe that this new procedure could represent a potential benefit in elderly BR.

Clinical, histological, and ultrasound follow-up of breast reconstruction with one-stage muscle-sparing "wrap" technique: A single-center experience

BACKGROUND

Prepectoral implant placement and complete coverage with porcine acellular matrix after mastectomy is a new concept in breast surgery presented in few cases in the literature. This paper aimed to present our single-center experience in one-stage breast reconstruction muscle-sparing "wrap" technique by evaluating clinical and aesthetic outcomes, ultrasound and histological examination, and patient quality of life.

METHODS

From January 2014 to January 2017, 52 patients (40 unilateral, 12 bilateral) underwent one-stage muscle-sparing breast reconstructions with Braxon^® acellular dermal matrix and implant. In 3 patients, a surgical biopsy and histological examination with immunohistochemical analysis of the periprosthetic tissue were performed. All patients underwent breast ultrasound examination, and the occurrence of capsular contracture was assessed through the Baker classification and by measuring the mammary compliance scores with the Antoon Paar Mammary compliance system. Breast appearance was evaluated using a visual analogue scale (VAS) and in terms of quality of life using the EOCRT QLQ C-30 and QLQ BR-23 questionnaires.

RESULTS

Early and late postoperative complications are reported. Histological and ultrasound evaluation showed a complete integration of the matrix. According to the VAS scale, the EOCRT QLQ C-30, and QLQ BR-23, patients' satisfaction resulted in a high score in terms of quality of life and aesthetic outcomes.

CONCLUSION

The results of this new surgical technique in selected cases are promising in terms of effectiveness and low rate of postoperative complications, but further long-terms evaluations are required.

Breast Durometer (Mammometer): A Novel Device for Measuring Soft-Tissue Firmness and Its Application in Cosmetic Breast Surgery

The measurement of soft-tissue firmness has many potential applications in medical practice. This study reports a user-friendly, novel device that is capable of measuring changes in soft-tissue firmness in a reproducible manner. The study reports the development of the equipment and how it has been applied to breast implant surgery. The device was tested for both intra- and inter-observer variability on an in vitro model, using a breast implant. Once reproducibility was confirmed, breast firmness was measured on a series of patients who underwent sub-fascial breast augmentation (n = 50) to examine how it varied post-operatively. Firmness in the upper half of the breast increased to a maximum level two weeks post-surgery (0.44-0.61 Pa), reducing to pre-operative levels by 6 weeks (0.37-0.54 Pa). There was no further significant change at 12 weeks. Firmness in the nipple areolar complex (NAC) and at the lower outer quadrant (LOQ) followed a similar pattern, but remained firmer at 12 weeks. We interpret these patterns as implying that measurements taken at the upper half of the breast are indicative of post-operative oedema, whereas those at the NAC and LOQ represent changes in firmness produced by the breast implant composite. We consider the potential for this novel device in the measurement of soft-tissue firmness in aesthetic breast surgery and would encourage other researchers to explore novel applications. Level of Evidence III 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 .

Effects of Zafirlukast on Capsular Contracture: Controlled Study Measuring the Mammary Compliance

Capsular contracture is a highly distressing, difficult complication after breast augmentation for both the patient and the surgeon. Although capsular contracture is a multifactorial process, one common denominator in the successful treatment of this complication is believed to be the abatement of inflammation. Leukotriene antagonists have recently emerged as effective prophylactic agents in reactive airway diseases. Anecdotal reports have indicated that zafirlukast (Accolate, AstraZeneca) effectively reverses capsular contracture. A prospective study of capsular contracture in 120 female patients in whom a total of 216 prostheses were implanted was performed. The hardness of capsular contracture was assessed by means of the mammary compliance method (Anton Paar Mammacompliance system). The patients were divided into two groups: patients in group A received zafirlukast for a 6-month period, while those in group B received vitamin E. The results show a significant decrease of the values of breast compliance after 6 months in group A but not in group B and that the variation in compliance after 6 months in group A compared to group B is statistically significant. In zafirlukast-treated patients, we observed a reduction in mammary compliance of 7.69% after 1 month, 16.78% after 3 months and 24.01% after 6 months. The present study suggests that zafirlukast may be effective in reducing pain and breast capsule distortion in patients with longstanding contracture who are either not surgical candidates or who do not wish to undergo surgery.

The impact of chemotherapy and radiation therapy on the remodeling of acellular dermal matrices in staged, prosthetic breast reconstruction

BACKGROUND

An acellular dermal matrix will typically incorporate, in time, with the overlying mastectomy skin flap. This remodeling process may be adversely impacted in patients who require chemotherapy and radiation, which influence neovascularization and cellular proliferation.

METHODS

Multiple biopsy specimens were procured from 86 women (n = 94 breasts) undergoing exchange of a tissue expander for a breast implant. These were divided by biopsy location: submuscular capsule (control) as well as superiorly, centrally, and inferiorly along the paramedian acellular dermis. Specimens were assessed for cellular infiltration, cell type, fibrous encapsulation, scaffold degradation, extracellular matrix deposition, neovascularization, mean composite remodeling score, and type I and III collagen. Patients were compared based on five oncologic treatment groups: no adjuvant therapy (untreated), neoadjuvant chemotherapy with or without radiation, and chemotherapy with or without radiation.

RESULTS

Biopsy specimens were procured 45 to 1805 days after implantation and demonstrated a significant reduction in type I collagen over time. Chemotherapy adversely impacted fibrous encapsulation (p = 0.03). Chemotherapy with or without radiation adversely impacted type I collagen (p = 0.02), cellular infiltration (p < 0.01), extracellular matrix deposition (p < 0.04), and neovascularization (p < 0.01). Radiation exacerbated the adverse impact of chemotherapy for several remodeling parameters. Neoadjuvant chemotherapy also caused a reduction in type I (p = 0.01) and III collagen (p = 0.05), extracellular matrix deposition (p = 0.03), and scaffold degradation (p = 0.02).

CONCLUSION

Chemotherapy and radiation therapy limit acellular dermal matrix remodeling.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Therapeutic, III.

Effects of zafirlukast on capsular contracture: long-term results

Capsular contracture is a distressing complication after breast augmentation for both the patient and surgeon. Although capsular contracture is a multifactorial process, one common denominator in the successful treatment of this complication is believed to be the abatement of inflammation. Leukotriene antagonists have recently emerged as effective prophylactic agents in reactive airway diseases. A prospective study was carried out on 60 female patients (120 prostheses implanted) with mild/severe capsular contracture in at least one breast. The hardness of capsular contracture was assessed by means of the mammary compliance method. Patients received zafirlukast (Accolate&#174;) for a 6-month period. Mammary compliance was assessed at the start of the study and thereafter monthly, during drug intake and for one year after drug withdrawal. The results show a significant decrease in breast compliance values in the first 6 months, followed by a significant increase one year after the end of drug intake. Indeed, zafirlukast-treated patients displayed a 6.93 percent reduction in mammary compliance after 1 month, 14.42 percent after 3 months, 22.05 percent after 6 months and 22.52 percent after 7 months (1 month after the withdrawal of the drug). Thereafter, mammary compliance values gradually increased. A 5.47 percent reduction in mammary compliance was observed 1 year after drug withdrawal. The present study suggests that zafirlukast may be effective in reducing breast capsule distortion in patients with long-standing contracture, though reduced capsular contracture values are strictly related to the duration of drug intake.

Effectiveness of antibacterial copper additives in silicone implants

Staphylococcus epidermidis plays a major role in capsular contractures of silicone breast implants. This in vitro study evaluates the antibacterial effect of copper on S. epidermidis in silicone implants. Specimens of a silicone material used for breast augmentation (Cu0) and specimens coated with different copper concentrations (Cu1, Cu2) were artificially aged. Surface roughness and surface free energy were assessed. The specimens were incubated in an S. epidermidis suspension. We assessed the quantification and the viability of adhering bacteria by live/dead cell labeling with fluorescence microscopy. Additionally, inhibition of bacterial growth was evaluated by agar diffusion, broth culture, and quantitative culture of surface bacteria. No significant differences in surface roughness and surface free energy were found between Cu0, Cu1 and Cu2. Aging did not change surface characteristics and the extent of bacterial adhesion. Fluorescence microscopy showed that the quantity of bacteria on Cu0 was significantly higher than that on Cu1 and Cu2. The ratio of dead to total adhering bacteria was significantly lower on Cu0 than on Cu1 and Cu2, and tended to be higher for Cu2 than for Cu1. Quantitative culture showed equal trends. Copper additives seem to have anti-adherence and bactericidal effects on S. epidermidis in vitro.

Implant infection after augmentation mammaplasty: a review of the literature and report of a multidrug-resistant Candida albicans infection

BACKGROUND

Implant breast augmentation is one of the most frequently performed surgical procedures, and fungal infection still is considered exceptional. This report presents a case of bilateral breast implant infection by multidrug-resistant Candida albicans treated with a targeted antifungal therapy.

METHODS

A young woman presented with breast pain and asymmetry as well as implant superficialization in the left breast 3 years after bilateral tuberous breast correction with implant insertion. She did not report any trauma to the chest wall or recent systemic infections. The breast was evaluated through mammary compliance analysis and magnetic resonance imaging (MRI).

RESULTS

At surgery, both implants showed capsule contracture and were surrounded by a gelatinous yellow-brown and turbid fluid, which was sent for microbial and fungal analysis. A bilateral capsulectomy was performed. After copious irrigation of the subglandular pockets, submuscular pockets were created, and implants were substituted. Culture swabs tested positive for C. albicans and showed drug resistance to amphotericin B, fluconazole, itraconazole, and voriconazole on the fungal antibiogram. Targeted antifungal therapy with caspofungin was administrated in association with oral antibiotic therapy. Follow-up assessment at 1, 3, 6, 12, and 24 months did not show any infection or contracture relapse.

CONCLUSIONS

This is the first report in the literature on a breast implant infection by a multidrug-resistant C. albicans. The study focused on the association between fungal contamination and capsular contracture and investigated the importance of a fungal antibiogram in cases of suspected prosthesis infection for performance of a targeted antifungal treatment.

Clinical and Morphological Conditions in Capsular Contracture Formed around Silicone Breast Implants

BACKGROUND

A study was performed to investigate histological changes in capsules formed around silicone breast implants and their correlation with the clinical classification of capsular contracture defined by the Baker score. For histological classification, the authors used the classification introduced by Wilflingseder, which identifies four grades of contracture.

METHODS

The study included 24 female patients (average age, 40 +/- 12 years) with capsular contracture after bilateral cosmetic breast augmentation with smooth silicone gel implants (Mentor, Santa Barbara, Calif.). The Baker score was determined preoperatively for each patient. Samples of capsular tissue were obtained from all patients for histologic and immunohistochemical analyses. Capsular thickness, age of the collagen fibers, presence of synovia-like metaplasia on the inner surface of the capsule, number of histiocytes, giant cells, and other inflammatory cells, amount of silicone, foreign body granulomas, and capsule calcification were evaluated.

RESULTS

There was a positive correlation between capsular thickness (p < 0.05) and Baker score. Silicone-containing deposits were found in all four histological capsule types. A trend toward greater capsular thickness was documented in patients with severe inflammatory reaction. These patients also had more clinical symptoms. Greater capsular thickness was associated with a higher number of silicone particles and silicone-loaded macrophages in the peri-implant capsule.

CONCLUSIONS

The authors demonstrated a positive correlation (p < 0.05) between the clinical classification (Baker score I to IV) and the histological classification introduced by Wilflingseder (Wilflingseder score I to IV). An exact histological classification is needed to describe precisely the morphological changes in capsular contracture.

The effects of zafirlukast on capsular contracture: preliminary report

Capsular contracture after breast augmentation is a distressing, troublesome event both for the patient and the surgeon. Fibrosis transforms the prosthesis into a hardened sphere, turning the initially satisfactory cosmetic result into a deformed mass. Treatment for capsular contracture can be either surgical, consisting of capsulotomy or capsulectomy with implant replacement, or pharmacologic, consisting of intracapsular instillation of steroids and antibiotics. The success rates for both types of treatment vary. Although capsular contracture is a multifactorial process, one common denominator in the successful treatment of this complication is believed to be the abatement of inflammation. Leukotriene antagonists have emerged recently as effective prophylactic agents for reactive airway diseases. Anecdotal reports have indicated that zafirlukast and montelukast effectively reverse capsular contracture. The authors investigated whether capsular contracture varies significantly over time after zafirlukast therapy by studying 20 women who had breast prostheses implanted and then experienced the development of capsular contracture. The results suggest that capsular contracture responds favorably to treatment with zafirlukast. The findings indicate that zafirlukast may reduce pain and breast capsule distortion for patients with long-standing contracture who either are not surgical candidates or do not wish to undergo surgery.

Changes over time in mammary compliance values after breast augmentation

Capsular contracture is the most troublesome and distressing complication after breast augmentation for both the surgeon and patient. The etiology of capsular contracture remains unclear. Clinical treatment for this complication is based on the surgeon's evaluation, the condition of the breast, and a number of other factors. In a previous study, the authors investigated whether measurement of mammary compliance as a means of assessing capsular contracture was comparable with other methods described for the assessment of capsular contracture. The purpose of this study was to evaluate whether capsular contracture varies significantly over time. A prospective study was performed to measure mammary compliance in 60 female patients who received a total of 120 implants between 2000 and 2002. The implants used were anatomic prostheses filled with cohesive silicone gel and round double-lumen prostheses filled with silicone gel and saline solution. All the patients were followed up for at least 2 years. Statistical analysis of the data also was performed to assess significance. The results showed a general trend in mammary compliance values over time.

Serologic and histologic findings in patients with capsular contracture after breast augmentation with smooth silicone gel implants: is serum hyaluronan a potential predictor?

BACKGROUND

In this study, breast implant capsular tissues and blood samples from 25 cases were studied to characterize the relationship between capsular findings and serum analysis. The serum fibrosis indexes hyaluronan and the aminoterminal propeptide of procollagen type III (PIIINP) are fairly well correlated in several other studies with the inflammation grade and fibrosis in patients with progressive fibrotic disorders such as liver cirrhosis.

METHODS

The study enrolled 25 female patients (average age, 40 +/- 12 years) with capsular contracture after bilateral cosmetic breast augmentation using smooth silicone gel implants (Mentor). The implants were placed in a submuscular position through an incision in the inframammary fold. The implant removals were prompted by development of capsular fibrosis (Baker grades 1-4). Samples of capsular tissue were obtained from all the patients for standard histologic and immunohistochemical analyses. Blood samples were drawn from all the patients immediately before surgery. Sera from 20 healthy female patients (average age, 34 +/- 9 years) who had undergone plastic surgery for reduction mammaplasty were used as controls.

RESULTS

Histology. Capsular tissue was significantly thicker in patients with grades 3 and 4 contracture than in women with grade 2 contracture according the classification by Baker. There was a moderate (n = 15) or severe (n = 10) chronic inflammatory reaction in the capsules around the implants. Fibroblasts and macrophages represented the major cell population found in the fibrous capsules. In addition, activated CD4+ cells were detected. An inner layer with synovia-like metaplasia and multinucleated giant cells was found. Fibroblast-like cells formed the most common cell type in the capsules, along with macrophages, scattered polymorphonuclear leukocytes, lymphocytes, plasma cells, and mast cells. Serum analysis. There was a significantly higher level (p < 0.05) of hyaluronan serum concentration in patients with capsular contracture (26 +/- 14 microg/l) than in control subjects (12 +/- 6 microg/l). There was a positive correlation between the grade of capsular contracture (Baker 1-4) and the hyaluronan serum concentration (Baker 1-2: 15 +/- 3 microg/l; Baker 3-4: 35 +/- 12 microg/l) (r2 = 0.73; p < 0.05).

CONCLUSION

: In this study, serum hyaluronan levels were significantly elevated in patients with constrictive fibrosis after breast augmentation, and there was a positive correlation with the stage of capsular contracture. Serum hyaluronan concentration may help in defining patients at risk for capsular fibrosis. If treatment with new drugs can be started as a preventive measure, it may be possible to reduce the rate of patients who require surgical intervention.