Development Of Capsular Contracture Research Articles

Smooth Operator: Nanotextured Breast Tissue Expanders Are Associated with Lower Rates of Capsular Contracture

Background: Continuous research on breast implant-associated anaplastic large cell lymphoma (BIA-ALCL) has introduced a focus on surface texturizations and a shift towards smooth breast devices, yet outcomes comparing the complication profiles of differently textured tissue expanders (TEs) remain conflicting. The study aim was to compare the complication profile of a new nanotextured and MRI-compatible TE to micro- and macrotextured TEs and to identify possible predictors for complications. Methods: A retrospective analysis of women undergoing expander-based breast reconstruction after mastectomy between January 2016 and March 2022 was conducted. The primary endpoint was the development of capsular contracture. Possible predictors were analyzed in a mixed-effects model using the least absolute shrinkage and selection operator (LASSO). Moreover, a comparison of complications and an evaluation of predictors were carried out. Results: A total of 147 breasts, encompassing 82 nanotextured, 43 microtextured and 22 macrotextured TEs, were analyzed. Breasts with nanotextured TEs were less likely to develop capsular contracture overall (OR, 0.12; 95%CI 0.05–0.28, p < 0.001). Post-mastectomy radiotherapy (PMRT) was identified as a predictor for capsular contracture (OR, 4.67; 95%CI 1.86–11.71, p < 0.001). Breasts with nanotextured TEs showed a higher rate of seroma, but lower rates of malposition and pain. Predictors for developing postoperative complications included higher mastectomy weight (p = 0.008). Conclusions: Breasts with nanotextured TEs exhibited the lowest rate of capsular contracture compared to micro- and macrotextured TEs. Together with its MRI-compatibility and improved oncologic follow-up, the nanotextured TE seems to be a favorable device for expander-based breast reconstruction.

Prevalence of risk factors associated with development of capsular contracture after placement of breast implants

Prevalence of risk factors associated with development of capsular contracture after placement of breast implants

Implant Texture and Capsular Contracture: A Review of Cellular and Molecular Pathways.

Capsular contracture (CC) is a leading cause of morbidity in implant-based breast surgery. Implant surface texture has been implicated in CC development, yet its etiopathogenesis remains unclear. We conducted a systematic review to determine the influence of implant surface texture on cellular and molecular mechanisms involved in the etiopathogenesis of CC. A systematic review of the MEDLINE, Embase, Web of Science, and Scopus databases was completed to examine the influence of implant texture on cellular and molecular pathways leading to CC. Excluded articles were reviews and those examining solely the clinical presentation of CC. Development of CC includes prolonged inflammation, increased myofibroblast density, parallel arrangement of collagen fibers, and biofilm formation. When compared with textured implants, smooth implants are associated with reduction in parallel collagen, capsule thickness, and sheer frictional force. Microtextured implants trigger a reduced macrophage response and decreased fibroblast activation as compared with smooth and macrotextured surfaces. Bacterial counts on microtextured and smooth surfaces are significantly lower than that of macrotextured surfaces. Both micro- and macrotextured implants have increased matrix metalloproteinases and activation of tumor necrosis factor α pathway, with increased activation of the transforming growth factor β1 pathway relative to smooth implants. Implant surface texture alters the cellular and molecular mechanisms in the chronic inflammatory process leading to CC. Given the complex biological system of cellular and molecular events in CC, a mathematical model integrating these influences may be optimal to deduce the etiopathogenesis.

Prevalence of risk factors associated with development of capsular contracture after placement of breast implants.

To determinate the prevalence of the main risk factors associated with development of capsular contracture after placement of breast implants in a referral center. Retrospect study on 210 patients where sociodemographic variables, Baker's clinical scale and histopathological results were recorded. Statistical analysis of 210 patients was performed; 98.1% were women. The average age was 47 years (± 11), body mass index 25 (± 10) and onset of symptoms 13 years (± 8.5). Sociodemographic factors: domestic work 63.3%. Alcoholism 70% and smoking 65.7%. The main reason for consultation was pain plus deformity in 81.6%. The risk factors with statistical significance were the history of trauma, with 83.3% (p = 0.004), and the subglandular plane, with 73.8% (p = 0.0115). Histopathology: fibrous capsule 81.4%. The prevalence of the risk factors described are similar to those reported in the literature. Only for the history of trauma and the subglandular plane there was statistical significance.

Risk factors for capsular contracture after breast reconstruction with tissue expanders and silicone implants in nonirradiated patients: A retrospective observational cohort study

Breast reconstruction surgery with tissue expanders and silicone implants is widely performed; however, risk factors for late complications such as capsular contracture have not been fully investigated despite their high prevalence. We investigated the association between expander and implant positions and the development of capsular contracture in patients who underwent breast reconstruction surgery over 10 years previously. In this retrospective observational study, we analyzed 239 patients, among whom 69 (28.9%) had developed capsular contracture of Baker Classification grade II or higher. The position of the expander was classified into six categories based on the inferior margin of the healthy breast. The position of the implant was defined as an upward movement from the position of the expander and was classified into three categories based on the inferior margin of the breast at the time of expander insertion. Using multivariate logistic regression analysis, we assessed whether the misalignment of the expander and silicone implant positions affected capsular contracture development. Both expander and implant positions were significantly different between the groups. The odds ratios, adjusted for confounding variables, were 3.4 and 5.2 for an expander position of 1 and 2 lateral fingers upward, respectively, and 4.8 and 45.4 for a silicone implant position of 2 and 3 lateral fingers upward, respectively. We identified malposition of expanders and silicone implants as risk factors for developing capsular contracture. Correct insertion and adequate dilatation of the expander in the correct position could reduce the risk for capsular contracture.

Keller Funnel Efficacy in "No Touch" Breast Augmentation and Reconstruction: A Systematic Review.

A systematic review of PubMed, Embase, the Cochrane database, and Google Scholar was performed between 2005 and 2021. All clinical-based, retrospective and prospective studies utilizing the Keller funnel method for breast implant insertion were selected. Six studies were identified for evaluation: five were retrospective cohorts and one was a prospective trial. No randomized controlled trials were found. Outcomes reported included lower rates of capsular contracture (RR, 0.42; P = 0.0006; 95% CI, 0.25-0.69), shorter incision lengths (35.5 ± 2.1 mm), less insertion time (mean = 6 seconds), and decreased complications, and one paper reported ultimately greater patient satisfaction with outcomes (BREAST-Q Score: 92%). This review suggests that the Keller funnel is a useful method for no-touch breast augmentation and reconstruction surgery. The Keller funnel reduces subsequent capsular contracture rate, surgical time, and incision length and allows for easier insertion. However, our findings support recommendation of a prospective randomized controlled clinical trial with larger population size and follow-up intervals.

Impact of radiotherapy on long-term treatment outcomes in patients with breast cancer who have undergone simultaneous one-stage and two-stage reconstructive surgeries. Literature review

The evolution in reconstructive breast surgery in the form of widespread use of implants allows you to abandon the “simple” mastectomy in most patients, provide faster rehabilitation and minimize the psychological trauma due to the absence of a breast. However, in most cases, radiation therapy and/or drug treatment are necessary, as they reduce the risk of relapse, disease progression and mortality. The combined or complex treatment increases the frequency of postoperative complications, such as prolonged wound healing, infection, protrusion/extrusion of the endoprosthesis, the development of capsular contracture, seroma, hematoma, etc. The greatest negative impact on the aesthetic result, both in the early and in the long-term period, is provided by remote radiation therapy. On the other hand, performing reconstructive plastic surgery may complicate radiation therapy. The issues of how long it is necessary to conduct radiation therapy, what type of reconstruction and how to conduct radiation therapy, how to minimize the frequency of complications without compromising the oncological and aesthetic results of treatment of breast cancer patients remain controversial.

Autologous Fat Grafting and the Occurrence of Radiation-Induced Capsular Contracture.

Radiation therapy is a known risk factor for capsular contracture formation after implant-based breast reconstruction. Although autologous fat grafting (AFG) has been shown to reverse radiation-induced tissue fibrosis, its use as a prophylactic agent against capsular contraction has not been assessed in the clinical setting. In the setting of 2-stage implant-based reconstruction and postmastectomy radiation therapy, we explored the effect AFG has on the prevalence of capsular contracture. A retrospective chart review of patients who underwent immediate tissue expander (TE) placement followed by postmastectomy radiation therapy and secondary implant-based reconstruction at our institution between January 2012 and December 2019 was performed. Patients were divided into 2 cohorts based on whether or not AFG was performed at the time of secondary reconstruction. The primary outcome of interest was the occurrence of capsular contracture after TE exchange. Overall 57 patients (57 breasts) were included, 33 of whom received AFG at the time of TE exchange. All but 1 patient underwent submuscular implant placement, and the mean follow-up was 1.96 years. There was no significant difference in the prevalence of medical comorbidities between the study groups.Capsular contracture occurred in 24 patients (42.1%). Seventeen of these patients had undergone AFG at the time of TE exchange (17/33 patients, 51.5%), and 7 of these patients had not (7/24 patients, 29.2%). Most of the capsular contracture cases were Baker grades III or IV (14 patients, 58.3%), and 50% of patients with capsular contracture of any grade ultimately required operative intervention. Multivariate logistic regression analysis demonstrated that AFG did not significantly influence the occurrence or severity of capsular contracture, or did not impact the need for operative intervention in this patient population. Implant-based reconstruction of the irradiated breast is associated with high postoperative capsular contracture rates. Although AFG has shown promise in reversing radiation-induced dermal fibrosis, no protective effect on the development of capsular contracture after stage 2 reconstruction was observed in this study population. Further investigation in the form of randomized, prospective studies is needed to better assess the utility of AFG in preventing capsular contracture in irradiated patients.

Development of capsular contracture in the presence of prolonged seroma

Development of capsular contracture in the presence of prolonged seroma

Characterizing the Microbiome of the Contracted Breast Capsule Using Next Generation Sequencing.

Recent work suggests that bacterial biofilms play a role in capsular contracture (CC). However, traditional culture techniques provide only a limited understanding of the bacterial communities present within the contracted breast. Next generation sequencing (NGS) represents an evolution of polymerase chain reaction technology that can sequence all DNA present in a given sample. The aim of this study was to utilize NGS to characterize the bacterial microbiome of the capsule in patients with CC following cosmetic breast augmentation. We evaluated 32 consecutive patients with Baker grade III or IV CC following augmentation mammoplasty. Specimens were obtained from all contracted breasts (n = 53) during capsulectomy. Tissue specimens from contracted capsules as well as intraoperative swabs of the breast capsule and implant surfaces were obtained. Samples were sent to MicroGenDX Laboratories (Lubbock, TX) for NGS. Specimens collected from 18 of 32 patients (56%) revealed the presence of microbial DNA. The total number of positive samples was 22 of 53 (42%). Sequencing identified a total of 120 unique bacterial species and 6 unique fungal species. Specimens with microbial DNA yielded a mean [standard deviation] of 8.27 [4.8] microbial species per patient. The most frequently isolated species were Escherichia coli (25% of all isolates), Diaphorobacter nitroreducens (12%), Cutibacterium acnes (12%), Staphylococcus epidermidis (11%), fungal species (7%), and Staphylococcus aureus (6%). NGS enables characterization of the bacterial ecosystem surrounding breast implants in unprecedented detail. This is a critical step towards understanding the role this microbiome plays in the development of CC.

Direct-to-Implant Extracellular Matrix Hammock-based Breast Reconstruction; Prepectoral or Subpectoral?

BackgroundSkin-sparing mastectomy followed by immediate implant-based breast reconstruction is a commonly used treatment for breast cancer. However, when placing the implant in a subpectoral pocket, a high incidence of breast animation deformity (BAD) has been reported. Besides the nuisance that BAD can cause, lifting of the pectoralis major muscle (PMM) can result in a more extended postoperative recovery period. When placing the implant solely prepectorally leaving the PMM undisturbed, the incidence and severity of BAD might be mitigated. However, new challenges may occur because of thinner skin cover.Methods/designA prospective, multi-centre, randomised controlled trial will be carried out with the primary aim of assessing and comparing the incidence and degree of BAD in women having a direct-to-implant breast reconstruction with either a prepectorally or a subpectorally placed implant. The secondary outcomes are shoulder and arm function, quality of life, aesthetic evaluation, length of stay, complications, need for surgical corrections, and development of capsular contracture. A total of 70 included patients will be followed under admittance and at clinical check-ups 3 months and 1 year after surgery.DiscussionTo our knowledge, this trial is the first randomised controlled trial evaluating and comparing subpectoral and prepectoral implant placement when performing direct-to-implant breast reconstruction following skin-sparing mastectomy. The results will hopefully provide us with a broader knowledge of the outcomes of immediate breast reconstruction, making better preoperative planning possible in the future by providing our patients with a more objective information.Trial registrationClinicalTrials.gov, ID: NCT03143335. Prospectively registered on 8 May 2017.

Management of Capsular Contracture in Cases of Silicone Gel Breast Implant Rupture with Use of Pulse Lavage and Open Capsulotomy.

Pulse lavage (PL) irrigation of prosthesis pockets has prior been described for breast implant salvages. However, PL for removal of leaked silicone from prosthesis pockets after implant ruptures has not been studied yet. Since open capsulotomies are regarded as equal treatment of capsular contracture (CC) than capsulectomies, this study analyzed the clinical outcome of PL for silicone removal and subsequent capsulotomy in cases of concurrent CC and breast implant rupture. Between 2012 and 2017, 55 patients (75 breasts) with suspected silicone implant rupture and CC (Baker grade III/IV), after primary breast augmentation or implant-based breast reconstruction, were included in a retrospective, observational study. Mean patient follow-up was 12.2 ± 3.6months. In all preoperatively suspected ruptured silicone breast implants, around a quarter were intact. In contrast to previously published data, implant exchanges in cases of implant ruptures did not lead to significantly higher CC recurrence rates (27.6% vs. 22.2% in cases of intact implants, p = 0.682), if the prosthesis pockets were treated with PL irrigation followed by open capsulotomy. PL reduced the amount of encapsulated silicone remnants histologically. The age of patients with CC after failed implant-based reconstruction was significant lower for salvage surgeries with flap reconstruction than for implant exchanges, p < 0.05. PL irrigation of prosthesis pockets prior to open capsulotomy is a safe and effective treatment of CC with concurrent silicone leakage. Remaining silicone remnants in breast capsules may affect the development of a recurrent CC. To avoid CC recurrences, patients should consider conversion to autologous tissue. 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 .

Pro-Fibrotic CD26-Positive Fibroblasts Are Present in Greater Abundance in Breast Capsule Tissue of Irradiated Breasts.

Breast capsular contracture is a major problem following implant-based breast reconstruction, particularly in the setting of radiation therapy. Recent work has identified a fibrogenic fibroblast subpopulation characterized by CD26 surface marker expression. This work aimed to investigate the role of CD26-positive fibroblasts in the formation of breast implant capsules following radiation therapy. Breast capsule specimens were obtained from irradiated and nonirradiated breasts of 10 patients following bilateral mastectomy and unilateral irradiation at the time of expander-implant exchange, under institutional review board approval. Specimens were processed for hematoxylin and eosin staining as well as for immunohistochemistry and fluorescence activated cell sorting for CD26-positive fibroblasts. Expression of fibrotic genes and production of collagen were compared between CD26-positive, CD26-negative, and unsorted fibroblasts. Capsule specimens from irradiated breast tissue were thicker and had greater CD26-postive cells on immunofluorescence imaging and on fluorescence activated cell sorting analysis than did capsule specimens from the nonirradiated breast. Compared with CD26-negative fibroblasts, CD26-positive fibroblasts produced more collagen and had increased expression of the profibrotic genes IL8, TGF-β1, COL1A1, and TIMP4. CD26-positive fibroblasts were found in a significantly greater abundance in capsules of irradiated compared with nonirradiated breasts and demonstrated greater fibrotic potential. This fibrogenic fibroblast subpopulation may play an important role in the development of capsular contracture following irradiation, and its targeted depletion or moderation may represent a potential therapeutic option.

Risk Factor Analysis for Survival of Becker-Type Expander in Immediate Breast Reconstruction.

Breast reconstruction with a Becker-type expander is a common technique following mastectomy. However, inconsistency remains in the literature regarding risk factors for the survival of a Becker-type expander following immediate breast reconstruction. This study's purpose is to investigate possible risk factors for the Becker-type expander survival and to evaluate the complications related to expander removal following immediate breast reconstruction. We performed a retrospective chart review of consecutive women who underwent a mastectomy followed by immediate breast reconstruction with a Becker-type expander from November 2010 to November 2016. Electronic medical records were analyzed retrospectively for demographic, clinical, operative characteristics, and outcomes. Univariate Cox regression analysis was performed to determine the risk factors for the survival of the Becker-type expander following immediate breast reconstruction. A total of 74 Becker-type expanders were used in 72 patients who underwent immediate breast reconstruction. The patients' ages ranged from 27 to 71years, with a mean ± standard deviation age of 44.6 ± 9.1years. The most frequent complication was capsular contracture which occurred in 25 breasts (33.8%) followed by mastectomy skin flap necrosis in 6 breasts (8.1%), seroma in 4 breasts (5.4%), nipple-areolar complex necrosis in 4 breasts (5.4%), hematoma in 3 breasts (4.1%), and infection in 2 breasts (2.7%). The mean intraoperative expander fill volume (109.6 ± 66.9cc [p = 0.039]) and mean total volume (386.5 ± 94.7cc [p = 0.034]) were both significantly lower for patients with capsular contracture compared with those without capsular contracture. In patients with partial NAC necrosis, the mean mastectomy specimen volume (737.5 ± 242.8cc) was significantly higher compared with patients without partial NAC necrosis (489.8 ± 219.0cc; p = 0.027). A univariate Cox regression analysis showed that smoking and neoadjuvant therapy were significantly associated with expander removal (p = 0.023 and p = 0.006, respectively). The total volume of the expander and intraoperative fill volume of the expander appear to be predictive factors in the development of capsular contracture. However, there is no statistically significant association between radiotherapy and capsular contracture or expander survival in contrast with other published reports. Our findings reveal that the main risk factors for the survival of Becker-type expanders following immediate breast reconstruction are smoking and neoadjuvant therapy. To our knowledge, this is the first study to evaluate the most likely risk factors associated with Becker-type expander survival in immediate breast reconstruction. 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 Factor Analysis for Capsular Contracture, Malposition, and Late Seroma in Subjects Receiving Natrelle Style 410 Form-Stable Silicone Breast Implants

PURPOSE: This study analyzed potential risk factors for capsular contracture, malposition, and late seroma in subjects receiving Natrelle 410 textured silicone breast implants. MATERIALS AND METHODS: Pooled data from 2 similarly designed, ongoing, prospective, multicenter clinical trials of subjects receiving Natrelle 410 breast implants were analyzed. Univariate and multivariate Cox proportional hazards regression analysis was performed to evaluate the association of subject, implant, surgical, and facility factors with the development of capsular contracture, malposition, and late seroma in subjects who underwent primary breast augmentation, revision-augmentation, primary breast reconstruction, and revision-reconstruction. RESULTS: In total, 17,656 subjects received Natrelle 410 breast implants for augmentation (n=5059), reconstruction (n=7502), revision-augmentation (n=2632), and revision-reconstruction (n=2463); median follow-up was 4.1 years, 2.1 years, 2.6 years, and 2.3 years, respectively. Significant risk factors for capsular contracture in the primary augmentation cohort included subglandular device placement (strongest multivariate risk factor; adjusted risk ratio [aRR]: 2.89; P<.0001), older device age, and periareolar incision site (both P<.0001). In the primary reconstruction cohort, significant risk factors were higher body mass index (BMI) (aRR: 1.03; P=.0026) and absence of betadine pocket irrigation (aRR: 2.00; P=.0006). The only significant risk factor in the revision-augmentation cohort was older subject age (aRR: 1.47; P<.0001). No significant risk factors were identified in the revision-reconstruction cohort. Significant risk factors for malposition included longer incision size in the primary augmentation cohort (aRR: 1.44; P=.0003) and capsulectomy performed at time of implantation in the primary reconstruction cohort (aRR: 1.55; P=.0028). In both revision cohorts, the risk was 2 to 3 times greater for implant surgeries performed in physicians’ offices versus hospitals or stand-alone surgical facilities (both P<.0001). Risk of malposition was not associated with any subject- or device-related factors. The incidence of late seroma (31 cases out of 31,992 implants) was insufficient to perform a risk factor analysis. Twenty-nine cases occurred with submuscular placement, one with subglandular placement, and one was unknown; no trends were observed for subject age, BMI, incision site, or device size, style, or age. CONCLUSION: These analyses reaffirm the low rates of complications in subjects receiving Natrelle 410 breast implants in primary and secondary surgical settings. Knowledge of the risk factors associated with capsular contracture and implant malposition offers additional guidance to surgeons for reducing complication rates and optimizing outcomes.

Pulsed Acoustic Cellular Expression (PACE) Reduces Capsule Formation Around Silicone Implants

Capsular contracture remains a major complication after reconstructive or aesthetic breast augmentation. Formation of capsular fibrosis is a multifactorial process. An initial inflammatory reaction appears to be key to the development of capsular contracture. Recent studies have shown that pulsed acoustic cellular expression (PACE) has significant antiinflammatory effects. Thus, this study aimed to determine the potential of PACE to prevent or attenuate capsular contracture around silicone implants in a rodent model. For this study, 36 Lewis rats were divided into two groups, and a textured silicone implant was placed in a dorsal submuscular pocket. One group received PACE treatment, whereas the other group served as the control group and received no treatment. Follow-up evaluations were performed after 10, 35, and 100days. Capsule thickness, collagen density, myofibroblasts, vascular density, and a semiquantitative real-time polymerase chain reaction that addressed differential gene expression were assessed. The PACE treatment significantly reduced capsule thickness on days 10, 35, and 100 compared with the control group (day 10: 632.9±164.5 vs 932.6±160.8, p<0.05; day 35: 709.5±175 vs 825.9±313.3, p<0.0.5; day 100: 736.3±198.1 vs 1,062.3±151.9, p<0.05). This was accompanied by a significant suppression of proinflammatory genes (cluster of differentiation 68, monocyte chemotactic protein-1, CCL4) and synergistic alterations of pro- and antifibrotic proteins (transforming growth factor-beta 1, matrix metalloproteinase-2). This study showed that the PACE application significantly reduces capsular contracture around silicone implants. A decrease in capsular thickness after PACE treatment seems to be associated with a downregulation of proinflammatory genes and proteins. The study identifies PACE technology as a potential low-cost technique that is easy to use for reduction of capsular contracture after augmentation using silicone implants. This journal requires that authors assign a level of evidence to each submission to which Evidence-Based Medicine rankings are applicable. This excludes Review Articles, Book Reviews, and manuscripts that concern Basic Science, Animal Studies, Cadaver Studies, and Experimental Studies. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors http://www.springer.com/00266 .

Capsular contracture by silicone breast implants: possible causes, biocompatibility, and prophylactic strategies

The most common implanted material in the human body consists of silicone. Breast augmentation and breast reconstruction using silicone-based implants are procedures frequently performed by reconstructive and aesthetic surgeons. A main complication of this procedure continues to be the development of capsular contracture (CC), displaying the result of a fibrotic foreign body reaction after the implantation of silicone. For many years, experimental and clinical trials have attempted to analyze the problem of its etiology, treatment, and prophylaxis. Different theories of CC formation are known; however, the reason why different individuals develop CC in days or a month, or only after years, is unknown. Therefore, we hypothesize that CC formation, might primarily be induced by immunological mechanisms along with other reasons. This article attempts to review CC formation, with special attention paid to immunological and inflammatory reasons, as well as actual prophylactic strategies. In this context, the word “biocompatibility” has been frequently used to describe the overall biological innocuousness of silicone in the respective studies, although without clear-cut definitions of this important feature. We have therefore developed a new five-point scale with distinct key points of biocompatibility. Hence, this article might provide the basis for ongoing discussion in this field to reduce single-publication definitions as well as increase the understanding of biocompatibility.

Revisiting Triple Antibiotic Irrigation of Breast Implant Pockets: A Placebo-controlled Single Practice Cohort Study.

Background:Capsular contracture is the most common complication following primary augmentation mammoplasty. It remains poorly understood but is attributed to subclinical infection, immunologic response to breast implants, and chronic inflammatory changes caused by the presence of the implants. The infectious theory of contracture has lead to the practice of irrigating implant pockets with a triple antibiotic solution. The purpose of this study was to determine if antibiotic irrigation reduced the incidence and severity of capsular contracture compared with saline irrigation.Methods:A cohort study enrolling all patients having undergone primary augmentation mammoplasty performed by surgeon A and surgeon B between 2011 and 2012 for all women satisfying inclusion and exclusion criteria was conducted. The only difference in surgical technique was the use of antibiotic irrigation by surgeon B. A chi-square test and analysis of variance with predetermined 95% confidence intervals were performed.Results:Fifty-five patients were operated on. Twenty-eight of surgeon A’s patients were included, ranging in age from 22 to 50 with a mean follow-up time of 1.8 years. Twenty-seven of surgeon B’s patients were included, ranging in age from 22 to 56 with a mean follow-up time of 1.6 years. Rate of capsular contracture was 3.6% (surgeon A) and 3.7% (surgeon B). Chi-square statistic was found to be 0.0014 (P = 0.97) and analysis of variance F value was 1 (P = 0.39).Conclusions:Triple antibiotic breast irrigation is not associated with a significant reduction in the incidence or severity of capsular contracture compared with sterile saline when high-quality surgical technique is used.

Histologische und immunhistochemische Untersuchung zur Kapselfibrose im Tiermodell - Vergleich zweier Implantate mittels einer histologischen Klassifikation in Modifikation nach Wilflingseder

The influence of silicone implants on the formation of a periprosthetic capsule can be well examined in animal studies. New implant materials have been developed to reduce capsular contracture. In order to evaluate the capsule formation, Wilflingseder et al. developed a histological score system. Because of new knowledge in the development of capsular contracture, the Wilflingseder classification is no longer appropriate. Current references are not considered so that a modification is required. In a randomised, experimental animal study 31 mini-implants were implanted into the dorsum of female Wistar rats [17 smooth, 10 mL saline-filled silicone implants (Group A) and 14 titanium coated silicone implants (Group B)]. After 12 (group A/B12) or 36 (group A/B36) weeks, surgical removal of the implants with subsequent histomorphological and immunohistochemical examination of periprosthetic capsule formation was performed by 2 independent investigators in a double-blind manner. An analysis of the studies showed that the inner synovia metaplasia and the infiltration by inflammatory cells such as lymphocytes, histiocytes, plasma cells and granulocytes are of crucial importance in the development of a fibrotic capsule. The occurrence of these factors correlated significantly with each other and influenced also significantly the capsule architecture depending on implant surface. An adjustment of the existing Wilflingseder classification system was evaluated. The current rating system contains the following parameters: capsule thickness and cell layers of the capsule, the thickness of the inner synovial metaplasia, collagen structure, presence of histiocytes and the incidence of inflammatory cells. According to this classification, titanium-coated implants show an advantage in terms of the formation of capsular contracture. In 1974 Wilflingseder et al. developed a classification system for capsular contracture which is no longer appropriate, since current histological and immunohistochemical findings are not mentioned. Our study presents a new system which includes the latest insights into the development of capsular contracture and provides an objective classification of histological changes. Furthermore, we were able to show that titanium-coated implants are a promising approach in the reduction of capsular contracture.

Preliminary report on the use of the Spectra™ implant for the correction of hypoplastic breasts with small-volume asymmetry

Small-volume breast asymmetry is a challenging problem. In 2008, an intra-operative volume-adjustable breast implant, consisting of a round textured implant with an outer chamber filled with cohesive silicone gel and inner chamber filled with varying amounts of saline solution was marketed in Europe. We describe our experience in the correction of hypoplastic breasts with small-volume asymmetry using this device. From May 2008 on, female patients presenting small-volume breast asymmetry were enrolled in the study. Standard pictures were taken before surgery and during follow-up visits over 1 year; standardised objective measurements of breast and chest were also taken. Statistical significance of value variation was assessed by Wilcoxon's rank sum test. A Visual Analogue Scale (VAS) was used to evaluate patients' and external physicians' judgement of breast symmetry achievement at the end of follow-up. The development of capsular contracture was assessed by measuring mammary compliance. A total of 38 females were treated. The implant pocket was subglandular in 14 cases, subpectoral in 14 and dual plane in 10. The adjustable implant was positioned in the smaller breast. A textured round implant, whose diameter was the same as the adjustable one, was positioned in the contralateral breast. Thirty-five patients were fully satisfied; three were partially satisfied. Good aesthetic and functional breast symmetry results were achieved in all patients, as demonstrated by the objective measurement statistical analysis. We observed one case of delayed wound healing, one of bleeding and one of seroma, with no major late complications. Baker's classification grade III capsular contracture was detected in one patient. Both implants maintained their initial volume. The possibility of intra-operatively modifying implant volume according to breast volume differences provides a reliable corrective option for hypoplastic breasts with small-volume asymmetry. Although these results are encouraging, a longer follow-up is required to evaluate implant ageing and long-term outcome.