Understanding the Etiology and Prevention of Capsular Contracture: Translating Science into Practice

In Vivo Comparison of the Efficacy and Duration of Local Antibiotics on Smooth, Textured and Polyurethane Implant Surfaces

BACKGROUND

Capsular contracture is one of the most common complications after breast surgery involving silicone implants. The most likely cause of this condition is biofilm formation. In this study, the efficacy of local antibiotherapy against biofilm formation on implant surfaces was investigated.

METHODS

Thirty-six rats were divided into six groups. Three pockets were created on the dorsum of each rat, and 1 × 2 cm implant surface samples from smooth, polyurethane and textured implants were randomly placed into pockets. All samples were inoculated with staphylococcus epidermidis. In groups 1-2-3, inoculated samples were placed into the pockets and removed after 1, 6 and 24 h, respectively. In groups 4-5-6, inoculated samples immersed with rifamycin were placed and removed after 1, 6 and 24 h, respectively. Bacterial load was measured with plate count method.

RESULTS

Bacterial load was lower in groups 4-5-6 than in groups 1-2-3 (p < 0.05). In groups 4-5-6, bacterial load was lower for polyurethane than for textured surfaces at all time points (1, 6 and 24 h; p < 0.05). Again, in groups 4-5-6, bacterial load was lower for smooth than for textured surfaces at 24 h (p < 0.05). In groups 4-5-6, bacterial load was lower for polyurethane than for smooth surfaces at all time points, but difference was not statistically significant (1, 6 and 24 h; p < 0.05).

CONCLUSION

The results suggest that local antibiotic therapy was effective in reducing the bacterial load on all surfaces. The effectiveness of local rifamycin on the polyurethane surface was higher, and the duration of activity was longer than other surfaces.

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 .

Revision Breast Reconstruction With Biologic or Synthetic Mesh: An Analysis of Postoperative Capsular Contracture Rates

Background

Both biologic and synthetic mesh have been found to reduce the risk of capsular contracture, yet there is limited data assessing the use of these scaffold materials in revision breast reconstruction.

Objectives

This investigation sought to assess the ability of either biologic or synthetic mesh to prevent capsular contracture in the revision breast reconstruction population.

Methods

A retrospective chart review was conducted of implant-based revision reconstructions performed by the senior author between 2008 and 2023. Patient demographics and outcomes were assessed, including the incidence of Baker Grade III or IV capsular contractures. Results were compared between biologic and synthetic mesh groups using univariate and multivariate analysis.

Results

Ninety-five breasts underwent revision reconstruction with 90 (94.7%) for correction of malposition, 4 (4.2%) for size change, and 1 (1.1%) for revision after additional oncologic breast surgery. Of these breasts, 26 (27.4%) used biologic mesh and 69 (72.6%) used synthetic mesh. Capsular contracture occurred in 1 (3.8%) biologic mesh breast and 4 (5.8%) synthetic mesh breasts. There was no significant difference in the incidence of capsular contracture between the 2 groups (P = 1.000). None of the recorded demographics were risk factors for capsular contracture, including the use of biologic or synthetic mesh (P = .801).

Conclusions

Both biologic and synthetic mesh are successful at preventing capsular contracture in patients undergoing implant-based revision reconstruction. This adds to the growing evidence that both scaffold materials can be used in complex revision breast reconstruction to aid in preventing capsular contracture.

Level of Evidence 4

Silicone implant surface microtopography modulates inflammation and tissue repair in capsular fibrosis

Excessive fibrous capsule formation around silicone mammary implants (SMI) involves immune reactions to silicone. Capsular fibrosis, a common SMI complication linked to host responses, worsens with specific implant topographies. Our study with 10 patients investigated intra- and inter-individually, reduced surface roughness effects on disease progression, wound responses, chronic inflammation, and capsular composition. The results illuminate the significant impact of surface roughness on acute inflammatory responses, fibrinogen accumulation, and the subsequent fibrotic cascade. The reduction of surface roughness to an average roughness of 4 μm emerges as a promising approach for mitigating detrimental immune reactions, promoting healthy wound healing, and curbing excessive fibrosis. The identified proteins adhering to rougher surfaces shed light on potential mediators of pro-inflammatory and pro-fibrotic processes, further emphasizing the need for meticulous consideration of surface design. The composition of the implant capsule and the discovery of intracapsular HSP60 expression highlight the intricate web of stress responses and immune activation that can impact long-term tissue outcomes.

Selective Capsulotomies and Partial Capsulectomy in Implant-Based Breast Reconstruction Revision Surgery

Background

Breast cancer with about 2.3 million diagnoses and 685,000 deaths globally is the most frequent malignancy in the female population. Continuous research has led to oncological and reconstructive advances in the management of breast cancer, thus improving outcomes and decreasing patient morbidity. Nowadays, the submuscular expander and prosthesis (E/P) implant-based breast reconstruction (IBR) accounts for 73% of all reconstructions. Despite its widely accepted efficacy, the technique is not free from complications and up to 28% of cases require revision surgery for mechanical complications such as capsular contracture, implant displacement/rotation, and implant rupture. With this study, the authors report their experience in the management of E/P IBR revision surgery through the technique of Selective Capsulotomies (SCs) and Partial Capsulectomy (PC).

Methods

A retrospective study was conducted on patients who had previously undergone E/P IBR and presented for revision reconstruction between January 2013 and May 2023 at the Department of Plastic Surgery of the University of Siena, Italy. Reasons for revision included capsular contracture, implant displacement/rotation, and implant rupture. Revision reconstructions involved SC and PC with implant replacement. Fat grafting was also considered. The complication rate was evaluated by analysis of patients' medical records. Patients' satisfaction with the treatment was assessed through a specific questionnaire.

Results

32 patients underwent revision surgeries. No early complication occurred. Recurrence rate was assessed at 19% with average follow-up of 59 months (range: 13-114 months). The average time between revision surgery and recurrence was 3 years (range: 1-6 years). 23 patients answered the questionnaire and were overall satisfied with the treatments (8.29/10).

Conclusions

SC possibly associated to PC is a valuable option for E/P IBR revision surgery with minimal complications, reduced surgical trauma, short operating time, and relatively low recurrence risk. In addition, treated patients are overall satisfied with the results over time.

Devil's Advocate: Evidence-Based Recommendation for "One Breast-One Insertion Funnel" Policy

BACKGROUND

Rates of capsular contracture have reduced significantly since the use of insertion funnels to place breast implants became routine. However, due to financial constraints, the same funnel is usually used for implantation of both sides.

OBJECTIVES

The aim of this study was to determine whether the risk of capsular contracture is higher for the second breast when the same insertion funnel is used for both breasts.

METHODS

The authors collected a sample of the insertion funnel tip immediately after removing the funnel from its sterile packaging and another tip sample after the funnel had been used to insert the first implant. These samples were sent for microbiological culture evaluations. Capsular contracture rates in the first implanted breast vs the second implanted breast were then retrospectively analyzed.

RESULTS

All samples taken from the funnel before the first implantation showed no bacterial growth. All 10 samples taken from the funnel after the first implantation showed organism growth (8 were positive for Staphylococcus epidermidis and 2 for Cutibacterium acnes). Retrospective analysis of the results revealed that the overall capsular contracture rate had reduced after the authors began to use insertion funnels. However, this complication was still more common on the second implanted breast.

CONCLUSIONS

Surgeons should consider the use of separate insertion funnels for each breast. This might help to slightly reduce the incidence of capsular contracture.See the abstract translated into Hindi, Portuguese, Korean, German, Italian, Arabic, and Chinese (Simplified and Traditional) online here: https://doi.org/10.1093/asj/sjad288.

LEVEL OF EVIDENCE: 4

An Antifibrotic Breast Implant Surface Coating Significantly Reduces Periprosthetic Capsule Formation

BACKGROUND

The body responds to prosthetic materials with an inflammatory foreign body response and deposition of a fibrous capsule, which may be deleterious to the function of the device and cause significant discomfort for the patient. Capsular contracture (CC) is the most common complication of aesthetic and reconstructive breast surgery. The source of significant patient morbidity, it can result in pain, suboptimal aesthetic outcomes, implant failure, and increased costs. The underlying mechanism remains unknown. Treatment is limited to reoperation and capsule excision, but recurrence rates remain high. In this study, the authors altered the surface chemistry of silicone implants with a proprietary anti-inflammatory coating to reduce capsule formation.

METHODS

Silicone implants were coated with Met-Z2-Y12, a biocompatible, anti-inflammatory surface modification. Uncoated and Met-Z2-Y12-coated implants were implanted in C57BL/6 mice. After 21, 90, or 180 days, periprosthetic tissue was removed for histologic analysis.

RESULTS

The authors compared mean capsule thickness at three time points. At 21, 90, and 180 days, there was a statistically significant reduction in capsule thickness of Met-Z2-Y12-coated implants compared with uncoated implants ( P < 0.05).

CONCLUSIONS

Coating the surface of silicone implants with Met-Z2-Y12 significantly reduced acute and chronic capsule formation in a mouse model for implant-based breast augmentation and reconstruction. As capsule formation obligatorily precedes CC, these results suggest contracture itself may be significantly attenuated. Furthermore, as periprosthetic capsule formation is a complication without anatomical boundaries, this chemistry may have additional applications beyond breast implants, to a myriad of other implantable medical devices.

CLINICAL RELEVANCE STATEMENT

Coating of the silicone implant surface with Met-Z2-Y12 alters the periprosthetic capsule architecture and significantly reduces capsule thickness for at least 6 months postoperatively in a murine model. This is a promising step forward in the development of a therapy to prevent capsular contracture.

Antiseptic Techniques in Breast Implant Surgery: Insights From Plastic Surgeons in Saudi Arabia

Background

Breast implant surgery is a popular procedure worldwide, and the same holds true for Saudi Arabia. Ensuring a sterile surgical environment is crucial to avert postoperative infections. This study explores the various antiseptic techniques adopted by Saudi plastic surgeons during breast implant procedures.

Objectives

This study aims to assess Saudi plastic surgeons' adherence to antiseptic measures in breast implant surgery, and determine what types of antiseptic measures are most commonly used among Saudi plastic surgeons.

Methods

The authors conducted a cross-sectional survey among board-certified plastic surgeons in Saudi Arabia, collecting data through a self-administered online questionnaire. This questionnaire, which covered their demographic information and their antiseptic practices during breast implant surgery, was disseminated via a WhatsApp (Menlo Park, CA) broadcast message from May 15 to June 27, 2023.

Results

Of the 52 Saudi plastic surgeons who completed the questionnaire, all reported employing preoperative antibiotics and skin disinfection. Other measures included pocket irrigation (86.5%), implant irrigation (92.3%), sleeve/funnel usage (65.4%), nipple shield usage (51.9%), and glove change during the procedure (96.2%). Nearly, all respondents used only a surgical cap for head cover (96.2%) and postoperative antibiotics as prophylaxis (98.1%). However, more than half of them did not minimize door movement during the procedure (51.9%).

Conclusions

This study offers a valuable insight into the antiseptic practices during breast implant surgery in Saudi Arabia. The findings underline the need for further research to establish evidence-based guidelines for antiseptic practices in this field.

Level of Evidence 5

Repeated Lipoteichoic Acid Injection at Low Concentration Induces Capsular Contracture by Activating Adaptive Immune Response through the IL-6/STAT3 Signaling Pathway

BACKGROUND

Capsular contracture is the most common complication of breast implantation surgery. Bacterial contamination was considered to play an important role in the occurrence of capsular contracture, and Gram-positive bacteria such as Staphylococcus epidermidis were discovered in the clinical specimens. Lipoteichoic acid (LTA) was a component of the cell wall of Gram-positive bacteria and was sufficient in the pathogenicity of the bacteria. The authors assumed that LTA could trigger the immunologic response against the implant and cause capsular contracture.

METHODS

The authors developed a rat model of capsular contracture by repeated injection of 10 μg/mL LTA. The histologic changes of the capsule tissue were measured by hematoxylin and eosin, sirius red, Masson, and immunohistochemical staining. The expression of related cytokines was measured by quantitative real-time polymerase chain reaction. The downstream pathway activation was shown by Western blot. The authors also applied tocilizumab, an interleukin (IL)-6 receptor antagonist, to verify the role of IL-6 in this pathologic process.

RESULTS

The authors discovered that repeated LTA injection, at a low concentration, could induce the thickening of capsule tissue, the deposition of collagen fiber, and the activation of myofibroblasts. The IL-6/signal transducer and activator of transcription 3 signaling pathway was activated in this process, and the inhibition of IL-6 receptor could relieve the symptoms. B cells and T-helper cells, especially T-helper type 1, could be related to this phenomenon.

CONCLUSIONS

The authors' research corroborated that subclinical infection could trigger capsular contracture, and the immune system played an important role in this process. The authors' results provided a possible research direction for the mechanism of bacterial infection-induced immune response against breast implants.

CLINICAL RELEVANCE STATEMENT

The authors' research provides a possible research direction for the mechanism of bacterial infection-induced immune response against breast implants, and a potential target for predicting the prognosis of capsular contracture.

Advances on Capsular Contracture-Prevention and Management Strategies: A Narrative Review of the Literature

Capsular contracture (CC) is the most relevant complication of both aesthetic and reconstructive breast implant surgery. For many years, experimental and clinical trials have attempted to analyze CC risk factors, clinical features, and appropriate management strategies. It is commonly accepted that a multifactorial etiology promotes CC development. However, the heterogeneity in patients, implants and surgical techniques make it difficult to suitably compare or analyze specific factors. As a consequence, discordant data are present in literature, and a true systematic review is often limited in its conclusions. Hence, we decided to present a comprehensive review of current theories on prevention and management strategies, rather than a specific "solution" to this complication.

Methods

The PubMed database was searched for literature regarding CC prevention and management strategies. Pertinent articles in English, published before December 1, 2022, were compared with selection criteria and eventually included in this review.

Results

Through the initial search, 97 articles were identified, of which 38 were included in the final study. Several articles explored different medical and surgical preventive and therapeutic strategies, showing numerous controversies on appropriate CC management.

Conclusions

This review provides a clear overview of the complexity of CC. The wide variety of clinical situations in term of patients, implants, and surgical techniques prevent the standardization of CC management strategies. By contrast, a patient-customized approach should be preferred, and different strategies should be considered depending on the specific case. Further research is desirable to better ascertain evidence-based protocols with regard to CC prevention and treatment.

Dermatoscopic and Dermatopathologic Features of a 3-Year-Old Buried Polypropylene Suture

ABSTRACT

Cutaneous foreign bodies are a well-known cause of delayed wound healing and complications such as abscesses, fistula formation, and secondary infections. Polypropylene sutures are widely utilized in cutaneous surgery because they easily travel through tissues while eliciting minimal tissue reactions. Despite these advantages, retained polypropylene sutures can cause complications. The authors report a case of a retained polypropylene suture that remained buried after a total excision 3 years prior. It started to cause cutaneous symptoms when the patient began exercising 1 week prior to presentation. The authors also examine the dermatoscopic and dermatopathologic features and other complications related to retained polypropylene sutures that have been reported in the literature.

An Experimental Murine Model to Assess Biofilm Persistence on Commercial Breast Implant Surfaces

Capsular contracture is the most frequently associated complication following breast implant placement. Biofilm formation on the surface of such implants could significantly influence the pathogenesis of this complication. The objective of this study was to design an experimental model of breast implant infection that allowed us to compare the in vivo S. epidermidis ability to form and perpetuate biofilms on commonly used types of breast implants (i.e., macrotexturized, microtexturized, and smooth). A biofilm forming S. epidermidis strain (ATCC 35984) was used for all experiments. Three different implant surface types were tested: McGhan BIOCELL® (i.e., macrotexturized); Mentor Siltex® (i.e., microtexturized); and Allergan Natrelle Smooth® (i.e., smooth). Two different infection scenarios were simulated. The ability to form biofilm on capsules and implants over time was evaluated by quantitative post-sonication culture of implants and capsules biopsies. This experimental model allows the generation of a subclinical staphylococcal infection associated with a breast implant placed in the subcutaneous tissue of Wistar rats. The probability of generating an infection was different according to the type of implant studied and to the time from implantation to implant removal. Infection was achieved in 88.9% of macrotextured implants (i.e., McGhan), 37.0% of microtexturized implants (i.e., Mentor), and 18.5% of smooth implants (i.e., Allergan Smooth) in the short-term (p < 0.001). Infection was achieved in 47.2% of macrotextured implants, 2.8% of microtexturized implants, and 2.8% of smooth implants (i.e., Allergan Smooth) in the long-term (p < 0.001). There was a clear positive correlation between biofilm formation on any type of implant and capsule colonization/infection. Uniformly, the capsules formed around the macro- or microtexturized implants were consistently macroscopically thicker than those formed around the smooth implants regardless of the time at which they were removed (i.e., 1−2 weeks or 3−5 weeks). We have shown that there is a difference in the ability of S epidermidis to develop in vivo biofilms on macrotextured, microtextured, and smooth implants. Smooth implants clearly thwart bacterial adherence and, consequently, biofilm formation and persistence are hindered.

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.

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.

Are late hernia mesh complications linked to Staphylococci biofilms?

Purpose

The purpose of this study was to investigate the link between bacterial biofilms and negative outcomes of hernia repair surgery. As biofilms are known to play a role in mesh-related infections, we investigated the presence of biofilms on hernia meshes, which had to be explanted due to mesh failure without showing signs of bacterial infection.

Methods

In this retrospective observational study, 20 paraffin-embedded tissue sections from explanted groin hernia meshes were analysed. Meshes have been removed due to chronic pain, hernia recurrence or mesh shrinkage. The presence and bacterial composition of biofilms were determined. First, specimens were stained with fluorescence in situ hybridisation (FISH) probes, specific for Staphylococcus aureus and coagulase-negative staphylococci, and visualised by confocal laser scanning microscopy. Second, DNA was extracted from tissue and identified by S. aureus and S. epidermidis specific PCR.

Results

Confocal microscopy showed evidence of bacterial biofilms on meshes in 15/20 (75.0%) samples, of which 3 were positive for S. aureus, 3 for coagulase-negative staphylococci and 9 for both species. PCR analysis identified biofilms in 17/20 (85.0%) samples, of which 4 were positive for S. aureus, 4 for S. epidermidis and 9 for both species. Combined results from FISH/microscopy and PCR identified staphylococci biofilms in 19/20 (95.0%) mesh samples. Only 1 (5.0%) mesh sample was negative for bacterial biofilm by both techniques.

Conclusion

Results suggest that staphylococci biofilms may be associated with hernia repair failure. A silent, undetected biofilm infection could contribute to mesh complications, chronic pain and exacerbation of disease.

Biomechanical Principles of Breast Implants and Current State of Research in Soft Tissue Engineering for Cosmetic Breast Augmentation

Currently there are limited implant-based options for cosmetic breast augmentation, and problems associated with those have been increasingly appreciated, most commonly capsular contracture, which occurs due to a chronic foreign body reaction against non-degradable implant materials such as silicone and polyurethane leading to scar tissue formation, pain, and deformity. The underlying biomechanical concepts with implants create a reciprocal stress-strain relationship with local tissue, whilst acting as a deforming force. This means that with time, as the implant continues to have an effect on surrounding tissue the implant and host's biomechanical properties diverge, making malposition, asymmetry, and other complications more likely. Research directed towards development of alternative therapies based on tissue engineering and regenerative medicine seeks to optimize new tissue formation through modulation of tissue progenitors and facilitating tissue regeneration. Scaffolds can guide the process of new tissue formation by providing both an implant surface and a three-dimensional space that promotes the development of a microenvironment that guides attachment, migration, proliferation, and differentiation of connective tissue progenitors. Important to scaffold design are the architecture, surface chemistry, mechanical properties, and biomaterial used. Scaffolds provide a void in which vascularization, new tissue formation, and remodelling can sequentially occur. They provide a conduit for delivery of the different cell types required for tissue regeneration into a graft site, facilitating their retention and distribution. Whilst recent research from a small number of groups is promising, there are still ongoing challenges to achieving clinical translation. This article summarizes the biomechanical principles of breast implants, how these impact outcomes, and progress in scaffold-guided tissue engineering approaches to cosmetic breast augmentation. 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 www.springer.com/00266 .

Comparison Of Endoscopic Transaxillary And Peri-areolar Approaches In Breast Augmentation With Smooth Implants

INTRODUCTION

The most common surgical approaches for breast augmentation in Asia have traditionally been peri-areolar and transaxillary. In recent years, transaxillary approach has become increasingly popular with the use of endoscopic methods, which result in safer and better outcomes. In the literature, there are no comparison studies of endoscopic transaxillary and peri-areolar approaches.

METHODS

This prospective study compared the outcomes of 275 women undergoing primary breast augmentation (endoscopic transaxillary n=205, peri-areolar n=70). All procedures were performed by a single surgeon using smooth round silicone implants and dual-plane pockets from April 2013 to March 2016. Every patient was monitored for a minimum of 4 years for minor and major complications.

RESULTS

Types and percentage of patients experiencing minor complications among transaxillary and peri-areolar patients were localized fluid collection in the wound (1% transaxillary, 7.1% peri-areolar), hypertrophic scarring or keloids (1% transaxillary, 8.6% peri-areolar), and areolar and nipple deformity (0% transaxillary, 8.6% peri-areolar). Major complications were postoperative bleeding (0% transaxillary, 2.9% peri-areolar) and capsular contracture, Baker Group III or IV (1% transaxillary, 5.7% peri-areolar).

CONCLUSIONS

Endoscopic transaxillary breast augmentation had better outcomes, with lower rates of complications than the peri-areolar approach. Reviewing the literature, our study is the first direct comparison of peri-areolar and endoscopic transaxillary incisions using smooth implants. With the risk of anaplastic large cell lymphoma associated with certain macrotexture implants, endoscopic transaxillary approach using smooth implants is the safer technique and very good alternative choice for Asian women who do not want any scarring on their breasts.

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.

Higher Prevalence of Capsular Contracture with Second-side Use of Breast Implant Insertion Funnels

Breast implant insertion funnels have become popular adjuncts to breast implant surgery to reduce access incision length and contact of the implant with the skin of the breast. Although labeled as single-use devices, due to cost considerations, many surgeons use a new breast implant insertion funnel with each patient rather than each breast. The purpose of this study was to evaluate the prevalence of capsular contracture of the first augmentation side and compare it to the second side utilizing one insertion funnel per patient.

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 .

Breast Implants: A Historical Review With Implications for Diagnosis and Modern Surgical Planning

ABSTRACT

Modern breast surgery was first introduced in the United States in 1962 with the use of silicone gel-filled breast implants. Over the past 6 decades, development of breast implants has been challenged by a variety of influencers including aesthetic appeal in shape, texture, and material; challenges in managing outcomes such as contracture, disease, and rupture; and public perception of risks associated with implants. In 1992, silicone breast prostheses were banned by the US Food and Drug Administration with exception for use in breast reconstruction, congenital deformities, or to replace existing implants.The ban led to heightened concerns about implants and possible disease manifestations. Knowledge of the historical evolution of breast prostheses is useful for understanding the associated risks and outcomes unique to each breast implant era. This article aimed to explore characteristics of breast implants by generation, with implications for diagnosis and assistance to modern surgical planning for novice plastic surgeons.

Four-Year Interim Results of the Safety of Augmentation Mammaplasty Using the Motiva Ergonomix™ Round SilkSurface: A Multicenter, Retrospective Study

BACKGROUND

The Motiva Ergonomix™ Round SilkSurface (Establishment Labs Holdings Inc., Alajuela, Costa Rica) is the fifth generation of a silicone gel-filled breast implant that is commercially available in Korea.

OBJECTIVES

In this study, we describe 4-year interim results of the safety of augmentation mammaplasty using the Motiva Ergonomix™ Round SilkSurface in Korean women.

METHODS

In the current multicenter, retrospective study, we performed a retrospective review of medical records of a total of 1314 patients who received augmentation mammaplasty using the Motiva Ergonomix™ Round SilkSurface at our hospitals between September 1, 2016, and August 31, 2020. For safety assessment, we analyzed incidences of postoperative complications and Kaplan-Meier complication-free survival of the patients.

RESULTS

We included a total of 873 patients (1746 breasts, mean age = 32.18 ± 6.88 years) in the current study. There were a total of 111 cases (12.70%) of postoperative complications; these include 24 cases (2.70%) of early seroma, 18 cases (2.10%) of hematoma, 18 cases (2.10%) of capsular contracture, 17 cases (1.95%) of dissatisfaction with shape, 16 cases (1.83%) of dissatisfaction with size, 9 cases (1.03%) of asymmetry, 6 cases (0.70%) of infection and 3 cases (0.34%) of rippling. Moreover, time-to-events were estimated at 918.34 ± 36.22 days (95% CI 845.44-988.52).

CONCLUSIONS

Here, we describe 4-year interim results of the safety of augmentation mammaplasty using the Motiva Ergonomix™ Round SilkSurface in Korean women in a non-manufacturer-sponsored study. But further large-scale, prospective, multicenter studies with a long period of follow-up are warranted to establish our results.

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 Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Plane Change Vs Capsulotomy: A Comparison of Treatments for Capsular Contraction in Breast Augmentation Using the Subfascial Plane

BACKGROUND

The management of capsular contraction following breast augmentation has numerous, often conflicting potential treatment protocols, each designed to reduce the incidence of further recurrence. The use of the subfascial plane has not been investigated as an alternative to other treatment options.

OBJECTIVES

To examine the outcomes from patients presenting with recurrent capsular contraction after being treated for the first capsule by placement of an implant into the subfascial (SF) plane.

METHODS

Retrospective analysis of 111 case notes of patients who presented with capsular contraction. 65 had undergone SF augmentation, 17 submuscular (SM) and 29 subglandular (SG) placement of implant at the primary procedure. At a secondary procedure, those with SF implants underwent open capsulotomy and those with SM and SG implants underwent a change in plane to SF.

RESULTS

There is a significant difference in the proportion of patients that developed a capsule following the second surgery between the groups that had undergone capsulotomy (SF = 16.9%) or plane change (SM = 47% and SG = 37.9%, X² (2,111) = 8.6, P =  0.02). When recurrence at the same site was examined, there was also a significant difference between the groups (X² (2111) = 10.7, P < 0.01). A ruptured implant significantly increased the incidence of further capsular contraction when in the SG plane (X² (2,29) = 12.1, P < 0.01).

CONCLUSIONS

In the absence of implant rupture, changing the plane of an implant to a SF position at revision surgery does not reduce the incidence of subsequent capsular contracture compared with open capsulotomy. Open capsulotomy is a reasonable choice following recurrence of capsular contraction following initial SF placement.

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 .

Autologous Fat Grafting and the Occurrence of Radiation-Induced Capsular Contracture

INTRODUCTION

Radiation therapy is a known risk factor for capsular contracture formation after implant-based breast reconstruction. Although autologous fat grafting (AFG) has been shown to reverse radiation-induced tissue fibrosis, its use as a prophylactic agent against capsular contraction has not been assessed in the clinical setting. In the setting of 2-stage implant-based reconstruction and postmastectomy radiation therapy, we explored the effect AFG has on the prevalence of capsular contracture.

MATERIALS AND METHODS

A retrospective chart review of patients who underwent immediate tissue expander (TE) placement followed by postmastectomy radiation therapy and secondary implant-based reconstruction at our institution between January 2012 and December 2019 was performed. Patients were divided into 2 cohorts based on whether or not AFG was performed at the time of secondary reconstruction. The primary outcome of interest was the occurrence of capsular contracture after TE exchange.

RESULTS

Overall 57 patients (57 breasts) were included, 33 of whom received AFG at the time of TE exchange. All but 1 patient underwent submuscular implant placement, and the mean follow-up was 1.96 years. There was no significant difference in the prevalence of medical comorbidities between the study groups.Capsular contracture occurred in 24 patients (42.1%). Seventeen of these patients had undergone AFG at the time of TE exchange (17/33 patients, 51.5%), and 7 of these patients had not (7/24 patients, 29.2%). Most of the capsular contracture cases were Baker grades III or IV (14 patients, 58.3%), and 50% of patients with capsular contracture of any grade ultimately required operative intervention. Multivariate logistic regression analysis demonstrated that AFG did not significantly influence the occurrence or severity of capsular contracture, or did not impact the need for operative intervention in this patient population.

CONCLUSIONS

Implant-based reconstruction of the irradiated breast is associated with high postoperative capsular contracture rates. Although AFG has shown promise in reversing radiation-induced dermal fibrosis, no protective effect on the development of capsular contracture after stage 2 reconstruction was observed in this study population. Further investigation in the form of randomized, prospective studies is needed to better assess the utility of AFG in preventing capsular contracture in irradiated patients.

Epidemiology and Prevention of Breast Prosthesis Capsular Contracture Recurrence

INTRODUCTION

Baker grade III and IV breast prosthesis capsular contractures represent a major problem for patients undergoing mammoplasties. The risk factors involved in recurrence are debated, and the best surgical approach for their prevention is not established. The objective was to identify these.

MATERIALS AND METHODS

We carried out a retrospective study of patients operated on for capsular contracture at the Saint-Louis Hospital in Paris from 2012 to 2014. The characteristics at inclusion were compared so as to determine the risk factors of recurrence. The surgical approaches were compared between the patients with recurrence and those without at 5 years.

RESULTS

Of the 100 patients included, 24 had a recurrence. The minimal follow-up was 5 years. No risk factors of recurrence of capsular contracture were identified. The surgical approach associated with the lowest rate of recurrence was anterior capsulectomy [OR total capsulectomy = 2.36 (0.73; 8.037) OR capsulotomy = 4.33 (1.37; 14.81)] (p < 0.040) with alteration of the volume of the implant, whether greater or less than initially [OR greater volume = 0.30 (0.096; 0.83); OR smaller volume = 0.14 (0.008; 0.85)] (p < 0.018).

CONCLUSION

The occurrence of capsular contracture is a major problem with prosthetic breast surgery. The main risk factors identified to date are essentially in regard to the occurrence of a first episode. No significant risk factors for recurrence were identified. The best prevention appears to be an anterior capsulectomy with reducing the volume of the implant.

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 . IV.

Silicone Breast Implant Injector: A Retooled Breast Augmentation Device

Silicone breast implants are used worldwide for breast augmentation. After an axillary, periareolar or inframmary incision has been made to create an adequately sized pocket; the surgeon usually uses his or her fingers to insert the implant. The use of fingers makes the insertion process time-consuming, a few minutes or more. There are some complications, including need to ensure that the incision is long enough for the implant to be inserted, scar hypertrophy caused by implant insertion friction damage to the edge of incision, and the occasional need to ask the surgical assistant to lend more fingers to facilitate satisfactory insertion and placement. In addition, the use of gloved fingers to repeatedly push on the implant can increase the risk of contamination, postoperative silicone microleakage, and capsular contracture. To resolve these problems, we developed an improved silicone breast implant injector (reusable stainless steel 2007; single use polypropylene 2018) that can be used more easily than fingers and other "no touch" devices. From 2013 to 2017, the first author, a plastic surgeon at our clinic, used the 2007 reusable stainless steel injector to perform breast augmentations in 53 patients (Ave. age 23.8 years; range 19-67 years), 5 (8.8%) receiving 250-ml implants, 41 (77.4%) 251-300-ml implants, and 7 (13.8%) 301-400-ml implants. Overall, results were satisfactory except for two patients (3.7%) in whom capsular contracture occurred. There were no ruptures. Use of the injector made it possible to shorten the length of the incisions from the traditional 4-7 to 3-4 cm and expedited insertion time from a few minutes to a few seconds. This "no touch" insertion technique reduced implant damage caused by finger pushing, leading to a decrease in silicone microleakage and capsular contracture rate. It was performed with no friction trauma to the incision edge or harm to the surgeon's fingers. It was found to be an effective alternative operative tool for the insertion of silicone breast implants.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 .

Simultaneous Augmentation Mammoplasty and Vacuum-Assisted Breast Biopsy for Enhanced Cosmesis and Efficacy

BACKGROUND

In this era of expanding life expectancy and popularity of aesthetic breast surgeries, more women are likely to live more years with their augmented breasts. Thus, consistent attention to general breast health is crucial, and preoperative ultrasound is helpful to locate suspicious lesions. In this study, we present a combinative procedure of augmentation mammoplasty and vacuum-assisted breast biopsy (VABB).

METHODS

From January of 2018 to December of 2019, a total of 102 patients received simultaneous augmentation mammoplasty and VABB in our institute. Only patients of primary augmentation mammoplasty who received VABB on unilateral breasts were included. We sought to investigate the results of each breast and safety of adding VABB before performing augmentation within the same incision.

RESULTS

Among 204 breasts and implants, 28.43% were done via endoscopic transaxillary approach and 71.57% via inframammary approach. The mean implant volume was 329.34 ± 44.79 ml, and the mean follow-up period was 14.23 ± 4.64 months. All of the complication rates exhibited no statistically significant differences between the two groups.

CONCLUSION

Simultaneous augmentation mammoplasty and VABB prevented unnecessary scars and pain, and the complication rates did not statistically differ from those of augmentation only group. This co-operation is a safe and simple method potentially beneficial to many women interested in breast surgery.

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 .

Endoscopic transaxillary capsulectomy with immediate reimplantation performed as a single-operator outpatient procedure

Capsulectomy is a standard treatment for capsular contracture after breast augmentation. Incision via the endoscopic transaxillary approach is generally preferred by Asian women, but relevant literature addressing endoscopic transaxillary capsulectomy is limited. This study described the techniques of endoscopic transaxillary capsulectomy with reimplantation performed as a single-operator outpatient procedure. This retrospective study included patients with diagnosis of capsular contracture underwent endoscopic transaxillary capsulectomy with immediate reimplantation between January 1, 2013 and December 31, 2017. Data regarding history, implant type, operation time, duration of postoperative drainage, and complications were collected and analyzed. A total of 42 patients with a mean age of 36 years were included (11 unilateral and 31 bilateral capsulectomy). Total capsulectomy was performed on four (10%) patients for previous subglandular augmentation, and anterior capsulectomy was performed on 38 (91%) patients for previous submuscular augmentation. Mean sizes of previous and new (or reused) implants were 268 ml (median 283 ml, SD 57) and 317 ml (median 307 ml, SD 49), respectively. Mean operation time for unilateral and bilateral procedures were 4 h 15 min and 6 h 28 min, respectively. Postoperatively, mean duration of wound drainage was 10 (SD 3) days. Six (14%) patients experienced complications, including two (5%) patients with seroma, two (5%) with hematoma, one (2%) with infection, and four (10%) with recurrent capsular contracture. The four recurrent cases underwent repeat endoscopic transaxillary capsulectomy. All of the 42 patients had satisfactory clinical and esthetic outcomes. This study demonstrated the feasibility of endoscopic transaxillary capsulectomy with immediate reimplantation performed as an ambulatory surgery by a single surgeon who is in a stable and comfortable sitting position without the aid of a surgical assistant.

Surface Texturization of Breast Implants Impacts Extracellular Matrix and Inflammatory Gene Expression in Asymptomatic Capsules

BACKGROUND

Texturing processes have been designed to improve biocompatibility and mechanical anchoring of breast implants. However, a high degree of texturing has been associated with severe abnormalities. In this study, the authors aimed to determine whether implant surface topography could also affect physiology of asymptomatic capsules.

METHODS

The authors collected topographic measurements from 17 different breast implant devices by interferometry and radiographic microtomography. Morphologic structures were analyzed statistically to obtain a robust breast implant surface classification. The authors obtained three topographic categories of textured implants (i.e., "peak and valleys," "open cavities," and "semiopened cavities") based on the cross-sectional aspects. The authors simultaneously collected 31 Baker grade I capsules, sorted them according to the new classification, established their molecular profile, and examined the tissue organization.

RESULTS

Each of the categories showed distinct expression patterns of genes associated with the extracellular matrix (Timp and Mmp members) and inflammatory response (Saa1, Tnsf11, and Il8), despite originating from healthy capsules. In addition, slight variations were observed in the organization of capsular tissues at the histologic level.

CONCLUSIONS

The authors combined a novel surface implant classification system and gene profiling analysis to show that implant surface topography is a bioactive cue that can trigger gene expression changes in surrounding tissue, even in Baker grade I capsules. The authors' new classification system avoids confusion regarding the word "texture," and could be transposed to implant ranges of every manufacturer. This new classification could prove useful in studies on potential links between specific texturizations and the incidence of certain breast-implant associated complications.

Label-free stimulated Raman scattering imaging reveals silicone breast implant material in tissue

Millions of women worldwide have silicone breast implants. It has been reported that implant failure occurs in approximately a tenth of patients within 10 years, and the consequences of dissemination of silicone debris are poorly understood. Currently, silicone detection in histopathological slides is based on morphological features as no specific immunohistochemical technique is available. Here, we show the feasibility and sensitivity of stimulated Raman scattering (SRS) imaging to specifically detect silicone material in stained histopathological slides, without additional sample treatment. Histology slides of four periprosthetic capsules from different implant types were obtained after explantation, as well as an enlarged axillary lymph node from a patient with a ruptured implant. SRS images coregistered with bright-field images revealed the distribution and quantity of silicone material in the tissue. Fast and high-resolution imaging of histology slides with molecular specificity using SRS provides an opportunity to investigate the role of silicone debris in the pathophysiology of implant-linked diseases.

The Reversed Glove Sleeve: A Readily Available and Cost-effective Way to Achieve "No Touch" Breast Implant Insertion

The reversed glove sleeve technique is a simple, available, reproducible, and cost-effective method of achieving “no touch” breast implant insertion. It allows a new glove to be used for each side, thus reducing the risk of contamination by reusing a sleeve/funnel for the subsequent implant insertion. The link between bacterial contamination of breast implants and capsular contracture is established. Further prospective evaluation of this technique is underway to show if there is benefit in reducing the risk of capsular contracture.

Pro-Fibrotic CD26-Positive Fibroblasts Are Present in Greater Abundance in Breast Capsule Tissue of Irradiated Breasts

BACKGROUND

Breast capsular contracture is a major problem following implant-based breast reconstruction, particularly in the setting of radiation therapy. Recent work has identified a fibrogenic fibroblast subpopulation characterized by CD26 surface marker expression.

OBJECTIVES

This work aimed to investigate the role of CD26-positive fibroblasts in the formation of breast implant capsules following radiation therapy.

METHODS

Breast capsule specimens were obtained from irradiated and nonirradiated breasts of 10 patients following bilateral mastectomy and unilateral irradiation at the time of expander-implant exchange, under institutional review board approval. Specimens were processed for hematoxylin and eosin staining as well as for immunohistochemistry and fluorescence activated cell sorting for CD26-positive fibroblasts. Expression of fibrotic genes and production of collagen were compared between CD26-positive, CD26-negative, and unsorted fibroblasts.

RESULTS

Capsule specimens from irradiated breast tissue were thicker and had greater CD26-postive cells on immunofluorescence imaging and on fluorescence activated cell sorting analysis than did capsule specimens from the nonirradiated breast. Compared with CD26-negative fibroblasts, CD26-positive fibroblasts produced more collagen and had increased expression of the profibrotic genes IL8, TGF-β1, COL1A1, and TIMP4.

CONCLUSIONS

CD26-positive fibroblasts were found in a significantly greater abundance in capsules of irradiated compared with nonirradiated breasts and demonstrated greater fibrotic potential. This fibrogenic fibroblast subpopulation may play an important role in the development of capsular contracture following irradiation, and its targeted depletion or moderation may represent a potential therapeutic option.

LEVEL OF EVIDENCE: 2

Aspergillus fumigatus Spores Are Not Able to Penetrate Silicone Breast Implant Shells

INTRODUCTION

Bacterial contamination is hypothesized to be one reason for the development of capsular contracture after alloplastic breast reconstruction using silicone breast implants. The role of fungal colonization or infection in this context as well as the question if microorganisms can penetrate the shell of silicone breast implants remains an unresolved question to date. Therefore, the aim of this study was to assess whether fungal spores are able to penetrate the shell of silicone implants.

MATERIALS AND METHODS

In an experimental in vitro setup with different arrangements of growth compartments, silicone chambers were placed in culture dishes filled with Aspergillus minimal medium or liquid culture medium. Inoculation was performed with conidia of Aspergillus fumigatus and incubated for seven days. On a daily basis, plates were inspected for conidial germination and hyphal growth.

RESULTS

In none of the different experimental settings nutrients or hyphae of Aspergillus fumigatus were able to penetrate the silicone material.

CONCLUSIONS

Fungal spores and hyphae do not permeate through an intact silicone shell used in breast implants; thus, the silicone material serves as an impenetrable barrier.

Back to Basics: Could the Preoperative Skin Antiseptic Agent Help Prevent Biofilm-Related Capsular Contracture?

BACKGROUND

Capsular contracture (CC) has remained an unresolved issue throughout history. Strong evidence focuses on bacterial biofilm as its main source. A literature review revealed that more than 90% of bacteria found in capsules and implants removed from patients with Baker grade III-IV CC belong to the resident skin microbiome (Staphylococcus epidermidis, predominant microorganism). The use of an adequate preoperative skin antiseptic may be a critical step to minimize implant contamination and help prevent biofilm-related CC.

OBJECTIVES

The authors sought to compare the effect of 2 different antiseptic skin preparations: povidone-iodine (PVP-I) vs chlorhexidine gluconate (CHG) on CC proportions after primary breast augmentation through a periareolar approach.

METHODS

In June of 2014, The Society for Healthcare Epidemiology of America proposed to use CHG for preoperative skin preparation in the absence of alcohol-containing antiseptic agents as strategy to prevent surgical site infection. The clinical safety committee of a surgical center in Colombia decided to change PVP-I to CHG for surgical site preparation thereafter. The medical records of 63 patients who underwent to primary breast augmentation through a periareolar approach during 2014 were reviewed. In the first 6 months PVP-I was used in 32 patients, and later CHG was employed in 31 patients.

RESULTS

Pearson's chi-squared test to compare CC proportions between subgroups showed a statistically significant difference. The CC proportion was higher for patients who had antisepsis with PVP-I. CC was absent when CHG was employed.

CONCLUSIONS

CHG as preoperative skin antiseptic for primary breast augmentation surgery was more effective than PVP-I to help prevent biofilm-related CC.

LEVEL OF EVIDENCE: 3

Endoscopic Transaxillary Versus Inframammary Approaches for Breast Augmentation Using Shaped Implants: A Matched Case-Control Study

PURPOSE

The incision for breast augmentation can be chosen from the transaxillary, inframammary fold, periareolar, or transumbilical approaches. While the inframammary fold approach is commonly used worldwide, the transaxillary approach is more popular in Asia due to the more conservative location of the scar. In this study, we performed augmentation mammoplasty using anatomically shaped implants via the endoscopic transaxillary and inframammary fold incisions and compared the outcomes.

METHODS

Three hundred sixty-four patients who underwent breast augmentation with shaped implants were enrolled. All were primary and bilateral cases. In total, 728 shaped implants were used. Patients' demographics, incision type, and complications were documented. Complications such as capsular contracture, hematoma, infection, implant malposition, wound problem, and chronic seroma were observed during the average 27 months of follow-up period and analyzed.

RESULTS

One hundred ninety-five patients underwent augmentation mammoplasty via the inframammary approach, whereas 169 patients underwent the endoscopic transaxillary approach. Implant type and size were matched between the two groups. Complication rates were 1.8% and 2.7% in the inframammary and transaxillary approach, respectively. There was no significant difference between the two approaches in terms of surgical complications (p = 0.593).

CONCLUSION

This study demonstrates that the endoscopic transaxillary approach is not inferior to the inframammary approach when shaped implants are used for augmentation mammoplasty. Therefore, the transaxillary approach may be an alternative method when using shaped implants for augmentation mammoplasty, especially for women who wish to avoid a visible scar on the inframammary fold.

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 .

Current Risk Estimate of Breast Implant-Associated Anaplastic Large Cell Lymphoma in Textured Breast Implants

BACKGROUND

With breast implant-associated anaplastic large cell lymphoma (BIA-ALCL) now accepted as a unique (iatrogenic) subtype of ALCL directly associated with textured breast implants, we are now at a point where a sound epidemiologic profile and risk estimate are required. The aim of this article is to provide a comprehensive and up-to-date global review of the available epidemiologic data and literature relating to the incidence, risk, and prevalence of BIA-ALCL.

METHODS

All current literature relating to the epidemiology of BIA-ALCL was reviewed. Barriers relating to sound epidemiologic study were identified, and trends relating to geographical distribution, prevalence of breast implants, and implant characteristics were analyzed.

RESULTS

Significant barriers exist to the accurate estimate of both the number of women with implants (denominator) and the number of cases of BIA-ALCL (numerator), including poor registries, underreporting, lack of awareness, cosmetic tourism, and fear of litigation. The incidence and risk of BIA-ALCL have increased dramatically from initial reports of 1 per million to current estimates of 1/2,832, and is largely dependant on the "population" (implant type and characteristics) examined and increased awareness of the disease.

CONCLUSIONS

Although many barriers stand in the way of calculating accurate estimates of the incidence and risk of developing BIA-ALCL, steady progress, international registries, and collegiality between research teams are for the first time allowing early estimates. Most striking is the exponential rise in incidence over the last decade, which can largely be explained by the increasingly specific implant subtypes examined-driven by our understanding of the pathologic mechanism of the disease. High-textured high-surface area implants (grade 4 surface) carry the highest risk of BIA-ALCL (1/2,832).

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

Background

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

Methods

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

Results

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

Conclusions

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

Indolent Rib Osteomyelitis Following Breast Implant Reconstruction: An Unusual Case and Review of the Literature

Rib osteomyelitis is an infrequently occurring but important complication of breast implant surgery. Although prosthetic or surgical site infection (SSI) and rib osteomyelitis as separate entities are well described in the literature, only five cases of rib or sternal osteomyelitis related to implant placement have been reported globally. Historically patients who experience this complication have not demonstrated an identifiable prevalence of the traditional risk factors associated with SSI or rib osteomyelitis. This report describes the sequence of clinical manifestations of an unusual case of breast implants complicated by rib osteomyelitis. A 56-year-old female underwent mastectomy and insertion of tissue expanders for bilateral invasive ductal carcinoma following which the tissue expanders became infected in the early postoperative period and were subsequently removed. The patient underwent successful expander insertion and subsequent implant exchange surgery several years later and enjoyed an uncomplicated recovery from this. Following nipple reconstruction more than 12 months after successful implant placement, she presented with Staphylococcus epidermidis bacteremia and a left-sided clinical peri-implant infection. Upon removal of her implant, an intraoperative discovery of rib necrosis/osteomyelitis was made for which she was treated. To provide context, the literature was reviewed for other reported cases of rib osteomyelitis following breast implant surgery. This patient, in combination with others reported in the literature, emphasises the diagnostic difficulties posed by this condition as a result of its low incidence and variable or absent clinical features.

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 www.springer.com/00266 .

Capsular Contracture Rate After Breast Augmentation with Periareolar Versus Other Two (Inframammary and Transaxillary) Incisions: A Meta-Analysis

BACKGROUND

Capsular contracture has been the most common complication of cosmetic breast augmentation. The effect of incision pattern on capsular contracture is still unclear. This meta-analysis demonstrates current evidence with regard to the comparison of capsular contracture rate between periareolar and other two (transaxillary and inframammary) incisions.

METHODS

PubMed, EMBASE, and Cochrane databases were searched up to January 2017. The results of selected studies were meta-analyzed to obtain a pooled odds ratio of the effect of periareolar versus other two incision patterns (transaxillary or inframammary incision) of breast augmentation on capsular contracture rates. In addition, subgroup analyses were performed on periareolar versus transaxillary groups and periareolar versus inframammary groups with regard to capsular contracture rate.

RESULTS

Seven comparative studies were selected and meta-analyzed. Five of the seven studies reported a higher rate of capsular contracture on patients with periareolar incisions. The results showed a significantly higher rate of capsular contracture with periareolar incisions compared with other two incisions (OR, 1.83; 95% CI, 1.06-3.15, p = 0.03). Subgroup results showed no significant difference of capsular contracture between periareolar incisions and transaxillary incisions (OR, 0.94; 95% CI, 0.52-1.64, p = 0.79) and showed a significantly higher rate of capsular contracture in periareolar incisions compared to inframammary incisions (OR, 1.91; 95% CI, 1.06-3.43, p = 0.03).

CONCLUSION

The results of this meta-analysis demonstrate the contributing effects of periareolar breast augmentation on the rate of capsular contracture. However, more studies with longer tracking periods and higher quality should be conducted to further verify this conclusion.

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 .

Antibiotic Irrigation of Pocket for Implant-Based Breast Augmentation to Prevent Capsular Contracture: A Systematic Review

Background

In vitro and in vivo studies have described a number of different antibiotic solutions for irrigation of the pocket in implant-based breast augmentation in an attempt to prevent the formation of capsular contracture (CC). Our objective was to evaluate the evidence that antibiotic irrigation reduced the rate of CC.

Methods

A systematic search of MEDLINE, EMBASE, and CENTRAL was conducted from inception to January 2016. We included studies which examined the use of intraoperative antibiotic irrigation in women undergoing primary breast augmentation. Our primary outcome was the rate of CC. Included studies were assessed for methodological quality using validated tools.

Results

Seven studies were included in the final analysis: 1 randomized controlled trial (RCT) and 6 non-randomized studies. The mean follow-up ranged from 14 to 72 months. The rate of CC was less than 2% in 8 studies, between 3% and 6% in 4 studies, and 13.9% in 1 study. Included studies demonstrated significant clinical and methodological heterogeneity. The solitary low-quality RCT concluded that antibiotic irrigation was superior to saline irrigation. Three non-randomized studies demonstrated no significant difference in the rate of CC with the use of antibiotics. One non-randomized controlled study showed that the use of mixture of antibiotic and povidone-iodine significantly lowered the rate of CC.

Conclusions

The available evidence on the use of antibiotic irrigation to prevent CC is weak and it is based on studies with high risk of bias. Methodologically robust studies are necessary to answer the question whether antibiotic breast pocket irrigation prevents CC.

Low rate of capsular contracture in a series of 214 consecutive primary and revision breast augmentations using microtextured implants

Capsular contracture is the most common major complication after implant-based breast augmentation. The aetiology of capsular contracture is multifactorial. The author reports a retrospective personal series of patients managed over a seven-year period with a nearly unchanged surgical strategy implementing most of known measures for capsular contracture prevention. A microtextured silicone gel-filled implant from a single manufacturer was used in all cases.

There were 214 consecutive patients (126 primary augmentations and 88 revision augmentations) operated on over the study period. Mean age of the population was 40.0 years, and mean BMI was 22.0 kg/m². Of the patients in the revision cohort, 44.3% were reoperated on because of previous capsular contracture.

Average follow-up was 20.2 months. There was a 0% capsular contracture rate in the primary augmentation cohort and a 3.4% capsular contracture rate in the revision cohort. At last follow-up, 91.2% of breasts received a Baker I grading.

Although the follow-up was relatively short, this rate of capsular contracture would still be considered very low. Determining the reason for such a low rate of capsular contracture on Multivariate Analyses would be difficult due to the potential myriad of confounding variables. However, given the constancy of the technique and implant type employed by a single surgeon, the author is of the opinion that the microtexturing topography on the implant surfaceused in this series contributed to the low rate of capsular contracture formation. However, this would need to be tested in arandomized controlled trial comparing microtextured devices with implants that have macrotextured surfaces.

Open Capsulotomy: An Effective but Overlooked Treatment for Capsular Contracture after Breast Augmentation

Background:

The prevailing theory for capsular contracture after breast augmentation is a subclinical capsular infection. A capsulectomy, site change, and implant replacement are recommended. An open capsulotomy leaves the capsule in the patient. Theoretically, such a procedure would be ineffective because it does not remove the infected tissue. Recurrences occurred frequently in women treated in the 1970s when leaky silicone gel implants were in use. Open capsulotomy has not been studied in women implanted with third-generation devices.

Methods:

Seventy-five consecutive women with Baker III/IV capsular contractures after breast augmentation treated with open capsulotomies between 1996 and 2016 were retrospectively evaluated. The original implants were usually saline-filled (72.2%). Replacements were all smooth and round, and 92.6% were also saline-filled.

Results:

Seventeen women (22.7%) developed a recurrent capsular contracture. Two patients (2.7%) experienced a second recurrence. Patients with ruptured silicone gel implants (n = 13) had a significantly greater risk of recurrence (P = 0.01). There was no significant difference in recurrence rates comparing patients whose intact implants were reinserted (12.5%) with women whose intact implants were replaced (18.2%). Povidone–iodine irrigation did not affect the recurrence rate. Capsular contracture was corrected with 1 procedure in 77.3% of patients and 2 procedures in 97.3% of patients.

Conclusions:

Open capsulotomy is a safe and effective treatment that avoids the additional morbidity and cost of a capsulectomy. The findings challenge the infected biofilm theory of capsular contracture. Open capsulotomy deserves reconsideration by plastic surgeons.