A literature review and summary of capsular contracture: An ongoing challenge to breast surgeons and their patients

Incidence and Risk Assessment of Capsular Contracture in Breast Cancer Patients following Post-Mastectomy Radiotherapy and Implant-Based Reconstruction

Our study aims to identify the risk factors and dosimetry characteristics associated with capsular contracture.

METHODS

We retrospectively analyzed 118 women with breast cancer who underwent PMRT following an IBR between 2010 and 2022. Patients were treated with PMRT of 50.0-50.4 Gy in 25-28 fractions. Capsular contracture was categorized according to the Baker Classification for Reconstructed Breasts.

RESULTS

After a median follow-up of 22 months, the incidence of clinically relevant capsular contracture (Baker III-IV) was 22.9%. Overall, capsular contracture (Baker I-IV) occurred in 56 patients (47.5%) after a median of 9 months after PMRT. The rate of reconstruction failure/implant loss was 25.4%. In the univariate analysis, postoperative complications (prolonged pain, prolonged wound healing, seroma and swelling) and regional nodal involvement were associated with higher rates of capsular contracture (p = 0.017, OR: 2.5, 95% CI: 1.2-5.3 and p = 0.031, respectively). None of the analyzed dosimetric factors or the implant position were associated with a higher risk for capsular contracture.

CONCLUSION

Postoperative complications and regional nodal involvement were associated with an increased risk of capsular contracture following breast reconstruction and PMRT, while none of the analyzed dosimetric factors were linked to a higher incidence. Additional studies are needed to identify further potential risk factors.

Risk Factors for Capsular Contracture in Alloplastic Reconstructive and Augmentation Mammaplasty: Analysis of the National Surgical Quality Improvement Program (NSQIP) Database

BACKGROUND

Capsular contracture is the most common complication of breast augmentation and reconstruction. It occurs in up to 45% of patients and is theorized to occur secondary to an immune reaction. It can lead to pain, dissatisfaction with aesthetic outcomes, and reoperation. The gold standard for management is capsulectomy. Prior similar studies are limited by narrow inclusion criteria, single-surgeon analysis, small sample size, or univariate analysis. The goal of the following study is to prospectively identify possible risk factors for capsular contracture using a national database.

METHODS

A retrospective review was conducted utilizing the National Surgical Quality Improvement Program (NSQIP) Database of prospectively collected data of patients undergoing periprosthetic and/or total capsulectomy for capsular contracture from 2013 to 2016. Odds ratios (OR) with 95% confidence intervals (CI) were calculated for variables using a multivariable binary logistic regression model.

RESULTS

A total of 6547 patients underwent reconstructive or augmentation mammaplasty with a prosthetic implant, out of which 2543 (39%) underwent capsulectomy. Capsular contracture was more likely in older (OR: 1.10, 95% CI: 1.09-1.10, p<.001), overweight (OR: 1.12, 95% CI: 1.10-1.13, p<.001), and cancer patients (OR: 7.71, 95% CI: 2.22-28.8, p=0.001). Wound infection was associated with capsulectomy (OR: 6.69, 95% CI: 1.74-25.8, p<.001).

CONCLUSION

These identified risk factors should be comprehensively addressed with patients during the informed consent process before breast augmentation or reconstruction with implants.

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 .

Matrix Metalloproteinase-9 as a Potential Biomarker in 631 Human Implant-Induced Fibrotic Capsules: Analysis and Biomarker Study

BACKGROUND

Capsular fibrosis (CF) often occurs around biomedical devices following implantation causing pain, discomfort, and device failure. Breast implantation remains among the most common medical procedures worldwide. Revealing specific genes that drive fibrotic deposition will help us to garner a better understanding of the pathophysiology of this disease and develop different strategies to combat it.

METHODS

The authors collected 631 capsules around breast implants and were able to connect clinical baseline characteristics with histopathologic findings. In addition, the authors were able to conduct the first large systematic analysis to identify differentially expressed genes in fibrotic human tissue samples, comparing the lowest form of fibrosis with the most aggravated one.

RESULTS

The authors identified 2559 differentially expressed genes on which they performed a knowledge-based network generation and pathway association study to identify putative novel biomarkers for CF. The authors were able to show changes of cellular influx during progression of CF and distinguish several genes as potential clinical biomarkers and drug targets. Among these, matrix metalloproteinase-9 was one of the most up-regulated ( P = 0.006) and is attractive because of its wide detectability.

CONCLUSIONS

Matrix metalloproteinase-9 seems to be a potential biomarker to detect capsular fibrosis. It is a measurable indicator that can easily be detected in blood, sputum, and urine. For the diagnosis of fibrosis, this biomarker might be exceedingly beneficial to developing novel screening methods and prophylaxes.

CLINICAL RELEVANCE STATEMENT

Discovering biomarkers at the earliest and mildest stages for the diagnosis of fibrosis is clinically important. These results bring new hope for biomarker-based diagnosis for capsular fibrosis.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Diagnostic, V.

The Impact of Botulinum Toxin Injection on the Outcomes of Breast Surgeries: A Systematic Review and Meta-Analysis

BACKGROUND

Breast surgeries aim to restore the natural appearance of the breasts with acceptable functional and cosmetic outcomes. However, these surgical procedures may be associated with considerable adverse events. The present systematic review and meta-analysis was designed to reveal the functional and aesthetic outcomes of botulinum toxins (BTX) injection in patients subjected to breast surgeries.

METHODS

A literature review was performed up to 21 September 2022. All clinical studies included patients older than 18 years old and treated with BTX injection for breast surgeries were included.

RESULTS

The present study included 12 articles, encompassing 496 patients. The average dosage of BTX injection ranged from 20 to 100 units. Injecting BTX significantly reduced the mean post-operative opioid analgesics usage (SMD -1.577; 95% -2.087, -1.067; P < 0.001) and the risk of severe animation deformity (RR 12.37; 95% 1.76, 86.66; P = 0.01). There was a statistically significant higher mean expansion volume per visit in the BTX injection group (SMD 1.166; 95% 0.313, 2.018; P = 0.007). There was no statistically significant impact of BTX injection on the risk of surgical site infection (RR 0.59; 95% 0.15, 2.34; P = 0.45) and seroma (RR 0.51; 95% 0.03, 10.15; P = 0.66).

CONCLUSIONS

The present study revealed the potential benefits of BTX injection in breast surgeries. This included reduced post-operative analgesics, as well as the risk of severe animation deformity. This was accomplished with increased expansion volume per visit and a similar risk of BTX injection-related complications.

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 .

Exploring the Overlooked Roles and Mechanisms of Fibroblasts in the Foreign Body Response

Significance: Foreign body response (FBR), wherein a fibrotic capsule forms around an implanted structure, is a common surgical complication that often leads to pain, discomfort, and eventual revision surgeries. Although believed to have some mechanistic overlap with normal wound healing, much remains to be discovered about the specific mechanism by which this occurs. Recent Advances: Current understanding of FBR has focused on the roles of the immune system and the biomaterial, both major contributors to FBR. However, another key player, the fibroblast, is often overlooked. This review summarizes key contributors of FBR, focusing on the roles of fibroblasts. As much remains to be discovered about fibroblasts' specific roles in FBR, we draw on current knowledge of fibroblast subpopulations and functions during wound healing. We also provide an overview on candidate biomaterials and signaling pathways involved in FBR. Critical Issues and Future Directions: While the global implantable medical devices market is considerable and continues to appreciate in value, FBR remains one of the most common surgical implant complications. In parallel with the continued development of candidate biomaterials, further exploration of potential fibroblast subpopulations at a transcriptional level would provide key insights into further understanding the underlying mechanisms by which fibrous encapsulation occurs, and unveil novel directions for antifibrotic and regenerative therapies in the future.

Angiogenic Modification of Microfibrous Polycaprolactone by pCMV-VEGF165 Plasmid Promotes Local Vascular Growth after Implantation in Rats

Insufficient vascular growth in the area of artificial-material implantation contributes to ischemia, fibrosis, the development of bacterial infections, and tissue necrosis around the graft. The purpose of this study was to evaluate angiogenesis after implantation of polycaprolactone microfiber scaffolds modified by a pCMV-VEGF165-plasmid in rats. Influence of vascularization on scaffold degradation was also examined. We investigated flat microfibrous scaffolds obtained by electrospinning polycaprolactone with incorporation of the pCMV-VEGF-165 plasmid into the microfibers at concentrations of 0.005 ng of plasmid per 1 mg of polycaprolactone (0.005 ng/mg) (LCGroup) and 0.05 ng/mg (HCGroup). The samples were subcutaneously implanted in the interscapular area of rats. On days 7, 16, 33, 46, and 64, the scaffolds were removed, and a histological study with a morphometric evaluation of the density and diameter of the vessels and microfiber diameter was performed. The number of vessels was increased in all groups, as well as the resorption of the scaffold. On day 33, the vascular density in the HCGroup was 42% higher compared to the control group (p = 0.0344). The dose-dependent effect of the pCMV-VEGF165-plasmid was confirmed by enhanced angiogenesis in the HCGroup compared to the LCGroup on day 33 (p-value = 0.0259). We did not find a statistically significant correlation between scaffold degradation rate and vessel growth (the Pearson correlation coefficient was ρ = 0.20, p-value = 0.6134). Functionalization of polycaprolactone by incorporation of the pCMV-VEGF165 plasmid provided improved vascularization within 33 days after implantation, however, vessel growth did not seem to correlate with scaffold degradation rate.

Chronic pain in breast cancer patients post mastectomy with alloplastic reconstruction: A scoping review

INTRODUCTION

Women diagnosed with breast cancer are receiving mastectomy with implant-based reconstruction at an increasing rate. Chronic post-surgical pain can be a major concern for these patients. This review sought to address the knowledge gap on the prevalence, severity and characteristics of chronic pain in this population.

METHODS

A scoping review was conducted using the Arksey and O'Malley framework. Five databases were searched using keywords. Two independent reviewers performed selection and data extraction of studies that met inclusion criteria.

RESULTS

Seventeen studies were included in this review. Ten studies reported prevalence of chronic pain which ranged from 7.3%-90.9% with pooled prevalence of 26.3%. Nine studies reported severity of chronic pain using various scales and methodology; most patients' pain was not severe. Risk factors for chronic pain included axillary dissection, lack of perioperative local anaesthetic, younger age and use of a tissue expander. No studies reported on possible correlation between ethnicity and pain. Eleven different assessment tools were used to measure pain.

CONCLUSION

Chronic pain following post-mastectomy implant-based breast reconstruction is prevalent, associated with specific risk factors and poorly characterised. There is a need to investigate and evaluate chronic pain in this population using validated breast cancer specific pain assessment tools.

Smooth versus Textured Implants and Their Association with the Frequency of Capsular Contracture in Primary Breast Augmentation

BACKGROUND

Capsular contracture is the most frequent complication of breast implant augmentation. Although studies indicate that textured implants have a low incidence of contracture, they have been associated with anaplastic cell lymphoma, which influences the choice of surface. This study estimated and compared the annual capsular contracture rate of both smooth and textured implants in primary breast implants.

METHODS

Two hundred fifty-three patients (506 implants) were evaluated from January of 2017 to July of 2019; 42.2 percent of the implants were smooth and 57.8 percent were textured. The inframammary approach was used in the subfascial (55.3 percent) and submuscular (44.7 percent) pockets. The primary outcome was the appearance of capsular contracture (Baker grade II, III, and IV) within the first postoperative year.

RESULTS

Smooth implants had a higher capsular contracture rate at 1 year postoperatively compared with textured implants, although with borderline statistical significance (p = 0.06). Smooth surface breast implants in the subfascial plane had a 4-fold higher risk of contracture than those with a textured surface in the same plane (OR, 4.4; 95 percent confidence interval, 1.6 to 12.4). However, when placed in the submuscular plane, both textures had a similar contracture risk. The rate of contracture was similar after 2 years postoperatively (p = 0.21).

CONCLUSIONS

Using the inframammary approach and a standardized technique, there were no significant differences in the incidence of capsular contracture between the smooth and textured implants. In the subfascial plane, the contracture rate with smooth implants was higher than with textured implants. However, in the submuscular plane, there was no difference between the surfaces.

CLINICAL QUESTION/LEVEL OF EVIDENCW

Therapeutic, III.

The botulinum neurotoxin for pain control after breast reconstruction: neural distribution of the pectoralis major muscle

INTRODUCTION

The use of the botulinum neurotoxin injection is a growing area of research and clinical activity, with a focus on its role in facilitating postoperative pain management after reconstructive breast surgery. The study aimed to find out the standard injection points for botulinum neurotoxin injection by revealing the intramuscular nerve arborization of the pectoralis major.

METHODS

Sihler's technique was conducted on the pectoralis major muscles (16 cadaveric specimens). The intramuscular nerve arborization was documented relative to the inferior border of the clavicle bone and lateral border of the sternum.

RESULTS

After the staining, the pectoralis major was divided into fifths transversely from the inferior border of the clavicle and vertically into fifths from the lateral border of the sternum. Intramuscular nerve arborization of the pectoralis major muscle was the largest in the middle sections of the muscle belly.

DISCUSSION

The results indicate that botulinum neurotoxin should be applied to the pectoralis major in certain regions. The regions of major arborization are optimal as the most effective and most reliable points for injecting botulinum neurotoxin.

Rinse But Don't Repeat: Single Application V.A.C. VERAFLO Salvages Infected Breast Prostheses

Introduction

Existing salvage protocols for infected breast prostheses using negative pressure wound therapy with instillation and dwell (NPWTi-d) require multiple returns to the operating room and prolonged length of stay. We present our expedited salvage protocol and discuss outcomes and associated costs savings.

Methods

Using a retrospective review, we identified 25 consecutive patients (27 breasts) with peri-prosthetic breast infection. Nine patients (10 breasts) underwent removal of infected breast prostheses followed by autologous or staged implant-based reconstruction. Sixteen patients (17 breasts) underwent our single application salvage protocol. A cost analysis was performed comparing the two groups, and an economic model was used to project the cost savings associated with using single application NPWTi-d protocol.

Results

Fifteen of the 16 patients (94%) who underwent single application NPWTi-d had successful implant salvage. Average duration of NPWTi-d was 2 days, 7 hours, and average length of stay was 4.43 days. Compared to control, patients who received the single application protocol required significantly fewer hospitalizations and office visits. A total savings of $58,275 could have been achieved by using the single application NPWTi-d protocol in the patients who did not undergo NPWTi-d.

Conclusions

Single application of NPWTi-d is a simple, safe, and cost-effective technique for salvage of breast prostheses, with 94% success rate, even in immunocompromised patients and severe infection. Compared to previous protocols, ours requires fewer trips to the operating room, shorter length of stay, and more permanent implants placed during salvage. Our protocol is also associated with fewer office visits and fewer returns to the operating room.

Functionalization of Silicone Surface with Drugs and Polymers for Regulation of Capsular Contracture

Breast reconstruction is achieved using silicone implants, which are currently associated with major complications. Several strategies have been considered to overcome the existing limitations as well as to improve their performance. Recently, surface modification has proved to be an effective clinical approach to prevent bacterial adhesion, reduce capsular thickness, prevent foreign body reactions, and reduce other implant-associated problems. This review article summarizes the ongoing strategies for the surface modification of silicone implants in breast reconstruction applications. The article mostly discusses two broad categories of surface modification: drug-mediated and polymer-based. Different kinds of drugs have been applied with silicone that are associated with breast reconstruction. Initially, this article discusses studies related to drugs immobilized on silicone implants, focusing on drug-loading methods and their effects on capsule contracture. Moreover, the pharmacological action of drugs on fibroblast cells is considered in this section. Next, the polymeric modification of the silicone surface is introduced, and we discuss its role in reducing capsule thickness at the cellular and biological levels. The polymeric modification techniques, their chemistry, and their physical properties are described in detail. Notably, polymer activities on macrophages and inflammation are also briefly discussed. Each of the reviewed articles is summarized, highlighting their discussion of capsular thickness, foreign body reactions, and bacterial attachment. The aim of this review is to provide the main points of some research articles regarding the surface modification of silicon, which can lead to a decrease in capsular thickness and provides better patient compliance.

Silicone Breast Implant Coated with Triamcinolone Inhibited Breast-Implant-Induced Fibrosis in a Porcine Model

Cosmetic silicone implants for breast reconstruction often lead to medical complications, such as abnormally excessive fibrosis driven by foreign body granulomatous inflammation. The purpose of this study was to develop a silicone breast implant capable of local and controlled release of a glucocorticoid drug triamcinolone acetonide (TA) for the prevention of silicone-breast-implant-induced fibrosis in a Yorkshire pig model (in vivo). Implants were dip-coated in a TA solution to load 1.85 μg/cm² of TA in the implant shell, which could release the drug in a sustained manner for over 50 days. Immunohistochemical analysis for 12 weeks showed a decline in tumor necrosis factor-α expression, capsule thickness, and collagen density by 82.2%, 55.2%, and 32.3%, respectively. Furthermore, the counts of fibroblasts, macrophages, and myofibroblasts in the TA-coated implants were drastically reduced by 57.78%, 48.8%, and 64.02%, respectively. The TA-coated implants also lowered the expression of vimentin and α-smooth muscle actin proteins, the major profibrotic fibroblast and myofibroblast markers, respectively. Our findings suggest that TA-coated silicone breast implants can be a promising strategy for safely preventing fibrosis around the implants.

Long-term outcomes of two-stage, immediate and delayed breast reconstruction with polyurethane-covered versus textured implants: protocol of a prospective, multicentre randomised controlled trial (TIPI trial)

INTRODUCTION

Two-stage implant-based breast reconstruction is the most commonly performed postmastectomy reconstructive technique. During the first stage, a tissue expander creates a sufficiently large pocket for the definite breast implant placed in the second stage. Capsular contracture is a common long-term complication associated with implant-based breast reconstruction, causing functional complaints and often requiring reoperation. The exact aetiology is still unknown, but a relationship between the outer surface of the implant and the probability of developing capsular contracture has been suggested. The purpose of this study is to determine whether polyurethane-covered implants result in a different capsular contracture rate than textured implants.

METHODS AND ANALYSIS

The Textured Implants versus Polyurethane-covered Implants (TIPI) trial is a multicentre randomised controlled trial with a 1:1 allocation rate and a follow-up of 10 years. A total of 321 breasts of female adults undergoing a two-stage breast reconstruction will be enrolled. The primary outcome is capsular contracture at 10-year follow-up which is graded with the modified Baker classification. It is analysed with survival analysis using a frailty model for clustered interval-censored data, with both an intention-to-treat and per-protocol approach. Secondary outcomes are other complication rates, surgical revision rate, patient satisfaction and quality of life and user-friendliness. Outcomes are measured 2 weeks, 6 months, 1, 2, 3, 5 and 10 years postoperatively. Interim analysis is performed when 1-year, 3-year and 5-year follow-up is completed.

ETHICS AND DISSEMINATION

The trial has been reviewed and approved by the Medical Research Ethics Committee of the Erasmus MC, University Medical Centre Rotterdam (MEC-2018-126) and locally by each participating centre. Written informed consent will be obtained from each study participant. The results will be disseminated by publication in peer-reviewed journals.

TRIAL REGISTRATION

NTR7265.

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.

A Systematic Review of Breast Irrigation in Implant-Based Breast Surgery

BACKGROUND

Aesthetic and reconstructive implant-based breast surgeries are some of the most frequently performed procedures by plastic surgeons. As such, prevention of implant infection is of high importance. However, there remains no criterion-standard protocol for irrigation of the breast pocket. This review focuses on current irrigation practices in implant-based breast surgery.

METHODS

Four databases were used to search for all studies, including randomized controlled trials, retrospective cohort, and prospective cohort, containing original data related to the outcomes investigated in this study. Search terms included "breast," "irrigation," and "infection" in different combinations to isolate studies that focused on irrigation methods in both reconstructive and augmentation surgeries. Our selection criteria specifically concentrated on those studies that explicitly related irrigation procedures to rates of clinical infection and/or capsular contracture. Each was compiled into a table in chronological order to make comparisons between the differing irrigation methods.

RESULTS

Our search returned 239 full-text articles eligible for our review. Two independent screeners identified 9 studies that met the inclusion criteria. This included 1 prospective study and 8 retrospective studies. Two studies reported the use of chlorhexidine gluconate irrigation resulting in protection from clinical infection. Two studies investigated the role of triple antibiotic solution (TAS) either alone or combined with something else on risk of infection, and 3 reported TAS use on rates of capsular contracture. Two additional studies investigated the role of single antibiotic irrigation, concluding that some antibiotic regimen for irrigation may be sufficient in the breast pocket. Interestingly, one study noted the potential use of povidone-iodine (Betadine) as a method of irrigation.

CONCLUSIONS

These data suggest that chlorhexidine gluconate, Betadine, and TAS irrigation of the breast pocket can provide protection against infection and implant loss in both reconstruction and augmentation surgeries.

Capsular contracture in the modern era: A multidisciplinary look at the incidence and risk factors after mastectomy and implant-based breast reconstruction

BACKGROUND

Capsular contracture causes pain, poor cosmesis, and reoperations. This study analyzes its incidence and risk factors in a more modern treatment era.

METHODS

Patients undergoing mastectomy with implant reconstruction from 2010 to 18 were reviewed. Univariate and multivariate analysis evaluated rates and risk factors for capsular contracture.

RESULTS

Among 451 patients, the majority underwent nipple-sparing mastectomy (262, 58.1%) with one-stage reconstruction (283, 62.7%) utilizing subpectoral implants (353, 77.4%) and acellular dermal matrix (354, 78.5%). Overall capsular contracture incidence was 9.8%; the rate after post-mastectomy radiation therapy (PMRT) was 18.7%, and 7.5% for patients without PMRT. Significant factors included neoadjuvant chemotherapy (P = 0.006), hematoma (P = 0.047), and PMRT (P = 0.001). Multivariate analysis showed that PMRT increased risk of capsular contracture (OR = 3.12, 95% CI 1.55-6.26, P = 0.001), and adjuvant chemotherapy was protective (OR = 0.289, 95% CI 0.114-0.731, P = 0.01).

CONCLUSIONS

Incidence of capsular contracture is lower than previously reported. Advancing therapeutic techniques may reduce the risk of this complication.

Silicone Induced Granuloma of Breast Implant Capsule (SIGBIC) diagnosis: Breast Magnetic Resonance (BMR) sensitivity to detect silicone bleeding

Objective

To evaluate the sensitivity (S) of BMRI to detect silicone gel bleeding in a prospective observational study, including consecutive patients referred for BMRI scan.

Methods

From January 2017 to March 2018, we evaluated patients with breast implants referred for BMRI in a prospective observational study. For SIGBIC diagnosis, we adopted three new original imaging features: black drop signal; T2* hyper signal mass; and delayed contrast enhancement, considered as irrevocable signs to detect gel bleeding (GB). Histology confirmed the presence of a silicone corpuscle in breast implant capsular specimens. The accuracy of BMRI SIGBIC findings to predict GB was determined. We also compared SIGBIC diagnosis criteria to those features proposed by the BI-RADS léxicon, considered as equivocal findings.

Results

208 patients had SIGBIC diagnosis at BMRI, and the histology confirmed GB in all cases. There were no false-positive results. Compared to the BI-RADS equivocal findings (S = 0.74), SIGBIC criteria had better sensitivity for GB diagnosis.

Conclusion

SIGBIC diagnosis has high sensitivity to predict GB by the three irrevocable BMRI features described by the authors. We suppose GB is underdiagnosed in clinical practice by BI-RADS features.

Trial certification

Study protocol: Plataforma Brasil CAAE: 77215317.0.0000.0072.

Comparative clinical evaluation of breast augmentation using silicone foam coated implants and textured implants

PURPOSE

To evaluate whether silicone foam implants have a different evolution pattern compared to conventional texture implants.

METHODS

Fifty-eight female patients underwent surgery. They were divided into two groups (silicone foam - Lifesil® - and microtexturized silicone - Lifesil®). The evolution was analyzed in postoperative consultations, with physical examination, photographic documentation and filling in a satisfaction questionnaire, in the postoperative period of one month, four months, one year and then annually, up to a maximum of 3 years of follow-up.

RESULTS

There were no statistically significant differences in presence of rippling, stretch marks, breast ptosis, capsular contracture and quality of scars. There was a higher rate of patients who were very satisfied with the outcome 360 days after surgery in the group receiving silicone foam implants (p = 0.036).

CONCLUSION

In short time, silicone foam envelope implants proved to be as reliable as textured silicone envelope implants, making them an option for augmentation mammoplasty.

Long-term impact of lipofilling in hybrid breast reconstruction: retrospective analysis of two cohorts

Lipofilling has recently gained popularity as a tool in primary treatment of breast cancer, and its association with two-stage implant breast reconstruction is considered as standard treatment in many centers. However, no data are available about the long-term results of the association of lipofilling in combination with expander-implant reconstruction. A retrospective analysis was conducted on patients treated between January 2010 and December 2014. Two groups were compared. Group 1 had a standard expander-implant two-stage reconstruction. Group 2 underwent hybrid breast reconstruction (HBR). Patient characteristics, hospitalization, outcomes, reoperation details, outpatient visits, and evaluation questionnaires were taken into consideration. Intergroup comparison was performed using Wilcoxon Mann-Whitney U test and Pearson’s chi-square test or Fisher’s exact test for categorical variables. Two hundred fourteen patients were evaluated: 130 patients in group 1 and 84 patients in group 2. Group 2 showed significant benefits over group 1 in terms of capsular contracture rate, breast pain, and displacement/rotation of the implant (p = 0.005). The HBR protocol is associated with lower rate of capsular contracture, less breast pain at long follow-up times, and lower overall rates of revision surgery compared to standard expander-implant reconstruction. A specific cost analysis will help further clarify the advantages of this protocol over a standard procedure.

Level of Evidence: Level III, risk/prognostic, therapeutic study.

New Evaluation Procedure for Multi-Dimensional Mechanical Strains and Tangent Moduli of Breast Implants: IDEAL IMPLANT® Structured Breast Implant Compared to Silicone Gel Implants

The IDEAL IMPLANT^® Structured Breast Implant is a dual lumen saline-filled implant with capsular contracture and deflation/rupture rates much lower than single-lumen silicone gel-filled implants. To better understand the implant’s mechanical properties and to provide a potential explanation for these eight-year clinical results, a novel approach to compressive load testing was employed. Multi-dimensional strains and tangent moduli, metrics describing the shape stability of the total implant, were derived from the experimental load and platen spacing data. The IDEAL IMPLANT was found to have projection, diametric, and areal strains that were generally less than silicone gel implants, and tangent moduli that were generally greater than silicone gel implants. Despite having a relatively inviscid saline fill, the IDEAL IMPLANT was found to be more shape stable compared to gel implants, which implies potentially less interaction with the capsule wall when the implant is subjected to compressive loads. Under compressive loads, the shape stability of a higher cross-link density, cohesive gel implant was unexpectedly found to be similar to or the same as a gel implant. In localized diametric compression testing, the IDEAL IMPLANT was found to have a palpability similar to a gel implant, but softer than a cohesive gel implant.

Silicone breast implant modification review: overcoming capsular contracture

Background

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

Main body

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

Conclusion

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

Botulinum Toxin A Plays an Important Role in the Placement of Implants Deep Within the Pectoralis Major Muscle for Mammaplasty: A Systematic Review and Meta-analysis

BACKGROUND

Breast prosthesis implants have been safely and efficiently used in the plastic surgery department. With the increasing demand for aesthetics, these silicon implants were not only used in breast augmentation surgery but also in breast reconstruction after mastectomy. Nevertheless, breast prosthesis implantation brings a lot of complications, such as: postoperative chronic pain, capsule contracture, prosthesis displacement and prosthesis rupture and infection in severe cases. From the year 1998, botulinum toxin A (BTX-A), a neurotoxin, has been reported to be effective for pain control, capsule contracture lessening, expander enlargement and so on. However, those articles included all kinds of study types: randomized, double-blinded controlled trial (RCT), nonrandomized trial, retrospective analysis and case series, besides the outcomes were varied. To clarify how BTX-A acts at the mammaplasty field, we made this systematic review and meta-analysis.

PURPOSE

To review how BTX-A acts in the field of mammaplasty as well as discuss the relative mechanisms of BTX-A and the related research progress.

METHODS

We searched Pubmed, Embase, Cochrane, Web of science, Clinical trials, Wanfang Database and VIP from inception until March 2018 for papers reporting the use of BTX-A in the breast surgery using implants deep within the pectoralis major muscle. System review, viewpoints and case reports were excluded.

RESULTS

Ten articles met the criteria for inclusion including six prospective controlled (2 RCT; 4 other trails), three retrospective cohorts and one case series. These studies were all about patients using BTX-A during or after breast surgery with expanders or prostheses. A total of 682 patients were enrolled, 543 (79.61%) accepted BTX-A injection, 185 underwent mastectomies with immediate reconstruction, 13 with delayed reconstruction, 295 mastectomies with either immediate or delayed reconstruction and 189 with breast augmentation using silicone prostheses. The study time ranging from 4 months to 13 years, 15 patients (2.76%) received BTX-A injection more than two times, 9.2% received less than 75 U BTX-A, 34.3% 75-100 U, 0.18% 250 U, and in 56.4% the dosage was not stated. No complications associated with BTX-A were mentioned, almost all the studies reported efficacy for pain control. Other assessments included increased speed of expander enlargement and volume were mentioned in four papers, two articles analyzed the visual analogue scores, three suggested relief of capsular contracture, two reported lower narcotic use, three mentioned shorter hospital stays and one proved lowering the rate of unplanned expander. It seems all the studies demonstrate the valid usage of BTX-A, but the quality of this evidence still under the line.

CONCLUSION

We could try to use BTX-A as a new method in the field of mammaplasty. There are so many advantages such as postoperative pain relief, reducing the hospital stay, and increasing operation success rate, but rigorous methodological evidence is still lacking. A lot of studies were retrospective, only two studies used the RCT method. Therefore, to obtain strong evidence to clarify the usage of BTX-A, more randomized double-blinded controlled trials will be required, meanwhile the mechanism study adds to the evidence.

LEVEL OF EVIDENCE III

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A murine model of radiation-induced capsule-tissue reactions around smooth silicone implants

As the availability of breast reconstruction using implants is becoming widespread and many implant recipients undergo radiation therapy, there is an increasing interest in understanding the potential complications associated with capsule-tissue interactions in response to irradiation. Accordingly, our medical institution designed an animal experiment to investigate the effects of irradiation on capsular contracture. A total of 40 mice (C57BL6) were divided into four groups according to whether or not they received irradiation and the time from implantation to irradiation. After each mouse received a specially-fabricated, 1.5 cm semi-spherical silicone implant inserted into the area below the panniculus carnosus, half of the mice were irradiated using singe administration of a 10 Gy dose of radiation (6 MeV). Subsequently, data from gross inspection, histological analysis and immunohistochemical analysis were obtained at one and three months postoperatively and analyzed. Changes that occurred near the capsule led to the phenomenon of contracture subsequent to encapsulation. Our findings suggest that the inflammation reaction occurring near the implant becomes aggravated by 'radiation toxicity' and creates an environment conducive to capsular contracture. The present study demonstrated the process by which the complication of capsular contracture may occur during the treatment of human breast cancer via radiotherapy. These findings may serve as the basis for research and development of future treatments of capsular contracture.