Microbial Evaluation in Capsular Contracture of Breast Implants:

Bacterial Lipoteichoic Acid Induces Capsular Contracture by Activating Innate Immune Response

BACKGROUND

Capsular contracture is attributed to an exaggerated fibrosis response within the capsule and is partly associated with bacterial contamination in situ. However, the cellular mechanisms that initiate this response are unclear.

METHODS

The authors developed a mouse model of capsular contracture by repeated injection of 10 μg/mL lipoteichoic acid (LTA). The histological changes in the capsule tissue were measured by hematoxylin and eosin, Masson trichrome, and immunohistochemical staining. The expression of cytokines was measured by quantitative reverse transcription polymerase chain reaction. The authors also used pharmacological methods to verify the roles of macrophages and toll-like receptor 2 (TLR2) signaling in this pathological process.

RESULTS

The authors discovered that repeated LTA injection, at a low concentration, could induce thickening of the capsule tissue. Macrophage infiltration and TLR2/nuclear factor-κB signaling activated in this process could be suppressed by macrophage depletion or TLR2 receptor inhibition.

CONCLUSION

As TLR2 signal activation was found to cause capsular contracture by inducing macrophage infiltration as a consequence of trace amounts of LTA contamination in situ, this target is helpful for understanding that chronic or repeated subclinical infection can activate capsular contracture.

CLINICAL RELEVANCE STATEMENT

This finding is of significant importance for understanding that chronic or repeated subclinical infection could activate a persistent immune response and capsular contracture, and provides novel strategies to interfere with the formation of capsular contracture.

Surgical Management of Breast Capsular Contracture-A Multi-institutional Data Analysis of Risk Factors for Early Complications

BACKGROUND

Capsular contracture (CC) is a common complication following implant-based breast surgery, often requiring surgical intervention. Yet, little is known about risk factors and outcomes following CC surgery.

METHODS

We reviewed the American College of Surgeons National Surgical Quality Improvement Program database (2008-2021) to identify female patients diagnosed with CC and treated surgically. Outcomes of interest included the incidence of surgical and medical complications at 30-days, reoperations, and readmissions. Confounder-adjusted multivariable analyses were performed to establish risk factors.

RESULTS

5,057 patients with CC were identified (mean age: 55 ± 12 years and mean body mass index [BMI]: 26 ± 6 kg/m2). While 2,841 (65%) women underwent capsulectomy, capsulotomy was performed in 742 patients (15%). Implant removal and replacement were recorded in 1,160 (23%) and 315 (6.2%) cases, respectively. 319 (6.3%) patients experienced postoperative complications, with 155 (3.1%) reoperations and 99 (2.0%) readmissions. While surgical adverse events were recorded in 139 (2.7%) cases, 86 (1.7%) medical complications occurred during the 30 day follow-up. In multivariate analyses, increased BMI (OR: 1.04; p = 0.009), preoperative diagnosis of hypertension (OR: 1.48; p = 0.004), and inpatient setting (OR: 4.15; p < 0.001) were identified as risk factors of complication occurrence.

CONCLUSION

Based on 14 years of multi-institutional data, we calculated a net 30 day complication rate of 6.3% after the surgical treatment of CC. We identified higher BMI, hypertension, and inpatient setting as independent risk factors of postoperative complications. Plastic surgeons may wish to integrate these findings into their perioperative workflows, thus optimizing patient counseling and determining candidates' eligibility for CC 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 .

Cathelicidin LL-37 Expression in Human Breast Implant Capsules

BACKGROUND

Capsular contracture is the most common complication following breast implant placement. Cathelicidin LL-37 is a cationic peptide involved in innate immunity. Initially investigated for its antimicrobial role, it was found to have pleiotropic activities, such as immunomodulation, angiogenesis stimulation, and tissue healing. The aim of the study was to investigate the expression and localization of LL-37 in human breast implant capsules and its relationship with capsular formation, remodeling, and clinical outcomes.

METHODS

The study enrolled 28 women (29 implants) who underwent expander substitution with definitive implant. Contracture severity was evaluated. Specimens were stained with hematoxylin and eosin, Masson trichrome, immunohistochemistry, and immunofluorescence for LL-37, CD68, α-smooth muscle actin, collagen type I and type III, CD31, and Toll-like receptor-4.

RESULTS

LL-37 was expressed in macrophages and myofibroblasts of capsular tissue in 10 (34%) and nine (31%) of the specimens, respectively. In eight cases (27.5%), it was expressed by both macrophages and myofibroblasts of the same specimen. In infected capsules, expression by both cell types was found in all (100%) specimens. LL-37 expression by myofibroblasts positively correlated with its expression by macrophages ( P < 0.001). Moreover, LL-37 expression by macrophages of periexpander capsules negatively correlated with the severity of capsular contracture on definitive implants ( P = 0.04).

CONCLUSIONS

This study demonstrates the expression of LL-37 in macrophages and myofibroblasts of capsular tissue and its negative correlation with the severity of capsular contracture following permanent implant placement. Expression or up-regulation of LL-37 may be involved in myofibroblast and macrophage modulation, thus playing a role in the pathogenic fibrotic process underlying capsular contracture.

CLINICAL RELEVANCE STATEMENT

This is the first study to demonstrate LL37 expression in capsular tissue and to hypothesize its role in contracture and as a prognostic marker for contracture severity. If confirmed, medical strategies or implant coating could be implemented to reduce the risk of contracture for high-risk patients.

Effect of prolonged antibiotic prophylaxis on the occurrence of surgical site wound infection after instant breast reconstruction: A meta-analysis

The purpose of the meta-analysis was to evaluate and compare the effects of prolonged antibiotic prophylaxis on the occurrence of surgical site wound infection after instant breast reconstruction. The results of this meta-analysis were analysed, and the odds ratio (OR) and mean difference with 95% confidence intervals (CIs) were calculated using dichotomous or contentious random- or fixed-effect models. For the current meta-analysis, 18 examinations spanning from 2009 to 2023 were included, encompassing 19 301 females with instant breast reconstruction. Systemic antibiotic prophylaxis had a significantly lower surgical site wound infection rate (OR, 0.85; 95% CI, 0.75-0.98, p = 0.02) compared with the standard of care after instant breast reconstruction in females. Topical antibiotic prophylaxis had a significantly lower surgical site wound infection rate (OR, 0.26; 95% CI, 0.13-0.52, p < 0.001) compared with the standard of care after instant breast reconstruction in females. The examined data revealed that systemic and topical antibiotic prophylaxis had a significantly lower surgical site wound infection rate compared with the standard of care after instant breast reconstruction in females. However, given that several examinations had a small sample size, consideration should be given to their values.

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

Evaluation of pathogen distribution and antimicrobial resistance in breast plastic surgery infection

BACKGROUND

The demand for mammaplasty has increased in recent years, and infection remains one of the common and serious post-operative complications. In this study, we analyzed the pathogen distribution and antibiotic susceptibility of breast plastic surgery infections, and compared the differences in pathogenic species between surgical procedures.

METHODS

The number of each species was counted in the microbial samples of breast plastic surgery infections in Plastic Surgery Hospital of Chinese Academy of Medical Sciences from January 2011 to December 2021. The in vitro antibiotic sensitivity testing data were analyzed using WHONET 5.6 software. The surgical techniques, the period of infection, and other details were gathered in accordance with the clinical data.

RESULTS

There were a total of 42 cases included, and 43 different types of pathogenic bacteria, mostly gram-positive bacteria, were found. CoNS (13/43) and Staphylococcus aureus (22/43) made up the majority. The most prevalent of the five Gram-negative bacteria was Pseudomonas aeruginosa. Results of drug sensitivity tests indicate that S. aureus is highly sensitive to vancomycin, cotrimoxazole, and linezolid, whereas CoNS is highly sensitive to vancomycin, linezolid, and chloramphenicol. Both of these bacteria show high resistance to erythromycin and penicillin. Breast augmentation, breast reconstruction, and breast reduction surgery were the most frequently associated breast surgery procedures in this study with infections, with the highest number of infections occurring following breast augmentation with fat grafting, breast reduction surgery, and breast reconstruction with autologous tissue. Various breast plastic surgery procedures have different common pathogens of infection, but the most prevalent are CoNS and S. aureus. Additionally, the majority of the infections in this study were in the early stages.

CONCLUSIONS

Gram-positive bacteria were the predominant cause of breast plastic surgery infections, and the types of infection strains, the period of infection onset, and the antibiotic susceptibility of prevalent strains varied between breast plastic procedures.

Zwitterionic polymer on silicone implants inhibits the bacteria-driven pathogenic mechanism and progress of breast implant-associated anaplastic large cell lymphoma

Breast implant-associated anaplastic large cell lymphoma (BIA-ALCL) occurs in the capsule surrounding breast implants. Malignant transformation of T cells by bacteria-driven chronic inflammation may be underlying BIA-ALCL mechanism. Here, we covalently grafted 2-methacryloyloxyethyl phosphorylcholine (MPC)-based polymers on a silicone surface and examined its effects against BIA-ALCL pathogenesis. MPC grafting strongly inhibited the adhesion of bacteria and bacteria-causing inflammation. Additionally, cancer T cell proliferation and capsule-derived fibroblast-cancer cell communication were effectively inhibited by MPC grafting. We further demonstrated the effect of MPC against the immune responses causing BIA-ALCL around human silicone implants in micro-pigs. Finally, we generated a xenograft anaplastic T cell lymphoma mouse model around the silicone implants and demonstrated that MPC grafting could effectively inhibit the lymphoma progression. This study is the first to show that bacteria-driven induction and progression of BIA-ALCL can be effectively inhibited by surface modification of implants. STATEMENT OF SIGNIFICANCE: Breast implant-associated anaplastic large cell lymphoma (BIA-ALCL) is a major concern in the field of plastic and reconstructive surgery. In this study, we demonstrate strong inhibitory effect of zwitterionic polymer grafting on BIA-ALCL pathogenesis and progression, induced by bacterial infection and inflammation, both in vitro and in vivo. This study provides a molecular basis for the development of novel breast implants that can prevent various potential complications such as excessive capsular contracture, breast implant illness, and BIA-ALCL incidence, as well as for expanding the biomedical applications of zwitterionic polymers.

Management of Biofilm with Breast Implant Surgery

LEARNING OBJECTIVES

After studying this article, the participant should be able to: 1. Understand how bacteria negatively impact aesthetic and reconstructive breast implants. 2. Understand how bacteria infect breast implants. 3. Understand the evidence associated with common implant infection-prevention strategies, and their limitations. 4. Understand why implementation of bacteria-mitigation strategies such as antibiotic administration or "no-touch" techniques may not indefinitely prevent breast implant infection.

SUMMARY

Bacterial infection of aesthetic and reconstructive breast implants is a common and expensive problem. Subacute infections or chronic capsular contractures leading to device explantation are the most commonly documented sequelae. Although bench and translational research underscores the complexities of implant-associated infection, high-quality studies with adequate power, control groups, and duration of follow-up are lacking. Common strategies to minimize infections use antibiotics-administered systemically, in the breast implant pocket, or by directly bathing the implant before insertion-to limit bacterial contamination. Limiting contact between the implant and skin or breast parenchyma represents an additional common strategy. The clinical prevention of breast implant infection is challenged by the clean-contaminated nature of breast parenchyma, and the variable behavior of not only specific bacterial species but also their strains. These factors impact bacterial virulence and antibiotic resistance.

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 .

Comparing the efficacy of antimicrobial pocket-irrigation protocols in an in vivo breast implant infection model

BACKGROUND

Breast implant infection and biofilm formation are major concerns in reconstructive and esthetic breast surgery, with significant medical and economic consequences. Staphylococcus is the common pathogen, with rapidly increasing rates of methicillin-resistant Staphylococcus aureus (MRSA). There is no consensus on prevention practices. This study compares the effect of several pocket irrigation and antibiotic prophylaxis regimens on implant colonization and biofilm formation in an established rat model of MRSA-infected silicone breast implants.

METHODS

Silicone discs were inserted in a sub-pectoral pocket in 57 rats (114 implants). Implant infection was induced by injection of free planktonic MRSA into the surgical pocket. Rats were allocated to study groups treated by different antimicrobial protocols: pocket irrigation with vancomycin, povidone-iodine, or saline. Each group was divided into subgroups treated with or without additional peri-operative systemic vancomycin. Implant colonization or overt infection was assessed at post-operative day 14 both clinically and by cultures.

RESULTS

Pocket irrigation with vancomycin prevented contamination in 87% of implants. Irrigation and systemic vancomycin prevented contamination in 100% of implants with no difference between a single preoperative dose and a 48-h regimen. Systemic vancomycin alone or irrigation with povidone-iodine alone resulted in 100% contamination rates.

CONCLUSIONS

In this in vivo model, combination of systemic vancomycin with vancomycin pocket irrigation was the most effective regimen, preventing contamination in 100% of implants. Continuation of post-operative antibiotic treatment showed no added advantage.

A prospective randomized clinical trial to assess antibiotic pocket irrigation on tissue expander breast reconstruction

Bacterial infection is the most common complication following staged post-mastectomy breast reconstruction initiated with a tissue expander (TE). To limit bacterial infection, antibiotic irrigation of the surgical site is commonly performed despite little high-quality data to support this practice. We performed a prospective randomized control trial to compare the impact of saline irrigation alone to a triple antibiotic irrigation regimen (1 g cefazolin, 80 mg gentamicin, and 50,000 units of bacitracin in 500 mL of saline) for breast implant surgery. The microbiome in breasts with cancer (n = 16) was compared to those without (n = 16), as all patients (n = 16) had unilateral cancers but bilateral mastectomies (n = 32). Biologic and prosthetic specimens procured both at the time of mastectomy and during TE removal months later were analyzed for longitudinal comparison. Outcomes included clinical infection, bacterial abundance, and relative microbiome composition. No patient in either group suffered a reconstructive failure or developed an infection. Triple antibiotic irrigation administered at the time of immediate TE reconstruction did not reduce bacterial abundance or impact microbial diversity relative to saline irrigation at the time of planned exchange. Implanted prosthetic material adopted the microbial composition of the surrounding host tissue. In cancer-naïve breasts, relative to saline, antibiotic irrigation increased bacterial abundance on periprosthetic capsules (P = 0.03) and acellular dermal matrices (P = 0.04) and altered the microbiota on both. These data show that, relative to saline only, the use of triple antibiotic irrigation in TE breast reconstruction does impact the bacterial abundance and diversity of certain biomaterials from cancer-naïve breasts. IMPORTANCE The lifetime risk of breast cancer is ~13% in women and is treated with a mastectomy in ~50% of cases. The majority are reconstructed, usually starting with a tissue expander to help restore the volume for a subsequent permanent breast implant or the women's own tissues. The biopsychosocial benefits of breast reconstruction, though, can be tempered by a high complication rate of at least 7% but over 30% in some women. Bacterial infection is the most common complication, and can lead to treatment delays, patient physical and emotional distress and escalating health care cost. To limit this risk, plastic surgeons have tried a variety of strategies to limit bacterial infection including irrigating the pocket created after removing the breast implant with antibiotic solutions, but good-quality data are scarce. Herein, we study the value of antibiotics in pocket irrigation using a robust randomized clinical trial design and molecular microbiology approaches.

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.

A multi-targeting bionanomatrix coating to reduce capsular contracture development on silicone implants

BACKGROUND

Capsular contracture is a critical complication of silicone implantation caused by fibrotic tissue formation from excessive foreign body responses. Various approaches have been applied, but targeting the mechanisms of capsule formation has not been completely solved. Myofibroblast differentiation through the transforming growth factor beta (TGF-β)/p-SMADs signaling is one of the key factors for capsular contracture development. In addition, biofilm formation on implants may result chronic inflammation promoting capsular fibrosis formation with subsequent contraction. To date, there have been no approaches targeting multi-facted mechanisms of capsular contracture development.

METHODS

In this study, we developed a multi-targeting nitric oxide (NO) releasing bionanomatrix coating to reduce capsular contracture formation by targeting myofibroblast differentiation, inflammatory responses, and infections. First, we characterized the bionanomatrix coating on silicon implants by conducting rheology test, scanning electron microcsopy analysis, nanoindentation analysis, and NO release kinetics evaluation. In addition, differentiated monocyte adhesion and S. epidermidis biofilm formation on bionanomatrix coated silicone implants were evaluated in vitro. Bionanomatrix coated silicone and uncoated silicone groups were subcutaneously implanted into a mouse model for evaluation of capsular contracture development for a month. Fibrosis formation, capsule thickness, TGF-β/SMAD 2/3 signaling cascade, NO production, and inflammatory cytokine production were evaluated using histology, immunofluorescent imaging analysis, and gene and protein expression assays.

RESULTS

The bionanomatrix coating maintained a uniform and smooth surface on the silicone even after mechanical stress conditions. In addition, the bionanomatrix coating showed sustained NO release for at least one month and reduction of differentiated monocyte adhesion and S. epidermidis biofilm formation on the silicone implants in vitro. In in vivo implantation studies, the bionanomatrix coated groups demonstrated significant reduction of capsule thickness surrounding the implants. This result was due to a decrease of myofibroblast differentiation and fibrous extracellular matrix production through inhibition of the TGF-β/p-SMADs signaling. Also, the bionanomatrix coated groups reduced gene expression of M1 macrophage markers and promoted M2 macrophage markers which indicated the bionanomatrix could reduce inflammation but promote healing process.

CONCLUSIONS

In conclusion, the bionanomatrix coating significantly reduced capsular contracture formation and promoted healing process on silicone implants by reducing myfibroblast differentiation, fibrotic tissue formation, and inflammation. A multi-targeting nitric oxide releasing bionanomatrix coating for silicone implant can reduce capsular contracture and improve healing process. The bionanomatrix coating reduces capsule thickness, α-smooth muscle actin and collagen synthesis, and myofibroblast differentiation through inhibition of TGF-β/SMADs signaling cascades in the subcutaneous mouse models for a month.

Enhancing Patient Outcomes in Aesthetic Breast Implant Procedures Using Proven Antimicrobial Breast Pocket Irrigations: A 20-Year Follow-up

BACKGROUND

Capsular contracture (CC) remains the most common complication of implant-based aesthetic and reconstructive breast surgery. With subclinical infection proven to be the primary etiology, antimicrobial breast pocket irrigation has been recommended as the key step to reduce CC but has not been universally adopted.

OBJECTIVES

The purpose of this study was to review the rates of CC observed when applying proven antimicrobial breast pocket irrigations.

METHODS

Data from patients undergoing cosmetic breast augmentation were recorded prospectively from 1997 to 2017. The irrigation was performed with either a Betadine-containing (50% Betadine or "Betadine triple") or a non-Betadine triple antibiotic regimen. The database was assessed to determine the type of implant used, the incidence of CC, and possible contributing factors. The degree of CC was recorded according to the Baker classification.

RESULTS

A 20-year prospective data collection yielded 2088 patients with 4176 implants; of these patients, 826 had textured implants and 1262 had smooth implants. The incidence of Grade III/IV CC was found to be 0.57% in all patients undergoing primary breast augmentation (1.21% in textured implants and 0.16% in smooth implants).

CONCLUSIONS

This study constitutes the largest and longest review of CC in a controlled, single-surgeon setting. The incidence of CC is low and reinforces the efficacy/utility of antimicrobial breast pocket irrigation. Both the Betadine and non-Betadine antibiotic regimens were found to be effective, with the Betadine regimen being preferred. Universal adoption of Betadine-containing antimicrobial breast pocket irrigation is recommended to reduce CC and other device-associated infections.

LEVEL OF EVIDENCE: 4

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

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

Case Report: Improved surgical treatment for breast capsular contracture by the punctiform-incision approach through the nipple

Capsular contracture is one of the most common complications of breast implants, which often leads to secondary surgery. Patients with unconspicuous breast contracture do not need treatment, while for those with severe symptoms, a capsule revision surgery is of great necessity, including a total periprosthetic capsulectomy and replacement with a new implant. However, if the capsular contracture happens in the submuscular space, it will be very difficult to release it completely, and it may lead to more complications such as damage to surrounding tissue. The new method of pouch can create a new subpectoral plane for the insertion of a new implant instead of a total capsulectomy, but this method is unsuitable for patients who have little breast tissue or thin skin. To solve this thorny clinical problem, we invented a double-headed separating instrument and came up with a novel operation method to release the capsular contracture, which opened from the nipple by the punctiform-incision approach and caused only a mild and undetectable trauma. This operation went off without a hitch, and the postoperative breast shape was good, and the breast felt and moved naturally. In addition, there were no significant complications throughout the one-year follow-up period. This case was an excellent demonstration of the novel breast capsular contracture release surgery using our optimized double-headed capsule contracture separator.

Changing Susceptibility of Staphylococci in Patients with Implant-Based Breast Reconstructions: A Single-Center Experience

Background and Objectives: Infections and capsular contractures remain unresolved issues in implant-based breast reconstruction. Capsular contractures are thought to be caused by the endogenous flora of the nipple duct. However, little is known about the antibiotic susceptibility of the microorganisms involved. This study aimed to evaluate the composition of endogenous breast flora and its antimicrobial susceptibility in patients with breast cancer. This study will aid in selecting a prophylactic antibiotic regimen for breast reconstruction surgery. Materials and Methods: We obtained bacteriologic swabs from the nipple intraoperatively in patients who underwent implant-based breast reconstruction following nipple-sparing mastectomy between January 2019 and August 2021. Antibiotic susceptibility tests were performed according to the isolated bacteriology. Statistical analysis was performed based on several patient variables to identify which factors influence the antibiotic resistance rate of endogenous flora. Results: A total of 125 of 220 patients had positive results, of which 106 had positive culture results for coagulase-negative Staphylococcus species (CoNS). Among these 106 patients, 50 (47%) were found to have methicillin-resistant staphylococci, and 56 (53%) were found to have methicillin-susceptible staphylococci. The methicillin resistance rate in the neoadjuvant chemotherapy group (56.3%) was significantly higher (OR, 2.3; p = 0.039) than that in the non-neoadjuvant chemotherapy group (35.5%). Conclusions: Based on the results, demonstrating high and rising incidence of methicillin-resistant staphylococci of nipple endogenous flora in patients with breast cancer compared to the past, it is necessary to consider the selection of prophylactic antibiotics to reduce infections and capsular contracture after implant-based breast reconstruction.

The Current Knowledge on the Pathogenesis of Tissue and Medical Device-Related Biofilm Infections

Biofilm is the trigger for the majority of infections caused by the ability of microorganisms to adhere to tissues and medical devices. Microbial cells embedded in the biofilm matrix are highly tolerant to antimicrobials and escape the host immune system. Thus, the refractory nature of biofilm-related infections (BRIs) still represents a great challenge for physicians and is a serious health threat worldwide. Despite its importance, the microbiological diagnosis of a BRI is still difficult and not routinely assessed in clinical microbiology. Moreover, biofilm bacteria are up to 100–1000 times less susceptible to antibiotics than their planktonic counterpart. Consequently, conventional antibiograms might not be representative of the bacterial drug susceptibility in vivo. The timely recognition of a BRI is a crucial step to directing the most appropriate biofilm-targeted antimicrobial strategy.

Rare Presentation of Breast Implant Infection and Breast Implant Illness Caused by Penicillium Species

What is breast implant illness? What is the proposed pathophysiology behind breast implant illness? What are the most common etiologies of fungal breast implant infections? What risks should patients undergoing breast augmentation be informed of?

Abdullah A, Alkhalidi H, Alrehaili M. Early onset of capsular contracture after breast augmentation with implant: report of two cases & review of literature

Capsular contracture (CC) is a local complication caused by an inflammatory reaction that leads to fibrosis. CC commonly occurs after one year of surgery. Hence, there has been no previously reported early onset of CC. Therefore, we report two unusual cases of early onset of post-breast reconstruction capsular contracture.

Breast Implant Illness: Surgical, Autoimmune, and Breast Reconstruction Associations

Breast implant illness refers to a combination of different symptoms related to breast implant surgery, including fatigue, brain fog, and arthralgias. This malaise occurs after cosmetic and reconstructive breast surgeries, although it has not been proven to be a disease. Even recent studies have reported concluding statements of the etiology, diagnosis, and treatment as unclear and widely unknown. Therefore, this review aimed to determine the associations between the manifestations of breast implant illness in surgery and breast reconstruction, as well as the autoimmune responses involved. Complications associated with breast implants include breast pain, capsular contracture, infections, as well as other manifestations specific to breast reconstruction. Moreover, patients with implants may present with new-onset systemic sclerosis, Sjögren’s syndrome, and connective tissue diseases. However, the incidence of capsular contracture has steadily decreased with each generation of implants, particularly since the development of textured implants, as well as with the use of antibiotics and antiseptic pocket irrigation. However, the incidence of anaplastic large cell lymphoma has increased with the use of textured implants. Remarkably, the autoimmune response to these implants remains unclear. Therefore, close follow-up, careful observation of any symptom presentation, and evidence-based treatment decisions are necessary for patients with breast implants.

Implants and Breast Pocket Irrigation: Outcomes of Antibiotic, Antiseptic, and Saline Irrigation

BACKGROUND

Breast implant-associated infection and capsular contracture are challenging complications that can result in poor outcomes following implant-based breast surgery. Antimicrobial irrigation of the breast pocket or implant is a widely accepted strategy to prevent these complications, but the literature lacks an evidence-based consensus on the optimal irrigation solution.

OBJECTIVES

The objective of this systematic review was to compare clinical outcomes, specifically capsular contracture, infection, and reoperation rates, associated with the use of antibiotic, antiseptic, and saline irrigation.

METHODS

A systematic review was performed in March 2020 based on the following search terms: "breast implant," "irrigation," "antibiotic," "bacitracin," "antiseptic," "povidone iodine," "betadine," "low concentration chlorhexidine," and "hypochlorous acid." Capsular contracture, infection, and reoperation rates were compared by analysis of forest plots.

RESULTS

Out of the 104 articles screened, 14 met the inclusion criteria. There was no significant difference in capsular contracture rates between antibiotic and povidone-iodine irrigation, although the data comparing these 2 groups were limited and confounded by the concurrent use of steroids. Antibiotic irrigation showed a significantly lower rate of capsular contracture compared with saline irrigation and a lower rate of capsular contracture and reoperation compared with no irrigation at all. Povidone-iodine was associated with lower rates of capsular contracture and reoperation compared with saline irrigation but there were no data on infection rates specific to povidone-iodine irrigation.

CONCLUSIONS

Our study supports the use of antibiotics or povidone-iodine for breast implant irrigation. Further research is required to better determine which of these 2 irrigation types is superior.

LEVEL OF EVIDENCE: 4

What are the likely causes of Breast Implant Associated Anaplastic Large Cell Lymphoma (BIA-ALCL)?

Breast implant-associated anaplastic large cell lymphoma (BIA-ALCL) is a CD30-positive, anaplastic lymphoma kinase-negative T-cell lymphoma. Where implant history is known, all confirmed cases to date have occurred in patients with exposure to textured implants. The etiopathogenesis of BIA-ALCL is likely to be multifactorial, with current evidence-based theories recognising the combination of chronic infection in setting of textured implants, gram-negative biofilm formation, chronic inflammation, host genetics (e.g. JAK/STAT, p53) and time in tumorigenesis. Proposed triggers for the development of malignancy are mechanical friction, silicone implant shell particulates, silicone leachables and bacteria. Of these, the bacterial hypothesis has received significant attention, supported by a plausible biological model. In this model, bacteria form an adherent biofilm in the favourable environment of the textured implant surface, producing a bacterial load that elicits a chronic inflammatory response. Bacterial antigens, primarily of gram-negative origin, may trigger innate immunity and induce T-cell proliferation with subsequent malignant transformation in genetically susceptible individuals. Future research, investigating BIA-ALCL genetic mutations and immunological modulation with Gram-negative biofilm in BIA-ALCL models is warranted to establish a unifying theory for the aetiology of BIA-ALCL.

Implant Replacement or Removal: What Happens after Capsular Contracture? A German Study Examining Breast Implant Revision Surgery and Patient Choices in 946 Cases

Introduction

Capsular contracture most often leads to implant revision surgery for aesthetic or reconstructive purposes. However, little is known about which operation is chosen when revision surgery has to be performed. We performed analysis of revision indications and performed revision surgery considering implant removal or replacement and additional surgical procedures. To our knowledge, this study presents the largest German single-center analysis regarding implant revision surgery after the onset of complications.

Methods

Retrospective 10-year data analysis of a single-center population undergoing breast implant revision surgery.

Results

Capsular contracture was the most frequent finding before reoperation, both removal and replacement (p < 0.05). It was linked to longer duration of in situ implant placement (p < 0.05) and more frequently in reconstructive patients (p < 0.05). Implant replacement was performed more often before definite implant removal for reconstructive patients (p < 0.05). Mean duration of in situ implant placement before definite removal was lower for reconstructive patients (p = 0.005). Overall reconstructive patients were older than aesthetic patients (p < 0.05). After implant removal, 61.7% of aesthetic patients chose to undergo mastopexy, 54.7% of reconstructive patients opted for autologous breast reconstruction, and 25.4% did not choose an additional surgical procedure after implant removal.

Conclusion

Significant differences are observed for reconstructive and aesthetic patients regarding indication leading to revision surgery, time of revision surgery, and the type of performed revision surgery itself. After implant removal, more than 60% of aesthetic patients undergo mastopexy, more than half of reconstructive patients choose autologous breast reconstruction, and over a quarter of patients choose no additional surgical procedures.

Current Concepts in Capsular Contracture: Pathophysiology, Prevention, and Management

Over 400,000 women in the United States alone will have breast implant surgery each year. Although capsular contracture represents the most common complication of breast implant surgery, surgeons continue to debate the precise etiology. General agreement exists concerning the inflammatory origin of capsular fibrosis, but the inciting events triggering the inflammatory cascade appear to be multifactorial, making it difficult to predict why one patient may develop capsular contracture while another will not. Accordingly, researchers have explored many different surgical, biomaterial, and medical therapies to address these multiple factors in an attempt to prevent and treat capsular contracture. In the current paper, we aim to inform the reader on the most up-to-date understanding of the pathophysiology, prevention, and treatment of capsular contracture.

Proper Skin Management in Breast Augmentation with a Periareolar Incision Prevents Implant Contamination and Biofilm-Related Capsular Contracture

BACKGROUND

Capsular contracture (CC) is a significant complication and major reason for revision in breast augmentation. Many studies indicate that most bacteria found in contracted capsules originate from the skin, especially that of the nipple-areolar complex (NAC). To prevent implant contamination, protocols without a periareolar incision have been proposed and have become a limitation for breast augmentation. We sought to propose a strategy of proper skin management for periareolar incisions to prevent implant contamination and biofilm-related CC.

METHODS

The analyses in this study are based on data collected from February 2017 to July 2020. A total of 129 patients were included, and they were randomized into two groups. The control group was subjected to no skin treatment before the surgery, and the treatment group underwent preoperative cleaning and disinfection of the NAC. We collected bacteriologic swabs used to rub the skin of the NAC and chest after draping and suturing from the control and treatment groups. We assessed the potential risk of detecting bacteria or fungi in the swabs, and we analyzed the data. The relationship between the positive culture rate and complication rate indicated the effectiveness of our strategy.

RESULTS

Initially, 774 swabs were obtained. In the control group, 6 swabs tested positive for pathogens, including 2 NAC swabs positive for Staphylococcus epidermidis (S. epidermidis) after draping and 3 and 1 NAC swabs positive for S. epidermidis and Staphylococcus aureus (S. aureus) after suturing, respectively. All the other samples in the control and treatment groups were negative for bacteria or fungi. All patients had at least 16 months of follow-up. No CC (Baker grades II-IV) was recorded during the follow-up, and the treatment group experienced a better outcome associated with a lower rate of minor complications.

CONCLUSIONS

Proper preoperative skin management helps keep the field pristine and potentially prevents implant contamination and even biofilm-related CC. With this strategy, breast augmentation using a periareolar incision or any other approach, even other surgery, could be a safe procedure.

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 .

Biocompatibility Evolves: Phenomenology to Toxicology to Regeneration

The word "biocompatibility," is inconsistent with the observations of healing for so-called biocompatible biomaterials. The vast majority of the millions of medical implants in humans today, presumably "biocompatible," are walled off by a dense, avascular, crosslinked collagen capsule, hardly suggestive of life or compatibility. In contrast, one is now seeing examples of implant biomaterials that lead to a vascularized reconstruction of localized tissue, a biological reaction different from traditional biocompatible materials that generate a foreign body capsule. Both the encapsulated biomaterials and the reconstructive biomaterials qualify as "biocompatible" by present day measurements of biocompatibility. Yet, this new generation of materials would seem to heal "compatibly" with the living organism, where older biomaterials are isolated from the living organism by the dense capsule. This review/perspective article will explore this biocompatibility etymological conundrum by reviewing the history of the concepts around biocompatibility, today's standard methods for assessing biocompatibility, a contemporary view of the foreign body reaction and finally, a compendium of new biomaterials that heal without the foreign body capsule. A new definition of biocompatibility is offered here to address advances in biomaterials design leading to biomaterials that heal into the body in a facile manner.

Zwitterionic polydopamine coatings suppress silicone implant-induced capsule formation

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

Late-Onset Inflammation in Asian Rhinoplasty Using Alloplastic Implants

BACKGROUND

Late-onset inflammation is a rare complication that may occur several months to years after undergoing an uneventful rhinoplasty using alloplastic implants and an uneventful postoperative course. Studies to determine the pathophysiological mechanisms of late-onset inflammation related to implants used in rhinoplasty are limited. The purpose of the study was to analyze differences between non-healthy capsules (NHC) with late-onset inflammation and healthy capsules (HC) without inflammation as controls to determine the possible cause of the inflammation.

METHODS

Between April 2009 and May 2018, 39 patients who underwent rhinoplasty with alloplastic implants underwent histological studies. Twenty-one patients in the NHC group showed late-onset inflammation, while 18 patients in the HC group did not display late-onset inflammation. Capsules around the alloplastic implants were harvested, and histological studies using hematoxylin and eosin, Masson's trichrome, colloidal iron, and CD31 staining were performed and compared between the NHC and HC groups.

RESULTS

In hematoxylin and eosin and Masson's trichrome staining, edematous granulation tissues, inflammatory cellular contents, and a disorganized collagen layer were increased in the NHC group compared to the HC group. The colloidal iron staining revealed mucin deposition in the NHC group. CD31-positive cells were observed lining the capsule in both groups; however, the lining cells were damaged in the NHC group.

CONCLUSION

Granulation tissues, inflammatory reaction, collagen degeneration, mucin deposition, and endothelial lining cell damage were greater in the NHC group compared to the HC group. Damaged capsules may play a crucial role in late-onset inflammation.

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 .

Preliminary Outcomes of Hypochlorous Acid as an Adjunct for Pocket Irrigation in Revision Aesthetic Breast Surgery

BACKGROUND

Capsular contracture is a challenging problem for plastic surgeons despite advances in surgical technique. Breast pocket irrigation decreases bacterial bioburden. Studies have shown that hypochlorous acid (HOCl; PhaseOne Health, Nashville, TN) effectively penetrates and disrupts biofilms; however, there are limited clinical data regarding this irrigation in breast augmentation.

OBJECTIVES

The aim of this study was to investigate the effects of HOCl pocket irrigation in revision breast augmentation by evaluating rates of capsular contracture recurrence, infection, and allergic reactions.

METHODS

We performed an institutional review board-approved retrospective chart review of revision breast augmentation cases for Baker grade III/IV capsular contractures in which pockets were irrigated with HOCl. Data were obtained from 3 board-certified plastic surgeons.

RESULTS

The study included 135 breasts in 71 patients, who ranged in age from 27 to 77 years (mean, 53.7 years). Follow-up ranged from 12 to 41 months (mean, 20.2 months). Postoperatively, there were 2 unilateral Baker grade III/IV recurrences at 13 months and 1 bilateral Baker grade II recurrence at 3 months. There were no infections or allergic reactions. The overall Baker grade III/IV capsular contracture recurrence rate was 0% at 12 months and 1.5% at 15 months.

CONCLUSIONS

Breast pocket irrigation decreases bioburden, which may influence capsular contracture recurrence. We evaluated 3 varied applications of HOCl in revision aesthetic breast surgery and found a low capsular contracture recurrence rate and no adverse reactions. We plan to report our findings with HOCl in primary breast augmentation in the future, and other studies are being conducted on the efficacy of HOCl in aesthetic surgery.

LEVEL OF EVIDENCE: 4

Characterizing the Microbiome of the Contracted Breast Capsule Using Next Generation Sequencing

BACKGROUND

Recent work suggests that bacterial biofilms play a role in capsular contracture (CC). However, traditional culture techniques provide only a limited understanding of the bacterial communities present within the contracted breast. Next generation sequencing (NGS) represents an evolution of polymerase chain reaction technology that can sequence all DNA present in a given sample.

OBJECTIVES

The aim of this study was to utilize NGS to characterize the bacterial microbiome of the capsule in patients with CC following cosmetic breast augmentation.

METHODS

We evaluated 32 consecutive patients with Baker grade III or IV CC following augmentation mammoplasty. Specimens were obtained from all contracted breasts (n = 53) during capsulectomy. Tissue specimens from contracted capsules as well as intraoperative swabs of the breast capsule and implant surfaces were obtained. Samples were sent to MicroGenDX Laboratories (Lubbock, TX) for NGS.

RESULTS

Specimens collected from 18 of 32 patients (56%) revealed the presence of microbial DNA. The total number of positive samples was 22 of 53 (42%). Sequencing identified a total of 120 unique bacterial species and 6 unique fungal species. Specimens with microbial DNA yielded a mean [standard deviation] of 8.27 [4.8] microbial species per patient. The most frequently isolated species were Escherichia coli (25% of all isolates), Diaphorobacter nitroreducens (12%), Cutibacterium acnes (12%), Staphylococcus epidermidis (11%), fungal species (7%), and Staphylococcus aureus (6%).

CONCLUSIONS

NGS enables characterization of the bacterial ecosystem surrounding breast implants in unprecedented detail. This is a critical step towards understanding the role this microbiome plays in the development of CC.

LEVEL OF EVIDENCE: 4

The Microbiota of the Human Mammary Ecosystem

Human milk contains a dynamic and complex site-specific microbiome, which is not assembled in an aleatory way, formed by organized microbial consortia and networks. Presence of some genera, such as Staphylococcus, Streptococcus, Corynebacterium, Cutibacterium (formerly known as Propionibacterium), Lactobacillus, Lactococcus and Bifidobacterium, has been detected by both culture-dependent and culture-independent approaches. DNA from some gut-associated strict anaerobes has also been repeatedly found and some studies have revealed the presence of cells and/or nucleic acids from viruses, archaea, fungi and protozoa in human milk. Colostrum and milk microbes are transmitted to the infant and, therefore, they are among the first colonizers of the human gut. Still, the significance of human milk microbes in infant gut colonization remains an open question. Clinical studies trying to elucidate the question are confounded by the profound impact of non-microbial human milk components to intestinal microecology. Modifications in the microbiota of human milk may have biological consequences for infant colonization, metabolism, immune and neuroendocrine development, and for mammary health. However, the factors driving differences in the composition of the human milk microbiome remain poorly known. In addition to colostrum and milk, breast tissue in lactating and non-lactating women may also contain a microbiota, with implications in the pathogenesis of breast cancer and in some of the adverse outcomes associated with breast implants. This and other open issues, such as the origin of the human milk microbiome, and the current limitations and future prospects are addressed in this review.

Overview of Risk Factors and Prevention of Capsular Contracture Following Implant-Based Breast Reconstruction and Cosmetic Surgery: A Systematic Review

Capsular contracture is one of the most common complications of implant-based breast reconstruction or augmentation surgery. Despite advanced molecular biology, the exact mechanism of this complication is not fully understood. PubMed was searched for studies, published from 2015 to 2020, focused on potential risk factors and preventions of capsular contracture (CC) in patients who underwent implant-based breast surgery. A total of 533 articles were identified from PubMed, and 13 articles were selected ultimately for our review after eligibility screening and quality appraisal. Common risk factors of CC include biofilm, surgical site infections (SSI), history of prior CC or fibrosis, history of radiation therapy, and implant characteristics. Interventions that decrease the rate of CC include antibiotic prophylaxis or irrigation, acellular dermal matrix (ADM), leukotriene (LTE) inhibitors, surgical techniques, and others. Multiple risk factors are proposed to be a component of the pathophysiology of CC. However, there is inconsistent evidence supporting these risk factors, and the current data was based on broad heterogeneous studies. While efforts are being undertaken to solve this complication with improved technologies and surgical practices, CC remains to be unsolved. Our objective was to provide a summary of the current data of contributing risk factors as well as preventative and treatment measures for CC.

Pocket Irrigation and Technique During Reconstructive Surgery: An American Society of Plastic Surgery Survey of Current Practice

BACKGROUND

Expander-to-implant is the most common breast reconstruction procedure in the United States. Irrigation with triple antibiotic solution (TAS), as described by Adams et al in 2006, has become standard of care to lower bacterial bioburden. However, several alternative solutions have been implemented with the literature lacking a consensus regarding use (Plast Reconstr Surg. 2006;117:30-36).

OBJECTIVE

We distributed a peer-reviewed survey among a cohort of American Society of Plastic Surgery (ASPS) members to assess pocket irrigation technique during implant-based reconstructive surgery. We then conducted a pilot in vitro study to determine antibacterial efficacy of the most preferred irrigation at preferred dwell times against select bacterial species linked to breast pocket contamination during reconstructive implant-based surgery.

METHODS

The survey was distributed a total of 3 times to a random cohort of 2488 ASPS members in January 2018. During in vitro studies, pure cultures of common breast flora were exposed to TAS versus saline control at 1, 2, and 5 minutes in a simulated in vivo cavity. Viable plate counts were used to assess cell viability.

RESULTS

The response rate was above the ASPS survey average at 16% (n = 407). The population reflected a cross-section of practice types and experience levels. Triple antibiotic solution without Betadine was the favored irrigation at 41%, with 73% of its users preferring dwell times of 2 minutes or less. Over 30 distinct breast pocket irrigation solutions were identified. Bacteria added to the in vivo cavity survived a 2-minute dwell time with TAS as follows: 51% Staphylococcus epidermidis, 69% Escherichia coli, 88% Enterococcus faecalis, 88% Pseudomonas aeruginosa, and 98% Acinetobacter baumannii.

CONCLUSION

Our survey data demonstrate significant variability in practice and lack of consensus among ASPS members regarding antimicrobial irrigation during reconstructive breast surgery. Our in vitro data underscores the importance of relating clinical practices with laboratory studies of microorganisms potentially linked to breast pocket contamination and suggests that TAS requires either dwell times greater than 5 minutes and/or the inclusion of efficacious antimicrobial agents (eg, Betadine). This finding has the potential to impact antimicrobial pocket irrigation and technique during breast reconstruction.

Multicenter Investigation of Fungal Infections of Inflatable Penile Prostheses

BACKGROUND

Fungal infections of inflatable penile prostheses (IPPs) are inadequately understood in the literature.

AIM

To review a multi-institution database of IPP infections to examine for common patient and surgical factors related to IPP fungal infections.

METHODS

This is a retrospective Institutional Review Board-approved analysis of 217 patients at 26 institutions who underwent salvage or device explant between 2001 and 2018. Patient data were compiled after an extensive record review.

OUTCOMES

26 patients (12%) with fungal infections were identified.

RESULTS

23 of 26 patients (83%) with a fungal IPP infection were either diabetic or overweight. 15 patients had undergone primary IPP implantation, and the other 11 had previously undergone an average of 1.7 IPP-related surgeries (range 1-3; median 2). The average age at implantation was 63 years (range 31-92; median 63). 18 of the 26 patients with fungal infection had diabetes (69%), with a mean hemoglobin A1c (HbA1c) value of 8.4 (range 5.8-13.3; median 7.5). Twenty-two patients (85%) were overweight or obese. The mean body mass index for all patients was 30.1 kg/m² (range 23.7-45 kg/m²; median 28.4 kg/m²), and that for diabetic patients was 30.8 kg/m² (range 24.1-45 kg/m², median 29.7 kg/m²). Ninety-one percent of implants were placed with intravenous antibiotics, consistent with current American Urological Association guidelines: an aminoglycoside plus first- or second-generation cephalosporin or vancomycin or ampicillin/sulbactam or piperacillin/tazobactam. 65% (17 of 26) of infected IPPs had only fungal growth in culture. No patient had concomitant immunosuppressive disease or recent antibiotic exposure before IPP implantation.

CLINICAL IMPLICATIONS

More than two-thirds of the fungal infections occurred in diabetic patients and 85% occurred in overweight or obese patients, suggesting that antifungal prophylaxis may be appropriate in these patients.

STRENGTHS & LIMITATIONS

This is the largest series of fungal infections reported to date in the penile prosthesis literature. The overall number of such cases, however, remains small.

CONCLUSION

Fungal infections represent 12% of all penile prosthesis infections in our series and were seen mostly in diabetic or overweight patients, who may benefit from antifungal prophylaxis. Gross MS, Reinstatler L, Henry GD, et al. Multicenter Investigation of Fungal Infections of Inflatable Penile Prostheses. J Sex Med 2019;16:1100-1105.

Interpositional Arthroplasty Using Mammary Capsule for Finger Joints: A Novel Technique

Degenerative osteoarthritis frequently affects the hands, altering the movements; surgical therapy includes arthrodesis and arthroplasty. We report the case of a female patient who presented arthrosis in the hands, severe on the proximal interphalangeal (PIP) joints, initially in her right index finger, and subsequently in the index and middle left fingers. At first, she received treatment in the PIP joint of the right index finger with a silicone implant; later on, she presented fracture of it and required replacement 8 years later. In the PIP joints of index and middle left fingers, treatment was made with interposition arthroplasty by mammary implant capsule. We present the postoperative progression of the silicone versus mammary capsule interposition arthroplasty. It is remarkable that, over time, articular function of the intervened joints with capsular arthroplasty remained stable with good motion, while range of motion in other fingers was reduced as a consequence of osteoarthritis. The frequency of patients presenting simultaneously with mammary capsule contracture and osteoarthritis is low, but this novel technique is nonetheless worthwhile to take into consideration.

Deposition of Host Matrix Proteins on Breast Implant Surfaces Facilitates Staphylococcus Epidermidis Biofilm Formation: In Vitro Analysis

BACKGROUND

Staphylococcus epidermidis is a primary cause of breast implant-associated infection. S epidermidis possesses several virulence factors that enable it to bind both abiotic surfaces and host factors to form a biofilm. In addition S epidermidis colocalizes with matrix proteins coating explanted human breast implants.

OBJECTIVES

The authors sought to identify matrix proteins that S epidermidis may exploit to infect various breast implant surfaces in vitro.

METHODS

A combination of in vitro assays was used to characterize S epidermidis strains isolated from human breast implants to gain a better understanding of how these bacteria colonize breast implant surfaces. These included determining the (1) minimum inhibitory and bactericidal concentrations for irrigation solutions commonly used to prevent breast implant contamination; (2) expression and carriage of polysaccharide intercellular adhesin and serine-aspartate repeat proteins, which bind fibrinogen (SdrG) and collagen (SdrF), respectively; and (3) biofilm formation on varying implant surface characteristics, in different growth media, and supplemented with fibrinogen and Types I and III collagen. Scanning electron microscopy and immunofluorescence staining analyses were performed to corroborate findings from these assays.

RESULTS

Textured breast implant surfaces support greater bacterial biofilm formation at baseline, and the addition of collagen significantly increases biomass on all surfaces tested. We found that S epidermidis isolated from breast implants all encoded SdrF. Consistent with this finding, these strains had a clear affinity for Type I collagen, forming dense, highly structured biofilms in its presence.

CONCLUSIONS

The authors found that S epidermidis may utilize SdrF to interact with Type I collagen to form biofilm on breast implant surfaces.

LEVEL OF EVIDENCE: 5

Size matters-in vitro behaviour of human fibroblasts on textured silicone surfaces with different pore sizes

Capsular contracture remains a challenge in plastic surgery and represents one of the most common postoperative complications following alloplastic breast reconstruction. The impact of the surface structure of silicone implants on the foreign body reaction and the behaviour of connective tissue-producing cells has already been discussed. The aim of this study was to investigate different pore sizes of silicone surfaces and their influence on human fibroblasts in an in vitro model. Four different textures (no, fine, medium and coarse texture) produced with the salt-loss technique, have been assessed in an in vitro model. Human fibroblasts were seeded onto silicone sheets and evaluated after 1, 4 and 7 days microscopically, with viability assay and gene expression analysis. Comparing the growth behaviour and adhesion of the fibroblasts on the four different textures, a dense cell layer, good adhesion and bridge-building ability of the cells could be observed for the fine and medium texture. Cell number and viability of the cells were increasing during the time course of experiments on every texture. TGFß1 was lowest expressed on the fine and medium texture indicating a trend for decreased fibrotic activity. For silicone surfaces produced with the salt-loss technique, we were able to show an antifibrotic effect of smaller sized pores. These findings underline the hypothesis of a key role of the implant surface and the pore size and pore structure in preventing capsular contracture.

Extended Prophylactic Antibiotics for Mastectomy with Immediate Breast Reconstruction: A Meta-analysis

Supplemental Digital Content is available in the text.

Background:

The risk of surgical site infection (SSI) for breast surgery in patients without additional risk factors is low, below 5%. Evidence shows the risk of SSI is significantly elevated in patients undergoing immediate breast reconstruction (IBR). However, there is no consensus regarding the use of extended antibiotic prophylaxis. We aim to determine the effect of extended antibiotic prophylaxis on the incidence of SSI after IBR.

Methods:

PubMed and Scopus were searched by 2 independent reviewers. Data abstracted included types of study, basic characteristics, detailed antibiotic prophylaxis information, SSI event, and other secondary outcomes. We calculated the risk ratio (RR) and 95% confidence interval (CI) for each study and used a random-effects model to estimate the results. Study quality, bias, and heterogeneity were also analyzed.

Results:

A total of 11 studies (15,966 mastectomy procedures) were included. We found an overall 5.99% SSI rate in our population. Three studies comparing topical antibiotics with no topical antibiotics demonstrated statistical significance (RR = 0.26, 95% CI: 0.12–0.60, P = 0.001), whereas 8 studies comparing extended systemic antibiotics with standard of care found no statistical significance (RR = 0.80, 95% CI: 0.60–1.08, P = 0.13).

Conclusions:

In the setting of IBR following mastectomy, there is insufficient evidence for the use of extended prophylactic antibiotics to reduce SSI rates. Well-designed randomized controlled trials in patients undergoing IBR should be conducted to determine the appropriate regimen and/or duration of prophylactic antibiotics on SSI outcomes.

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.

Insights into the Microbiome of Breast Implants and Periprosthetic Tissue in Breast Implant-Associated Anaplastic Large Cell Lymphoma

Though rare, breast implant-associated anaplastic large cell lymphoma (BIA-ALCL), a CD30+ T-cell lymphoma associated with textured breast implants, has adversely impacted our perception of the safety of breast implants. Its etiology unknown, one hypothesis suggests an initiating inflammatory stimulus, possibly infectious, triggers BIA-ALCL. We analyzed microbiota of breast, skin, implant and capsule in BIA-ALCL patients (n = 7), and controls via culturing methods, 16S rRNA microbiome sequencing, and immunohistochemistry. Alpha and beta diversity metrics and relative abundance of Gram-negative bacteria were calculated, and phylogenetic trees constructed. Staphylococcus spp., the most commonly cultured microbes, were identified in both the BIA-ALCL and contralateral control breast. The diversity of bacterial microbiota did not differ significantly between BIA-ALCL and controls for any material analyzed. Further, there were no significant differences in the relative abundance of Gram-negative bacteria between BIA-ALCL and control specimens. Heat maps suggested substantial diversity in the composition of the bacterial microbiota of the skin, breast, implant and capsule between patients with no clear trend to distinguish BIA-ALCL from controls. While we identified no consistent differences between patients with BIA-ALCL-affected and contralateral control breasts, this study provides insights into the composition of the breast microbiota in this population.

Fused Deposition Modeling 3D Printing: Test Platforms for Evaluating Post-Fabrication Chemical Modifications and In-Vitro Biological Properties

3D printing is attracting considerable interest for its capacity to produce prototypes and small production runs rapidly. Fused deposit modeling (FDM) was used to produce polyvalent test plates for investigation of the physical, chemical, and in-vitro biological properties of printed materials. The polyvalent test plates (PVTPs) are poly-lactic acid cylinders, 14 mm in diameter and 3 mm in height. The polymer ester backbone was surface modified by a series of ramified and linear oligoamines to increase its hydrophilicity and introduce a positive charge. The chemical modification was verified by FT-IR spectroscopy, showing the introduction of amide and amine functions, and contact angle measurements confirmed increased hydrophilicity. Morphology studies (SEM, optical microscopy) indicated that the modification of PVTP possessed a planar morphology with small pits. Positron annihilation lifetime spectroscopy demonstrated that the polymeric free volume decreased on modification. An MTT-based prolonged cytotoxicity test using Caco-2 cells showed that the PVTPs are non-toxic at the cellular level. The presence of surface oligoamines on the PVTPs reduced biofilm formation by Candida albicans SC5314 significantly. The results demonstrate that 3D printed objects may be modified at their surface by a simple amidation reaction, resulting in a reduced propensity for biofilm colonization and cellular toxicity.