The Polyurethane-Covered Mammary Prosthesis: Facts and Fiction (II)

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 .

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.

Polyurethane Implants in 2-Stage Breast Reconstruction: 9-Year Clinical Experience

BACKGROUND

Capsular contracture (CC) is a major complication of breast surgery with smooth and textured implants. Polyurethane (PU) foam-coated breast implants were developed to decrease the incidence of CC.

OBJECTIVES

The authors determined the incidence of CC following 2-stage breast reconstruction using PU foam-covered implants, with and without radiation therapy.

METHODS

The records of 92 patients who received 115 PU implants were retrospectively reviewed. The rates of CC over time were compared for irradiated and nonirradiated groups with a Kaplan-Meier analysis and log-rank test. CC rates also were analyzed with respect to age.

RESULTS

The median follow-up time for patients was 103.3 months. Nine patients experienced unilateral Baker grade III or IV fibrous CC, including 6 patients from the irradiated group and 3 patients from the nonirradiated group. The overall cumulative incidence of CC at 9 years was 8.1%. In the irradiated and nonirradiated groups, the 9-year cumulative incidence was 10.7% and 5.5%, respectively. CC occurred within 3 years in the irradiated group and within 7 years in the nonirradiated group. The incidence of CC appeared to be higher among younger patients.

CONCLUSIONS

Radiation therapy increases the risk of high-grade CC with textured or smooth implants. PU implants are associated with a much lower cumulative incidence of CC following 2-stage breast reconstruction, even when radiotherapy is performed. LEVEL OF EVIDENCE 3.

The Use of "Precapsular Space" in Secondary Breast Reconstruction

BACKGROUND

Periprosthetic capsule formation is a physiological phenomenon occurring around breast implants. In case of capsular contracture, several surgical techniques are described; among them, total capsulectomy is considered the gold standard, but it is not free of complications. A more conservative procedure is the use of "precapsular space", leaving intact the preexisting capsule. The method presents minor complications and further advantages over total capsulectomy.

METHOD

From November 2010 to June 2014, we treated 92 postmastecttomy patients who previously underwent implant-based reconstruction. They presented implant malposition (bottoming-out, double bubble deformity, upward migration) and different degrees of capsular contracture. The implant was repositioned in a neoprecapsular pocket. Sixty-eight out of 92 patients presented a follow-up longer than 24 months, and they are included in the present study. They were evaluated with a questionnaire 1 month before surgery, at 6 months and 2 years postoperatively. Moreover, two independent plastic surgeons completed the same questionnaire at 6 months and 2 years after surgery.

RESULTS

Mean follow-up is 29 months. Baker III-IV capsular contracture occurred in 9.5 % of the patients, implant malposition in 2.9 % of the cases and no implant displacement rotation was observed. Patient self-assessment preoperatively and postoperatively (at 2 years) revealed improved cosmetic outcomes (p < 0.01). Surgeon assessment correlated with patient self-assessment.

CONCLUSION

The use of precapsular space, first described for aesthetic augmentation, is a valid alternative to total capsulectomy for the treatment of capsular contracture or implant malposition, even in the reconstructive field.

LEVEL OF EVIDENCE IV

This journal requires that the 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 .

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

Capsular contracture remains a common and preventable complication of implanted breast prostheses. As our understanding of the pathophysiology continues to develop, it is prudent to reexamine existing beliefs in a contemporary context. This article presents a current summary of clinical and laboratory evidence, expressed as an interaction between potentiating and suppressing factors, and how this understanding can be applied to practice.

The effect of a bacterial contamination on the formation of capsular contracture with polyurethane breast implants in comparison with textured silicone implants: an animal study

INTRODUCTION

One of the most common complications following breast augmentation is capsular contracture. The subclinical infection of the implant is often considered to be one of the main risk factors. It is believed that polyurethane (PU) implants, because of their larger foam-like surface, have lower capsular contracture rates due to better tissue integration. It remains unclear if bacterial contamination and biofilm formation result in higher capsular contracture rates under the condition of the increased surface of PU implants compared to textured silicone-gel implants. The effect of this bacterial contamination was examined in an animal-based study.

METHODS

A total of 80 mini implants (40 textured silicone-gel implants and 40 PU implants) were implanted in the dorsum of female Wistar rats. In each group, 20 implants were inoculated before implantation with a standard amount of Staphylococcus epidermidis. Capsules and implants were explanted after 60 days, followed by double-blind histological, immunohistochemical, and microbiological examinations.

RESULTS

Macroscopic separation of the total capsule in the textured implant group was possible whereas the growth of surrounding tissue into the foam structure of PU implants made separation in that group difficult. After contamination, a thicker capsule could be observed in both groups without significant differences. Histologically, capsules around PU implants showed significantly lower expression of parallel myofibrils. We were able to describe a significant higher infiltration with inflammatory cells in capsules around PU implants both with and without contamination. Microbiological investigations revealed positive growth of S. epidermidis around one PU implant without related signs of capsular contracture.

DISCUSSION

This study demonstrates that aside from the surface of silicone implants, bacterial contamination has major impact on the architecture of capsule formation. In our study, we were able to demonstrate that bacterial contamination leads to a thicker capsule and an increased tissue reaction with a higher amount of inflammatory cells. However, a resulting bacterial infection was only demonstrated in one case and had an insignificant influence on capsule architecture. The observed inflammatory reaction around PU implants was observed as a nonbacterial, granulomatose foreign body reaction.

EBM RATING

Level I: Evidence obtained from at least one properly designed randomized controlled trial.

Biomimetic polyurethanes in nano and regenerative medicine

Nature's inspiration is a promising tool to design new biomaterials especially for frontier technological areas such as tissue engineering and nanomedicine.

Conical polyurethane implants: an uplifting augmentation

BACKGROUND

Polyurethane-coated conical implants were introduced by Silimed (US distributor: Sientra, Santa Barbara, California) in 2008 and offer an alternative to round or anatomically shaped implants. By their design and volume distribution, they naturally create central volume and give a reasonable fullness to the upper pole while lifting some ptotic breasts, thus avoiding the need for classical mastopexy.

OBJECTIVES

The authors discuss the advantages of conical implants as an alternative to conventional silicone implants for women with breast ptosis.

METHODS

In the 2-year period between December 2010 and December 2012, a consecutive series of 302 women underwent implant-based breast surgery procedures (236 primary augmentations, 59 revisions, and 7 mastopexy-augmentations) with conical polyurethane devices. Implant volumes ranged from 225 to 560 cc, with low- to medium-profile devices predominating. No extra-high-profile implants were used. Only 1 patient had a drain inserted on completion of a revision augmentation.

RESULTS

There were no infections (0%) and no wound dehiscence (0%). Four cases required reoperation (1.3%). Patient satisfaction scores were universally high (average, 9.94/10). There have been no capsular contractures to date, but follow-up is short.

CONCLUSION

The modern conical, polyurethane implant has many advantages over the conventional round or anatomically shaped implants and offers patients an ideal compromise between volume, natural upper pole fullness, and a lift without mastopexy scars.

Breast implants: saline or silicone?

The United States has seen significant shifts in the breast implant market over the past five decades. From the moratorium on silicone gel breast implants in 1992 to their approval in 2006, there have been many developments in their manufacturing and usage. Meanwhile, saline breast implants have remained somewhat unchanged, still offering a few distinct advantages but none of the technological innovation of the silicone gel models. In this article, the authors review the current state of silicone gel and saline implants, as well as the advantages and disadvantages of each. Much of the current data on complications of gel and saline implants are examined, as well as some practical implications associated with the use of each implant type.

Possible future development of implants and breast augmentation

Since the introduction of the silicone gel prosthesis in 1962, breast augmentation has become one of the most frequently performed operations in plastic surgery. As we strive for perfect results, it is important to continue to gather and review data evaluating innovative techniques and devices. Now we even have more options available for breast augmentation, whether we use them in combination or alone. By combining all of the available options (acellular dermal matrix products, silicone implant, fat grafting), we have been able to create "bioengineered breasts" with high patient and surgeon satisfaction. As always in plastic surgery, our concern is with safety; as newer technology and products are introduced to us, patient education, consent, and follow-up remain important.

Voies de recherche pour la mise au point de nouvelles prothèses mammaires

Despite the improvement of breast implant quality across the last decade, the perfect implant does not exist. Therefore research should manage to improve those implants. In this article we have tried to identify different directions to investigate for better prosthesis: improvement of the shell, the filling and the form. Moreover, other targets as fat transfer or other permanent soft tissue filler also need further experimental and clinical investigation.