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Park BC, Alving-Trinh AL, Prigmore HL, Harrell FE, Sarhane K, Joseph JT, Thomas H, Lupi AL, Perdikis G, Higdon KK. Impact of Tissue Expander Surface Texture on Two-Stage Breast Reconstruction Outcomes: A Combined Analysis. Plast Reconstr Surg 2024; 153:1053e-1062e. [PMID: 37252917 DOI: 10.1097/prs.0000000000010763] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/01/2023]
Abstract
BACKGROUND With ongoing investigations of the impact of device texturing on breast implant-associated anaplastic large-cell lymphoma (BIA-ALCL), studies have begun comparing complication profiles of tissue expanders. However, there is a paucity of timing and severity data of complications. The aim of this study was to provide a comparative survival analysis of postoperative complications between smooth (STEs) and textured tissue expanders (TTEs) in breast reconstruction. METHODS A single-institution experience with tissue expander breast reconstruction was reviewed for complications up to 1 year after second-stage reconstruction from 2014 to 2020. Demographics, comorbidities, operation-related variables, and complications were evaluated. Kaplan-Meier curves, Cox proportional hazard models, and a consensus-based ordinal logistic regression model were used to compare complication profiles. RESULTS Of 919 total patients, 600 (65.3%) received TTEs and 319 (34.7%) received STEs. There was increased risk of infection ( P < 0.0001), seroma ( P = 0.046), expander malposition ( P < 0.0001), and wound dehiscence ( P = 0.019) in STEs compared with TTEs. However, there was also a decreased risk of capsular contracture ( P = 0.005) in STEs compared with TTEs. Failure of breast reconstruction ( P < 0.001) and wound dehiscence ( P = 0.018) occurred significantly earlier in STEs compared with TTEs. Predictors for significantly higher severity complications included the following: smooth tissue expander use ( P = 0.007), shorter time to complication ( P < 0.0001), higher body mass index ( P = 0.005), smoking history ( P = 0.025), and nipple-sparing mastectomy ( P = 0.012). CONCLUSIONS Differences in the timing and severity of complications contribute to the safety profiles of tissue expanders. STEs are associated with increased odds of higher severity and earlier complications. Therefore, tissue expander selection may depend on underlying risk factors and severity predictors. CLINICAL QUESTION/LEVEL OF EVIDENCE Therapeutic, III.
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Affiliation(s)
| | | | | | | | - Karim Sarhane
- Plastic Surgery, Vanderbilt University Medical Center
| | - Jeremy T Joseph
- Division of Plastic and Cosmetic Surgery, Eastern Virginia Medical School
| | | | | | | | - Kent K Higdon
- Plastic Surgery, Vanderbilt University Medical Center
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2
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Reducing Capsular Contracture Formation in Breast Augmentation with Silicone Implants: Experimental Study on Rats. APPLIED SCIENCES-BASEL 2022. [DOI: 10.3390/app12084056] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Silicone implants are frequently used for breast augmentation and reconstruction. However, late complication, such as capsular contracture, remain the most important side effect. In this study we compare different methods for reducing the inflammatory reaction around the silicone implant by introducing one microtextured breast implant in wistar rats. The rats were dividing in 4 groups: the first one was the control group that received untreated implant; in the second we used silicone implants impregnated with rifampin solution, the third one had implant combined with intramuscular dexamethasone injection and the last one had silicone implant associated with autologous centrifuged fat introduced in the implant pocket. The implants and the capsular tissue surrounding were removed after eight weeks. Capsule samples were submitted to histological evaluations. The present study demonstrated that fat grafting may have a role in reducing and preventing capsular contractures after breast augmentation with silicone implants by decreasing the inflammatory process.
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Larsen A, Rasmussen LE, Rasmussen LF, Weltz TK, Hemmingsen MN, Poulsen SS, Jacobsen JCB, Vester-Glowinski P, Herly M. Histological Analyses of Capsular Contracture and Associated Risk Factors: A Systematic Review. Aesthetic Plast Surg 2021; 45:2714-2728. [PMID: 34312696 DOI: 10.1007/s00266-021-02473-3] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2021] [Accepted: 07/08/2021] [Indexed: 11/30/2022]
Abstract
BACKGROUND Capsular contracture is a severe complication to breast surgery with implants. Previous studies suggest multiple risk factors are associated with capsular contracture, but the etiology is still unknown. We performed a literature review to investigate existing studies on histological analyses of breast implant capsules and how clinical risk factors impact the capsule morphology. METHODS The literature search was conducted in PubMed. Studies that performed histological analyses of breast implant capsules were included. Animal studies or studies with a study population of less than five patients were excluded. RESULTS Fifty-two studies were included. The histological analyses showed that the breast implant capsules were organized in multiple layers with an inner layer of synovial-like metaplasia which was reported to diminish in capsules with capsular contracture. The remaining layers of the capsule mostly consisted of collagen. The alignment of the collagen fibers differed between contracted and non-contracted capsules, and capsules with higher Baker grade were generally thickest and contained more tissue inflammation. Studies investigating capsules affected by radiotherapy found a more pronounced inflammatory response and the capsules were generally thicker and fibrotic compared with nonirradiated capsules. CONCLUSIONS The included studies offer valuable insights into the histological changes caused by capsular contracture and their relation to clinical risk factors. Further studies with larger sample sizes and more strict inclusion criteria are needed to further investigate implant capsules and the role of the synovial-like metaplasia for the development of capsular contracture. 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 https://www.springer.com/00266 .
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Affiliation(s)
- Andreas Larsen
- Department of Plastic Surgery and Burns Treatment, Copenhagen University Hospital, Rigshospitalet, Blegdamsvej 9, 2100, Copenhagen, Denmark.
| | - Louise E Rasmussen
- Department of Plastic Surgery and Burns Treatment, Copenhagen University Hospital, Rigshospitalet, Blegdamsvej 9, 2100, Copenhagen, Denmark
| | - Leonia F Rasmussen
- Department of Plastic Surgery and Burns Treatment, Copenhagen University Hospital, Rigshospitalet, Blegdamsvej 9, 2100, Copenhagen, Denmark
| | - Tim K Weltz
- Department of Plastic Surgery and Burns Treatment, Copenhagen University Hospital, Rigshospitalet, Blegdamsvej 9, 2100, Copenhagen, Denmark
| | - Mathilde N Hemmingsen
- Department of Plastic Surgery and Burns Treatment, Copenhagen University Hospital, Rigshospitalet, Blegdamsvej 9, 2100, Copenhagen, Denmark
| | - Steen S Poulsen
- Department of Biomedical Sciences, Faculty of Health Sciences, University of Copenhagen, Copenhagen, Denmark
| | - Jens C B Jacobsen
- Department of Biomedical Sciences, Faculty of Health Sciences, University of Copenhagen, Copenhagen, Denmark
| | - Peter Vester-Glowinski
- Department of Plastic Surgery and Burns Treatment, Copenhagen University Hospital, Rigshospitalet, Blegdamsvej 9, 2100, Copenhagen, Denmark
| | - Mikkel Herly
- Department of Plastic Surgery and Burns Treatment, Copenhagen University Hospital, Rigshospitalet, Blegdamsvej 9, 2100, Copenhagen, Denmark
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Acellular Dermal Matrix-Associated Contracture: A Clinical and Histologic Analysis of Patients Undergoing Prosthetic Breast Reconstruction. Plast Reconstr Surg 2021; 148:968-977. [PMID: 34495907 DOI: 10.1097/prs.0000000000008485] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Capsular contracture is a well-recognized complication following prosthetic breast reconstruction. It has been the authors' observation that some patients undergoing breast reconstruction experience contracture specifically of the acellular dermal matrix placed at the time of their tissue expander insertion. The goal of the authors' study was to identify clinical and histologic findings associated with the development of acellular dermal matrix-associated contracture. METHODS The authors performed a retrospective cohort study of all patients undergoing bilateral implant-based breast reconstruction performed by the senior author (M.S.A.). Patients were excluded if they had radiation therapy to the breast. Patients with suspected acellular dermal matrix-associated contracture were identified by clinical photographs and review of operative notes. Histologic analysis was performed on specimens taken from two patients with acellular dermal matrix contracture. RESULTS The authors included a total of 46 patients (92 breasts), of which 19 breasts had suspected acellular dermal matrix-associated contracture. Acellular dermal matrix contracture was less common in direct-to-implant reconstruction (4.2 percent versus 26.5 percent; p = 0.020) and more common in breasts that had seromas (0 percent versus 15.8 percent; p = 0.001) or complications requiring early expander replacement. Contracted acellular dermal matrix had less vascularity and a lower collagen I-to-collagen III ratio, and was twice as thick as noncontracted acellular dermal matrix. CONCLUSIONS The authors have described a distinct phenomenon of acellular dermal matrix-associated contracture that occurs in a small subset of breasts where acellular dermal matrix is used. This merits further investigation. Future work will be required to better characterize the clinical factors that make acellular dermal matrix-associated contracture more likely to occur. CLINICAL QUESTION/LEVEL OF EVIDENCE Risk, III.
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Bellaire CP, Sayegh F, Janssen P, Rutland JW, Salzberg CA. Major Complications After Textured Versus Non-textured Breast Implants in Direct-to-Implant Breast Reconstruction: A Propensity Score Analysis. Aesthetic Plast Surg 2021; 45:2077-2085. [PMID: 34100107 DOI: 10.1007/s00266-021-02377-2] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2020] [Accepted: 05/22/2021] [Indexed: 12/17/2022]
Abstract
BACKGROUND While the risks and benefits of smooth versus textured implants for breast reconstruction and primary breast augmentation are thoroughly supported in the literature, few studies have examined the relationship between implant shell texture and complications following direct-to-implant (DTI) breast reconstruction. OBJECTIVES The present study examines the relationship between implant shell texture and complications in patients receiving DTI breast reconstruction. METHODS Retrospective chart review of patients undergoing DTI breast reconstruction between 2011 and 2018 by a single surgeon was performed. A propensity score matching algorithm was used to eliminate unwanted bias stemming from clinical covariates. Chi-squared and Fisher's exact tests were used to examine the association between implant shell texture and the following major postoperative complications: capsular contracture, hematoma, seroma, necrosis, infection, and implant loss. RESULTS A total of 402 unique patients (751 breasts) were included. The majority received smooth implants compared with textured implants (80.3% vs. 19.7%, respectively); 444 breasts were included for comparative analysis after 2:1 propensity score matching (296 smooth implants, 148 textured implants). The only statistically significant difference in outcomes between the two groups was a higher incidence of hematoma in the textured group (2.0% vs 0.0%), Fisher's Exact Test p = 0.04. Additionally, the matched cohort revealed a very low overall rate of capsular contracture (1.0%) for smooth implants. CONCLUSIONS Our data demonstrated non-significant differences for most major complication rates or revision surgery rates for smooth versus textured implants after matching. DTI breast reconstruction with smooth implants remains a safe and effective reconstructive option for select patients. 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 Table of Contents or online Instructions to Authors www.springer.com/00266 .
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Affiliation(s)
- Christopher P Bellaire
- Division of Plastic and Reconstructive Surgery, Icahn School of Medicine at Mount Sinai, 1 Gustave L. Levy Place, New York, NY, 10029, USA.
| | - Farah Sayegh
- Division of Plastic and Reconstructive Surgery, Icahn School of Medicine at Mount Sinai, 1 Gustave L. Levy Place, New York, NY, 10029, USA
| | - Pierce Janssen
- Division of Plastic and Reconstructive Surgery, Icahn School of Medicine at Mount Sinai, 1 Gustave L. Levy Place, New York, NY, 10029, USA
| | - John W Rutland
- Division of Plastic and Reconstructive Surgery, Icahn School of Medicine at Mount Sinai, 1 Gustave L. Levy Place, New York, NY, 10029, USA
| | - C Andrew Salzberg
- Division of Plastic and Reconstructive Surgery, Icahn School of Medicine at Mount Sinai, 1 Gustave L. Levy Place, New York, NY, 10029, USA
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Retchkiman M, El-Khatib A, Nazhat Al Yafi M, Danino MA. Biocell-Initial patents versus user instructions guide: A discrepancy at the core of a crisis. ANN CHIR PLAST ESTH 2021; 66:277-284. [PMID: 34140175 DOI: 10.1016/j.anplas.2021.05.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2021] [Accepted: 05/01/2021] [Indexed: 11/28/2022]
Abstract
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.
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Affiliation(s)
- M Retchkiman
- Division of Plastic and Reconstructive Surgery, University of Montreal Medical Center, Montreal, Quebec, Canada
| | - A El-Khatib
- Division of Plastic and Reconstructive Surgery, University of Montreal Medical Center, Montreal, Quebec, Canada
| | - M Nazhat Al Yafi
- Division of Plastic and Reconstructive Surgery, University of Montreal Medical Center, Montreal, Quebec, Canada
| | - M A Danino
- Division of Plastic and Reconstructive Surgery, University of Montreal Medical Center, Montreal, Quebec, Canada.
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- Division of Plastic and Reconstructive Surgery, University of Montreal Medical Center, Montreal, Quebec, Canada
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Fan S, Chen H, Grant A, DeLyzer T. Outcomes of Immediate Alloplastic Breast Reconstruction in Patients Receiving Post-Mastectomy Radiotherapy. Plast Surg (Oakv) 2020; 30:136-143. [PMID: 35572088 PMCID: PMC9096855 DOI: 10.1177/2292550320969646] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
Background: Immediate alloplastic breast reconstruction is traditionally avoided in patients who require post-mastectomy radiation therapy (PMRT). However, a subset of patients who undergo alloplastic reconstruction may unpredictably require adjuvant radiation. The purpose of this study was to compare outcomes and complications in patients at our institution who had undergone immediate alloplastic breast reconstruction and received PMRT to either the permanent implant or temporary tissue expander. Materials and Methods: A retrospective cohort study was performed looking at patients who underwent immediate alloplastic breast reconstruction over a 10-year period (2009-2019) at our regional breast centre. All patients who underwent immediate alloplastic breast reconstruction and had PMRT were included in the study. Major (wound dehiscence with device exposure, or reconstructive failure) and minor (infection, capsular contracture, revision surgery) complication rates between those patients receiving radiation to a tissue expander versus implant were compared using Fisher exact test ( P < .05). Results: Six-hundred ninety-two patients were identified, and 43 patients met inclusion criteria. Of this group, 29 received PMRT to implants and 14 received PMRT to tissue expanders. Complication rates were similar between groups for superficial wound infection (3.4% vs 7.1%), periprosthetic infection (3.4% vs 7.1%), capsular contracture (41.4% vs 21.4%), revision surgery for aesthetics (41.4% vs 21.4%), wound dehiscence and device exposure (3.4% vs 21.3%), and reconstructive failure (10.3% vs 6.7%). Total complication rates were similar between groups (51.7% vs 42.9%). Discussion: Overall 6.4% of patients who underwent immediate alloplastic breast reconstruction required PMRT over a 10-year period. Complication rates for infection, capsular contracture, revision surgery, wound dehiscence and device exposure, and reconstructive failure were similar between both groups. Total complication rates were similar between groups. This information will help to inform decision-making regarding immediate alloplastic reconstruction and expected complications when PMRT is needed.
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Affiliation(s)
- Stacy Fan
- Division of Plastic and Reconstructive Surgery, Western University, London, Ontario, Canada
| | - Hanny Chen
- Schulich School of Medicine & Dentistry, Western University, London, Ontario, Canada
| | - Aaron Grant
- Division of Plastic and Reconstructive Surgery, LHSC—University Hospital Campus, London, Ontario, Canada
| | - Tanya DeLyzer
- Division of Plastic and Reconstructive Surgery, LHSC—Victoria Hospital Campus, London, Ontario, Canada
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Peters W. The Evolution of Breast Implants. THE CANADIAN JOURNAL OF PLASTIC SURGERY = JOURNAL CANADIEN DE CHIRURGIE PLASTIQUE 2020. [DOI: 10.1177/229255030201000508] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
The present review traces the evolution of breast implants over the past 50 years. During the early years (from 1951 to 1962), a number of different sponges were used for breast augmentation. The first of these was Ivalon, a polyvinyl alcohol sponge. Other sponges were introduced subsequently, including Etheron (a poly-ether sponge popularized by Dr Paule Regnault in Montreal) and Polystan (fabric tapes that were wound into a ball). Subsequently, polyethylene strips enclosed in a fabric or polyethylene casing were also used for breast augmentation. All of these materials had similar outcomes. Although the initial results were encouraging, within one year of augmentation, breasts became very firm and lost over 25% of their volume. This was due to capsular contracture, a process that would lead to the collapse of the sponge and would continue to plague plastic surgeons and their patients for the next 50 years. In 1963, Cronin and Gerow introduced the silicone gel ‘natural feel’ implant, which revolutionized breast augmentation surgery. Approximately 10 companies have manufactured many types of silicone gel breast implants over the years. They obtained their raw materials for gels and shells from a similar number of other companies that entered and left the market at intervals. Many of the suppliers and manufactures changed their names and ownership over the years, and most of the companies no longer exist. No formal process of United States Food and Drug Administration premarket testing was in effect until 1988. There have been three generations of gel implants and a number of other lesser variations. First-generation implants (1963 to 1972) had a thick gel and a thick wall. They have generally remained intact over the years. Second-generation implants (1973 to the mid-1980s) had a thin gel and a thin wall. They have tended to disrupt over time. Third-generation implants (mid-1980s to 1992) had a thick wall and a thick gel. Except for those made by Surgitek, these implants remain intact. The breast implant business was competitive and companies introduced changes such as softer gels; barrier low-bleed shells; greater or lesser shell thickness; surface texturing; different sizes, contours and shapes; and multiple lumens in search of better aesthetics. Ultimately, more than 240 styles and 8300 models of silicone gel breast implants were manufactured in the United States alone. Inflatable breast implants were introduced in Toulons, France in 1965 (the Simaplast implant). There have been three main eras of inflatable implants: seamed, high-temperature vulcanized and room temperature vulcanized implants. In 1973, spontaneous deflation rates of 76% to 88% over three years were reported for many types of inflatable implants. Because of this, most plastic surgeons abandoned their use. From 1963 until the moratorium on gel implants (January 6, 1992), about 95% of all breast implants inserted were silicone gel filled. Only 5% were saline filled. Since the moratorium, this ratio has been reversed and 95% of all implants have been saline-filled, with only 5% being gel filled. Polyurethane-coated (PU) silicone gel implants were introduced in 1968. Over the next 20 years, they were shown to reduce the prevalence of capsular contracture to 2% to 3%. Other forms of surface texturing (Biocell, Siltex, multistructured implant) also appear to reduce capsular contracture with gel implants, but the reduction has been much less dramatic than that seen with PU implants. Contoured (anatomical) shaping appears to have advantages in some patients with gel implants. No such advantage has been seen for texturing or shaping with saline-filled implants. The story of gel implants has culminated in the largest class action lawsuit in medical history, with US$4.2 billion being awarded to women with silicone gel implants. During the past decade, there has been a tremendous amount of research on the reaction of a woman's body to gel implants. A plethora of studies have demonstrated that silicone gel implants are not associated with the development of any medical diseases. Silicone gel-filled implants have therefore been approved for use under Health Canada's Special Access Program. Silicone gel-filled implants may now be used in certain patients in whom they would provide advantages over saline implants. Silicone gel implants have not been approved for unrestricted general use. The evolution of breast implants occupies the past half century. It has been a stormy course, with many exciting advances and many bitter disappointments. The universe of breast implants is large and the variation among the implants is substantial. The purpose of the present review is to trace the evolution of breast implants over the past 50 years.
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Affiliation(s)
- Walter Peters
- Division of Plastic Surgery, University of Toronto, Toronto, Ontario
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Corcione S, Lupia T, De Rosa FG. Skin and soft tissue infections after breast surgery. Curr Opin Infect Dis 2019; 32:87-94. [PMID: 30695000 DOI: 10.1097/qco.0000000000000531] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
PURPOSE OF REVIEW Breast surgery is considered a clean surgical procedure; nevertheless, infection rates are often higher than those reported after other similarly considered clean surgeries (e.g., thyroid, hernia). Acute bacterial skin and soft tissue infections, mostly surgical site infections and implant-associated infections are commonest events that could complicate postoperative care. RECENT FINDINGS Risk of infection is closely related to surgery procedure itself and patients host factors. Gram-positive bacteria with pattern of antimicrobial resistance are increasingly isolated and before today less frequent causes such as gram negative and mycobacteria infections. Impact of postoperative complications is underestimated and lacking an appropriate care and education for local and systemic management. SUMMARY We report the current evidence on the management of infections after breast surgery. New drugs options for methicillin-resistant Staphylococcus aureus and other gram positive should have a place in this setting. Stewardship activities aiming at reducing infections risks with the correct considerations of host, microbiological and surgical risk factors.
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Affiliation(s)
- Silvia Corcione
- Department of Medical Sciences, University of Turin, City of Health and Sciences, Turin, Italy
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10
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Cifuentes I, Dagnino B, Rada G. Do textured breast implants decrease the rate of capsular contracture compared to smooth implants? Medwave 2017. [DOI: 10.5867/medwave.2017.07.7020] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
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11
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Reply: Role of Mitomycin C in Preventing Capsular Contracture in Implant-Based Reconstructive Breast Surgery: A Randomized Controlled Trial. Plast Reconstr Surg 2017; 140:823e-824e. [PMID: 28820813 DOI: 10.1097/prs.0000000000003851] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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12
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Webb LH, Aime VL, Do A, Mossman K, Mahabir RC. Textured Breast Implants: A Closer Look at the Surface Debris Under the Microscope. Plast Surg (Oakv) 2017; 25:179-183. [PMID: 29026824 DOI: 10.1177/2292550317716127] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
BACKGROUND Texturing of breast implants is done to decrease the risk of associated complications. Each manufacturer utilizes unique and at times proprietary techniques to texture the surface of their implants. Little is known about the integrity of this surface structure texturing or the propensity for the surfaces to shed particulate matter. This study aimed to determine the extent of surface particulate shedding from 3 textured implants approved by the US Food and Drug Administration (FDA), which are manufactured by Allergan, Mentor, and Sientra. METHODS Control images of each of the 3 textured breast implants were obtained with scanning electron microscopy (SEM). A liquid adhesive, ethylene vinyl acetate (EVA) copolymer was then applied to the external shell of the implants, allowed to cool, and peeled from the surface. Images of the EVA copolymer were taken with SEM to qualitatively analyze displacement of surface particulate debris. Scanning electron microscopy imaging of the implants was repeated for qualitative comparisons with the control images. RESULTS The peeled copolymer of the 3 implants exhibited surface shedding. Comparison of the 3 breast implants showed the shedding to be greatest for the Allergan implant. CONCLUSIONS This study highlights the dynamic surface material properties of the 3 FDA-approved breast implants. Shedding of particulate matter from the implant surfaces can be precipitated by moderate adhesion. Our qualitative examination of SEM findings showed more debris shed from the Allergan breast implants than from the Mentor or Sientra implants.
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Affiliation(s)
- Leland H Webb
- Division of Plastic and Reconstructive Surgery, Mayo Clinic Hospital, Phoenix, AZ, USA
| | - Victoria L Aime
- Division of Plastic and Reconstructive Surgery, Mayo Clinic Hospital, Phoenix, AZ, USA
| | - Annie Do
- Creighton University School of Medicine, Omaha, NE, USA
| | - Kenneth Mossman
- John M. Cowley Center for High Resolution Electron Microscopy, Arizona State University, Tempe, AZ, USA
| | - Raman C Mahabir
- Division of Plastic and Reconstructive Surgery, Mayo Clinic Hospital, Phoenix, AZ, USA
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VIEIRA VILBERTOJ, D'ACAMPORA ARMANDO, NEVES FERNANDAS, MENDES PAULOR, VASCONCELLOS ZULMARADE, NEVES RODRIGOD, FIGUEIREDO CLAUDIAP. Capsular Contracture In Silicone Breast Implants: Insights From Rat Models. AN ACAD BRAS CIENC 2016; 88:1459-70. [DOI: 10.1590/0001-3765201620150874] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2015] [Accepted: 02/04/2016] [Indexed: 01/19/2023] Open
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14
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Potter S, Conroy EJ, Williamson PR, Thrush S, Whisker LJ, Skillman JM, Barnes NLP, Cutress RI, Teasdale EM, Mills N, Mylvaganam S, Branford OA, McEvoy K, Jain A, Gardiner MD, Blazeby JM, Holcombe C. The iBRA (implant breast reconstruction evaluation) study: protocol for a prospective multi-centre cohort study to inform the feasibility, design and conduct of a pragmatic randomised clinical trial comparing new techniques of implant-based breast reconstruction. Pilot Feasibility Stud 2016; 2:41. [PMID: 27965859 PMCID: PMC5154059 DOI: 10.1186/s40814-016-0085-8] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2016] [Accepted: 06/10/2016] [Indexed: 11/30/2022] Open
Abstract
BACKGROUND Implant-based breast reconstruction (IBBR) is the most commonly performed reconstructive procedure in the UK. The introduction of techniques to augment the subpectoral pocket has revolutionised the procedure, but there is a lack of high-quality outcome data to describe the safety or effectiveness of these techniques. Randomised controlled trials (RCTs) are the best way of comparing treatments, but surgical RCTs are challenging. The iBRA (implant breast reconstruction evaluation) study aims to determine the feasibility, design and conduct of a pragmatic RCT to examine the effectiveness of approaches to IBBR. METHODS/DESIGN The iBRA study is a trainee-led research collaborative project with four phases:Phase 1 - a national practice questionnaire (NPQ) to survey current practicePhase 2 - a multi-centre prospective cohort study of patients undergoing IBBR to evaluate the clinical and patient-reported outcomesPhase 3- an IBBR-RCT acceptability survey and qualitative work to explore patients' and surgeons' views of proposed trial designs and candidate outcomes.Phase 4 - phases 1 to 3 will inform the design and conduct of the future RCT All centres offering IBBR will be encouraged to participate by the breast and plastic surgical professional associations (Association of Breast Surgery and British Association of Plastic Reconstructive and Aesthetic Surgeons). Data collected will inform the feasibility of undertaking an RCT by defining current practice and exploring issues surrounding recruitment, selection of comparator arms, choice of primary outcome, sample size, selection criteria, trial conduct, methods of data collection and feasibility of using the trainee collaborative model to recruit patients and collect data. DISCUSSION The preliminary work undertaken within the iBRA study will determine the feasibility, design and conduct of a definitive RCT in IBBR. It will work with the trainee collaborative to build capacity by creating an infrastructure of research-active breast and plastic surgeons which will facilitate future high-quality research that will ultimately improve outcomes for all women seeking reconstructive surgery. TRIAL REGISTRATION ISRCTN37664281.
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Affiliation(s)
- Shelley Potter
- Bristol Centre for Surgical Research, School of Social and Community Medicine, University of Bristol, Room 3.12 Canynge Hall, 39 Whatley Road, Bristol, BS8 2PS UK
| | - Elizabeth J. Conroy
- MRC North West Hub for Trials Methodology Research, Department of Biostatistics, Clinical Trials Research Centre, University of Liverpool, Liverpool, L69 3GS UK
| | - Paula R. Williamson
- MRC North West Hub for Trials Methodology Research, Department of Biostatistics, Clinical Trials Research Centre, University of Liverpool, Liverpool, L69 3GS UK
| | - Steven Thrush
- Breast Unit, Worcester Royal Hospital. Charles Hastings Way, Worcester, WR5 1DD UK
| | - Lisa J. Whisker
- Breast Institute, Nottingham University Hospitals NHS Trust, Hucknall Road, Nottingham, NG5 1PB UK
| | - Joanna M Skillman
- Department of Plastic Surgery, University Hospitals Coventry and Warwickshire NHS Trust, Clifford Bridge Road, Coventry, CV2 2DX UK
| | - Nicola L. P. Barnes
- The Nightingale Centre Breast Unit, University Hospital of South Manchester NHS Foundation Trust, Southmoor Road, Manchester, M23 9LT UK
| | - Ramsey I. Cutress
- Breast Unit, University Hospital Southampton, Tremona Road, Southampton, Hampshire SO16 6YD UK
- Faculty of Medicine, University of Southampton, University Road, Southampton, SO17 1BJ UK
| | - Elizabeth M. Teasdale
- Linda McCartney Centre, Royal Liverpool and Broadgreen University Hospital, Prescot Street, Liverpool, L7 8XP UK
| | - Nicola Mills
- Bristol Centre for Surgical Research, School of Social and Community Medicine, University of Bristol, Room 3.12 Canynge Hall, 39 Whatley Road, Bristol, BS8 2PS UK
| | - Senthurun Mylvaganam
- New Cross Hospital, Royal Wolverhampton Hospitals NHS Trust, Wednesfield Way, Wolverhampton, WV10 0QP UK
| | - Olivier A. Branford
- Department of Plastic Surgery, The Royal Marsden NHS Foundation Trust, Fulham Road, London, SW3 6JJ UK
| | | | - Abhilash Jain
- Imperial College London NHS Trust, London, SW7 2AZ UK
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Nuffield Orthopaedic Centre, Windmill Road, Headington, Oxford OX3 7HE UK
| | - Matthew D. Gardiner
- Imperial College London NHS Trust, London, SW7 2AZ UK
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Nuffield Orthopaedic Centre, Windmill Road, Headington, Oxford OX3 7HE UK
| | - Jane M. Blazeby
- Bristol Centre for Surgical Research, School of Social and Community Medicine, University of Bristol, Room 3.12 Canynge Hall, 39 Whatley Road, Bristol, BS8 2PS UK
| | - Christopher Holcombe
- Linda McCartney Centre, Royal Liverpool and Broadgreen University Hospital, Prescot Street, Liverpool, L7 8XP UK
| | - on behalf of the Breast Reconstruction Research Collaborative
- Bristol Centre for Surgical Research, School of Social and Community Medicine, University of Bristol, Room 3.12 Canynge Hall, 39 Whatley Road, Bristol, BS8 2PS UK
- MRC North West Hub for Trials Methodology Research, Department of Biostatistics, Clinical Trials Research Centre, University of Liverpool, Liverpool, L69 3GS UK
- Breast Unit, Worcester Royal Hospital. Charles Hastings Way, Worcester, WR5 1DD UK
- Breast Institute, Nottingham University Hospitals NHS Trust, Hucknall Road, Nottingham, NG5 1PB UK
- Department of Plastic Surgery, University Hospitals Coventry and Warwickshire NHS Trust, Clifford Bridge Road, Coventry, CV2 2DX UK
- The Nightingale Centre Breast Unit, University Hospital of South Manchester NHS Foundation Trust, Southmoor Road, Manchester, M23 9LT UK
- Breast Unit, University Hospital Southampton, Tremona Road, Southampton, Hampshire SO16 6YD UK
- Faculty of Medicine, University of Southampton, University Road, Southampton, SO17 1BJ UK
- Linda McCartney Centre, Royal Liverpool and Broadgreen University Hospital, Prescot Street, Liverpool, L7 8XP UK
- New Cross Hospital, Royal Wolverhampton Hospitals NHS Trust, Wednesfield Way, Wolverhampton, WV10 0QP UK
- Department of Plastic Surgery, The Royal Marsden NHS Foundation Trust, Fulham Road, London, SW3 6JJ UK
- City Hospital, Dudley Road, West Midlands, B18 7QH UK
- Imperial College London NHS Trust, London, SW7 2AZ UK
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Nuffield Orthopaedic Centre, Windmill Road, Headington, Oxford OX3 7HE UK
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Rocco N, Rispoli C, Moja L, Amato B, Iannone L, Testa S, Spano A, Catanuto G, Accurso A, Nava MB. Different types of implants for reconstructive breast surgery. Cochrane Database Syst Rev 2016; 2016:CD010895. [PMID: 27182693 PMCID: PMC7433293 DOI: 10.1002/14651858.cd010895.pub2] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
BACKGROUND Breast cancer is the most common cancer in women worldwide, and is a leading cause of cancer death among women. Prophylactic or curative mastectomy is often followed by breast reconstruction for which there are several surgical approaches that use breast implants with which surgeons can restore the natural feel, size and shape of the breast. OBJECTIVES To assess the effects of different types of breast implants on capsular contracture, surgical short- and long-term complications, postoperative satisfaction level and quality of life in women who have undergone reconstructive breast surgery after mastectomy. SEARCH METHODS We searched the Cochrane Breast Cancer Group's Specialised Register on 20 July 2015, MEDLINE (1985 to 20 July 2015), EMBASE (1985 to 20 July 2015) and the Cochrane Central Register of Controlled Trials (CENTRAL; Issue 8, 2015). We also searched the World Health Organization's International Clinical Trials Registry Platform (WHO ICTRP) and ClinicalTrials.gov on 16 July 2015. SELECTION CRITERIA We included randomised controlled trials (RCTs) and quasi-RCTs that compared different types of breast implants for reconstructive surgery. We considered the following types of intervention: implant envelope surfaces - texturised versus smooth; implant filler material - silicone versus saline, PVP-Hydrogel versus saline; implant shape - anatomical versus round; implant volume - variable versus fixed; brands - different implant manufacturing companies and implant generation (fifth versus previous generations). DATA COLLECTION AND ANALYSIS Two review authors independently assessed methodological quality and extracted data. We used standard Cochrane methodological procedures. The quality of the evidence was assessed using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) system. MAIN RESULTS Five RCTs with 202 participants met the inclusion criteria. The women participants were typically in their 50s, and the majority of them (about 82%) received reconstructive surgery following breast cancer, while the others had reconstructive surgery after prophylactic mastectomy. The studies were heterogenous in terms of implant comparisons, which prevented us from pooling the data.The studies were judged as being at an unclear risk of bias for most risk of bias items owing to poor quality of reporting in the trial publications. Three of the five RCTs were judged to be at high risk of attrition bias, and one at high risk of detection bias.Textured silicone versus smooth silicone implants: textured implants were associated with worse outcomes when compared to smooth implants (capsular contracture: risk ratio (RR) 0.82, 95% CI 0.14 to 4.71; 1 study, 20 participants; very low quality evidence; reintervention: RR 0.82, 95% CI 0.14 to 4.71; 1 study, 20 participants; very low quality evidence). No results in this comparison were statistically significant.Silicone versus saline implants: saline-filled implants performed better than silicone-filled implants for some outcomes; specifically, they produced less severe capsular contracture (RR 3.25, 95% CI 1.24 to 8.51; 1 study, 60 participants; very low quality evidence) and increased patient satisfaction (RR 0.60, 95% CI 0.41 to 0.88; 1 study, 58 participants; very low quality evidence). However reintervention was significantly more frequent in the saline-filled implant group than in the silicone-filled group (OR 0.08, 95% CI 0.01 to 0.43; 1 study, 60 participants; very low quality evidence).Poly(N-vinyl-2-pyrrolidone) hydrogel-filled (PVP-hydrogel) versus saline-filled implants: PVP-hydrogel-filled implants were associated with worse outcomes when compared to saline-filled implants (capsular contracture: RR 3.50, 95% CI 0.83 to 14.83; 1 study, 40 participants; very low quality evidence; short-term complications: RR 2.10, 95% CI 0.21 to 21.39; 1 study, 41 participants; very low quality evidence).Anatomical versus round implants: anatomical implants were associated with worse outcomes than round implants (capsular contracture: RR 2.00, 95% CI 0.20 to 20.15; 1 study, 36 participants; very low quality evidence; short-term complications: RR 2.00, 95% CI 0.42 to 9.58; 1 study, 36 participants; very low quality evidence; reintervention: RR 1.50, 95% CI 0.51 to 4.43; 1 study, 36 participants; very low quality evidence). No results in this comparison were statistically significant.Variable-volume versus fixed-volume implants: data about one-stage reconstruction using variable-volume implants were compared with data about fixed-volume implants positioned during the second surgical procedure of two-stage reconstructions. Fixed-volume implant reconstructions were possibly associated with a greater number of women reporting that their reconstruction corresponded with expected results (RR 0.25, 95% CI 0.10 to 0.62; 1 study, 40 participants; very low quality evidence) and fewer reinterventions (RR 7.00, 95% CI 1.82 to 26.89; 1 study, 40 participants; very low quality evidence) when compared to variable-volume implants. A higher patient satisfaction level (rated from 1 to 6, with 1 being very bad and 6 being very good) was found with the fixed-volume implants for overall aesthetic result (mean difference (MD) -1.10, 95% CI -1.59 to -0.61; 1 study, 40 participants; very low quality evidence).There were no studies that examined the effects of recent (fifth) generation silicone implants versus previous generations or different implant manufacturing companies. AUTHORS' CONCLUSIONS Despite the central role of breast reconstruction in women with breast cancer, the best implants to use in reconstructive surgery have been studied rarely in the context of RCTs. Furthermore the quality of these studies and the overall evidence they provide is largely unsatisfactory. Some of our results can be interpreted as early evidence of potentially large differences between different surgical approaches, which should be confirmed in new high-quality RCTs that include a larger number of women. These days - even after a few million women have had breasts reconstructed - surgeons cannot inform women about the risks and complications of different implant-based breast reconstructive options on the basis of results derived from RCTs.
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Affiliation(s)
- Nicola Rocco
- University of Naples "Federico II"Department of Clinical Medicine and SurgeryVia S. Pansini, 5NaplesItaly
| | | | - Lorenzo Moja
- University of MilanDepartment of Biomedical Sciences for HealthVia Pascal 36MilanItaly20133
- IRCCS Galeazzi Orthopaedic InstituteClinical Epidemiology UnitMilanItaly
| | - Bruno Amato
- University of Naples "Federico II"Department of Clinical Medicine and SurgeryVia S. Pansini, 5NaplesItaly
| | - Loredana Iannone
- Fatebenefratelli HospitalDepartment of General SurgeryVia Gabriele Jannelli 520NaplesItaly80131
| | - Serena Testa
- University of Naples "Federico II"Department of Anaesthesia and Intensive Care MedicineNaplesItaly
| | - Andrea Spano
- Fondazione IRCCS, Istituto Nazionale dei TumoriPlastic and Reconstructive Surgery UnitMilanItaly
| | - Giuseppe Catanuto
- Azienda Ospedaliera CannizzaroMultidisciplinary Breast UnitCataniaItaly
| | - Antonello Accurso
- University of Naples "Federico II"Department of General, Geriatric, Oncologic Surgery and Advanced TechnologiesNaplesItaly
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Liu X, Zhou L, Pan F, Gao Y, Yuan X, Fan D. Comparison of the postoperative incidence rate of capsular contracture among different breast implants: a cumulative meta-analysis. PLoS One 2015; 10:e0116071. [PMID: 25680100 PMCID: PMC4332657 DOI: 10.1371/journal.pone.0116071] [Citation(s) in RCA: 65] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2014] [Accepted: 12/05/2014] [Indexed: 11/18/2022] Open
Abstract
Background A large number of clinical studies have reported that the different materials used in breast implants were a possible cause of the different incidence rates of capsular contracture observed in patients after implantation. However, this theory lacks comprehensive support from evidence-based medicine, and considerable controversy remains. Objectives In this study, a cumulative systematic review examined breast augmentation that used implants with textured or smooth surfaces to analyze the effects of these two types of implants on the occurrence of postoperative capsular contracture. Methods We conducted a comprehensive search of literature databases, including PubMed and EMBASE, for clinical reports on the incidence of capsular contracture after the implantation of breast prostheses. We performed a cumulative meta-analysis on the incidence of capsular contracture in order from small to large sample sizes and conducted subgroup analyses according to the prosthetic material used, the implant pocket placement, the incision type and the duration of follow-up. Relative risks (RR) and 95% confidence intervals (CI) were used as the final pooled statistics. Results This meta-analysis included 16 randomized controlled trials (RCTs) and two retrospective studies. The cumulative comparison of textured and smooth breast implants showed statistical significance at 2.13 (95% CI, 1.18-3.86) when the fourth study was entered into the analysis. With the inclusion of more reports, the final results indicated that smooth breast implants were more likely to be associated with capsular contracture, with statistical significance at 3.10 (95% CI, 2.23-4.33). In the subgroup analyses, the subgroups based on implant materials included the silicone implant group and the saline implant group, with significant pooled statistical levels of 4.05 (95% CI, 1.97-8.31) and 3.12 (95% CI, 2.19-4.42), respectively. According to implant pocket placement, a subglandular group and a submuscular group were included in the analyses, and only the subglandular group had a statistically significant pooled result of 3.59 (95% CI, 2.43-5.30). Four subgroups were included in the analyses according to incision type: the inframammary incision group, the periareolar incision group, the transaxillary incision group and the mastectomy incision group. Among these groups, only the pooled results of the inframammary and mastectomy incision groups were statistically significant, at 2.82 (95% CI, 1.30-6.11) and 2.30 (95% CI, 1.17-4.50), respectively. Three follow-up duration subgroups were included in the analyses: the one-year group, the two- to three-year group and the ≥five-year group. These subgroups had statistically significant results of 4.67 (95% CI, 2.35-9.28), 3.42 (95% CI, 2.26-5.16) and 2.71 (95% CI, 1.64-4.49), respectively. Conclusion In mammaplasty, the use of textured implants reduces the incidence of postoperative capsular contracture. Differences in implant pocket placement and incision type are also likely to affect the incidence of capsular contracture; however, this conclusion awaits further study.
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Affiliation(s)
- Xing Liu
- Department of Plastic and Cosmetic Surgery, Xinqiao Hospital, Third Military Medical University, Chongqing, China 400037
| | - Liang Zhou
- Department of Health Statistics, College of Preventive Medicine, Third Military Medical University, Chongqing, China 400038
| | - Fuqiang Pan
- Department of Plastic and Aesthetic Surgery, Southwest Hospital, Third Military Medical University, Chongqing, China 400038
| | - Yang Gao
- Department of Plastic and Cosmetic Surgery, Research Institute of Surgery, Daping Hospital, Third Military Medical University, Chongqing, China 400042
| | - Xi Yuan
- Department of Plastic and Aesthetic Surgery, Southwest Hospital, Third Military Medical University, Chongqing, China 400038
| | - Dongli Fan
- Department of Plastic and Cosmetic Surgery, Xinqiao Hospital, Third Military Medical University, Chongqing, China 400037
- * E-mail:
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Potter S, Mills N, Cawthorn SJ, Donovan J, Blazeby JM. Time to be BRAVE: is educating surgeons the key to unlocking the potential of randomised clinical trials in surgery? A qualitative study. Trials 2014; 15:80. [PMID: 24628821 PMCID: PMC4003809 DOI: 10.1186/1745-6215-15-80] [Citation(s) in RCA: 39] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2013] [Accepted: 02/26/2014] [Indexed: 01/11/2023] Open
Abstract
BACKGROUND Well-designed randomised clinical trials (RCTs) provide the best evidence to inform decision-making and should be the default option for evaluating surgical procedures. Such trials can be challenging, and surgeons' preferences may influence whether trials are initiated and successfully conducted and their results accepted. Preferences are particularly problematic when surgeons' views play a key role in procedure selection and patient eligibility. The bases of such preferences have rarely been explored. Our aim in this qualitative study was to investigate surgeons' preferences regarding the feasibility of surgical RCTs and their understanding of study design issues using breast reconstruction surgery as a case study. METHODS Semistructured qualitative interviews were undertaken with a purposive sample of 35 professionals practicing at 15 centres across the United Kingdom. Interviews were transcribed verbatim and analysed thematically using constant comparative techniques. Sampling, data collection and analysis were conducted concurrently and iteratively until data saturation was achieved. RESULTS Surgeons often struggle with the concept of equipoise. We found that if surgeons did not feel 'in equipoise', they did not accept randomisation as a method of treatment allocation. The underlying reasons for limited equipoise were limited appreciation of the methodological weaknesses of data derived from nonrandomised studies and little understanding of pragmatic trial design. Their belief in the value of RCTs for generating high-quality data to change or inform practice was not widely held. CONCLUSION There is a need to help surgeons understand evidence, equipoise and bias. Current National Institute of Health Research/Medical Research Council investment into education and infrastructure for RCTs, combined with strong leadership, may begin to address these issues or more specific interventions may be required.
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Affiliation(s)
- Shelley Potter
- Bristol Centre for Surgical Research, School of Social and Community Medicine, University of Bristol, Canynge Hall, 39 Whatley Road, Bristol BS8 2PS, UK
- Division of Surgery, Head and Neck, University Hospitals Bristol NHS Foundation Trust, Upper Maudlin Street, Bristol BS2 8HW, UK
| | - Nicola Mills
- Bristol Centre for Surgical Research, School of Social and Community Medicine, University of Bristol, Canynge Hall, 39 Whatley Road, Bristol BS8 2PS, UK
| | - Simon J Cawthorn
- Bristol Breast Care Centre, North Bristol NHS Trust, Southmead Hospital, Bristol BS10 5NB, UK
| | - Jenny Donovan
- Bristol Centre for Surgical Research, School of Social and Community Medicine, University of Bristol, Canynge Hall, 39 Whatley Road, Bristol BS8 2PS, UK
| | - Jane M Blazeby
- Bristol Centre for Surgical Research, School of Social and Community Medicine, University of Bristol, Canynge Hall, 39 Whatley Road, Bristol BS8 2PS, UK
- Division of Surgery, Head and Neck, University Hospitals Bristol NHS Foundation Trust, Upper Maudlin Street, Bristol BS2 8HW, UK
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Potter S, Brigic A, Whiting PF, Cawthorn SJ, Avery KNL, Donovan JL, Blazeby JM. Reporting Clinical Outcomes of Breast Reconstruction: A Systematic Review. J Natl Cancer Inst 2010; 103:31-46. [DOI: 10.1093/jnci/djq438] [Citation(s) in RCA: 71] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
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Unlu RE, Yilmaz AD, Orbay H, Can B, Tekdemir I, Sensoz O. Influence of rifampin on capsule formation around silicone implants in a rat model. Aesthetic Plast Surg 2007; 31:358-64. [PMID: 17551775 DOI: 10.1007/s00266-006-0248-8] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
This study investigated the effect of rifampin on the thickness of capsules around silicone implants by bactericidal activity against Stapylococcus epidermidis. Silicone blocks (1 x 1 cm) were placed into pockets created for each of the 40 rats included in the study. In group 1, the operation was performed under aseptic conditions. In group 2, standard S. epidermidis was inoculated into the pocket, whereas rifampin and S. epidermidis were applied in group 3. In group 4, only rifampin was applied topically on implants. After 12 weeks, the peri-implant capsules were removed and examined under a photomicroscope and a scanning electron microscope. The mean thickness of the capsules was 63.307 microm in group 1, 111.538 microm in group 2, 43.076 microm in group 3, and 30.384 mum in group 4. The differences between groups 2 and 3 and groups 2 and 4 were found to be statistically significant (p < 0.001). Rifampin appears to be an agent for preventing peri-implant capsule formation.
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Affiliation(s)
- Ramazan Erkin Unlu
- Department of 2nd Plastic and Reconstructive Surgery, Ankara Numune Training and Research Hospital, Ankara, Turkey
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Barnsley GP, Sigurdson LJ, Barnsley SE. Textured Surface Breast Implants in the Prevention of Capsular Contracture among Breast Augmentation Patients: A Meta-Analysis of Randomized Controlled Trials. Plast Reconstr Surg 2006; 117:2182-90. [PMID: 16772915 DOI: 10.1097/01.prs.0000218184.47372.d5] [Citation(s) in RCA: 226] [Impact Index Per Article: 12.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Capsular contracture is a common complication associated with the use of breast implants. Numerous randomized controlled trials addressing the efficacy of textured surface breast implants in reducing capsular contracture have yielded nonuniform results. This meta-analysis addresses the use of textured breast implants in the prevention of capsular contracture. METHODS MEDLINE, EMBASE, and the Cochrane Central Register of Controlled Trials databases were searched to identify all randomized controlled trials involving the use of textured versus smooth breast implants. The results of these trials were meta-analyzed to obtain a pooled odds ratio of the effect of textured surfacing on capsular contracture rates. In addition, subgroup analyses were performed based on implant type (saline or silicone gel), type of surface texturing (Siltex or Biocell), placement (subglandular or submuscular), and length of follow-up. RESULTS Eleven trials were reviewed. Four were excluded because they failed to meet a priori inclusion criteria. The remaining seven trials were meta-analyzed. Only three of these studies found significantly lower rates of capsular contracture with the use of textured implants. However, when all seven studies were pooled, the odds ratio was found to be 0.19 (95 percent confidence interval, 0.07 to 0.52), indicating a protective effect for surface texturing on the rate of capsular contracture. Submuscular placement was the only subgroup in which significance was not achieved. However, this subgroup consisted of a single study, which was dramatically underpowered. CONCLUSION The results of this meta-analysis demonstrate the superiority of textured over smooth breast implants in decreasing the rate of capsular contracture.
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Affiliation(s)
- G Philip Barnsley
- Department of Surgery, Division of Plastic Surgery, Dalhousie University
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M D NK, Cobanoğlu U, Ambarcioğlu O, Topal U, Kutlu N. Effect of amniotic fluid on peri-implant capsular formation. Aesthetic Plast Surg 2005; 29:174-80. [PMID: 15948022 DOI: 10.1007/s00266-004-0135-0] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
Although commonly used biomaterials are physically and chemically stable, nonimmunogenic, and nontoxic, implanted and blood-contact biomaterials trigger a wide variety of unwanted responses, including inflammation, thrombosis, infection, and fibrosis. Peri-implant fibrosis is the response most commonly seen by plastic surgeons. In this study, the authors hypothesized that as hyaluronic acid (HA) reduces scar formation by inhibiting the activity of mononuclear phagocytes and lymphocytes, human amniotic fluid (HAF), which contains high concentrations of HA, HA-stimulating activator (HASA), and other factors, might prevent the formation of fibrous capsules and capsule contracture when applied intraluminally. Two 1 x 1-cm silicone blocks were placed dorsally into separate surgically created pockets underneath the panniculus carnosus muscle, distant from the incisions, in each of the 10 rats in the study. At the time of implant insertion, 2 ml of HAF was instilled into the cranially located pockets in group 1, whereas 2 ml of saline solution was instilled into the caudally located pockets in group 2. After 6 months, intracapsular static and dynamic pressure measurements were made, and then all the peri-implant capsules were excised and fixed in 10% neutral buffered formaldehyde. The thicknesses of the capsules were measured in three different areas of each section, and a mean was calculated. Capsular firmness, according to the static and dynamic pressure readings, was significantly greater in the control group, which had saline solution introduced into the pocket, than in the treatment group, which had HAF used in the same manner. The mean total thickness of the capsules surrounding the implants was 876.7 microm in the control group, as comparied with 466.8 microm in the HAF-treated group. This difference was statistically significant (p < 0.001). Because of its ability to reduce capsular thickness and firmness and also because it can be stored in a freezer if it is prepared in a cell-free manner, HAF would appear to be a useful adjunct in the prevention of capsular contracture formation.
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Henriksen TF, Fryzek JP, Hölmich LR, McLaughlin JK, Kjøller K, Høyer AP, Olsen JH, Friis S. Surgical Intervention and Capsular Contracture After Breast Augmentation. Ann Plast Surg 2005; 54:343-51. [PMID: 15785269 DOI: 10.1097/01.sap.0000151459.07978.fa] [Citation(s) in RCA: 133] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
Epidemiologic data on local complications after breast augmentation are scarce. In particular, few prospectively collected data are available on modern breast implants on this issue. Using data from the Danish Registry for Plastic Surgery of the Breast, the authors examined determinants of surgery-requiring complications and capsular contracture grades III to IV among 2277 women who underwent cosmetic breast implantation from June 1999 through April 2003. During an average follow-up period of 1.6 years after implantation, 4.3% of these women (3% of implants) required secondary surgery as a result of short-term complications. The most frequent clinical indications for surgery were displacement of the implant (38%), capsular contracture grades III to IV (16%), ptosis (13%), and hematoma (11%). Overall, the authors found that inframammary incision and subglandular placement were associated with decreased risks of developing complications requiring surgical intervention, whereas implants larger than 350 mL increased the risk of such complications (relative risk [RR], 2.3; 95% confidence interval [CI], 1.3-4.0). Thirty-nine Baker III to IV capsular contractures were identified, of which 22 were treated surgically within the study period. Submuscular placement of the implant decreased the risk of capsular contracture grades III to IV (RR, 0.3; 95% CI, 0.2-0.8), whereas surgical routes other than inframammary and drainage of implant cavity were associated with increased risk of capsular contracture. Current surgical practices and modern implants used for breast augmentation produce fewer short-term complications than procedures and devices of the past. This prospective study indicates that surgical procedures are more important predictors for local (short-term) complications than implant or patient characteristics.
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Affiliation(s)
- Trine F Henriksen
- The Danish Registry for Plastic Surgery of the Breast, DK-2100 Copenhagen, Denmark.
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Ajmal N, Riordan CL, Cardwell N, Nanney LB, Shack RB. The effectiveness of sodium 2-mercaptoethane sulfonate (mesna) in reducing capsular formation around implants in a rabbit model. Plast Reconstr Surg 2003; 112:1455-61; discussion 1462-3. [PMID: 14504532 DOI: 10.1097/01.prs.0000081070.36511.5c] [Citation(s) in RCA: 29] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
The development of capsular contracture is the most common complication associated with the insertion of breast implants. The authors studied the role of sodium 2-mercaptoethane sulfonate (mesna) in reduction of capsular formation in a rabbit model. Two 40-cc textured saline implants were placed dorsally into each of the 20 rabbits in the study. At the time of insertion of the implants, 10 ml of a 10% solution of mesna was instilled into one of the pockets and normal saline was instilled into the other. The implants were removed and a capsulectomy was performed at 5 months. The capsules were examined histologically for qualitative differences between the two groups. Quantitative analysis of the thickness of the capsule and the myofibroblast populations was also performed and compared between the two groups. The mean total thickness of the capsule around the implants was 496.8 microm in the mesna-treated group compared with 973.7 microm in the saline-treated group (p < 0.001). Likewise, the thickness of the myofibroblast layer was reduced in the mesna-treated group at 283.2 microm versus 555 microm in the saline-treated group (p < 0.0001). The capsules were also relatively less vascular in the mesna-treated group. Because of its ability to reduce the extent of capsular formation and to diminish development of myofibroblasts in the capsules, mesna would appear to be a useful adjunct in the prevention of capsular contracture formation.
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Affiliation(s)
- Nadeem Ajmal
- Department of Plastic Surgery, Vanderbilt University Medical Center, Nashville, Tennesse 37232, USA
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Kjøller K, Hölmich LR, Jacobsen PH, Friis S, Fryzek J, McLaughlin JK, Lipworth L, Henriksen TF, Jørgensen S, Bittmann S, Olsen JH. Epidemiological investigation of local complications after cosmetic breast implant surgery in Denmark. Ann Plast Surg 2002; 48:229-37. [PMID: 11862025 DOI: 10.1097/00000637-200203000-00001] [Citation(s) in RCA: 92] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Concern has been raised recently regarding the absence of information on the occurrence and severity of local complications after cosmetic breast implantation. The authors evaluated the occurrence of local complications in a large epidemiological retrospective cohort study of women with cosmetic breast implants in Denmark. All women with breast implants were identified from the files of two private clinics of plastic surgery in Denmark. Information on implant characteristics, surgical procedure, as well as short- and long-term complications was obtained through medical record review. Patient characteristics were obtained through a self-administered questionnaire. A total of 754 women (1,572 implants) had at least one cosmetic implantation performed at the study clinics. Average age at implantation was 32 years. Implant types included silicone double lumen with textured surface, 31.2%; silicone single lumen with textured surface, 27.8%; silicone single lumen with smooth surface, 24.5%; silicone double lumen with smooth surface, 0.8%; and other or missing information, 15.7%. Average implant size was 247 ml (range, 110-630 ml). Placement was submuscular for 91.3% of implants, subglandular for 2.6%, and 6.1% had no available information. Overall, 77.8% of implantations were not followed by complications, 17.8% were followed by one complication, 3.6% were followed by two complications, and 0.8% were followed by three or more complications. In 94.6% of implantations, no additional hospitalizations were recorded as a result of complications. Forty-seven of 57 explantations/reimplantations were secondary to postoperative complications. General complications such as hematoma and infection were rare, occurring in 2.3% and 2.0% of implantations respectively. Capsular contracture remains the most common complication, occurring in 11.4% of implantations. In this investigation, among the first epidemiological studies of local complications, the authors found cosmetic breast implant surgery to be associated with a low frequency of normal surgical complications such as infection, hematoma, and wound dehiscence. Most complications were mild and did not lead to additional hospitalization. The complication that led most frequently to the need for additional surgery/hospitalization was capsular contracture. Kjøller K, Hölmich LR, Jacobsen PH, Friis S, Fryzek J, McLaughlin JK, Lipworth L, Henriksen TF, Jørgensen S, Bittmann S, Olsen JH. Epidemiological investigation of local complications after cosmetic breast implant surgery in Denmark.
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Affiliation(s)
- Kim Kjøller
- Institute of Cancer Epidemiology, Danish Cancer Society, Copenhagen, Denmark
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Kjøller K, Hölmich LR, Jacobsen PH, Friis S, Fryzek J, McLaughlin JK, Lipworth L, Henriksen TF, Jørgensen S, Bittmann S, Olsen JH. Capsular contracture after cosmetic breast implant surgery in Denmark. Ann Plast Surg 2001; 47:359-66. [PMID: 11601569 DOI: 10.1097/00000637-200110000-00001] [Citation(s) in RCA: 36] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
The authors investigated the association between the occurrence of capsular contracture and implant and patient characteristics. All women with breast implants from 1977 to 1997 were identified from the files of two private plastic surgery clinics in Denmark. Information on implant and patient characteristics, surgical procedure, and complications was obtained through medical records and self-administered questionnaires. Of 754 women (1,572 implants), average age at implantation was 32 years. Implant types were silicone double lumen, textured, 31.2%; silicone single lumen, textured, 27.8%; silicone single lumen, smooth, 24.5%; silicone double lumen, smooth, 0.8%; and other or missing, 15.7%. Placement was submuscular for more than 90% of implants. Capsular contracture occurred in 7.9% of implanted breasts, on an average of 621 days postoperatively, with 51.6% being bilateral. Overall, 66.1% of capsular contractures were recorded within the first 12 months postoperatively, and 79.0% were recorded within 24 months. Double-lumen implants were associated with a significantly (p < 0.01) reduced occurrence of capsular contracture. In summary, capsular contracture typically occurs within the first 2 years of implantation. Host factors may be important because more than half the capsular contractures in the current study were bilateral. Occurrence of capsular contracture did not appear to be associated with implant surface or placement, occurrence of local complications, or patient characteristics, although these findings should be interpreted cautiously.
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Affiliation(s)
- K Kjøller
- Institute of Cancer Epidemiology, Danish Cancer Society, Copenhagen
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Snyder JW. Silicone breast implants. Can emerging medical, legal, and scientific concepts be reconciled? THE JOURNAL OF LEGAL MEDICINE 1997; 18:133-220. [PMID: 9230567 DOI: 10.1080/01947649709511032] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/22/2023]
Affiliation(s)
- J W Snyder
- Jefferson Medical College, Thomas Jefferson University, Philadelphia, PA, USA
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