The Role of Silicone Granulomas in Recurrent Capsular Contracture: A Review of the Literature and an Approach to Management

Management of Patients with Textured Surface Breast Implants

SUMMARY

The purpose of this special topic article is to present an evidence-based approach and provide recommendations for the management of both asymptomatic and symptomatic patients with textured surface breast implants. There are currently no scientific data to support complete removal of a benign capsule. When unnecessary capsulectomies are performed, the patient is at higher risk for developing postoperative complications. Ultimately, the decision to keep, exchange, or remove breast implants is the patient's decision and the procedure should be performed only by a qualified surgeon.

A 10-Year Follow-Up Experience of 383 Patients with Bilateral Smooth Inflatable Breast Implants Filled with Saline Solution

INTRODUCTION

In light of the concerns regarding the occurrence of anaplastic large-cell lymphoma, seromas, and scar capsules, there appears to be merit in analysis and presentation of the results of our series of inflatable smooth implants filled with saline solution, for which the follow-up was more than 10 years.

PATIENTS AND METHOD

We carried out a retrospective study, including all of the patients who underwent a first breast implant for cosmetic reasons, between 2003 and 2006.

RESULTS

A total of 383 patients with 766 smooth implants filled with saline solution were included in our study. No cases of lymphoma and seroma were diagnosed. Eleven patients exhibited a postoperative hematoma, and four went on to develop a capsule. Twenty-two patients (5.7%) developed a Baker Grade III or IV capsule that required revision surgery. Two patients (0.5%) opted for a bilateral prosthesis replacement due to visual rippling. In total, there were 26 (3.4%) early deflations of prostheses.

DISCUSSION

There is not a statistically significant correlation between the occurrence of hematomas and the formation of a capsule. We found a lower shell rate with smooth-walled versus textured implants. The fact of having a decline of 10 years allows to be exhaustive. As for wrinkling and ripples, their occurrence has not been increased by the use of inflatable retropectoral implants.

CONCLUSION

Smooth inflatable implants filled with saline solution have numerous advantages such as the possibility of a very small approach route and perioperative adaptability of the volume. In light of the lack of indication of anaplastic large-cell lymphoma with smooth implants, they are clearly an attractive alternative to textured implants filled with silicone gel.

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.

The Histological Composition of Capsular Contracture Focussed on the Inner Layer of the Capsule: An Intra-Donor Baker-I Versus Baker-IV Comparison

Background

Capsular contracture remains one of the major complications after breast implantation surgery. The extent of capsular contraction is scored using the Baker scale. The aim of this study was to compare intra-individual Baker-I with Baker-IV capsules, and in particular the prevalence and histological properties of the inner capsule layer.

Methods

Twenty capsules from ten patients were included after bilateral explantation surgery due to unilateral capsular contracture (Baker-IV) after cosmetic augmentation with textured implants. All capsules underwent (immune-)histochemical analysis: haematoxylin–eosin (morphology), CD68 (macrophages), cytokeratin (epithelial cells) and vimentin (fibroblasts), and were visually scored for cell density and the presence of an inner layer and measured for thickness.

Results

Baker-IV (n = 10) capsules were significantly thicker compared to Baker-I (n = 10) capsules (P = 0.004). An inner layer was present in 8 Baker-I capsules. All Baker-I capsules were vimentin and CD68-positive and cytokeratin-negative. Positive vimentin was seen throughout the inner layer, and CD-68 staining was observed adjacent to the intermediate capsule layer. In contrast, only 2 Baker-IV capsules had an inner layer, of which only 1 showed the same profile as Baker-I capsules (P = 0.016). No cytokeratin positivity was seen in any capsule. In Baker-IV capsules, outer layers showed more positivity for both vimentin and CD68.

Conclusion

The inner layer is morphologically consistent with synovial metaplasia and is more prevalent in healthy, uncontracted Baker-I capsules. This inverse relation between the presence of the inner layer and higher Baker classification or pathological contracture could indicate a protective role of the inner layer against capsular contracture formation.

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.

Poly Implant Prothèse silicone breast implants: implant dynamics and capsular contracture

Background

The Poly Implant Prothèse (PIP) implants were withdrawn from the market in 2010 due to the use of low-grade silicone, causing a high risk for implant rupture. The aim of this study was to investigate the implant dynamics of PIP breast implants, as well as to determine the rate and predictors of implant gel bleeding, rupture, and capsular contracture in PIP implants.

Methods

Eighty women with a total of 152 PIP implants who underwent a reoperation in 2012 were enrolled in this study. Physical investigation included assessing the Baker score and demographics were retrospectively traced in medical records. The pre- and post-operative volumes of the implants were calculated and their state was determined intraoperatively by the surgeon.

Results

The implants were removed after a mean implant duration of 11 ± 2.1 years. Gel bleed and implant rupture occurred in respectively 42 and 25% of the implants. Intact implants had post-operative volume increase as well as decrease. There was a correlation between gel bleeding and more post-operative implant volume increase (P ≤ 0.05). Capsular contracture had a protective effect against post-operative implant volume increase (P ≤ 0.05), while a post-operative implant volume increase provided a protective influence in developing capsular contracture (P ≤ 0.05). Additionally, implant rupture led to a higher risk of capsular contracture (P ≤ 0.05).

Conclusions

We managed to illustrate that PIP implant shells were too permeable and that there is a correlation between gel bleeding and the increase of the post-operative implant volume. Implant rupture led to a higher risk for developing capsular contracture.

Level of evidence: Level III, risk / prognostic study.

Electronic supplementary material

The online version of this article (10.1007/s00238-018-1427-y) contains supplementary material, which is available to authorized users.

Modern therapies and iatrogenic changes in breast pathology

Iatrogenic changes within the breast can provide challenges for the histopathologist in routine practice. Diagnostic procedures, such as core biopsies, result in reactive changes and can cause displacement of benign and malignant cells, the interpretation of which may cause difficulties in the resection specimen. Breast augmentation surgery with implants or injection of fillers, performed for cosmetic reasons or as part of a reconstructive process following removal of breast cancer, also produces reactive changes locally and at distant sites that may mimic cancer. The entity of implant-associated anaplastic large-cell lymphoma is now well recognized, with progress in our understanding of the underlying biological factors that drive its development. Chemotherapy and radiotherapy used in the treatment of breast cancer causes characteristic changes in normal breast tissue, and can alter the histological appearance and receptor status of the tumour. Radiotherapy to the breast, for breast cancer or childhood malignancies, increases the risk of developing a secondary malignancy in the breast long after treatment. In this review, we describe some of the iatrogenic changes that may be seen in histological specimens from the breast.

Foreign Body Reaction after Implantation of a Device for Intervertebral Assisted Motion

The device for intervertebral assisted motion (DIAM) is a dynamic implant that consists of a silicone bumper enveloped by a polyethylene terephthalate (PET) fiber sack. Silicone and PET were used because of their biological inertness, but repetitive motion of the spine can cause wear on the implant nonetheless. The purpose of this study is to report a case of foreign body reaction (FBR) against a DIAM. A 72-year-old female patient presented with lower back pain and both legs radiating pain. She had undergone DIAM implantation at L4-5 for spinal stenosis 5 years previously. The intervertebral disc space of L4-5, where the DIAM was inserted, had collapsed and degenerative scoliosis had developed due to left-side collapse. MRI showed L3-4 thecal sac compression and left L4-5 foraminal stenosis. The patient underwent removal of the DIAM and instrumented fusion from L3 to L5. During surgery, fluid and granulation tissue were evident around the DIAM. Histopathology showed scattered wear debris from the DIAM causing chronic inflammation due to the resulting FBR. A FBR due to wear debris of a DIAM can induce a hypersensitivity reaction and bone resorption around the implant, causing it to loosen.