The aetiopathogenesis of capsular contracture: A systematic review of the literature

Long-term breast sensation following breast augmentation: A retrospective analysis of influencing factors

BACKGROUND

Breast augmentation is associated with high patient satisfaction; however, preserving breast sensation remains challenging. This study aimed to evaluate long-term breast sensation and identify factors affecting sensation following breast augmentation.

METHODS

This retrospective study included breast augmentation patients (experimental group) and an unoperated control group to evaluate the sensory changes following surgery. Sensory assessments were conducted using the Semmes-Weinstein monofilament test at 9 specific points on each breast, measuring central, peripheral and total sensory values. Comparisons of the sensory outcomes were made between the experimental and control groups, as well as within the experimental group. Factors such as smoking, systemic diseases, pregnancy, breastfeeding, implant plane, implant size and type and complications were analysed for their impact on sensation.

RESULTS

The study included 55 breast augmentation patients (110 breasts) and 20 controls (40 breasts). Sensory outcomes were significantly better in controls than in the operated group. Smoking, systemic diseases, implant size and type showed no significant impact on sensation. Pregnancy and breastfeeding were associated with better central sensation, whereas peripheral sensation was unaffected. Subglandular placement preserved central sensation better than dual-plane 2 and 3 placements but significantly reduced peripheral sensation. Post-operative complications were linked to decreased central sensation.

CONCLUSIONS

Breast augmentation is associated with decreased sensation compared to controls. Subglandular placement preserves central sensation better than dual-plane placement. Smoking, systemic diseases and implant size and type were not significantly related to sensory outcomes, while post-operative surgical complications were associated with diminished central sensation.

Silicone Loss During Histological Preparation of Breast Implant Tissue From Capsular Contracture, Quantified by Stimulated Raman Scattering Microscopy

Breast augmentations, commonly performed for aesthetic or medical reasons, often use silicone (polydimethylsiloxane [PDMS]) implants. Some patients develop complications like capsular contracture, where scar tissue forms around the implant. Previously, we used stimulated Raman scattering (SRS) microscopy to detect and quantify silicone in stained capsule tissue, finding a correlation between silicone amount and contracture severity. However, we suspected silicone loss during histological preparation, which includes multiple steps like formalin fixation and paraffin embedding. In this study, we assessed silicone loss by comparing adjacent tissue samples from the same capsule: one prepared conventionally and the other snap-frozen. SRS microscopy revealed that snap-frozen samples had roughly five times more silicone, indicating significant silicone loss during conventional preparation. Thus, measuring silicone in histologically prepared samples likely underestimates PDMS content.

In Vivo Comparison of the Efficacy and Duration of Local Antibiotics on Smooth, Textured and Polyurethane Implant Surfaces

BACKGROUND

Capsular contracture is one of the most common complications after breast surgery involving silicone implants. The most likely cause of this condition is biofilm formation. In this study, the efficacy of local antibiotherapy against biofilm formation on implant surfaces was investigated.

METHODS

Thirty-six rats were divided into six groups. Three pockets were created on the dorsum of each rat, and 1 × 2 cm implant surface samples from smooth, polyurethane and textured implants were randomly placed into pockets. All samples were inoculated with staphylococcus epidermidis. In groups 1-2-3, inoculated samples were placed into the pockets and removed after 1, 6 and 24 h, respectively. In groups 4-5-6, inoculated samples immersed with rifamycin were placed and removed after 1, 6 and 24 h, respectively. Bacterial load was measured with plate count method.

RESULTS

Bacterial load was lower in groups 4-5-6 than in groups 1-2-3 (p < 0.05). In groups 4-5-6, bacterial load was lower for polyurethane than for textured surfaces at all time points (1, 6 and 24 h; p < 0.05). Again, in groups 4-5-6, bacterial load was lower for smooth than for textured surfaces at 24 h (p < 0.05). In groups 4-5-6, bacterial load was lower for polyurethane than for smooth surfaces at all time points, but difference was not statistically significant (1, 6 and 24 h; p < 0.05).

CONCLUSION

The results suggest that local antibiotic therapy was effective in reducing the bacterial load on all surfaces. The effectiveness of local rifamycin on the polyurethane surface was higher, and the duration of activity was longer than other surfaces.

NO LEVEL ASSIGNED

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 .

Unraveling the Immune Web: Advances in SMI Capsular Fibrosis from Molecular Insights to Preclinical Breakthroughs

Breast implant surgery has evolved significantly, yet challenges such as capsular contracture remain a persistent concern. This review presents an in-depth analysis of recent advancements in understanding the immune mechanisms and clinical implications associated with silicone mammary implants (SMIs). The article systematically examines the complex interplay between immune responses and capsular fibrosis, emphasizing the pathophysiological mechanisms of inflammation in the etiology of this fibrotic response. It discusses innovations in biomaterial science, including the development of novel anti-biofilm coatings and immunomodulatory surfaces designed to enhance implant integration and minimize complications. Emphasis is placed on personalized risk assessment strategies, leveraging molecular insights to tailor interventions and improve patient outcomes. Emerging therapeutic targets, advancements in surgical techniques, and the refinement of post-operative care are also explored. Despite notable progress, challenges such as the variability in immune responses, the long-term efficacy of new interventions, and ethical considerations remain. Future research directions are identified, focusing on personalized medicine, advanced biomaterials, and bridging preclinical findings with clinical applications. As we advance from bench to bedside, this review illuminates the path forward, where interdisciplinary collaboration and continued inquiry weave together to enhance the art and science of breast implant surgery, transforming patient care into a realm of precision and excellence.

SMI-Capsular Fibrosis and Biofilm Dynamics: Molecular Mechanisms, Clinical Implications, and Antimicrobial Approaches

Silicone mammary implants (SMIs) frequently result in capsular fibrosis, which is marked by the overproduction of fibrous tissue surrounding the implant. This review provides a detailed examination of the molecular and immunological mechanisms driving capsular fibrosis, focusing on the role of foreign body responses (FBRs) and microbial biofilm formation. We investigate how microbial adhesion to implant surfaces and biofilm development contribute to persistent inflammation and fibrotic responses. The review critically evaluates antimicrobial strategies, including preoperative antiseptic protocols and antimicrobial-impregnated materials, designed to mitigate infection and biofilm-related complications. Additionally, advancements in material science, such as surface modifications and antibiotic-impregnated meshes, are discussed for their potential to reduce capsular fibrosis and prevent contracture of the capsule. By integrating molecular insights with clinical applications, this review aims to elucidate the current understanding of SMI-related fibrotic responses and highlight knowledge gaps. The synthesis of these findings aims to guide future research directions of improved antimicrobial interventions and implant materials, ultimately advancing the management of capsular fibrosis and enhancing patient outcomes.

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.

Transcriptomic and machine learning analyses identify hub genes of metabolism and host immune response that are associated with the progression of breast capsular contracture

Capsular contracture is a prevalent and severe complication that affects the postoperative outcomes of patients who receive silicone breast implants. At present, prosthesis replacement is the major treatment for capsular contracture after both breast augmentation procedures and breast reconstruction following breast cancer surgery. However, the mechanism(s) underlying breast capsular contracture remains unclear. This study aimed to identify the biological features of breast capsular contracture and reveal the potential underlying mechanism using RNA sequencing. Sample tissues from 12 female patients (15 breast capsules) were divided into low capsular contracture (LCC) and high capsular contracture (HCC) groups based on the Baker grades. Subsequently, 41 lipid metabolism-related genes were identified through enrichment analysis, and three of these genes were identified as candidate genes by SVM-RFE and LASSO algorithms. We then compared the proportions of the 22 types of immune cells between the LCC and HCC groups using a CIBERSORT analysis and explored the correlation between the candidate hub features and immune cells. Notably, PRKAR2B was positively correlated with the differentially clustered immune cells, which were M1 macrophages and follicular helper T cells (area under the ROC = 0.786). In addition, the expression of PRKAR2B at the mRNA or protein level was lower in the HCC group than in the LCC group. Potential molecular mechanisms were identified based on the expression levels in the high and low PRKAR2B groups. Our findings indicate that PRKAR2B is a novel diagnostic biomarker for breast capsular contracture and might also influence the grade and progression of capsular contracture.

Surface Topography, Microbial Adhesion, and Immune Responses in Silicone Mammary Implant-Associated Capsular Fibrosis

Breast cancer is the most common cancer in women globally, often necessitating mastectomy and subsequent breast reconstruction. Silicone mammary implants (SMIs) play a pivotal role in breast reconstruction, yet their interaction with the host immune system and microbiome remains poorly understood. This study investigates the impact of SMI surface topography on host antimicrobial responses, wound proteome dynamics, and microbial colonization. Biological samples were collected from ten human patients undergoing breast reconstruction with SMIs. Mass spectrometry profiles were analyzed for acute and chronic wound proteomes, revealing a nuanced interplay between topography and antimicrobial response proteins. 16S rRNA sequencing assessed microbiome dynamics, unveiling topography-specific variations in microbial composition. Surface topography alterations influenced wound proteome composition. Microbiome analysis revealed heightened diversity around rougher SMIs, emphasizing topography-dependent microbial invasion. In vitro experiments confirmed staphylococcal adhesion, growth, and biofilm formation on SMI surfaces, with increased texture correlating positively with bacterial colonization. This comprehensive investigation highlights the intricate interplay between SMI topography, wound proteome dynamics, and microbial transmission. The findings contribute to understanding host-microbe interactions on SMI surfaces, essential for optimizing clinical applications and minimizing complications in breast reconstruction.

A Comparative Analysis of Local and Systemic Immunological Biomarkers in Females With Breast Implants and Capsular Contracture

Background

The etiology of capsular contracture (CC), the most common complication following breast augmentation, remains unclear. Chronic, fibrotic inflammation resulting in excessive fibrosis has been proposed as a potential mechanism.

Objectives

In this study, we aimed to investigate the relation between biomarkers that are associated with inflammation and fibrosis and the severity of CC.

Methods

Fifty healthy females were categorized into 3 groups: females with no-to-mild CC (Baker 1-2; n = 15), females with severe CC (Baker 3-4; n = 20), and a control group awaiting breast augmentation (n = 15). We assessed 5 biomarkers (galectin-1 [Gal-1], interferon-β [INF-β], interferon-γ [INF-γ], interleukin-6 [IL-6], and tumor necrosis factor-α [TNF-α]) in breast implant capsules and serum samples.

Results

No significant differences in intracapsular cytokine levels were observed between the Baker 1-2 and the Baker 3-4 groups, as the levels were generally low and, in some cases, almost undetectable. In the blood samples, no significant differences in Gal-1, INF-γ, IL-6, or TNF-α levels were found within the 3 groups. We identified significantly increased levels of INF-β (P = .009) in the blood samples of females with severe CC, driven mainly by 3 extremely high values.

Conclusions

The cytokines assessed in this study did not reflect the degree of CC among females with silicone breast implants. However, 3 females with severe CC, who all had prolonged silicone exposure, showed extremely elevated levels of INF-β in their serum samples. This possible association between prolonged silicone exposure and systemic inflammation in some females should be further investigated.

Level of Evidence 3

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

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

METHODS

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

RESULTS

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

CONCLUSION

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

Surgical outcomes following breast reconstruction in patients with and without a history of chest radiotherapy for Hodgkin lymphoma: a multicentre, matched cohort study

BACKGROUND

Breast cancer is the most common treatment-related second malignancy among women with previous chest radiotherapy for Hodgkin lymphoma (HL). Little is known about the effects of this kind of radiotherapy on the outcomes of postmastectomy breast reconstruction (BR). This study compared adverse outcomes of BR after HL-related chest radiotherapy to matched controls.

METHODS

The authors conducted a retrospective, matched cohort study in two expert cancer centres in the Netherlands. BRs after therapeutic or prophylactic mastectomy in HL survivors who received chest radiotherapy were matched with BRs in nonirradiated patients without HL on age at mastectomy date, date of BR, and type of BR. The primary outcome was complication-related BR failure or conversion and secondary outcomes were complication-related re-operation, capsular contracture, major donor-site complications, and complication-related ICU admission. The authors analyzed all outcomes univariably using Fisher's exact tests and the authors assessed reconstruction failure, complication-related re-operation, and capsular contracture with multivariable Cox regression analysis adjusting for confounding and data clustering.

RESULTS

Seventy BRs in 41 patients who received chest radiotherapy for HL were matched to 121 BRs in 110 nonirradiated patients. Reconstruction failure did not differ between HL survivors (12.9%) and controls (12.4%). The comparison groups showed no differences in number of reoperations, major donor-site complications, or capsular contractures. BR in HL survivors more often let to ICU admission due to complications compared with controls ( P =0.048).

CONCLUSIONS

We observed no increased risk of adverse outcomes following BR after previous chest radiotherapy for HL. This is important information for counselling these patients and may improve shared decision-making.

Transvaginal Mesh-related Complications and the Potential Role of Bacterial Colonization: An Exploratory Observational Study

STUDY OBJECTIVE

This study aimed to investigate the potential role of transvaginal mesh bacterial colonization in the development of mesh-related complications (MRCs).

DESIGN

An observational and exploratory study.

SETTING

Tertiary referral center (Amsterdam UMC, location AMC, Amsterdam, The Netherlands). PATIëNTS: 49 patients indicated for mesh removal and 20 women of whom vaginal tissue was retrieved during prolapse surgery as a reference cohort.

INTERVENTIONS

collection of mesh-tissue complex (patient cohort) or vaginal tissue (reference cohort) MEASUREMENTS AND MAIN RESULTS: Homogenized samples were used for quantitative microbiological culture. Inflammation and fibrosis were semiquantitatively histologically scored; Gram staining and fluorescence in situ hybridization were used to detect bacteria and bacterial biofilms. Of the 49 patients, 44 samples (90%) were culture positive, with a higher diversity of species and more Gram-negative bacteria and polymicrobial cultures in the MRC cohort than the reference cohort, with mostly staphylococci, streptococci, Actinomyces spp., Cutibacterium acnes, and Escherichia coli. Patients with clinical signs of infection or exposure had the highest bacterial counts. Histology demonstrated moderate to severe inflammation in most samples. Gram staining showed bacteria in 57% of culture-positive samples, and in selected samples, fluorescence in situ hybridization illustrated a polymicrobial biofilm.

CONCLUSION

In this study, we observed distinct differences in bacterial numbers and species between patients with MRCs and a reference cohort. Bacteria were observed at the mesh-tissue interface in a biofilm. These results strongly support the potential role of bacterial mesh colonization in the development of MRCs.

The effect of explantation on systemic disease symptoms and quality of life in patients with breast implant illness: a prospective cohort study

Silicone breast implants (SBIs) have been subject to scientific scrutiny since the 1960's because of their potential link with systemic disease symptoms. Breast implant illness (BII) is a cluster of over 56 (systemic) symptoms attributed by patients to their SBIs. BII remains an unofficial medical diagnosis, although its symptoms include but are not limited to the clinical manifestations of autoimmune/inflammatory syndrome induced by adjuvants (ASIA). The aim of this study was to prospectively analyse the effect of explantation on clinical manifestations of ASIA/BII symptoms, as well as to compare (breast-surgery specific) QoL in patients pre- and postoperatively while recording relevant perioperative/patient data. A prospective cohort study was conducted on 140 patients consulting a single surgeon for explantation of SBIs at a single clinic from 2019 to 2021 via their general practitioner, a medical specialist or self-referral. Of all patients, medical (implant) history, lifestyle factors and biometric data were obtained. Patients filled out a novel ASIA/BII symptom-survey termed the ASIA-scale, three domains of the SF-36 and the augmentation module of the BREAST-Q before and four months after the operation. A total of 109 patients completed both the pre- and postoperative survey with a mean follow-up duration of 205 days. There was a significant decrease in all individual symptom scores as well as ASIA-scale summary scores after explantation (p < .001). All SF-36 subdomains showed significant improvement postoperatively (p < .001). The BREAST-Q subdomain 'satisfaction with breasts' improved significantly after explantation (p = .036). No statistically significant association was found between any clinical parameters (such as age, capsulectomy, rupture etc.) and the recovery of symptom scores. This is the largest prospective cohort study on SBI explantation to date showing significant improvement of the most common systemic complaints in SBI patients as well as improvement of satisfaction with breasts and overall quality of life.

The effect of explantation on systemic disease symptoms and quality of life in patients with breast implant illness: a prospective cohort study

Silicone breast implants (SBIs) have been subject to scientific scrutiny since the 1960's because of their potential link with systemic disease symptoms. Breast implant illness (BII) is a cluster of over 56 (systemic) symptoms attributed by patients to their SBIs. BII remains an unofficial medical diagnosis, although its symptoms include but are not limited to the clinical manifestations of autoimmune/inflammatory syndrome induced by adjuvants (ASIA). The aim of this study was to prospectively analyse the effect of explantation on clinical manifestations of ASIA/BII symptoms, as well as to compare (breast-surgery specific) QoL in patients pre- and postoperatively while recording relevant perioperative/patient data. A prospective cohort study was conducted on 140 patients consulting a single surgeon for explantation of SBIs at a single clinic from 2019 to 2021 via their general practitioner, a medical specialist or self-referral. Of all patients, medical (implant) history, lifestyle factors and biometric data were obtained. Patients filled out a novel ASIA/BII symptom-survey termed the ASIA-scale, three domains of the SF-36 and the augmentation module of the BREAST-Q before and four months after the operation. A total of 109 patients completed both the pre- and postoperative survey with a mean follow-up duration of 205 days. There was a significant decrease in all individual symptom scores as well as ASIA-scale summary scores after explantation (p < .001). All SF-36 subdomains showed significant improvement postoperatively (p < .001). The BREAST-Q subdomain 'satisfaction with breasts' improved significantly after explantation (p = .036). No statistically significant association was found between any clinical parameters (such as age, capsulectomy, rupture etc.) and the recovery of symptom scores. This is the largest prospective cohort study on SBI explantation to date showing significant improvement of the most common systemic complaints in SBI patients as well as improvement of satisfaction with breasts and overall quality of life.

Defining the Relationship Between Pocket and Breast Implant Surface Area as the Basis for a New Classification System for Capsular Contracture

BACKGROUND

The precise etiology and treatment for capsular contracture remains uncertain at least partially due to the fact that there is no reliable quantitative measurement tool. To address this, it is postulated that the surface area of an implant as defined by the surrounding pocket may provide a quantifiable variable that can be measured to evaluate the degree of capsular contracture.

METHODS

A bench model for capsular contracture was developed. The surface area of a series of spherical test objects and non-contracted and contracted breast implants was measured using a wax coating technique as well as three-dimensional reconstructions created from CT scan images.

RESULTS

Comparison of the mathematically calculated surface areas to the wax and CT results for spheres of known dimension provided nearly identical values documenting the accuracy of the two experimental methods. Comparison of the surface area measurements between the test groups showed that the average decrease in surface area for all implants was 20%, ranging from a high of 30.9% for a low profile implant to a low of 14.1 % for a high profile implant. The anatomically shaped devices demonstrated nearly uniform degrees of surface area change over three different heights with volume and projection held relatively constant.

CONCLUSIONS

The described bench model provides a useful tool for the study of capsular contracture. Surface area is a descriptive variable that can assess the degree of capsular contracture that is present. A classification system based on surface area is presented.

Tumor Remnant After Silicone Implant En Bloc Capsulectomy: The Magnetic Resonance Role

Recently, there has been an increase in surgeries to treat silicones implant complications. These procedures are generally related to diseased fibrous capsules, with capsular contracture the most common clinical manifestation. However, patients often do not undergo a magnetic resonance imaging (MRI) scan for the explant surgical programming to access the fibrous capsule status and avoid residual diseased tissue. The accuracy of MRI to assess fibrous capsule breast neoplasm remnants depends on the surgical time. The ideal time for the evaluation is up to 72 hours after the surgery when the repaired tissue starts to appear. Up to 2-3 weeks after surgery, MRI can provide information on the presence of a residual tumor. After this period, the presence of scar tissue and granuloma impairs the analysis. This communication discusses the role of MRI in evaluating residual fibrous capsules in the postoperative period. This article is protected by copyright. All rights reserved.

Treatment and Prevention of Periprosthetic Capsular Contracture in Breast Surgery With Prosthesis Using Leukotriene Receptor Antagonists: A Meta-Analysis

BACKGROUND

Capsular contracture (CC) is the most common long-term complication of breast surgery with prosthesis. Leukotriene receptor antagonists (LRAs) have been tested as a potential treatment; however, mixed results have been observed.

OBJECTIVES

The aim of this study was to undertake a meta-analysis to clarify the treatment and prophylactic capabilities of LRAs in the management of CC.

METHODS

A systematic literature search of the most popular English-language databases was performed to identify relevant primary publications. We included all studies that used the Baker scale to evaluate the treatment and preventive capabilities of LRAs.

RESULTS

Six eligible studies were included based on predefined inclusion and exclusion criteria, totalling 2276 breasts, of which 775 did not receive LRAs and 1501 did. Final pooled results showed that LRAs could help manage CC with a risk difference (RD) of -0.38 with a corresponding 95% CI of -0.69 to -0.08, showing statistical significance at a Z value of 2.48, P = 0.01. Subgroup analysis based on the type of drug showed that only montelukast yielded statistical significance (RD = -0.27, 95% CI = -0.51 to -0.03, Z = 2.20, P = 0.03). Zafirlukast did not seem to influence CC. Further subgroup analysis based on treatment timing showed that prophylaxis was ineffective and only treatment for ongoing CC yielded statistically significant improvements.

CONCLUSIONS

The current meta-analysis proved that LRAs could be used in the management of CC. Only treatment for ongoing CC showed statistically significant improvements. Montelukast seemed to be more efficient with a safer profile for adverse effects, whereas zafirlukast yielded no statistically significant results.

LEVEL OF EVIDENCE: 4

Effects of Silicone Breast Implants on Human Cell Types In Vitro: A Closer Look on Host and Implant

BACKGROUND

Silicone (gel) breast implants (SBI) are used world-wide for breast augmentation, and reconstruction or to correct breast deformities. They consist of two compounds: an elastomer silicone shell (envelope) and a silicone gel filler (core). Breast Implant Illness (BII) is a term used for women with SBI, who suffer from various of symptoms including myalgia, arthralgia, fatigue, fever, dry eyes and/or dry mouth (sicca), as well as cognitive disturbances, which are rated by these woman as response to SBI. The pathogenesis of these adverse effects as well as the histocompatibility and the SBI-cell interaction of silicone and its surrounding tissue (implant-host tissue interface) is a subject of current research. The main purpose of this review is to provide an overview of the current knowledge regarding the effects of silicone (gel and elastomer surfaces) of a SBI on different human cell types from experimental - in vitro - models.

METHODS

A comprehensive research was conducted by two independent reviewers in March and July of 2020 in the PubMed, MEDLINE, and Cochrane databases.

RESULTS

A number of 1328 articles on this topic were initially identified, of which 62 could be finally included an analysed in this review.

CONCLUSION

SBI may lead to a physiologic pro-inflammatory and foreign body host response with fibrous encapsulation accompanied by a disturbed Th17/Treg balance and IL-17 production. No causal relationship is known for systemic symptoms and/or autoimmune outcomes in the context of BII.

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 .

TGF-β1 and CD68 immunoexpression in capsules formed by textured implants with and without mesh coverage: a study on female rats

PURPOSE

To evaluate fibrosis formation and number of macrophages in capsules formed around textured implants without and with mesh coverage.

METHODS

Fibrosis was analyzed through transforming growth factor-beta 1 (TGF-β1) immunomarker expression and the number of macrophages through CD68 percentage of cells in magnified field. Sixty female Wistar rats were distributed into two groups of 30 rats (unmeshed and meshed). Each group was then subdivided into two subgroups for postoperative evaluation after 30 and 90 days. The p value was adjusted by Bonferroni lower than 0.012.

RESULTS

No difference was observed in fibrosis between meshed and unmeshed groups (30 days p = 0.436; 90 days p = 0.079) and from 30 to 90 days in the unmeshed group (p = 0.426). The meshed group showed higher fibrosis on the 90th day (p = 0.001). The number of macrophages was similar between groups without and with mesh coverage (30 days p = 0.218; 90 days p = 0.044), and similar between subgroups 30 and 90 days (unmeshed p = 0.085; meshed p = 0.059).

CONCLUSIONS

In the meshed group, fibrosis formation was higher at 90 days and the mesh-covered implants produced capsules similar to microtextured ones when analyzing macrophages. Due to these characteristics, mesh coating did not seem to significantly affect the local fibrosis formation.

Comparing the Antimicrobial Effect of Silver Ion-Coated Silicone and Gentamicin-Irrigated Silicone Sheets from Breast Implant Material

BACKGROUND

Post-operative infection is a significant complication of breast implant surgery that may require extensive use of antibiotics and surgical interventions. Here, we developed a biomaterial coating that is chemically bonded to silicone implants which delivers antimicrobial ions over time.

METHODS

After coating the silicone implants with a "mediator" polymer (γ-PGA), the implants were impregnated with silver (Ag) ions. Antimicrobial effects of these implants were assayed with modified Kirby-Bauer disk diffusion method. The silicone disks were transferred to a plate with fresh bacteria. Control was intended to simulate an intra-operative wash.

RESULTS

The Ag-γ-PGA coated silicone demonstrated antimicrobial effects against the most common etiological agents of breast implant infections, including Pseudomonas aeruginosa, Staphylococcus aureus, Staphylococcus epidermidis, Escherichia coli and Klebsiella pneumoniae. There was no effect of inhibition of bacterial growth around the control silicone or the silicone coated only with γ-PGA. The zone of inhibition was generally larger around the Ag-γ-PGA coated silicone as compared to the silicone irrigated with gentamicin, and continued antibacterial effect was also observed at 48 hours in the Ag-γ-PGA coated silicone for all bacteria groups with the exception of P. aeruginosa. Gentamicin-irrigated silicone did not inhibit bacterial growth at 48 hours.

CONCLUSION

The observed antibacterial performance of the Ag-γ-PGA coating as compared to simulated intra-operative antibiotic wash is promising and should be further evaluated to develop the next generation of implants with diminished risk for post-operative implant infections.

Hematoma and deep surgical site infection following primary breast augmentation: A retrospective review of 1128 patients

BACKGROUND

Breast augmentation is one of the most frequently performed cosmetic surgery worldwide. Some of the most severe short-term complications after breast augmentation are hematoma and deep surgical site infection. However, these complications are relatively rare; therefore, large patient populations are required to perform statistical analyses. In this study, we provide a detailed analysis of the complications after primary breast augmentation with an emphasis on deep surgical site infection and hematoma.

METHOD

We retrospectively reviewed the medical records of women who underwent primary breast augmentation without the use of pocket irrigation between 2012 and 2019 in a single private clinic. A cumulative hazard function and a multivariate analysis on the risk of hematoma were performed.

RESULTS

We included 1128 patients in the study. Thirty patients (2.7%) developed postoperative hematoma after a median time of 14 h (IQR 5 h-9 days). Six patients (0.5%) contracted a deep surgical site infection after a median time of 14 days (range 4-41 days). Age, BMI, implant volume, or implant placement was not significantly associated with hematoma.

CONCLUSION

Our findings support that the risk of hematoma after primary breast augmentation is highest within the first 24 h after the surgery. This time period should be considered when planning postoperative care for these patients. We did not find an increased rate of deep surgical site infection compared with studies of breast augmentations with pocket irrigation. Further studies and meta-analyses are needed to explore the effect of pocket irrigation and other risk factors.

Assessment of Silicone Particle Migration Among Women Undergoing Removal or Revision of Silicone Breast Implants in the Netherlands

IMPORTANCE

Silicone breast implants have been on the market for breast augmentation or breast reconstruction for approximately 60 years but may lead to medical complications, also called breast implant illness.

OBJECTIVE

To evaluate the existence of silicone gel bleed and migration over a long time period, including the period in which the newer cohesive silicone gel breast implants were used.

DESIGN, SETTING, AND PARTICIPANTS

In this single-center case series, capsule tissue and lymph node samples were collected from women who underwent removal or revision of silicone breast implants from January 1, 1986, to August 18, 2020, and data were extracted from the pathological reports and revision of the histology if data were missing. All tissues were examined using standard light microscopy, some extended with modified oil red O staining and energy-dispersive radiographic spectroscopy. A total of 365 women had capsular tissue removed, including 15 patients who also had lymph nodes removed, and 24 women had only lymph nodes removed. Data were analyzed from January to May 2021.

EXPOSURES

Silicone breast implants.

MAIN OUTCOMES AND MEASURES

The main outcome was presence or absence of silicones inside or outside the capsule. One-way analysis of variance was used to determine significance between groups.

RESULTS

Among a total of 389 women with silicone breast implants (mean [SD] age, 50.5 [11.2] years), 384 women (98.8%) had silicone particles present in the tissues, indicating silicone gel bleed. In 337 women (86.6%), silicone particles were observed outside the capsule (ie, in tissues surrounding the capsule and/or lymph nodes), indicating silicone migration. In 47 women (12.1%), silicone particles were only present within the capsule. In 5 women (1.2%), no silicone particles were detected in the tissues. Patients were divided into 2 groups, with 46 women who received cohesive silicone gel breast implants and 343 women who received either an older or a newer type of breast implant. There were no differences in silicone gel bleed or migration between groups (silicone detected outside or inside capsule: 44 women [95.7%] vs 340 women [99.1%]; P = .19).

CONCLUSIONS AND RELEVANCE

In this case series including women with noncohesive or cohesive silicone gel breast implants, silicone leakage occurred in 98.8% of women, indicating silicone gel bleed, and in 86.6% of women, migration of silicone particles outside the capsule was detected.

Augmentation mastopexy using a double skin incision: the inframammary fold approach with periareolar de-epithelialization

Background For the correction of small breasts with grade I ptosis, it is very challenging for plastic surgeons to obtain excellent aesthetic results by performing simultaneous breast augmentation and nipple-areolar complex (NAC) lifting. Previous research has introduced one-stage augmentation mastopexy, but most studies described using the periareolar approach. The current study proposes a technique for augmentation mastopexy using the inframammary fold approach for augmentation and the periareolar approach for mastopexy.Methods Twenty patients were enrolled, and surgery was performed on 40 breasts. A pocket was made with the inframammary fold approach and the dual-plane method; subsequently, a tear-drop shape implant was inserted using a funnel. We performed NAC lifting using the de-epithelialization and interlocking purse-string suture method through the periareolar approach.Results The mean distance from the mid-clavicular line to the nipple was 23.4 cm preoperatively, 19.6 cm at 7 days of follow-up, and 20.3 cm at 12 months of follow-up. Complications such as hematoma, infection, NAC necrosis, capsular contracture, and wound dehiscence were not reported.Conclusions We performed successful breast augmentation and mild ptosis correction. No specific complications were observed during 1 year of postoperative follow-up. Our method is a simple and fast method that enables surgeons to perform augmentation and mastopexy in one stage for breasts with grade I ptosis.

Biocell-Initial patents versus user instructions guide: A discrepancy at the core of a crisis

PURPOSE

Our aim is to do a comparative qualitative analysis of patents and "User Manuals" of the Biocell textured implants in order to determine if red flags were omitted when marketing and using Biocell textured implants.

MATERIALS AND METHODS

We performed a systematic qualitative analysis using the NVivo software version 11 of the patents describing the Biocell textured implants prior to their approval by the FDA and of user guides published by the 3 companies owning the patents (McGhan, Inamed, Allergan). To guide our thematic analysis, we used a form of systems theory known as the complexity theory.

RESULTS

Four patents related to Biocell and 2 user manuals (McGhan- Inamed and Allergan) were analyzed. Four themes emerged from the patents: invention description, mechanism of action (Tissue ingrowth), the timing of the mechanism of action and hypothetical actions on capsular contractures prevention. Of all patent's content, 34% described the invention, 29% the mechanism of action (tissue ingrowth), 1% the timing of this mechanism of action and 34% a hypothetical action against capsular contracture. Solid evidence was found on the concept of anchoring and very little on capsular contracture. On the user guide side, the main themes were indications and contraindications, surgical techniques and long-term effects. The "directed" content analysis approach of the user guides regarding the patent's themes reflected that 94% of the user guides content related to the patent thematics was about the hypothetical role on capsular contracture while only 4% was about invention description and 1.5% about tissue ingrowth.

CONCLUSIONS

This analysis highlights the discrepancies between patents of Biocell textured implants and user guides for these implants. The indications of use of a treatment or device can evolve quicker than the study of its potential complications and side effects. The BIA-ALCL crisis should serve as a cautionary tale to the plastic surgery community which embraces new technologies eagerly, and sometimes precariously, in a mission to advance patient care.

Revision Breast Augmentation

Breast augmentation is consistently one of the most commonly performed aesthetic operations every year. Unfortunately, revision rates following primary augmentation remain as high as 36%. There are several causes for revision breast augmentation; however, the most common and challenging of these include capsular contracture, implant malposition, and ptosis of the aging breast following augmentation. Successful management of these problems requires knowledge on how to best treat the implant and capsule with the corresponding soft tissue simultaneously. While surgical management is important, understanding the pathological causes of these entities during the primary operation can reduce the need for revision. This article utilizes the most up-to-date literature to review the appropriate clinical evaluation and surgical management of these complex cases.

The effect of implant surface on the recurrence rates of capsular contracture following revision breast surgery: Early results from a single surgeon retrospective comparative study

INTRODUCTION

This retrospective comparative study aimed to evaluate the effect of implant surface in two cohorts of consecutive patients who underwent revision surgery following capsular contracture (Baker III-IV) after primary breast augmentation with textured implants.

METHODS

All patients underwent the same surgical procedure (capsulectomy - pocket plane change - implant exchange) and the only difference was that two different types of implants were used during the implant exchange: textured(Group A - biocell) or nanotextured(Group B - silksurface). A comparative analysis was performed using the following parameters: patients' demographics, age, the time between the primary breast augmentation and the revision surgery, the surgical and follow-up outcomes; and the incidence, timing, and capsular contracture recurrence.

RESULTS

Eighty consecutive females were included, Group A(textured): age of 35(19-65) years and time between primary and secondary surgery of 59(6-209) months; and Group B(nanotextured): age of 39(26-58) years and time between primary and secondary surgery of 65(7-218) months. For both groups, at a mean follow-up of 25(21-36) months for Group A(textured), and at a mean follow-up of 24(21-34) months for Group B(nanotextured); capsular contracture reoccurred in 3 cases (7.5%), at 7, 10, and 14 months in Group A and in 3 cases (7,5%), at 9, 10, and 16 months in Group B, post revision surgery. Students' t-test demonstrated no statistically significant differences between the recurrences of the two implant surfaces (p-value>0.05).

CONCLUSION

In capsular contracture revision surgery, the type of implant surface (textured or nanotextured) does not appear to influence recurrence rates. Further studies are required to identify the clinical impact on the implant surface in long-term outcomes of capsular contracture breast surgery.

Capsular Contracture in Breast Implant Surgery: Where Are We Now and Where Are We Going?

Capsular contracture is the leading complication after surgery with breast implants. A lot of progress has been made investigating this complication over the years, and knowledge has been gained on this complication. Currently, the exact cause for capsular contracture is still unclear. It has been hypothesized that immunobiological factors (i.e., immunological and bacterial factors) and several risk factors play a central role in its development. In this paper, we give an overview of the known immunological factors that have been investigated in contracted and non-contracted capsules, as well as the role of bacterial formation around breast implants. We also report on risk factors that might increase the risk of capsular development. Lastly, it provides the latest research on this matter and discusses future perspectives as follow-up research is needed to unravel the pathogenic process leading to capsular contracture. This knowledge is of interest to establish medical therapies in order to prevent such side effects. Overall, capsular contracture seems to be a multifactorial condition consisting of several risk factors. LEVEL OF EVIDENCE V: 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.

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

INTRODUCTION

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

METHODS AND ANALYSIS

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

ETHICS AND DISSEMINATION

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

TRIAL REGISTRATION

NTR7265.

SEM and TEM for identification of capsular fibrosis and cellular behavior around breast implants - a descriptive analysis

BACKGROUND

Capsular fibrosis (CF) is the most common long-term complication in implant-based breast augmentation. It is well accepted that the foreign body response (FBR) instigates the development of fibrotic disease. Our study aims to compare murine and human samples of CF and describe the cellular and extracellular matrix (ECM) composition using scanning and transmission electron microscopy (SEM and TEM).

RESULTS

Miniature microtextured silicone breast implants were implanted in mice and subsequently harvested at days 15, 30, and 90 post-operation. Isolated human capsules with the most aggravated form of CF (Baker IV) were harvested post-operation. Both were analyzed with SEM and TEM to assess cellular infiltration and ECM structure. An architectural shift of collagen fiber arrangement from unidirectional to multidirectional was observed at day 90 when compared to days 15 and 30. Fibrosis was observed with an increase of histiocytic infiltration. Moreover, bacterial accumulation was seen around silicone fragments. These findings were common in both murine and human capsules.

CONCLUSIONS

This murine model accurately recapitulates CF found in humans and can be utilized for future research on cellular invasion in capsular fibrosis. This descriptive study helps to gain a better understanding of cellular mechanisms involved in the FBR. Increases of ECM and cellularity were observed over time with SEM and TEM analysis.

Histopathological evaluation of the effect of hyperbaric oxygen therapy on capsule occurrence around silicone breast prosthesis: an experimental study

BACKGROUND

In general, capsular contracture is the underlying cause of complications such as pain, stiffening, breast asymmetry, and animation deformity that are seen in the late postoperative period due to the use of silicone breast prostheses. Considering the positive effects of HBO therapy on wound healing, the objective of this study was to investigate the effect of HBO therapy on capsule reaction occurring due to silicone implants.

MATERIAL AND METHODS

Rats were divided into four groups. 1 cm × 1 cm silicone implants with rough surface were inserted in subcutaneous plane on the m spinotrapezius muscle fascia at just right of the dorsal region midline in rats in Group 1, while implants with same properties were inserted beneath m spinotrapezius muscle in rats in Group 2.Implants with the same properties were inserted in the subcutaneous area on the m spinotrapezius muscle in rats in Group 3 and into the area under the muscle in rats in Group 4. Beginning from the first postoperative day, rats in Groups 3 and 4 received HBO therapy for 90 min under 2.5 ATM pressure as one session a day over 15 days.

RESULTS

The mean capsule thickness was statistically significantly lower in the groups treated with HBO compared to the control groups. Fibroblast, neutrophil and macrophage counts were statistically significantly lower in the groups treated with HBO compared to the control groups.

CONCLUSION

We believe that HBO therapy can be used as an adjuvant treatment options to decrease capsule contraction occurring after silicone implant application.

Increased risk of late-onset, immune-mediated, adverse reactions related to dermal fillers in patients bearing HLA-B*08 and DRB1*03 haplotypes

Even though manufacturers claim that the dermal fillers are nontoxic and nonimmunogenic, adverse events may occur. Clinically and histologically, most of the late onset adverse events present as an inflammatory response. To assess whether HLA polymorphisms are associated with late-onset inflammatory adverse events related to dermal fillers. A total of 211 patients were included, of whom 129 experienced late-onset inflammatory adverse events to different fillers (Inflammation group) and 82 who did not (Reference group). Patients completed a standardized questionnaire and provided a blood sample or oral swap for HLA testing. The study population consisted of 188 (89%) women and 23 (11%) men. The two study groups were similar in the distributions of filler type, location of injecting, allergy, autoimmune disease, gender, age, ethnicity, and smoking status. Of the 211 patients in the sample, 25 had the combination of HLA subtype-B*08 and HLA subtype-DRB1*03. This was 16.3% of the inflammatory group and 4.9% of the reference group. This combination of HLA subtypes was associated with an almost 4-fold increase in the odds of developing immune mediated adverse events (odds ratio = 3.79, 95% CI 1.25-11.48). Genetic polymorphisms such as HLA combinations may identify patients at risk of developing late onset immune mediated adverse events to dermal fillers.

Immediate Breast Reconstruction after mastectomy with polyurethane implants versus textured implants: A retrospective study with focus on capsular contracture

BACKGROUND

Capsular contracture (CC) is the most common complication following Immediate Breast Reconstruction (IBR) with breast implants. Different implant surfaces were developed aiming to reduce the incidence of CC. We evaluated the incidence and degree of CC after Direct-to-Implant (DTI) IBR with insertion of textured (TE) or polyurethane (PU) covered implants.

METHODS

A retrospective review of consecutive patients treated at our Institution with mastectomy and one-stage IBR and implant reconstruction between 2013 and 2018, with or without post mastectomy radiation therapy (PMRT), was conducted. Immediate breast reconstruction was performed by implanting 186 PU covered implants and 172 TE implants.

RESULTS

Three-hundred-twelve women underwent 358 DTI IBR with PU or TE implants, were analyzed with a median follow-up time of 2.3 years (range 1.0-3.0). The overall rate of CC Baker grade III and IV was 11.8% (95%CI: 8.4-16.3), while, after PU and TE implant placement it was 8.1% (95% CI: 4.1-15.7) and 15.8% (95% CI: 4.1-15.7) [p = 0.009]), respectively. Irradiated breasts developed CC more frequently rather than non-irradiated breasts (HR = 12.5, p < 0.001), and the relative risk was higher in the TE group compared with the PU group (HR = 0.3, p = 0.003).

CONCLUSIONS

After mastectomy and one-stage IBR, the use of PU covered implants is associated with a lower incidence of CC compared to TE implants. This advantage is amplified several folds for patients who necessitate PMRT. Footnote: Capsular contracture (CC); Immediate Breast Reconstruction (IBR); Directto- Implant (DTI); Textured (TE); Polyurethane (PU); Post mastectomy radiation therapy (PMRT); Nipple Sparing mastectomy (NSM).

Hot Topics in Breast Surgery

Since the first implant-based breast surgeries were performed nearly 70 years ago, breast augmentation it has changed drastically. As understanding of breast augmentation has advanced, so too have the technologies and techniques used to improve results and minimize the risk of complications in breast implant surgery. This article reviews some of the novel techniques and technologies used today in breast augmentation surgery. How these tools and techniques will withstand the test of time remains to be seen, but they no doubt will add to the fascinating and ever-evolving history of breast augmentation.

Co-effects of C/Ag dual ion implantation on enhancing antibacterial ability and biocompatibility of silicone rubber

Although silicone implants are the most popular choice around the world for breast augmentation, reconstruction, and revision, due to the poor antibacterial properties and limited biocompatibility of silicone rubber (SR), one of the major complications, capsule contracture, is a lingering problem. To overcome the two main shortcomings, a dual ion implantation technique was applied to modify the surface of SR with the basic skeleton element of organic matter, carbon (C) and the broad-spectrum bactericide, silver (Ag). We present surface characterization, toxicological effects, and evaluation of the mechanical, antibacterial and biocompatible properties of C and Ag co-implanted SR (C/Ag-SRs). After ion implantation, surface roughness and tensile strength of these new materials increased. Biotoxicity was fully assessed by in vitro experiments on human fibroblasts and in vivo experiments on rats, showing that the low-Ag groups met safety standards. Both the anti-bacterial adhesion and bactericidal abilities of C/Ag-SRs were superior to those of SR, which had few antibacterial activities, especially against Staphylococcus epidermidis. With respect to biocompatibility, the adhesion of fibroblasts was promoted, while their proliferation was moderately inhibited on ion-implanted surfaces. After subcutaneous implantation in rats for 7, 30, 90 and 180 d, the capsular thickness around C/Ag-SRs was significantly lower than that around the SR. Additionally, there was no difference in the inflammatory reaction after 7 d of retention in vivo between C/Ag-SRs and SR. The results demonstrate that C/Ag-SRs are desirable shell materials for breast implants.

CD68+ macrophages as crucial components of the foreign body reaction demonstrate an unconventional pattern of functional markers quantified by analysis with double fluorescence staining

Implants like meshes for the reinforcement of tissues implement the formation of a persistent inflammation with an ambient fibrotic reaction. In the inflammatory infiltrate several distinct cell types have been identified, but CD68+ macrophages are supposed to be most important. To investigate the collaboration among the various cell types within the infiltrate we performed at explanted meshes from humans double fluorescence staining with CD68 as a constant marker and a variety of other antibodies as the second marker. The list of second markers includes lymphocytes (CD3, CD4, CD8, CD16, CD56, FoxP3, and CD11b) stem cells (CD34), leucocytes (CD45, CD15), macrophages (CD86, CD105, CD163, and CD206); deposition of EC matrix (collagen-I, collagen-III, MMP2, and MMP8); Ki67 as a marker for proliferation; and the tyrosine-protein kinase receptor AXL. The present study demonstrates within the inflammatory infiltrate the abundant capability of CD68+ cells to co-express a huge variety of other markers, including those of lymphocytes, varying between 5 and 83% of investigated cells. The observation of co-staining was not restricted to a specific polymer but was seen with polypropylene fibers as well as with fibers made of polyvinylidene fluoride, although with differences in co-expression rates. The persisting variability of these cells without the functional reduction toward differentiated mature cell types may favor the lack of healing at the interface of meshes.

Does Implant Surface Texture Affect the Risk of Capsular Contracture in Subglandular Breast Augmentation and Breast Augmentation-Mastopexy?

BACKGROUND

Previous studies have reported decreased rates of capsular contracture associated with the use of textured surface breast implants placed in the subglandular plane during breast augmentation. However, since the publication of these studies, our understanding of the pathophysiology of capsular contracture, as well as the surgical techniques utilized to minimize bacterial contamination of the implant, have advanced considerably.

OBJECTIVES

The purpose of this study was to re-evaluate the relation between implant surface texturization and capsular contracture rates for breast implants placed in the subglandular plane during primary breast augmentation.

METHODS

Retrospective chart review was performed of all primary subglandular breast augmentation procedures involving the use of either smooth or textured round silicone gel implants, with or without simultaneous mastopexy. The primary outcome measures included clinically significant capsular contracture (Baker grade III/IV) and revision surgery for capsular contracture.

RESULTS

Between 2010 and 2017, 526 patients underwent primary subglandular breast augmentation with either smooth (n = 212) or textured (n = 314) round silicone gel implants; 248 patients underwent breast augmentation, whereas 278 underwent breast augmentation-mastopexy. Average follow-up was 756 days in the textured group and 461 days in the smooth group. Five cases of capsular contracture were observed in the textured group, and 7 cases of capsular contracture were observed in the smooth group (P = 0.20).

CONCLUSIONS

Smooth surface implants placed in the subglandular plane were not at a significantly increased risk of capsular contracture compared with textured surface implants. We suggest that adherence to a surgical technique focused on minimizing bacterial contamination of the implant is of greater clinical significance than implant surface characteristics when discussing capsular contracture.

LEVEL OF EVIDENCE: 4

Transaxillary Endoscopic Approach to Capsular Contracture Following Previous Breast Augmentation: Operative Technique and Clinical Outcome

BACKGROUND

Capsular contracture (CC) is a complication of breast augmentation that frequently requires revision surgery. The axillary approach reduces the visibility of the postoperative scar. It is unclear whether the previous incision can be used to repair the deformity caused by CC.

METHODS

This study analyzed 21 patients (42 breasts) with grade III-IV CC during 2012-2017. The mean age of the patients was 32 years (range 23-48). Previous axillary scars were used to expose, and CCs were taken out completely or partially. Breast implants were removed. The dissection was performed with endoscopic assistance, using electrocautery under direct visualization.

RESULTS

The mean follow-up period was 13 months (range 6-24 months). The dissection plane was changed to dual plane. Thirty-five CCs were taken out completely. Thirty-eight breast implants taken out remained intact. None of the patients required additional surgery.

CONCLUSION

Endoscopic-assisted treatment may be an effective technique for treating CC and avoiding the additional scar.

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.

Creating a Favorable Microenvironment for Fat Grafting in a Novel Model of Radiation-Induced Mammary Fat Pad Fibrosis

BACKGROUND

Radiofibrosis of breast tissue compromises breast reconstruction by interfering with tissue viability and healing. Autologous fat transfer may reduce radiotherapy-related tissue injury, but graft survival is compromised by the fibrotic microenvironment. Elevated expression of receptor for hyaluronan-mediated motility (RHAMM; also known as hyaluronan-mediated motility receptor, or HMMR) in wounds decreases adipogenesis and increases fibrosis. The authors therefore developed RHAMM peptide mimetics to block RHAMM profibrotic signaling following radiation. They propose that this blocking peptide will decrease radiofibrosis and establish a microenvironment favoring adipose-derived stem cell survival using a rat mammary fat pad model.

METHODS

Rat mammary fat pads underwent a one-time radiation dose of 26 Gy. Irradiated (n = 10) and nonirradiated (n = 10) fat pads received a single intramammary injection of a sham injection or peptide NPI-110. Skin changes were examined clinically. Mammary fat pad tissue was processed for fibrotic and adipogenic markers using quantitative polymerase chain reaction and immunohistochemical analysis.

RESULTS

Clinical assessments and molecular analysis confirmed radiation-induced acute skin changes and radiation-induced fibrosis in rat mammary fat pads. Peptide treatment reduced fibrosis, as detected by polarized microscopy of picrosirius red staining, increased collagen ratio of 3:1, reduced expression of collagen-1 crosslinking enzymes lysyl-oxidase, transglutaminase 2, and transforming growth factor β1 protein, and increased adiponectin, an antifibrotic adipokine. RHAMM was expressed in stromal cell subsets and was downregulated by the RHAMM peptide mimetic.

CONCLUSION

Results from this study predict that blocking RHAMM function in stromal cell subsets can provide a postradiotherapy microenvironment more suitable for fat grafting and breast reconstruction.

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.

Does Choice of Reconstruction Type Affect Survival in Patients With Metastatic Breast Cancer?

BACKGROUND

To compare the breast cancer-specific survival (BCSS) and overall survival (OS) between patients who underwent implant or tissue reconstruction after mastectomy with distant metastatic breast cancer (MBC).

MATERIALS AND METHODS

Using the Surveillance, Epidemiology, and End Results database, we enrolled 371 female MBC cases diagnosed during the years 2004-2014. Patients were subdivided into implant (176) and tissue groups (195) for survival comparison between the two groups. The end points were BCSS and OS. Comparisons of the distribution of clinicopathologic characteristics were evaluated by chi-square test and Fisher exact test. Survival outcomes were compared by Kaplan-Meier model and multivariate Cox regression model for known clinicopathologic variables in both the entire population and in the reconstruction cohorts.

RESULTS

In the entire cohort, patients with implant exhibited distinctly better BCSS (log rank, P = 0.002) and OS (log rank, P = 0.001) than patients with tissue reconstruction. Multivariate Cox regression model revealed that patients, who received prosthetic implants, were married, and progesterone receptor-positive group showed better survival rates in BCSS and OS. In addition, after stratification of the implant group and tissue groups according to clinicopathologic variables, the survival rate of patients in the implant group was higher than that in the tissue reconstruction group under the influence of factors, such as married, estrogen receptor-negative, nonradiotherapy, and chemotherapy.

CONCLUSIONS

Our study provides further survival evidence supporting the practice of mastectomy with prosthetic implant reconstruction in patients with MBC under certain conditions.

PCR Characterization of Microbiota on Contracted and Non-Contracted Breast Capsules

BACKGROUND

The aetiology of capsular contracture around breast implants remains unclear. The leading theory is that a subclinical infection around the implant plays a role in the development of capsular contractions. Several studies found associations between the presence of bacteria and the occurrence of capsular contraction. However, it is unclear whether detected bacteria originate from the breast capsule, breast glandular tissue or skin contamination. Moreover, this has never been investigated with molecular techniques. The aim of this study was to assess the bacterial microbiota on breast capsules, glandular tissue and skin using a highly sensitive PCR assay.

MATERIALS AND METHODS

Fifty breast capsules were collected during implant removal or replacement. Ten specimens of glandular breast tissue and breast skin were collected in females who were undergoing reduction mammoplasty. A sample specimen (4 mm) was sterilely obtained from all tissues. All specimens were analysed by IS-pro, a 16S-23S interspace region-based PCR assay.

RESULTS

Low numbers of Staphylococcus spp. (four species in four capsules) were found on breast capsules. There was no difference in bacterial presence between normal and contracted capsules. The skin of the breast-harboured Streptococcus spp. and Staphylococcus spp. while the glandular tissue was sterile.

CONCLUSION

The low numbers of bacteria found on the capsules are most likely caused by contamination during capsule removal. More and larger studies are needed to investigate the bacterial presence on breast capsules using a PCR assay. This is the first study in which breast capsules have been studied using a highly sensitive PCR assay.

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 .

Toll-Like Receptors (TLRs) Expression in Contracted Capsules Compared to Uncontracted Capsules

INTRODUCTION

The etiology of capsular contracture after surgical implantation of breast implants remains unclear, but an important role is seen for the immune system. Toll-like receptors are immune receptors recognizing both pathogen-associated molecular patterns and damage-associated molecular patterns. The former are present on bacteria such as Staphylococcus epidermidis (bacteria earlier associated with capsular contracture), and the latter are released after (mechanical) stress. The aim of this study was to investigate the expression of TLRs 1-10 in relation to capsular contracture.

MATERIALS AND METHODS

Fifty consecutive breast capsules were collected during implant removal or replacement. The extent of capsular contracture was scored according to the Baker score. A sample specimen (0.5 cm3) was obtained from all tissues. cDNA was synthesized from isolated mRNA from the collected specimens. PCR analyses were conducted to test for cDNA presence and to quantify concentration. TLR1-10 expression was measured for each of the Baker scores separately and compared to all Baker scores.

RESULTS

Expression of all TLRs in all Baker scores was seen. TLR2 and TLR6 were more often present in contracted samples (Baker 3 or 4) compared to uncontracted samples (Baker 1 or 2) [Baker 2 vs. 3 (p = 0.034) and Baker 2 vs. 3 (p = 0.003), respectively]. None of the TLRs displayed a significantly higher expression in contracted capsules compared to uncontracted capsules.

CONCLUSION

This study shows that TLR2 and TLR6 are more often expressed in contracted capsules compared to non-contracted capsules however not in higher concentrations.

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 .

Risk factors for developing capsular contracture in women after breast implant surgery: A systematic review of the literature

BACKGROUND

Capsular contracture is the most frequent complication in breast augmentation or reconstruction with breast implants. The exact mechanism for this complication is not completely understood. Yet, it is most likely to be a multifactorial condition. Several patient-, surgery-, and implant-specific risk factors have been related to cause capsular contracture. This review aims to provide a clear overview of all risk factors for capsular contracture.

METHODS

A systematic literature review was performed focusing on patient-, surgery-, and/or implant-related factors related to capsular contracture in breast implants. PubMed, Embase, and Wiley/Cochrane Library databases were searched for relevant articles published from inception up to October 20, 2016. The included studies were assessed for the following main variables: study characteristics, patient characteristics, indication for surgery, type of surgery, implant characteristics, and other characteristics.

RESULTS

Data on the risk factors for the development of capsular contracture were retrieved from 40 studies. A presumptive increased risk in the development of capsular contracture is shown for the following variables: longer duration of follow-up, breast reconstructive surgery in patients with a history of breast cancer, subglandular implant placement, postoperative hematoma, and a textured implant surface. There is little, weak, or no evidence for the association of other factors with capsular contracture. This review also shows a large heterogeneity between studies and within the definition of capsular contracture.

CONCLUSION

This review provides an overview of the relationship between patient-, surgery-, and implant-specific risk factors in the development of capsular contracture.