Efficacy of Acellular Dermal Matrix Type in Treatment of Capsular Contracture in Breast Augmentation: A Systematic Review and Meta-Analysis

Revisiting low complications of VICRYL mesh in breast reconstruction: Insights from an updated systematic review

Background

Alloplastic breast reconstruction continues to be the most prevalent breast reconstruction performed in the United States. Plastic surgeons are challenged to recreate the breast footprint after the ablative surgeon's mastectomy. Mesh augmentation has emerged as a valuable tool in controlling implant migration. Several soft tissue support breast meshes have been introduced, each characterized by a different risk profile, cost, and associated complications.

Objectives

This manuscript presents a comprehensive systematic review, with updated data over the last decade, of the use of a resorbable and less costly VICRYL (Ethicon, Somerville, NJ, USA) mesh in breast reconstruction after mastectomy.

Methods

The authors conducted a systematic review of the use of VICRYL mesh in breast reconstruction using Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. The authors queried five databases. Data was collected using a standardized form and underwent review using set inclusion and exclusion criteria. The primary outcome variable was reconstructive failure, with secondary outcomes including seroma, hematoma, skin necrosis, and infection.

Results

A total of 693 articles were found after the multi database search. Forty articles met inclusion criteria. Following full text review, six articles analyzing 511patients were included. VICRYL mesh was utilized in 711 breast reconstructions, of which 5% were complicated by reconstructive failure (confidence interval (CI): 4.75-5.25%); 1.6% by seroma (CI: 1.53-1.67%); 3.33% by infection (CI: 3.14-3.52%); 1.83% by hematoma (CI: 1.71-1.95%); and 6.33% by skin necrosis (CI: 6.03-6.63%).

Conclusion

VICRYL mesh repeatedly demonstrates low reconstructive failure in breast reconstruction with an acceptable complication profile.

Development of an in vitro platform for epithelial-stromal interactions: A basement membrane-containing scaffold from decellularized porcine bladders

The first organized extracellular matrix that appears during mammalian embryogenesis is a basement membrane (BM), BM is present in all adult epithelia, endothelia, muscle, nerve and fat tissues. BM is a sub-micrometer thick compact lattice of macromolecules that is maintained by the adhered cells. Systems such as collagen gels, Matrigel® or synthetic polymeric scaffolds have been proposed to mimic the BM and to study the interactions between different cell types, but all lack a structured BM. Here we aimed to obtain and characterize a natural, thin basement membrane-containing scaffold from pig urinary bladders that are subjected to blunt dissection of layers and decellularization steps, preserving the near native BM with a few layers of underlying connective tissue to maintain its structural integrity. The scanning electron microscopy, confocal multiphoton microscopy and immunohistochemistry helped confirm the presence of the BM. A veil-like network composed of thin fibers was present on top of a course network, and glycosaminoglycans, collagen and basement membrane proteins were present. The scaffold's ability to repopulation and basement membrane barrier function were further confirmed when HaCaT and MRC5 cells attached and remained respectively on the epithelial and mesenchymal side without any crossover. Cells remained viable till 2 weeks. This BM-containing scaffold allows to create in vitro models of epithelial-mesenchymal tissues through a structured basement membrane and investigate basement membrane dynamics. The basement membrane-containing scaffold was found to be isotropic under uniaxial tension with a failure strain of 0.25 allowing its use to investigate strain induced basement membrane dynamics.

Statistical Fragility of Outcomes on Breast Reconstruction with Acellular Dermal Matrix: A Systematic Review of Randomized Controlled Trials

BACKGROUND

Acellular dermal matrix (ADM) is pivotal in breast surgery, yet the statistical robustness of surgical outcomes remains underexplored. This study uses the fragility index (FI), reverse FI, and fragility quotient (FQ) to investigate the statistical fragility of ADM breast reconstruction outcomes.

METHODS

Randomized controlled trials (2013 to present) with dichotomous outcomes were sourced from PubMed, Embase, SCOPUS, Medline, and Cochrane databases. FI and reverse FI (event reversals needed to alter outcome significance) and FQ (standardized fragility across trials) were computed and reported as median (interquartile range [IQR]). Subgroup analysis focused on intervention types.

RESULTS

Of 33 studies screened, 19 RCTs comprising 204 outcomes were included, with a median FI of 4 (IQR, 3 to 5) and FQ of 0.039 (IQR, 0.029 to 0.070). Twenty-six outcomes achieved statistical significance, with a median FI of 3.5 (IQR, 1 to 5) and FQ of 0.033 (IQR, 0.010 to 0.073). The remaining 178 outcomes were not significant, exhibiting a median FI of 4 (IQR, 3 to 5) and FQ of 0.040 (IQR, 0.030 to 0.070). Of the 204 outcomes, 18% had a number of patients lost to follow-up equal to or surpassing the FI. By intervention type, the median FIs were similar in value but remained low.

CONCLUSIONS

ADM-related breast reconstruction outcomes are statistically fragile; thus, reversal of a few outcomes or maintaining follow-up with patients may alter the significance of findings. Future researchers are thus recommended to report FI and FQ metrics with P values to accurately portray reconstructive surgery outcomes.

A Comparison of Ovine-Reinforced Hybrid Mesh (OviTex PRS) With Porcine Acellular Dermal Matrix (STRATTICE) in the Treatment of Advanced Breast Implant Capsular Contracture

Background

Tissue reinforcement techniques with porcine acellular dermal matrices (ADMs) have been widely adopted as standard care in treating capsular contracture. However, the application of alternative xenograft or mesh materials has not been widely studied.

Objectives

To examine the efficacy of OviTex PRS Reinforced Tissue Matrix (Resorbable) (TELA Bio, Malvern, PA), a hybrid ovine-reinforced mesh, in comparison with STRATTICE Reconstructive Tissue Matrix (Allergan, Irvine, CA), in patients with advanced capsular contracture.

Methods

A retrospective review was conducted on patients who underwent breast revision surgery for Baker Grade III or IV capsular contracture. Patient data were reviewed for outcomes, complications, cost, and postoperative incidence of recurrent capsular contracture after treatment with each specific mesh.

Results

Fifty-nine of 89 breasts (66.3%) were treated with OviTex and 30 (33.7%) were treated with STRATTICE. All patients experienced a reduction in Baker grades. In patients treated with OviTex, 96.6% (n = 57) of breasts had a postoperative Baker Grade I with the remaining 3.4% (n = 2) breasts presenting with a Baker Grade II. In comparison, 73.3% (n = 22), 23.3% (n = 7), and 3.3% (n = 1) of the STRATTICE cohort presented with Baker Grades I, II, and III, respectively. This demonstrated a statistically significant improvement in Baker grade capsular contracture in the OviTex cohort (P < .05) compared with STRATTICE. Average cost was $27.37/cm2 for STRATTICE compared with $22.28/cm2 for OviTex PRS.

Conclusions

OviTex may be successfully utilized to treat capsular contracture. Patient outcomes may be superior to STRATTICE in recurrent capsular contracture, particularly when a previous ADM had been utilized. Cost data show improved savings with the use of OviTex compared with STRATTICE.

Level of Evidence 3

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

Selective Capsulotomies and Partial Capsulectomy in Implant-Based Breast Reconstruction Revision Surgery

Background

Breast cancer with about 2.3 million diagnoses and 685,000 deaths globally is the most frequent malignancy in the female population. Continuous research has led to oncological and reconstructive advances in the management of breast cancer, thus improving outcomes and decreasing patient morbidity. Nowadays, the submuscular expander and prosthesis (E/P) implant-based breast reconstruction (IBR) accounts for 73% of all reconstructions. Despite its widely accepted efficacy, the technique is not free from complications and up to 28% of cases require revision surgery for mechanical complications such as capsular contracture, implant displacement/rotation, and implant rupture. With this study, the authors report their experience in the management of E/P IBR revision surgery through the technique of Selective Capsulotomies (SCs) and Partial Capsulectomy (PC).

Methods

A retrospective study was conducted on patients who had previously undergone E/P IBR and presented for revision reconstruction between January 2013 and May 2023 at the Department of Plastic Surgery of the University of Siena, Italy. Reasons for revision included capsular contracture, implant displacement/rotation, and implant rupture. Revision reconstructions involved SC and PC with implant replacement. Fat grafting was also considered. The complication rate was evaluated by analysis of patients' medical records. Patients' satisfaction with the treatment was assessed through a specific questionnaire.

Results

32 patients underwent revision surgeries. No early complication occurred. Recurrence rate was assessed at 19% with average follow-up of 59 months (range: 13-114 months). The average time between revision surgery and recurrence was 3 years (range: 1-6 years). 23 patients answered the questionnaire and were overall satisfied with the treatments (8.29/10).

Conclusions

SC possibly associated to PC is a valuable option for E/P IBR revision surgery with minimal complications, reduced surgical trauma, short operating time, and relatively low recurrence risk. In addition, treated patients are overall satisfied with the results over time.