A review of the literature on the etiology of capsular contracture and a pilot study to determine the outcome of capsular contracture interventions

A Histological Assessment Tool for Breast Implant Capsules Validated in 480 Patients with and Without Capsular Contracture

BACKGROUND

Understanding the impact of breast implants on the histological response in the surrounding fibrous capsule is important; however, consensus is lacking on how to analyze implant capsules histologically. We aimed to develop a standardized histological assessment tool to be used in research potentially improving diagnostic accuracy and treatment strategies for capsular contracture.

METHODS

Biopsies of breast implant capsules from 480 patients who had undergone breast augmentation or reconstruction were collected and stained with hematoxylin and eosin. Initially, biopsies from 100 patients were analyzed to select histological parameters demonstrating the highest relevance and reproducibility. Then, biopsies from the remaining 380 patients were used to determine intra- and interobserver agreements of two blinded observers and agreement with a pathologist. Finally, we tested the association between the parameters and capsular contracture.

RESULTS

The histological assessment tool included ten parameters assessing the inflammatory, fibrotic, and foreign-body reaction to breast implants, each graded on two-, three-, or four-point scales. Intra- and interobserver agreements were almost perfect (0.83 and 0.80), and agreement with the pathologist was substantial (0.67). Four parameters were significantly correlated with capsular contracture, namely chronic inflammation with lymphocyte infiltration (p < 0.01), thickness of the collagen layer (p < 0.0001), fiber organization (p < 0.01), and calcification (p < 0.001).

CONCLUSIONS

This is the first validated histological assessment tool for breast implant capsules. The validated tool not only advances our understanding of capsular contracture but also sets a new standard for histological evaluation in breast implant research and clinical diagnostics.

NO LEVEL ASSIGNED

This journal requires that authors assign a level of evidence to each submission to which Evidence-Based Medicine rankings are applicable. This excludes Review Articles, Book Reviews, and manuscripts that concern Basic Science, Animal Studies, Cadaver Studies, and Experimental Studies. 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 .

Capsular Contracture After Breast Augmentation: Our Approach to Prevent Reoccurrence with Combined Total Capsulectomy and Implantation of Motiva Ergonomix® Implants

BACKGROUND

Breast augmentation is the second most common aesthetic surgery worldwide. Capsular contracture, a prevalent complication which affects up to 30% of patients post-surgery, often leads to further necessary surgeries.

OBJECTIVES

This study investigates the effectiveness of total capsulectomy combined with Motiva Ergonomix® implant replacement in resolving capsular contracture and minimizing recurrence rates.

METHODS

We conducted a retrospective study of 1067 patients and enrolled 51 women with capsular contracture post-breast augmentation. Patients were treated between 2014 and 2023 in a single center by three surgeons. Capsular contracture severity was graded using Baker's classification. Surgical interventions included total capsulectomy and implant replacement, using various incision techniques and changes in implant anatomical planes. Patients were followed up for a minimum of 12 months to a maximum of 9 years.

RESULTS

A total of 51 patients with grade III or IV capsular contracture underwent revisional surgery, involving the implantation of 102 Motiva Ergonomix® prostheses; 77 explanted implants resulted intact, 15 exhibited silicone bleeding, and 10 showed ruptured. Capsular contracture recurrence was observed in only 1.96% of cases during the follow-up period.

CONCLUSIONS

The combination of total capsulectomy and implantation of Motiva Ergonomix® implants significantly reduces the recurrence rate of capsular contracture. Despite the study's limitations, including its single-center design and a small sample size, our results suggest that this approach is a viable and effective solution to manage this common complication in breast augmentation patients. Further multicentric studies are recommended to validate these results.

LEVEL OF EVIDENCE V

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 https://www.springer.com/00266 .

Quality of life in breast reconstruction: a comparison of lightweight and conventional breast implants

BACKGROUND

Due to the declining mortality rates of breast carcinoma and the rising incidence of risk-reducing mastectomies, enhancing the quality of life after breast reconstructions has become an increasingly important goal. The advantages of lightweight breast implants (B-Lite®) may significantly contribute to achieving this objective. This study aims to investigate whether lightweight implants are suitable for patients undergoing breast reconstruction and could improve the quality of life in comparison to conventional implants.

METHODS

In this study, we retrospectively analyzed 48 patients (38 implants in each group) who underwent implant-based breast reconstruction with either B-Lite® or conventional breast implants between 2019 and 2022 at the University Center for Plastic Surgery in Regensburg. As part of the postoperative follow-up, a clinical examination and a survey using the Breast-Q® questionnaire were conducted to evaluate the postoperative quality of life.

RESULTS

The implants used were similar in weight and shape. On average, the B-Lite® implants had a higher implant volume and patients in this group had a slightly higher BMI. Patients who received B-Lite® implants showed a significantly better result regarding the sensation of sensitivity in the surgical area and the scar formation also appeared to be more favorable. However, patients with B-Lite® implants perceived their implants as more uncomfortable than those with conventional breast implants. In other terms concerning quality of life, both groups appeared similar.

CONCLUSION

In summary, there are confounding factors that could influence the outcome of some aspects in this study, which could not be avoided due to the retrospective study design and the temporary suspension of B-Lite implants. Nevertheless, as the first of its kind, this study demonstrated that B-Lite implants could also be suitable for usage in breast reconstructions, thus providing an important foundation for further prospective studies to build upon.

A Phase II Study Evaluating the Effect of Intensity Modulated Postmastectomy Radiation Therapy on Implant Failure Rates in Breast Cancer Patients With Immediate, 2-Stage Implant Reconstruction With an MRI Imaging Correlative Substudy

PURPOSE

Postmastectomy radiation therapy is a mainstay in the adjuvant treatment of node-positive breast cancer, but it poses risks for women with breast reconstruction. Multibeam intensity-modulated radiation therapy improves dose conformality and homogeneity, potentially reducing complications in breast cancer patients with implant-based reconstruction. To investigate this hypothesis, we conducted a single-arm phase 2 clinical trial of breast cancer patients who underwent mastectomy/axillary dissection and prosthesis-based reconstruction.

METHODS AND MATERIALS

The primary endpoint was the rate of implant failure (IF) within 24 months of permanent implant placement, which would be considered an improvement over historical controls if below 16%. IF was defined as removal leading to a flat chest wall or replacement with another reconstruction. Patients were analyzed in 2 cohorts. Cohort 1 (RT-PI) received radiation therapy to the permanent implant. Cohort 2 (RT-TE) received radiation therapy to the TE. IF rates, adverse events, and quality of life were analyzed. Follow-up/postradiation therapy assessments were compared with the baseline/preradiation therapy assessments at 3 to 10 weeks after exchange surgery. A subgroup underwent serial magnetic resonance imaging (MRI) sessions to explore the association between MRI-detected changes and capsular contracture, a known adverse effect of radiation therapy.

RESULTS

Between June 2014 and March 2017, 119 women were enrolled. Cohort 1 included 45 patients, and cohort 2 had 74 patients. Among 100 evaluable participants, 25 experienced IF during the study period. IF occurred in 8/42 (19%) and 17/58 (29%) in cohorts 1 and 2, respectively. Among the IFs, the majority were due to capsular contracture (13), infection (7), exposure (3), and other reasons (2). Morphologic shape features observed in longitudinal MRI images were associated with the development of Baker grade 3 to 4 contractures.

CONCLUSIONS

The rate of IF in reconstructed breast cancer patients treated with intensity-modulated radiation therapy was similar to, but not improved over, that observed with conventional, 3-dimensional-conformal methods. MRI features show promise for predicting capsular contracture but require validation in larger studies.

Acute and chronic mammary periprosthetic histological changes of the muscle

Background

Augmentation mammoplasty with subpectoral prosthesis implantation is a frequent performed procedure in plastic surgery for reconstructive and aesthetic purposes. Although prosthesis implantation in a pocket under the major pectoralis muscle has been related to volumetric and functional alterations, there is not much information about the associated short- and long-term histological changes. Therefore, the aim of our study was to describe the acute and chronic histological muscle alterations associated with subpectoral prosthesis implantation.

Materials and Method

We collected samples from patients with breast tissue expander (<6 months after implantation) and prosthesis (>1 year after implantation) and from patients without implantation as a control group. The samples were processed for assessing their histological, histochemical and immunohistochemical properties.

Results

In the control group, no relevant histological findings were identified. Additionally, in the patients with expander, we observed mild augmentation of the internalised nuclei, normal morphology, significant muscle atrophy and fibrosis, whereas in the patients with prosthesis considerable augmentation of internalised nuclei, significant muscle atrophy, fibrosis and alteration of normal muscle morphology were observed.

Conclusion

Prosthesis implantation induces histological changes in the periprosthetic striated muscle. Chronic fibrosis and inflammation play key roles in this process, which should be characterised in more detail from the histological and molecular biological perspective.

A Comparison of Ovine-Reinforced Hybrid Mesh (OviTex PRS) With Porcine Acellular Dermal Matrix (STRATTICE) in the Treatment of Advanced Breast Implant Capsular Contracture

Background

Tissue reinforcement techniques with porcine acellular dermal matrices (ADMs) have been widely adopted as standard care in treating capsular contracture. However, the application of alternative xenograft or mesh materials has not been widely studied.

Objectives

To examine the efficacy of OviTex PRS Reinforced Tissue Matrix (Resorbable) (TELA Bio, Malvern, PA), a hybrid ovine-reinforced mesh, in comparison with STRATTICE Reconstructive Tissue Matrix (Allergan, Irvine, CA), in patients with advanced capsular contracture.

Methods

A retrospective review was conducted on patients who underwent breast revision surgery for Baker Grade III or IV capsular contracture. Patient data were reviewed for outcomes, complications, cost, and postoperative incidence of recurrent capsular contracture after treatment with each specific mesh.

Results

Fifty-nine of 89 breasts (66.3%) were treated with OviTex and 30 (33.7%) were treated with STRATTICE. All patients experienced a reduction in Baker grades. In patients treated with OviTex, 96.6% (n = 57) of breasts had a postoperative Baker Grade I with the remaining 3.4% (n = 2) breasts presenting with a Baker Grade II. In comparison, 73.3% (n = 22), 23.3% (n = 7), and 3.3% (n = 1) of the STRATTICE cohort presented with Baker Grades I, II, and III, respectively. This demonstrated a statistically significant improvement in Baker grade capsular contracture in the OviTex cohort (P < .05) compared with STRATTICE. Average cost was $27.37/cm2 for STRATTICE compared with $22.28/cm2 for OviTex PRS.

Conclusions

OviTex may be successfully utilized to treat capsular contracture. Patient outcomes may be superior to STRATTICE in recurrent capsular contracture, particularly when a previous ADM had been utilized. Cost data show improved savings with the use of OviTex compared with STRATTICE.

Level of Evidence 3

Ultrathin Nanostructured Films of Hyaluronic Acid and Functionalized β-Cyclodextrin Polymer Suppress Bacterial Infection and Capsular Formation of Medical Silicone Implants

A type of ultrathin films has been developed for suppressing capsule formation induced by medical silicone implants and hence reducing the inflammation response to such formation and the differentiation to myofibroblasts. The films were each fabricated from hyaluronic acid (HA) and modified β-cyclodextrin (Mod-β-CyD) polymer which was synthesized with a cyclodextrin with partially substituted quaternary amine. Ultrathin films comprising HA and Mod-β-CyD or poly(allylamine hydrochloride) (PAH) were fabricated by using a layer-by-layer dipping method. The electrostatic interactions produced from the functional groups of Mod-β-CyD and HA influenced the surface morphology, wettability, and bio-functional activity of the film. Notably, medical silicone implants coated with PAH/HA and Mod-β-CyD multilayers under a low pH condition exhibited excellent biocompatibility and antibiofilm and anti-inflammation properties. Implantation of these nanoscale film-coated silicones showed a reduced capsular thickness as well as reduced TGFβ-SMAD signaling, myofibroblast differentiation, biofilm formation, and inflammatory response levels. We expect our novel coating system to be considered a strong candidate for use in various medical implant applications in order to decrease implant-induced capsule formation.

Complete Implant Wrapping with Porcine-Derived Acellular Dermal Matrix for the Treatment of Capsular Contracture in Breast Reconstruction: A Case-Control Study

Background

Capsular contracture (CC) represents one of the most common complications in breast reconstruction surgery, impairing final result and patients’ well-being. The role of acellular dermal matrixes (ADM) has been widely described for the treatment and prevention of contracture. The aim of the study was to evaluate the efficacy and safety of complete implant coverage with porcine-derived ADM in preventing CC limiting complications. In addition, patients’ reported outcomes were evaluated in order to define the role of ADM in improving sexual, physical and psychosocial well-being and satisfaction.

Methods

42 patients who underwent surgical treatment of 46 contracted reconstructed breasts from May 2018th to May 2019th were collected in the two groups (ADM group vs. Control group).

Results

The ADM group showed lower rate of CC recurrence and a higher rate of implant losses and minor complications. A significant difference was observed in red breast syndrome (27.3% in the ADM group vs. absent in control the group) and skin ulceration rates (18.2% in the ADM group vs. 4.18% in the control group). As for patients’ perceived outcomes, the ADM group showed a statistically significant higher postoperative Satisfaction of Breast Scale score compared to the control group. In addition, a significant difference was observed in the improvement of Physical Well-Being of the Chest Scale and the Satisfaction of Breast Scale after surgery, in favor to the ADM group.

Conclusion

Complete implant coverage with ADM may reduce the risk of CC recurrence in breast reconstruction. An accurate patient selection allows minimizing complications improving patient well-being and satisfaction.

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.

Histological Analyses of Capsular Contracture and Associated Risk Factors: A Systematic Review

BACKGROUND

Capsular contracture is a severe complication to breast surgery with implants. Previous studies suggest multiple risk factors are associated with capsular contracture, but the etiology is still unknown. We performed a literature review to investigate existing studies on histological analyses of breast implant capsules and how clinical risk factors impact the capsule morphology.

METHODS

The literature search was conducted in PubMed. Studies that performed histological analyses of breast implant capsules were included. Animal studies or studies with a study population of less than five patients were excluded.

RESULTS

Fifty-two studies were included. The histological analyses showed that the breast implant capsules were organized in multiple layers with an inner layer of synovial-like metaplasia which was reported to diminish in capsules with capsular contracture. The remaining layers of the capsule mostly consisted of collagen. The alignment of the collagen fibers differed between contracted and non-contracted capsules, and capsules with higher Baker grade were generally thickest and contained more tissue inflammation. Studies investigating capsules affected by radiotherapy found a more pronounced inflammatory response and the capsules were generally thicker and fibrotic compared with nonirradiated capsules.

CONCLUSIONS

The included studies offer valuable insights into the histological changes caused by capsular contracture and their relation to clinical risk factors. Further studies with larger sample sizes and more strict inclusion criteria are needed to further investigate implant capsules and the role of the synovial-like metaplasia for the development of capsular contracture.

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 https://www.springer.com/00266 .

A comparative discussion of incisional methods in total capsulectomy of the breast

Background Capsular contracture is a frequent complication of breast augmentation that constitutes one of the most common reasons for secondary operations. Capsular contracture is treated surgically, often with total capsulectomy. Therefore, in this study, we aimed to study correlations among intraoperative observations, physical examination findings, and characteristics of the previous operation in patients with capsular contracture who underwent total capsulectomy.Methods A retrospective chart review was conducted for patients treated from May 2017 to April 2019, analyzing 24 breasts in 12 female patients. The patients were classified in terms of the Baker grade, incision type, implant type, and implant plane. During the operation, we evaluated the ease of dissection based on intraoperative features such as anterior and posterior wall dissection, bleeding tendency, and scar length. Statistical analysis was performed to identify association between variablesResults The implant was changed in eight patients, while only explantation was performed in the remaining four patients. The ease of capsule dissection had a proportional correlation with the Baker grade (P=0.005). Intraoperative dissection was significantly easier in the inframammary fold (IMF) group than in the periareolar group (P=0.035).Conclusions An IMF incision is preferable for planning en bloc capsulectomy. However, for aesthetic concerns, a periareolar incision would be preferable. In addition, a lower Baker grade (grade I or II) was associated with easier dissection. Therefore, surgeons should choose the incision type depending on the necessity of performing en bloc capsulectomy, Baker grade, and scar length.

Surgical Treatment of Capsular Contracture (CC): Literature Review and Outcomes Utilizing Implants in Revisionary Surgery

BACKGROUND

The objective of this clinical review is to provide an overview of the use of breast implants after capsular contracture (CC) surgical treatment, with a focus on type of implants used. Furthermore, our experience in this field is also reviewed.

METHODS

MEDLINE, EMBASE, Web of Science, Scopus, the Cochrane Central, and Google Scholar databases were reviewed to identify literature related to surgical treatment of capsular contracture and implant replacement. Each article was reviewed by two independent reviewers to ensure all relevant publications were identified. The literature search identified 54 applicable articles. Of these, 26 were found to have a therapeutic level of evidence. The reference lists in each relevant paper were screened manually to include relevant papers not found through the initial search.

RESULTS

Only four articles report the replacement of implants after surgical treatment of capsular contracture. Six articles reported an implant exchange with only smooth silicone gel filled implants. Two reviews advice to use smooth implants in implant replacement.

CONCLUSION

With our expertise in the field and the results of this up-to-date literature review, it can be concluded that implant exchange is recommended in case of breast revision for capsular contracture, and the use of subpectoral smooth silicone gel breast implants is a good option after surgical treatment in patients with primary or recurrence Baker III-IV.

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 .

Zwitterionic polydopamine coatings suppress silicone implant-induced capsule formation

A synthetic zwitterionic dopamine derivative (ZW-DOPA) containing both catechol and amine groups was recently shown to exhibit excellent antifouling activity on marine surfaces. Here, we have extended these analyses to investigate the effects of ZW-DOPA coating on silicone implants. Successful formation of ZW-DOPA coatings on silicone implants was confirmed based on a combination of decreased static water contact angles on silicone implants, evidence of new peaks at 400.2 (N 1s), 232.2 (S 2s), and 168.0 (S 2p) eV, and increased quantitative atomic composition of C 1s with a concurrent decrease of Si 2p. Anti-biofilm formation assays revealed that ZW-DOPA coating prevented biofilm formation on silicone at a non-lethal concentration (0.5 mg mL-1). Capsule formation was also significantly inhibited by ZW-DOPA coating in vivo and the differentiation of fibroblasts into myofibroblasts was significantly suppressed. Together, these data suggest that silicone implants coated with ZW-DOPA may prevent capsular contracture after insertion when used in breast surgery.

Evaluating the Necessity of Capsulectomy in Cases of Textured Breast Implant Replacement

BACKGROUND

Capsulectomy has traditionally been recommended as a treatment for capsular contracture after breast augmentation. With the advent of breast implant-associated anaplastic large-cell lymphoma (BIA-ALCL), and the Food and Drug Administration's decision to ban Biocell textured devices, this operation has taken on new importance. This review was undertaken to better inform clinical recommendations for women with textured devices.

METHODS

An electronic search was performed using PubMed to identify all the available literature on the subject of capsulectomy and open capsulotomy (the alternative treatment).

RESULTS

Fifty-seven articles on this topic were identified. Capsulectomy was widely recommended for treatment of capsular contracture, although many authors recommended leaving thin capsular tissue behind in the absence of symptoms. En bloc resection was recommended only for women with a diagnosis of BIA-ALCL. No information supported a prophylactic role for capsulectomy in asymptomatic women with textured breast implants who are concerned regarding their future risk of BIA-ALCL. Routine pathologic examination in asymptomatic patients was not supported.

DISCUSSION

Capsulectomy adds substantially to the surgical risk, discomfort, recovery time, and expense. Implant removal or replacement without a simultaneous capsulectomy is atraumatic and poses negligible risk.

CONCLUSIONS

Capsulectomy introduces additional morbidity and is not mandatory for asymptomatic patients. Implant removal or exchange for smooth implants without a capsulectomy may be an acceptable choice for many women who do not demonstrate capsular pathology. However, any symptoms or surgical findings suggesting pathology warrant a capsulectomy. En bloc resections are reserved for patients diagnosed with BIA-ALCL.

Capsulectomy, Implant Exchange, and Placement of Acellular Dermal Matrix Is Effective in Treating Capsular Contracture in Breast Augmentation Patients

BACKGROUND

Capsular contracture is a common complication of breast augmentation surgery and many techniques to prevent and treat it have been suggested with inconsistent or variably effective results.

OBJECTIVES

The aim of this paper was to describe a protocol for treating established capsular contracture after breast augmentation with a low recurrence rate.

METHODS

From January 2009 to December 2012, 79 previous bilateral breast augmentation patients presented for treatment of established capsular contracture. There were 135 breasts with capsular contracture: 56 were bilateral and 23 were unilateral. Ten patients opted for no treatment; 2 patients opted for implant removal. Twenty-four were treated with the ICES (implant exchange, capsulectomy, and possible exchange of site) protocol and 43 were treated with the SPICES (Strattice placement in the reconstructive position, implant exchange, capsulectomy, and possible exchange of site) protocol.

RESULTS

The 24 patients treated with the ICES protocol had a recurrent capsular contracture rate of 15%. The 43 patients treated with the SPICES protocol had a 2.7% recurrent capsular contracture incidence and an 2.7% complication rate.

CONCLUSIONS

Capsular contracture after breast augmentation, whether primary or recurrent, can be successfully treated with the SPICES protocol.

LEVEL OF EVIDENCE: 4

3D images of the silicone implants in capsular contracture after breast augmentation using magnetic resonance imaging with SPACE sequence

BACKGROUND

Capsular contracture is a common complication after breast augmentation. However, no objective methods are available to assess capsular contracture at present. The goal of the present study was to evaluate the correlation between capsular contracture and 3D images of the silicone implants by using magnetic resonance imaging (MRI) with sampling perfection with application optimized contrast using different flip angle evolutions (SPACE) sequence.

METHODS

Twenty-one patients (42 breasts) underwent breast augmentation, had postoperative MRI examinations with SPACE sequence, and the evaluation of the Baker grade by two trained plastic surgeons. Capsular thickness was measured on the T2-weighted images. The software ITK-SNAP was used to reconstruct 3D images of the implants. The fold characteristics such as number, depth, direction, and distribution were compared with the Baker grade.

RESULTS

Of the 42 breasts, 14, 8, 12, and 8 breasts were classified as Baker grade I, II, III, and IV, respectively. The MRI images of breasts with Baker grade III or IV revealed a thicker capsule (mean of 2.29 mm) as compared to the capsule with the lower Baker grades (mean of 1.58 mm). The 3D images of implants showed no difference in the number of folds between the groups with different Baker grades. The fold direction and fold distribution differed between grade I to II and grade III to IV.

CONCLUSION

The 3D image of an implant with pathological folds is a potential and feasible diagnostic indication of capsular contracture.

LEVEL OF EVIDENCE

IV.

Suppressive Effect of Leukotriene Antagonists on Capsular Contracture in Patients Who Underwent Breast Surgery with Prosthesis: A Meta-Analysis

BACKGROUND

Capsular contracture is a troublesome and distressing complication in mammaplasty or breast reconstruction involving a prosthesis. Previous studies have indicated that leukotriene antagonists effectively reverse capsular contracture. However, this treatment method lacks comprehensive support from evidence-based medicine and remains considerably controversial. In this study, a meta-analysis was conducted to evaluate the therapeutic and preventive effects of leukotriene antagonists on capsular contracture in patients after breast prosthesis implantation.

METHODS

A comprehensive literature search was performed in English and Chinese databases. All clinical studies assessing the therapeutic and prophylactic effects of leukotriene antagonists on capsule contracture after breast prosthesis implantation were selected. Risk differences and 95 percent confidence intervals were applied as the final pooled statistics.

RESULTS

A total of five eligible studies were included, involving 1710 breast prosthesis implantations. The final results indicated that leukotriene antagonists markedly inhibited capsular contracture formation, with statistical significance at 32.02 (p < 0.001) (pooled risk difference, 0.84; 95 percent CI, 0.79 to 0.89). In subgroup analysis, subgroups based on different leukotriene antagonists included the montelukast and zafirlukast groups, with significant pooled statistical levels of 19.34 (p < 0.001) and 79.48 (p < 0.001), respectively (montelukast: pooled risk difference, 0.83; 95 percent CI, 0.75 to 0.92; zafirlukast: pooled risk difference, 0.85; 95 percent CI, 0.83 to 0.87), indicating that both montelukast and zafirlukast were effective in inhibiting encapsulation.

CONCLUSIONS

This meta-analysis demonstrated that leukotriene antagonists (montelukast and zafirlukast) have significant effects in treating and preventing capsular contracture. These medications should be administered in a reasonable and safe way. Further studies of clinical efficacy, duration, safety, and exact mechanism of leukotriene antagonists for periprosthetic capsular contracture are warranted.

Current Approaches Including Novel Nano/Microtechniques to Reduce Silicone Implant-Induced Contracture with Adverse Immune Responses

Capsular contracture, which is the pathologic development of fibrous capsules around implants, is a major complication of reconstructive and aesthetic breast surgeries. Capsular contracture can cause implant failure with breast hardening, deformity, and severe pain. The exact mechanisms underlying this complication remain unclear. In addition, anaplastic large cell lymphoma is now widely recognized as a very rare disease associated with breast implants. Foreign body reactions are an inevitable common denominator of capsular contracture. A number of studies have focused on the associated immune responses and their regulation. The present article provides an overview of the currently available techniques, including novel nano/microtechniques, to reduce silicone implant-induced contracture and associated foreign body responses.

In Vitro Analysis of Modified Surfaces of Silicone Breast Implants

Background

Although silicone breast implants are well tolerated, local complications such as capsular contracture occur because of insufficient integration with surrounding tissues. In this study, cell behaviour on hydrophilized silicone breast implant foils was analysed qualitatively and quantitatively under in vitro conditions in order to provoke the desired responses in a defined environment.

Methods

Silicone breast implant foils with different surface modifications were tested after 24 hours, 5 days and 7 days. The following modifications of silicone implant foils were tested: Unmodified silicone, silicone after-graft polymerisation for polyacrylic acid (pAAc), silicone-pAAc-fibronectin adsorptive, silicone-pAAC-fibronectin covalent, positive and negative controls. Experiments were conducted using cell culture with murine mouse fibroblasts L-929. Cytotoxicity assays were carried out in direct and indirect contact with cells grown on the material. For the viability test and qualitative analysis of cell proliferation on different foils, both fluoresceine-diacetate and ethidiumbromide were used and in addition the morphologic description of hemalaun-stained cells were used. Quantitative cell analysis was carried out using XTT after resuspension.

Results

Toxic influence on cell cultures could be excluded for coated and uncoated surfaces in contact with dissolved biomaterials. Unmodified silicone surfaces showed poor cell growth in direct contact. We found a gradual improvement of cell morphology, with the spread and proliferation depending on the type of surface modification. Better results were achieved with covalently coupled fibronectin and GRGDS than with pAAc.

Conclusion

Covalent immobilisation of hydrophobic silicone rubber can improve the initial cellbiomaterial interactions that are required to aid the successful development of tissue-like structures.

Effect of Botulinum Toxin Type A on TGF-β/Smad Pathway Signaling: Implications for Silicone-Induced Capsule Formation

BACKGROUND

One of the most serious complications of breast surgery using implants is capsular contracture. Several preventive treatments have been introduced; however, the mechanism of capsule formation has not been resolved completely. The authors previously identified negative effects of botulinum toxin type A on capsule formation, expression of transforming growth factor (TGF)-β1, and differentiation of fibroblasts into myofibroblasts. Thus, the authors investigated how to prevent capsule formation by using botulinum toxin type A, particularly by means of TGF-β1 signaling, in human fibroblasts.

METHODS

In vitro, cultured human fibroblasts were treated with TGF-β1 and/or botulinum toxin type A. Expression of collagen, matrix metalloproteinase, and Smad was examined by Western blotting. The activation of matrix metalloproteinase was observed by gelatin zymography. In vivo, the effect of botulinum toxin type A on the phosphorylation of Smad2 in silicone-induced capsule formation was evaluated by immunocytochemistry.

RESULTS

In vitro, the phosphorylation of Smad2 was inhibited by botulinum toxin type A treatment. The expression levels of collagen types 1 and 3 were inhibited by botulinum toxin type A treatment, whereas those of matrix metalloproteinase-2 and matrix metalloproteinase-9 were enhanced. Gelatin zymography experiments confirmed enhanced matrix metalloproteinase-2 activity in collagen degradation. In vivo, botulinum toxin type A treatment reduced capsule thickness and Smad2 phosphorylation in silicone-induced capsules.

CONCLUSION

This study suggests that botulinum toxin type A plays an important role in the inhibition of capsule formation through the TGF-β/Smad signaling pathway.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Therapeutic, V.

Capsular contracture in implant based breast reconstruction-the effect of porcine acellular dermal matrix

BACKGROUND

Irradiation of implant-based breast reconstructions (BR) is known to increase capsular contracture (CC) rates on average by 4-fold over non-irradiated reconstructions. The use of acellular dermal matrix (ADM) has been associated with lower CC rates in non-irradiated reconstructions (0-3%). Experimental and clinical studies suggest that ADM may also reduce CC rates in irradiated breasts. The aim of this study was to evaluate CC rates in non-irradiated and irradiated one- and two-stage BRs performed with the assistance of porcine ADM (PADM).

METHODS

A single centre, retrospective, cohort study was designed from December 2008 to October 2012. A total of 200 immediate implant-based BRs were performed using PADM for inferior pole reinforcement. We included non-irradiated BR with a minimum follow up of 6 month from primary surgery (one stage) or from explantation of expander and implantation of the definitive implant (two stage). Of the postoperatively irradiated BR we included patients with 1 year or more follow up time from termination of radiotherapy. CC was graded using the conventional Spear-Baker classification and modified version for irradiated BR. According to the literature Grade III and IV CC were defined as clinically significant CC.

RESULTS

Of 200 BRs with PADM, 122 were included in this study (84 non-irradiated and 38 irradiated). Sixty-five BR were one stage and 57 were two stage BR. Grade III/IV CC was remarkable low in non-irradiated (6%) and irradiated BR (13%). There was a non-significant trend to increased Grade III and IV CC in irradiated BR vs. non-irradiated BR (13% vs. 6%, P=0.216). In this study follow up time (P<0.001) and the stage of ADM reconstruction (two vs. one stage, P=0.022) were significant risk factors for occurrence of grade III/IV CC on univariate analysis and remained significant for the follow up time (P=0.013) and remarkable for the stages (P=0.093) in multivariate analysis.

CONCLUSIONS

Our data support the current clinical evidence that ADM use in implant-based BR is associated with a reduced risk of CC when compared to the standard submuscular techniques in literature. The reduced risk is maintained in the setting of radiotherapy. Two stage procedures in our study population showed increased grade III/IV CC compared to one stage procedures with or without exposure to radiation.

Morphologic Features of Magnetic Resonance Imaging as a Surrogate of Capsular Contracture in Breast Cancer Patients With Implant-based Reconstructions

PURPOSE

Capsular contracture (CC) is a serious complication in patients receiving implant-based reconstruction for breast cancer. Currently, no objective methods are available for assessing CC. The goal of the present study was to identify image-based surrogates of CC using magnetic resonance imaging (MRI).

METHODS AND MATERIALS

We analyzed a retrospective data set of 50 patients who had undergone both a diagnostic MRI scan and a plastic surgeon's evaluation of the CC score (Baker's score) within a 6-month period after mastectomy and reconstructive surgery. The MRI scans were assessed for morphologic shape features of the implant and histogram features of the pectoralis muscle. The shape features, such as roundness, eccentricity, solidity, extent, and ratio length for the implant, were compared with the Baker score. For the pectoralis muscle, the muscle width and median, skewness, and kurtosis of the intensity were compared with the Baker score. Univariate analysis (UVA) using a Wilcoxon rank-sum test and multivariate analysis with the least absolute shrinkage and selection operator logistic regression was performed to determine significant differences in these features between the patient groups categorized according to their Baker's scores.

RESULTS

UVA showed statistically significant differences between grade 1 and grade ≥2 for morphologic shape features and histogram features, except for volume and skewness. Only eccentricity, ratio length, and volume were borderline significant in differentiating grade ≤2 and grade ≥3. Features with P<.1 on UVA were used in the multivariate least absolute shrinkage and selection operator logistic regression analysis. Multivariate analysis showed a good level of predictive power for grade 1 versus grade ≥2 CC (area under the receiver operating characteristic curve 0.78, sensitivity 0.78, and specificity 0.82) and for grade ≤2 versus grade ≥3 CC (area under the receiver operating characteristic curve 0.75, sensitivity 0.75, and specificity 0.79).

CONCLUSIONS

The morphologic shape features described on MR images were associated with the severity of CC. MRI has the potential to further improve the diagnostic ability of the Baker score in breast cancer patients who undergo implant reconstruction.

Sonoelastography in the evaluation of capsule formation after breast augmentation - preliminary results from a follow-up study

INTRODUCTION

There are many indications for breast augmentation, including reconstruction after mastectomy, correction of congenital disorders and cosmetic procedures. The most frequent local complication of this surgery is capsule formation due to fibrosis. The aim of the study was to assess the usefulness of sonoelastography in the evaluation of capsule formation around silicone implants.

MATERIAL AND METHODS

The study group included 13 patients aged 20 to 41, who underwent breast augmentation with silicone implants. Their 26 breasts were examined before surgery, 7 and 14 days and a minimum of 8.5 months after surgery. The breast stiffness was assessed with tonometry and shear wave elastography to evaluate elasticity of the breast tissue and capsule formation after surgery.

RESULTS

We assessed the correlation between capsular elasticity measured at successive visits and the Baker scale. There were no significant relationships between any pairs of variables (p > 0.05). We also analyzed the correlation between the time of the follow-up and changes in the tissue elasticity of every region - no significant relationship was found. The greatest decrease in pericapsular elasticity was established in lower and inner quadrants. Moreover, there was a significant difference between the elasticity of the tissue before and 1 week after surgery (p < 0.05) and no significant changes in the elasticity before surgery and at the end of the follow-up.

CONCLUSIONS

Sonoelastography is precise in evaluation of capsule formation after breast augmentation. It may show changes that cannot be assessed using palpation.

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.

Noninvasive Shock Wave Treatment for Capsular Contractures After Breast Augmentation: A Rabbit Study

BACKGROUND

Capsular contracture is the most common complication of breast augmentation. Although numerous procedures are intended to prevent capsular contracture, their efficacy does not satisfy surgeons or patients. In the present study, we used shock waves to develop innovative protocols to treat capsular contracture in rabbits.

METHODS

We used shock waves to treat capsular contracture in a rabbit model. Six clinical parameters were evaluated to determine the treatment efficacy of shock waves on the pathological histology of capsular contracture. Dual-flip-angle T1-mapping magnetic resonance imaging was used to confirm the pathological findings.

RESULTS

Among the parameters, myxoid change, vascular proliferation, and lymphoplasma cell infiltration around the capsule increased more after treatment than they did in a control group. Capsular thickness, inner thinner collagen layer, and capsule wall collagen deposition decreased after shock wave treatment; only the inner thinner collagen layer and capsule wall collagen deposition changed significantly. The MRI findings for both scar thickness and water content were consistent with pathological biology findings.

CONCLUSION

This was the first pilot study and trial to treat capsular contractures using shock waves. We found that shock waves can cause changes in the structure or the composition of capsular contracture. We conclude that the treatment could decrease water content, loosen structure, decrease collagen deposition, and might alleviate scar formation from capsular contracture. We believe that the treatment could be a viable remedy for capsular contractures.

NO LEVEL ASSIGNED

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 .

Prosthetic breast reconstruction: indications and update

BACKGROUND

Despite 82% of patients reporting psychosocial improvement following breast reconstruction, only 33% patients choose to undergo surgery. Implant reconstruction outnumbers autologous reconstruction in many centres.

METHODS

A systematic review of the literature was undertaken. Inclusion required: (I) Meta-analyses or review articles; (II) adult patients aged 18 years or over undergoing alloplastic breast reconstruction; (III) studies including outcome measures; (IV) case series with more than 10 patients; (V) English language; and (VI) publication after 1(st) January, 2000.

RESULTS

After full text review, analysis and data extraction was conducted for a total of 63 articles. Definitive reconstruction with an implant can be immediate or delayed. Older patients have similar or even lower complication rates to younger patients. Complications include capsular contracture, hematoma and infection. Obesity, smoking, large breasts, diabetes and higher grade tumors are associated with increased risk of wound problems and reconstructive failure. Silicone implant patients have higher capsular contracture rates but have higher physical and psychosocial function. There were no associations made between silicone implants and cancer or systemic disease. There were no differences in outcomes or complications between round and shaped implants. Textured implants have a lower risk of capsular contracture than smooth implants. Smooth implants are more likely to be displaced as well as having higher rates of infection. Immediate breast reconstruction (IBR) gives the best aesthetic outcome if radiotherapy is not required but has a higher rate of capsular contracture and implant failure. Delayed-immediate reconstruction patients can achieve similar aesthetic results to IBR whilst preserving the breast skin if radiotherapy is required. Delayed breast reconstruction (DBR) patients have fewer complications than IBR patients.

CONCLUSIONS

Implant reconstruction is a safe and popular mode of post-mastectomy reconstruction. Evidence exists for the settings in which complications are more likely, and we can now more reliably predict outcomes of reconstruction on an individual basis and assess patient suitability.

Influence of patient age on capsular contracture after aesthetic breast augmentation

The influence of age on capsular contracture rates remains unclear. Most studies have only investigated early capsule development and not whether a link between age at primary surgery and the later development of capsular fibrosis exists. To clarify whether patient age impacts the development of late capsular fibrosis, the authors conducted a retrospective case study involving 43 patients who presented for surgical revision of capsular contracture (Baker grade ≥III) between four and 40 years after primary breast augmentation. Possible correlations between age and implant placement were analyzed. Late presentation of capsular fibrosis occurred a mean of 15.6 years after primary augmentation, with a slightly negative, but not significant, correlation between age at primary operation and duration of implant placement. Patients <40 years of age underwent an operative revision after a mean of 18.9 years, while patients ≥40 years of age needed an operative revision a mean of 11.9 years after primary breast augmentation (P=0.0368). The results suggest that with advancing age, the average time to develop capsular fibrosis is significantly shorter in individuals who develop capsular contracture. As more data are collected, appropriate advice can be provided to patients regarding factors that influence the long-term outcomes of breast augmentation.

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.

Influence of patient age on capsular contracture after aesthetic breast augmentation

The influence of age on capsular contracture rates remains unclear. Most studies have only investigated early capsule development and not whether a link between age at primary surgery and the later development of capsular fibrosis exists. To clarify whether patient age impacts the development of late capsular fibrosis, the authors conducted a retrospective case study involving 43 patients who presented for surgical revision of capsular contracture (Baker grade ≥III) between four and 40 years after primary breast augmentation. Possible correlations between age and implant placement were analyzed. Late presentation of capsular fibrosis occurred a mean of 15.6 years after primary augmentation, with a slightly negative, but not significant, correlation between age at primary operation and duration of implant placement. Patients <40 years of age underwent an operative revision after a mean of 18.9 years, while patients ≥40 years of age needed an operative revision a mean of 11.9 years after primary breast augmentation (P=0.0368). The results suggest that with advancing age, the average time to develop capsular fibrosis is significantly shorter in individuals who develop capsular contracture. As more data are collected, appropriate advice can be provided to patients regarding factors that influence the long-term outcomes of breast augmentation.

Comparison of the postoperative incidence rate of capsular contracture among different breast implants: a cumulative meta-analysis

Background

A large number of clinical studies have reported that the different materials used in breast implants were a possible cause of the different incidence rates of capsular contracture observed in patients after implantation. However, this theory lacks comprehensive support from evidence-based medicine, and considerable controversy remains.

Objectives

In this study, a cumulative systematic review examined breast augmentation that used implants with textured or smooth surfaces to analyze the effects of these two types of implants on the occurrence of postoperative capsular contracture.

Methods

We conducted a comprehensive search of literature databases, including PubMed and EMBASE, for clinical reports on the incidence of capsular contracture after the implantation of breast prostheses. We performed a cumulative meta-analysis on the incidence of capsular contracture in order from small to large sample sizes and conducted subgroup analyses according to the prosthetic material used, the implant pocket placement, the incision type and the duration of follow-up. Relative risks (RR) and 95% confidence intervals (CI) were used as the final pooled statistics.

Results

This meta-analysis included 16 randomized controlled trials (RCTs) and two retrospective studies. The cumulative comparison of textured and smooth breast implants showed statistical significance at 2.13 (95% CI, 1.18-3.86) when the fourth study was entered into the analysis. With the inclusion of more reports, the final results indicated that smooth breast implants were more likely to be associated with capsular contracture, with statistical significance at 3.10 (95% CI, 2.23-4.33). In the subgroup analyses, the subgroups based on implant materials included the silicone implant group and the saline implant group, with significant pooled statistical levels of 4.05 (95% CI, 1.97-8.31) and 3.12 (95% CI, 2.19-4.42), respectively. According to implant pocket placement, a subglandular group and a submuscular group were included in the analyses, and only the subglandular group had a statistically significant pooled result of 3.59 (95% CI, 2.43-5.30). Four subgroups were included in the analyses according to incision type: the inframammary incision group, the periareolar incision group, the transaxillary incision group and the mastectomy incision group. Among these groups, only the pooled results of the inframammary and mastectomy incision groups were statistically significant, at 2.82 (95% CI, 1.30-6.11) and 2.30 (95% CI, 1.17-4.50), respectively. Three follow-up duration subgroups were included in the analyses: the one-year group, the two- to three-year group and the ≥five-year group. These subgroups had statistically significant results of 4.67 (95% CI, 2.35-9.28), 3.42 (95% CI, 2.26-5.16) and 2.71 (95% CI, 1.64-4.49), respectively.

Conclusion

In mammaplasty, the use of textured implants reduces the incidence of postoperative capsular contracture. Differences in implant pocket placement and incision type are also likely to affect the incidence of capsular contracture; however, this conclusion awaits further study.

Effect of propranolol on capsular reaction around silicone implants in guinea pigs

PURPOSE

To evaluate the effect of propranolol on capsular architecture around silicone implants by measuring the inflammation, capsular thickness, and collagen fiber density, using a guinea pig experimental model.

METHODS

Thirty six adult male guinea pigs randomly divided into two groups (n=18) were used. Each one received a silicone implant with textured-surface. The capsular tissue around implants from untreated or treated animals with the beta-adrenoceptor antagonist propranolol (10 mg/kg, dissolved in daily water) were analyzed for inflammation by histological scoring, capsular thickness by computerized histometry, and collagen fibers type I and Type III density by picrosirius polarization at different time points (7, 14 or 21 days after silicone implantation).

RESULTS

Propranolol treatment reduced inflammation and impaired capsular thickness and delayed collagen maturation around the textured implant.

CONCLUSION

Propranolol reduces the risk of developing capsular contracture around silicone implants with textured surface.

The effect of botulinum neurotoxin type A on capsule formation around silicone implants: the in vivo and in vitro study

This study confirms that botulinum neurotoxin type A (BoNT-A) decreases capsular contracture and elucidates a possible mechanism. Silicone blocks were implanted subcutaneously in 20 mice. The experimental groups received BoNT-A (1, 2·5 or 5 U) instilled into the subcutaneous pocket. After 30 days, periprosthetic capsules were harvested and evaluated. The effect of BoNT-A on the differentiation of human dermal fibroblasts to myofibroblasts in culture was examined by Western blot analysis. Changes in transforming growth factor-beta1 (TGF-β1) expression in cultured fibroblasts were determined by enzyme-linked immunosorbent assay (ELISA). In in vivo study, the thickness of capsules (P < 0·05) and the number of alpha-smooth muscle actin (α-SMA)(+) cells in capsules (P < 0·05) were significantly decreased in the experimental groups. TGF-β1 was significantly underexpressed in the experimental groups (P < 0·05). In in vitro study, BoNT-A did not significantly affect fibroblast viability. Western blot analysis showed that α-SMA protein levels were significantly decreased in the experimental groups (P < 0·05). Based on ELISA, the amount of TGF-β1 was significantly decreased in the experimental groups (P < 0·05), especially cells treated with a high dose of BoNT-A (P < 0·001). This study confirms that BoNT-A prevents capsular formation around silicone implants, possibly by blocking TGF-β1 signalling and interrupting the differentiation of fibroblasts to myofibroblasts.

Treatment of capsular contracture using complete implant coverage by acellular dermal matrix: a novel technique

BACKGROUND

Capsular contracture is a frequent complication of breast reconstruction that affects 2.8 to 15.9 percent of patients. Use of acellular dermal matrix has been reported for treatment of contracture, with a recurrence rate of 6.3 percent, but this was limited to partial implant coverage only. The authors describe a novel surgical technique using acellular dermal matrix to completely cover the implant anteriorly to treat and prevent capsular contracture.

METHODS

Charts were reviewed to identify patients who had received implant insertion with complete acellular dermal matrix coverage performed by a single surgeon. Patient demographic information, history of irradiation or capsular contracture, prior treatment, and postoperative complications were recorded.

RESULTS

Eleven patients (16 breasts) were identified. Mean age and body mass index were 52.3 ± 6.9 years and 23.6 ± 4.4 kg/m, respectively. Four patients (five breasts) had a history of capsular contracture requiring previous capsulectomy and implant exchange. Ten cases were for correction of new-onset grade III (n = 2) or IV (n = 8) capsular contracture and one was to prevent future capsular contracture. Mean acellular dermal matrix size was 229.8 ± 46.5 cm (range, 144 to 256 cm). Average follow-up was 9.2 months (range, 2.4 to 18.8 months). One patient (one breast) developed an infection requiring implant removal. No patients experienced recurrent capsular contracture.

CONCLUSIONS

Capsular contracture may be treated successfully using complete acellular dermal matrix coverage. This technique may be a useful addition to therapies currently used to treat recalcitrant capsular contracture (early recurrence or refractory to standard therapy).

Propionibacterium acnes: an underestimated pathogen in implant-associated infections

The role of Propionibacterium acnes in acne and in a wide range of inflammatory diseases is well established. However, P. acnes is also responsible for infections involving implants. Prolonged aerobic and anaerobic agar cultures for 14 days and broth cultures increase the detection rate. In this paper, we review the pathogenic role of P. acnes in implant-associated infections such as prosthetic joints, cardiac devices, breast implants, intraocular lenses, neurosurgical devices, and spine implants. The management of severe infections caused by P. acnes involves a combination of antimicrobial and surgical treatment (often removal of the device). Intravenous penicillin G and ceftriaxone are the first choice for serious infections, with vancomycin and daptomycin as alternatives, and amoxicillin, rifampicin, clindamycin, tetracycline, and levofloxacin for oral treatment. Sonication of explanted prosthetic material improves the diagnosis of implant-associated infections. Molecular methods may further increase the sensitivity of P. acnes detection. Coating of implants with antimicrobial substances could avoid or limit colonization of the surface and thereby reduce the risk of biofilm formation during severe infections. Our understanding of the role of P. acnes in human diseases will likely continue to increase as new associations and pathogenic mechanisms are discovered.

Preliminary study of non-invasive shock wave treatment of capsular contracture after breast implant: animal model

The incidence rate of capsular contracture after breast implant is about 8% to 12%. Patients would feel extremely uncomfortable after scar formation. Administering oral medications (such as vitamin E and Zafirlukast tablets, etc.) or invasive breast capsulectomy surgery was commonly used for capsular contracture repair in clinical therapy. However, the therapeutic effect is still under investigation. Shock waves can be used to remove soft connective tissue in clinical applications. It has been widely used in orthopedics and rehabilitation. No related research paper about shock wave treatment of capsular contracture has been published yet. It might provide another choice for capsular contracture repair. In order to simulate breast implantation, two silica-gel bags filled with normal saline were implanted into New Zealand rabbit's thighs bilaterally as an animal model. Six weeks later, daily shock wave treatment on the right thigh was performed for six weeks after capsular contractures were formed, while the other thigh was used as a control. Then, magnetic resonance imaging (MRI) was used to compare the difference between treated and un-treated thighs. Afterwards, pathological sections were analyzed to confirm the findings. It has been demonstrated that shock wave treatments are capable of changing the structure and composition of capsular contractures. The structure of scar became myxoid changed or collagen deposition of scar decreased after shock wave treatment, hence, the formation of scars decreased. Increased myxoid and decreased collagen deposition has also been found.

An innovative procedure for the treatment of primary and recurrent capsular contracture (CC) following breast augmentation

BACKGROUND

Capsular contracture (CC) is the most frequently reported complication following alloplastic breast augmentation. At present, none of the available preventive measures are effective, and various treatment modalities have been advocated. Reduction of the inflammatory process is critical for successful treatment. Late intracapsular glucocorticosteroid (GC) injections have been somewhat effective for the treatment, but the fine balance between the effectiveness of therapeutic GC dosages and their potential serious side effects is of utmost importance.

OBJECTIVES

The authors investigate whether instillation of a rapid-acting water-soluble GC in the implant pocket during the early proliferative phase of wound healing is more effective than delayed instillation during the remodeling phase.

METHODS

Between 2003 and 2009, 33 consecutive patients presenting with CC (Baker grades III and IV) were managed by capsulectomy with implant replacement and corticosteroid therapy immediately as well as 2 to 3 days later through an indwelling catheter left in place for that period. This delayed but early administration is a novel technique for GC injection.

RESULTS

Complete correction of the contracture with no recurrence was achieved in all patients with a follow-up range of 2 to 10 years.

CONCLUSIONS

This GC administration technique avoids the potential complications of long-term, slow corticosteroid release. It has a targeted anti-inflammatory effect, probably at a critical stage of the healing process, and could effectively prevent CC following alloplastic breast augmentation.

Identification of molecular phenotypic descriptors of breast capsular contracture formation using informatics analysis of the whole genome transcriptome

Breast capsular contracture formation following silicone implant augmentation/reconstruction is a common complication that remains poorly understood. The aim of this study was to identify potential biomarkers implicated in breast capsular contracture formation by using, for the first time, whole genome arrays. Biopsy samples were taken from 18 patients (23 breast capsules) with Baker Grade I-II (Control) and Baker Grade III-IV (Contracted). Whole genome microarrays were performed and six significantly dysregulated genes were selected for further validation with quantitative reverse transcriptase polymerase chain reaction and immunohistochemistry. Hematoxylin and eosin was also carried out to compare the histological characteristics of control and contracted samples. Microarray results showed that aggrecan, tissue inhibitor of metalloproteinase 4 (TIMP4), and tumor necrosis factor superfamily (ligand) member 11 were significantly down-regulated in contracted capsules; while matrix metallopeptidase 12, serum amyloid A 1, and interleukin 8 (IL8) were significantly up-regulated. The dysregulation of aggrecan, tumor necrosis factor superfamily (ligand) member 11, TIMP4, and IL8 was validated by quantitative reverse transcriptase polymerase chain reaction (p < 0.05). Immunohistochemistry confirmed an increased protein expression for IL8 and matrix metallopeptidase 12 in contracted capsules (p < 0.05), and decreased protein expression of TIMP4 (p < 0.05). This study has shown, for the first time, a number of unique biomarkers of significance in capsular contracture formation. IL8 and TIMP4 may serve as potential key diagnostic, therapeutic, and prognostic biomarkers in capsular contracture formation.

Experimental total wrapping of breast implants with acellular dermal matrix: a preventive tool against capsular contracture in breast surgery?

BACKGROUND

Capsular contracture remains a hitherto unsolved complication after implantation of silicone gel-filled breast prostheses. Based on clinical and experimental data, the use of an acellular dermal matrix as a sheath around implants may lead to lesser capsular contracture acting as a proposed biological environment mimicking wound bed tissue. The aim of our study was to analyse the tissue reaction after implantation of silicone prosthesis with and without an envelope of acellular dermal matrix.

METHODS

Implantation of 60 silicone prostheses in the back of Lewis rats were carried out, randomly paired taking one rat from group A and one from group B. Group A included implants completely enveloped with xenogenic acellular dermis and group B undraped silicone implants. At 3, 6 and 12 weeks postoperatively, the samples were explanted and subjected to histological and immunohistochemical evaluation.

RESULTS

A new myofibroblast tissue layer was identified in proximity to the implant in both groups. The thickness of the layer in group A was continuously thinner than in group B regarding the different explantation time points. Implants completely wrapped with acellular dermal matrix showed significantly lesser inflammatory signs at 3 and 12 weeks after implantation compared to controls. Cell proliferation after 12 weeks was significantly decreased in group A.

CONCLUSION

The slight myofibroblast layer and reduced rate of inflammation and proliferation in the treatment group show a positive effect of total acellular dermal matrix envelope and hypothesise the decrease of capsular contracture in long-term periods.

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.

Bacterial biofilms and capsular contracture in patients with breast implants

Background

It has been hypothesized that bacterial biofilms on breast implants may cause chronic inflammation leading to capsular contracture. The association between bacterial biofilms of removed implants and capsular contracture was investigated.

Methods

Breast implants explanted between 2006 and 2010 at five participating centres for plastic and reconstructive surgery were investigated by sonication. Bacterial cultures derived from sonication were correlated with patient, surgical and implant characteristics, and the degree of capsular contracture.

Results

The study included 121 breast implants from 84 patients, of which 119 originated from women and two from men undergoing gender reassignment. Some 50 breast prostheses were implanted for reconstruction, 48 for aesthetic reasons and 23 implants were used as temporary expander devices. The median indwelling time was 4·0 (range 0·1–32) years for permanent implants and 3 (range 1–6) months for temporary devices. Excluding nine implants with clinical signs of infection, sonication cultures were positive in 40 (45 per cent) of 89 permanent implants and in 12 (52 per cent) of 23 temporary devices. Analysis of permanent implants showed that a positive bacterial culture after sonication correlated with the degree of capsular contracture: Baker I, two of 11 implants; Baker II, two of ten; Baker III, nine of 23; and Baker IV, 27 of 45 (P &lt; 0·001). The most frequent organisms were Propionibacterium acnes (25 implants) and coagulase-negative staphylococci (21).

Conclusion

Sonication cultures correlated with the degree of capsular contracture, indicating the potential causative role of bacterial biofilms in the pathogenesis of capsular contracture. Registration number: NCT01138891 (http://www.clinicaltrials.gov).

The impact of triamcinolone acetonide in early breast capsule formation in a rabbit model

BACKGROUND

The etiology and clinical treatment of capsular contracture remain unresolved as the causes may be multifactorial. Triamcinolone acetonide applied in the pocket during surgery was reported to be ineffective in prevention of capsular contracture. However, if injected 4-6 weeks after surgery or as a treatment for capsular contracture, decreased applanation tonometry measurements and pain were observed. It was assumed that intraoperative application of triamcinolone was not effective because its effect does not last long enough. However, betadine, antibiotics, and fibrin were found to be effective in preventing capsular contracture with intraoperative applications and are more effective in the early phases of wound healing than in later stages. The role of triamcinolone acetonide in capsule formation is unknown. The purpose of this study was to determine if triamcinolone acetonide modulates breast capsule formation or capsular contracture in the early phases of wound healing in a rabbit model.

METHODS

Rabbits (n=19) were implanted with one tissue expander and two breast implants and were killed at 4 weeks. Implant pocket groups were (1) Control (n=10) and (2) Triamcinolone (n=9). Pressure/volume curves and histological, immunological, and microbiological evaluations were performed. Operating room air samples and contact skin samples were collected for microbiological evaluation.

RESULTS

In the triamcinolone group, a decreased capsular thickness, mild and mononuclear inflammation, and negative or mild angiogenesis were observed. There were no significant differences in intracapsular pressure, fusiform cell density, connective tissue, organization of collagen fibers, and microbiological results between the groups. There was no significant difference in the dialysate levels of IL-8 and TNF-α, but correlation between IL-8 and TNF-α was observed.

CONCLUSION

Triamcinolone acetonide during breast implantation influences early capsule formation and may reduce capsular contracture.

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 at www.springer.com/00266.