Development and Validation of a Diagnostic Histopathological Scoring System for Capsular Contracture Based on 720 Breast Implant Capsules

BACKGROUND

Capsular contracture is traditionally evaluated with the Baker classification, but this has notable limitations regarding reproducibility and objectivity.

OBJECTIVES

The aim of this study was to develop and validate procedure-specific histopathological scoring systems to assess capsular contracture severity.

METHODS

Biopsies of breast implant capsules were used to develop histopathological scoring systems for patients following breast augmentation and breast reconstruction. Ten histological parameters were evaluated by multivariable logistic regression to identify those most associated with capsular contracture. Significant parameters (P < .05) were selected for the scoring systems and assigned weighted scores (1-10). Validation was assessed from the area under the curve (AUC) and the mean absolute error (MAE).

RESULTS

A total of 720 biopsies from 542 patients were included. Four parameters were selected for the augmentation scoring system, namely, collagen layer thickness, fiber organization, inflammatory infiltration, and calcification, providing a combined maximum score of 26. The AUC and MAE for the augmentation scoring system were 81% and 0.8%, which is considered strong. Three parameters were selected for the reconstruction scoring system, namely, fiber organization, collagen layer cellularity, and inflammatory infiltration, providing a combined maximum score of 19. The AUC and MAE of the reconstruction scoring system were 72% and 7.1%, which is considered good.

CONCLUSIONS

The new histopathological scoring systems provide an objective, reproducible, and accurate assessment of capsular contracture severity. We propose these novel scoring systems as a valuable tool for confirming capsular contracture diagnosis in the clinical setting, for research, and for implant manufacturers and insurance providers in need of a confirmed capsular contracture diagnosis.

LEVEL OF EVIDENCE: 3

Toward a Consensus Aproach for Assessing Capsular Contracture Severity and Progression: A Systematic Review

BACKGROUND

Breast implants are the most commonly used medical devices in plastic surgery, and capsular contracture (CC) is one of the most common complications. However, our assessment of CC is based largely on Baker grade, which is problematically subjective and affords only four possible values.

METHODS

The authors performed a systematic review concluding in September of 2021 in compliance with Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. It identified 19 articles that propose approaches to measuring CC.

RESULTS

In addition to Baker grade, the authors identified several modalities reported to measure CC. These included magnetic resonance imaging, ultrasonography, sonoelastography, mammacompliance measuring devices, applanation tonometry, histologic evaluation, and serology. Capsule thickness and other measures of CC inconsistently correlated with Baker grade, whereas the presence of synovial metaplasia was consistently associated with Baker grade I and II, but not III and IV capsules.

CONCLUSIONS

There remains no particular method to reliably and specifically measure the contracture of capsules that form around breast implants. As such, we would recommend that research investigators use more than one modality to measure CC. Other variables that can impact breast implant stiffness and associated discomfort beyond CC need to be considered when evaluating patient outcomes. Given the value placed on CC outcomes in assessing breast implant safety, and the prevalence of breast implants overall, the need for a more reliable approach to measuring this outcome persists.

The Relationship of Bacterial Biofilms and Capsular Contracture in Breast Implants

Capsular contracture is a common sequelae of implant-based breast augmentation. Despite its prevalence, the etiology of capsular contracture remains controversial. Numerous studies have identified microbial biofilms on various implantable materials, including breast implants. Furthermore, biofilms have been implicated in subclinical infections associated with other surgical implants. In this review, we discuss microbial biofilms as a potential etiology of capsular contracture. The review also outlines the key diagnostic modalities available to identify the possible infectious agents found in biofilm, as well as available preventative and treatment measures.

Thermal capsulorrhaphy: a modified technique for breast pocket revision

BACKGROUND

Scant attention has been paid to breast capsule revision after augmentation mammaplasty. Dissatisfaction with traditional techniques prompted the senior authors to develop a thermal capsulorrhaphy (TC) technique to obliterate excess breast pocket space using ball cautery followed by barbed suture closure.

OBJECTIVES

The authors propose a new periprosthetic technique for pocket closure, present a corresponding guide for surgical and postoperative management, and provide results of their retrospective review.

METHODS

Medical records were reviewed for all patients who underwent TC after cosmetic augmentation mammaplasty during a 5-year period, for whom clinical photographs were available from at least 1 year postoperatively. Operating details and complications were documented. Outcomes were rated a success, partial success, or failure, based on analysis of the photographs.

RESULTS

Of the 157 TC cases (41 unilateral, 58 bilateral) with a mean follow-up of 2 years, 141 (90%) outcomes were successful, 4 (2%) were partially successful, and 12 (8%) had failed. There were 16 complications: 10 over- or undercorrections and 1 episode each of hematoma, capsular contracture, slight deformity, nipple sensitivity, exposed suture knot, and suture abscess.

CONCLUSIONS

The efficacy of TC derives from the symbiosis of stitches and heat: capsulorrhaphy reinforces apposition of the damaged walls, and cautery contracts and thickens the capsule, thus reducing dead space and improving suture purchase. Initially popularized in shoulder surgery, TC is even better suited for breast pocket closure due to superior visibility and maneuverability, more aggressive practices, and the lack of similar complications. Postoperative stabilization and guideline compliance are essential to successful revision.

LEVEL OF EVIDENCE

4.

Autologous Fat Grafting for Treatment of Breast Implant Capsular Contracture: A Study in Pigs

BACKGROUND

Capsular contracture (CC) is a common complication after breast augmentation. Autologous fat grafting may be effective for restoring tissue vascularization and function.

OBJECTIVE

The authors evaluated the efficacy of autologous fat grafting in a porcine model as a treatment for CC after breast augmentation.

METHODS

This prospective study was performed in 20 female 30-day-old pigs. Each animal was implanted with three 30-cc textured silicone implants (stage 1 of the experiment). Group A served as the untreated control group. To induce CC, 2 mL of autologous fibrin glue was applied to the pericapsular space in group B and C animals at implantation. Three months after implantation (stage 2), the CCs of all groups were assessed by Baker classification and applanation tonometry (AT). Liposuction was performed in group B to harvest fat for these animals. Three months after group B underwent fat grafting, all 3 groups were reevaluated. Reassessments included Baker classification, AT, histologic analysis, and tensiometry (stage 3).

RESULTS

The deposition of mature and immature collagen was similar for the 3 groups. The amount of fat remaining around the implanted capsules did not differ significantly between the groups. At stage 3, group B exhibited significantly larger tonometry areas than did group C. The CCs in groups B and C were significantly thicker than those of group A, but the difference between groups B and C was not significant. Capsule rupture forces did not differ significantly between groups A and B but were significantly higher in group C compared with the other groups.

CONCLUSIONS

Results in this animal model indicate that pericapsular lipoinjection may be a promising treatment for CC in humans.

Capsular contracture rate in a low-risk population after primary augmentation mammaplasty

BACKGROUND

The safety of augmentation mammaplasty has increased dramatically in the past 20 years. Capsular contracture (CC) is the most commonly reported complication of augmentation mammaplasty.

OBJECTIVES

The authors report the incidence of CC in a low-risk patient population after primary augmentation.

METHODS

The authors retrospectively reviewed the charts of 856 consecutive patients who underwent primary augmentation mammaplasty between 1999 and 2009. This series did not include patients who underwent breast augmentation-mastopexy, secondary augmentation, revision, and/or reconstruction. Data points included demographics, functional and aesthetic outcomes, complications, and revision rate/type.

RESULTS

The overall incidence of CC in 856 patients was 2.8%. Average follow-up time was 14.9 months. Antibiotic irrigation decreased CC rates from 3.9% to 0.4% (P = .004). Tobacco users had higher rates of contracture than nonsmokers (5.5% vs 1.9%; P = .036). Saline implants had a higher CC rate than silicone gel (4.3% vs 1.3%; P = .032). Using multivariate logistic regression, CC was 7.89 times more likely in saline implants than in silicone gel (P = .027, 95% confidence interval, 1.26-49.00).

CONCLUSIONS

Based on our findings, it is apparent that the early CC rate in primary augmentation can be less than 1%. To avoid CC, we advocate an inframmamary approach, submuscular implant placement, and antibiotic irrigation of the breast pocket.

LEVEL OF EVIDENCE

3.