Higher Rate Of Capsular Contracture Research Articles

Patient-Reported Outcomes and Complication Profiles of Implant-Based Breast Reconstruction in Patients With Postmastectomy Radiation Therapy.

This study aims to investigate the patient-reported outcomes (PROs) and complications of distinct implant-based breast reconstruction modality for patients with postmastectomy radiation therapy (PMRT). A retrospective review was conducted on breast cancer patients with stage II-III disease who performed implant-based breast reconstruction following with PMRT between September 2016 and April 2022. The patients were categorized into two matched groups: (1) patients receiving prepectoral breast reconstruction (PBR) or (2) subpectoral breast reconstruction (SBR) followed by PMRT. Following reconstruction, the patients were further compared for PMRT with the tissue expander (PMRT-TE) versus PMRT with permanent implant (PMRT-PI). PROs were measured with BREAST-Q questionnaire. Early and late complications were recorded and analyzed. A total of 55 eligible patients were recruited. Patients who underwent PBR reported significantly higher satisfaction with breasts scores (P = 0.003) compared with the SBR group. The PMRT-TE group had higher satisfaction with breasts (P = 0.001) but lower physical well-being (P = 0.029) scores compared with PMRT-PI group. Moreover, patients in SBR cohort had a higher risk of capsular contracture (Baker grade III or IV) (20.5% vs 6.3%) and implant dislocation (48.7% vs 12.5%) than patients in PBR cohort. Patients in PMRT-PI group had a slightly higher rate of capsular contracture (Baker grade III or IV) than PMRT-TE group (20.8% vs 12.9%). PBR was associated with lower rates of late complications, especially for implant dislocation, and higher satisfaction with breasts scores compared to SBR. In addition, compared to PMRT-TE with PMRT-PI, patients in PMRT-TE cohort reported superior PROs of satisfaction with breasts.

Abstract PO3-23-04: Patient-reported outcomes and complication profiles of implant-based breast reconstruction in patients with postmastectomy radiation therapy

Abstract Objective: This study aims to investigate the patient-reported outcomes (PROs) and complications of distinct implant-based breast reconstruction (IBBR) modality for patients with postmastectomy radiation therapy (PMRT). Methods: A retrospective review was conducted on breast cancer patients with stage II-III disease who performed IBBR following with PMRT between September 2016 and April 2022. The patients were categorized into two matched groups: (1) patients receiving prepectoral breast reconstruction (PBR) or subpectoral breast reconstruction (SBR) followed by PMRT; (2) patients undergoing PMRT with the tissue expander (PMRT-TE) or permanent implant (PMRT-PI) groups. PROs were measured with BREAST-Q questionnaire. Early and late complications were recorded and analysed. Results: A total of 55 eligible patients were recruited. For PROs, patients underwent PBR reported significantly higher Satisfaction with Breasts scores (P = 0.003) compared with SBR group, and PMRT-TE group presented higher Satisfaction with Breasts (P = 0.001) but lower Physical Well-being (P = 0.029) scores compared with PMRT-PI group. Moreover, Patients in SBR cohort had a higher risk of capsular contracture (Baker grade III or IV) (20.5% vs 6.3%) and implant dislocation (48.7% vs 12.5%) than patients in PBR cohort. Patients in PMRT-PI group had a slightly higher rate of capsular contracture (Baker grade III or IV) than PMRT-TE group (20.8% vs 12.9%). Conclusions: PBR was associated with lower rates of late complications, especially for implant dislocation, and higher Satisfaction with Breasts scores compared to SBR. In addition, compared to PMRT-TE with PMRT-PI, patients in PMRT-TE cohort reported superior patient-reported outcomes of Satisfaction with Breasts. Table 1. Patient and Tumor Characteristics of 55 Patients Stratified with Prepectoral/Subpectoral and PMRT-TE/PMRT-PI Reconstructive Procedure. XX- XX Table 2. Patient-Reported BREAST-Q Scores XX- XX Table 3. Association of Reconstruction Techniques with Late Complications. XX- XX Citation Format: Jian Liu, Cong Chen, Honggang Chen, Aizhai Xiang, Ruzhen Zheng, Shufang Hu, Jufeng Guo, Li Qu, Jun Zhou, Jiong Wu. Patient-reported outcomes and complication profiles of implant-based breast reconstruction in patients with postmastectomy radiation therapy [abstract]. In: Proceedings of the 2023 San Antonio Breast Cancer Symposium; 2023 Dec 5-9; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2024;84(9 Suppl):Abstract nr PO3-23-04.

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

We retrospectively analyzed 118 women with breast cancer who underwent PMRT following an IBR between 2010 and 2022. Patients were treated with PMRT of 50.0-50.4 Gy in 25-28 fractions. Capsular contracture was categorized according to the Baker Classification for Reconstructed Breasts. After a median follow-up of 22 months, the incidence of clinically relevant capsular contracture (Baker III-IV) was 22.9%. Overall, capsular contracture (Baker I-IV) occurred in 56 patients (47.5%) after a median of 9 months after PMRT. The rate of reconstruction failure/implant loss was 25.4%. In the univariate analysis, postoperative complications (prolonged pain, prolonged wound healing, seroma and swelling) and regional nodal involvement were associated with higher rates of capsular contracture (p = 0.017, OR: 2.5, 95% CI: 1.2-5.3 and p = 0.031, respectively). None of the analyzed dosimetric factors or the implant position were associated with a higher risk for capsular contracture. Postoperative complications and regional nodal involvement were associated with an increased risk of capsular contracture following breast reconstruction and PMRT, while none of the analyzed dosimetric factors were linked to a higher incidence. Additional studies are needed to identify further potential risk factors.

The Impact of Adjuvant Radiotherapy on Immediate Prepectoral Implant-Based Breast Reconstruction.

Immediate prepectoral implant-based breast reconstruction (IBBR) rates have increased in recent years owing to improved cosmetic and psychological benefits. However, there is a lack of studies regarding complications rates following adjuvant radiotherapy (RT) among patients undergoing immediate prepectoral IBBR. We conducted a retrospective monocentric analysis of a cohort of consecutively treated patients who underwent NSM following immediate prepectoral IBBR at our institution between March 2017 and November 2021. Patient demographics, quality of life, complication rates, and oncological safety were evaluated in the RT and non-RT groups. Data analysis was performed using IBM SPSS Version 24 (IMB Corp., Armonk, NY, USA). A total of 98 patients were examined: 70 were assigned to have prepectoral IBBR without RT and 28 to the group who had prepectoral IBBR with RT. There was a statistically significant difference in overall capsular contracture rate between the RT and non-RT group (18% vs. 4.3%, p=0.04). The total implant loss in the cohort was 4% (10.7% vs. 1.4%, p=0.05). We obtained a high percentages of all BREAST-Q categories in both groups; however, satisfaction with the breast and sexual well-being was higher in the non-RT group. The three-year overall survivals were 97.4% in the RT group and 98.5% in the non-RT group. Our findings showed that patients in the RT group had a higher rate of capsular contracture and implant loss than those in the non-RT group. However, complication rates were within acceptable range and with accurate preoperative information patients have more benefits from immediate reconstruction showing excellent overall quality of life irrespectively of radiation. 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 .

Long-Term Outcomes in Prepectoral versus Subpectoral Two-Stage Implant-Based Breast Reconstruction after Nipple-Sparing Mastectomy.

Implant-based breast reconstruction remains the most often used method following mastectomy, but data are lacking regarding differences in complications and long-term patient-reported outcomes for two-stage subpectoral versus prepectoral reconstruction. This study sought to better understand the risks and impact of these reconstructive approaches on overall satisfaction. Patients who underwent unilateral or bilateral nipple-sparing mastectomy and two-stage implant-based reconstruction from 2014 to 2019 were identified from the electronic medical records and contacted via email to complete the BREAST-Q survey. Overall satisfaction was measured by the question, "How happy are you with the outcome of your breast reconstruction?" using a six-point Likert scale. Patients were grouped into subpectoral or prepectoral cohorts. Complications were evaluated retrospectively. Only patients who were at least 6 months from their final reconstruction were included in the analysis. Of the 582 patients contacted, 206 (35%) responded. The subpectoral ( n = 114) and prepectoral ( n = 38) groups did not differ significantly by demographic or treatment characteristics. BREAST-Q scores were also comparable. Complication rates were similar, but prepectoral patients had a significantly higher rate of capsular contracture (16% versus 4%, P < 0.05). Bivariate ordered logistic regression identified prepectoral implant placement, having any postoperative complication, and capsular contracture as predictors of less overall happiness. The authors' study suggests that prepectoral patients may have slightly higher complication rates but are as satisfied as subpectoral patients after at least a year of follow-up. Further studies should investigate risk factors for capsular contracture, how the risk changes over time, and how the risk affects patient satisfaction.

Silicone Breast Implant Surface Texture Impacts Gene Expression in Periprosthetic Fibrous Capsules.

Silicone breast implants with smooth outer shells are associated with higher rates of capsular contracture, whereas textured implants have been linked to the development of breast implant-associated anaplastic large cell lymphoma. By assessing the gene expression profile of fibrous capsules formed in response to smooth and textured implants, insight into the development of breast implant-associated abnormalities can be gained. Miniature smooth or textured silicone implants were surgically inserted into female rats ( n = 10) and harvested for the surrounding capsules at postoperative week 6. RNA sequencing and quantitative polymerase chain reaction were performed to identify genes differentially expressed between smooth and textured capsules. For clinical correlation, the expression of candidate genes was assayed in implant capsules harvested from human patients with and without capsular contracture. Of 18,555 differentially expressed transcripts identified, three candidate genes were selected: matrix metalloproteinase-3 ( MMP3 ), troponin-T3 ( TNNT3 ), and neuregulin-1 ( NRG1 ). In textured capsules, relative gene expression and immunostaining of MMP3 and TNNT3 was up-regulated, whereas NRG1 was down-regulated compared to smooth capsules [mean relative fold change, 8.79 ( P = 0.0059), 4.81 ( P = 0.0056), and 0.40 ( P < 0.0001), respectively]. Immunostaining of human specimens with capsular contracture revealed similar gene expression patterns to those of animal-derived smooth capsules. An expression pattern of low MMP3 /low TNNT3 /high NRG1 is specifically associated with smooth implant capsules and human implant capsules with capsular contracture. The authors' clinically relevant breast implant rat model provides a strong foundation to further explore the molecular genetics of implant texture and its effect on breast implant-associated abnormalities. The authors have demonstrated that there are distinct gene expression profiles in response to smooth versus textured breast implants. Since surface texture may be linked to implant-related pathology, further molecular analysis of periprosthetic capsules may yield strategies to mitigate implant-related complications.

The Impact of Premastectomy Versus Postmastectomy Radiation Therapy on Outcomes in Prepectoral Implant-Based Breast Reconstruction.

Prepectoral implant-based breast reconstruction is being increasingly performed over subpectoral reconstruction because of the reduced invasiveness of the procedure, postoperative pain, and risk of animation deformity. Radiation therapy is a well-known risk factor for complications in implant-based breast reconstruction. The effect of premastectomy versus postmastectomy radiation therapy on outcomes after prepectoral breast reconstruction has not been well-defined. The purpose of this study was to compare the impact of premastectomy versus postmastectomy radiation therapy on outcomes after prepectoral breast reconstruction. A retrospective chart review was performed on all patients who underwent prepectoral implant-based breast reconstruction with inferior dermal flap and acellular dermal matrix performed by a single surgeon from 2010 to 2019. Demographic, clinical and operative data were reviewed and recorded. Outcomes were assessed by comparing rates of capsular contracture, infection, seroma, hematoma, dehiscence, mastectomy skin flap necrosis, rippling, implant loss, local recurrence and metastatic disease, between patients receiving premastectomy and postmastectomy radiation therapy and nonradiated patients. Three hundred and sixty-nine patients (592 breasts) underwent prepectoral implant-based breast reconstruction. Twenty-six patients (28 breasts) received premastectomy radiation, 45 patients (71 breasts) received postmastectomy radiation, and 305 patients (493 breasts) did not receive radiation therapy. Patients with premastectomy radiation had higher rates of seroma (14.3% vs 0.2%), minor infection (10.7% vs 1.2%), implant loss (21.4% vs 3.4%) and local recurrence (7.1% vs 1.0%), compared with nonradiated patients (P < 0.05). Patients with postmastectomy radiation had higher rates of major infection (8.4% vs 2.4%), capsular contracture (19.7% vs 3.2%), implant loss (9.9% vs 3.4%), and local recurrence (5.6% vs 1.0%) when compared with nonradiated patients (P < 0.03). Outcomes after prepectoral breast reconstruction were comparable between premastectomy and postmastectomy radiation patients, respectively, with regard to major infection (7.1% vs 8.4%), dehiscence (3.6% vs 1.4%), major mastectomy skin flap necrosis (7.1% vs 2.8%), capsular contracture (10.7% vs 19.7%), implant loss (21.4% vs 9.9%), and local recurrence (7.1% vs 5.6%) (P ≥ 0.184). However, premastectomy radiation patients had a higher rate of seroma compared with postmastectomy radiation patients (14.3% vs 0%; P = 0.005). In prepectoral implant breast reconstruction, premastectomy and postmastectomy radiation therapy were associated with higher rates of infection and implant loss compared with nonradiated patients. Postmastectomy radiation was associated with a higher rate of capsular contracture compared with nonradiated patients, and a comparable rate of capsular contracture compared with premastectomy radiation therapy patients. Premastectomy radiation was associated with a higher rate of seroma compared with postmastectomy radiation and nonradiated patients.

Differential Gene Expression in Capsules Derived From Smooth and Textured Silicone Implants

PURPOSE: Capsular contracture is the most common complication of implant-based breast surgery in the United States, leading to abnormal breast contour, increased firmness, and pain to touch. It is well established that smooth implants have higher rates of capsular contracture than textured implants. Assessing the effect of implant texture on contracture pathogenesis may help identify therapeutic targets for this disease process. The purpose of this study is to elucidate the pathogenesis of capsular contracture by examining RNA expression in a rat model of capsular formation around textured and smooth silicone implants, with pathologic correlation. METHODS: A small animal model of capsular contracture was developed using Fischer rats. Ten animals underwent miniature smooth or textured silicone implant insertion in the submammary gland position. Six weeks postoperatively, implant capsules were harvested for histologic and molecular analysis. RNA sequencing was performed to identify target genes expressed in extracted capsules. Selected gene expression levels were confirmed with quantitative reverse transcriptase polymerase chain reaction and immunohistochemistry (IHC). Additionally, implant capsules collected from patients with and without capsular contracture were analyzed and correlated with results from our animal model. RESULTS: RNA sequencing data were subjected to the Probability of Positive Log Ratio (PPLR) algorithm. Transcripts were identified for further characterization using cutoff values of PPLR ≥0.975 (2-fold increase) or a PPLR ≤0.025 (2-fold decrease). We identified 18,555 transcripts that met PPLR inclusion criteria. Quantitative reverse transcriptase polymerase chain reaction was performed for matrix metalloproteinase-3 (MMP-3), troponin T3 (TNNT-3), and neuregulin-1 (NRG-1). Expression of MMP-3 and TNNT-3 was upregulated in textured implant capsules compared to smooth implant capsules with a mean relative fold change of 8.79 (P = 0.0059) and 4.81 (P = 0.0056), respectively. Expression of NRG-1 was downregulated in textured implant capsules with a mean relative fold change of 0.40 (P < 0.0001) compared to smooth implant capsules. IHC staining of capsules extracted from our animal model was consistent with differential expression patterns, with smooth implant capsules expressing less MMP-3 and TNNT-3, and more NRG-1 than textured implant capsules. Similarly, IHC staining of human specimens revealed that contracted capsules had lower expression of MMP-3 and TNNT-3 and greater expression of NRG-1 compared to healthy capsules. CONCLUSION: We demonstrated that capsules around smooth and textured implants have different histologic appearances and different patterns of gene expression. Importantly, pathologic correlation reveals that contracted capsules have expression patterns for MMP-3, TNNT-3, and NRG-1 that are consistent with capsules derived from smooth implants, which are known to have higher contracture rates. These results may help elucidate the mechanism of capsular contracture and identify potential genes for the development of future therapeutic targets for this condition.

Abstract: Clinical Outcomes of Implant-Based Breast Reconstruction in Patients with Prior Radiation Therapy: Does Timing of Prior Radiation Matter?

OBJECTIVE: Although radiation therapy(XRT) is a known predictor of complications in implant-based breast reconstruction, implant-based options remain important due to patient preference and suboptimal autologous candidates. Furthermore, indications for XRT continue to expand. Currently, there is limited data on outcomes for implant-based reconstruction in patients with remote history of XRT due to prior failed breast-conservation therapy. Little is known about how overall timing of prior XRT may affect complication rates. METHODS: A retrospective review was conducted on all patients who underwent expander-implant-based breast reconstruction at our institution between November 2010 and June 2016. Demographics, operative details, and history/timing of XRT were recorded. Patients with non-breast-related XRT and reconstructions involving autologous flaps were excluded. For bilateral breast reconstructions, each breast was recorded separately. Outcomes including infection, wound dehiscence, skin necrosis, capsular contracture, and reoperation were documented. Baseline characteristics and complication rates were compared for no-XRT, prior-XRT(XRT before mastectomy), and adjuvant XRT(adj-XRT) groups using Chi-square and Fisher’s exact tests. Logistic regression and multi-way ANOVA were performed for multivariate analyses. RESULTS: 919 cases, representing 537 unique patients, were identified in total. After applying the exclusion criteria, 896 cases of implant-based breast reconstruction(603 patients) were analyzed: 718 cases no-XRT, 146 adj-XRT, and 32 prior-XRT. The three groups were similar for most demographic and peri-operative variables; however, prior-XRT patients were significantly older (59 yrs vs 49 yrs no-XRT and 47 yrs adj-XRT, p < 0.001 for both) and had smaller average final tissue-expander fill volume (333 cc vs 449 cc no-XRT and 440 cc adj-XRT, p < 0.001). Prior-XRT patients completed XRT at an average of 10.9 years prior to reconstruction. Average postoperative follow-up was 3.7 years. Compared to no-XRT, patients who received any XRT had higher rates of overall acute complications requiring surgical intervention (7.7% no-XRT vs 15% XRT, p< 0.005), including specifically for infection (3.1% no-XRT vs 6.7% XRT, p<0.05). XRT patients also had higher rates of capsular contracture (16.9% XRT vs 3.6% no-XRT, p< 0.001). Within the XRT group, prior-XRT was associated with higher rates of takeback (28% prior-XRT vs 12% adj-XRT, p<0.005), particularly for infection and skin necrosis. Multivariate regression analysis adjusting for potential confounders among groups’ independent demographic and peri-operative factors revealed that while XRT overall was associated with higher rate of complications, timing of XRT was not itself an independent predictor in the development of these complications. CONCLUSION: Radiation therapy results in higher overall complications in implant-based reconstruction, including higher rate of takebacks for complications such as infection and skin necrosis. The damaging effects of XRT appear long-lasting, as patients with history of XRT more than 10 years prior to reconstruction had similar complication rates compared to those with more recent XRT and those undergoing adjuvant XRT. Additional investigations will be needed to further characterize specific effects of XRT timing on reconstruction outcomes, but this study represents a rare longitudinal analysis of these variables and their ability to predict surgical outcomes, which are crucial for patient counseling and selection of reconstructive options.

Nine-Year Core Study Data for Sientra's FDA-Approved Round and Shaped Implants with High-Strength Cohesive Silicone Gel.

Since approval in March 2012, data on Sientra's (Santa Barbara, CA) silicone gel implants have been updated and published regularly to provide immediate visibility to the continued safety and performance of these devices. The 9 year follow-up data support the previously published data confirming the ongoing safety and efficacy of Sientra silicone gel breast implants. The authors provide updated 9 year study data for Sientra's round and shaped silicone gel breast implants. The Core Study is an ongoing 10 year study that enrolled 1788 patients with 3506 Sientra implants across four indications (primary augmentation, revision-augmentation, primary reconstruction, and revision-reconstruction). For the safety analysis, Kaplan-Meier risk rates were calculated to evaluate postoperative complications, including all breast implant-related adverse effects. For the effectiveness analyses, results were presented through 8 years as patient satisfaction scores were assessed at even years. Through 9 years, the overall risk of capsular contracture was 12.6%. Smooth devices (16.6%, 95% CI, 14.2%, 19.5%) had a statistically significantly higher rate of capsular contracture compared to textured devices (8.0%, 95% CI, 6.2%, 10.4%). Out of the 610 reoperations in 477 patients, over half of all reoperations were due to cosmetic reasons (n = 315; 51.6%). Patient satisfaction remains high through 8 years, with 90% of primary augmentation patients indicating their breast implants look natural and feel soft. The 9-year follow-up data from the ongoing Core Study of the Sientra portfolio of HSC and HSC+ silicone gel breast implants reaffirm the very strong safety profile as well as continued patient satisfaction. 2 Therapeutic.

Commentary on: Microbiologic Safety of the Transareolar Approach in Breast Augmentation.

The authors of this article systematically evaluate the bacteria present in the surgical field of a breast augmentation procedure in an attempt to dispel the notion that periareolar augmentation mammaplasty yields a higher rate of capsular contracture than do other approaches.1 The goal is to refute the notion that the breast harbors endogenous bacteria, which are here strictly defined beyond the scope of their original description.2 The concept of endogenous breast bacteria defines bacterial colonies present in significant concentrations and residing within the breast tissue, as opposed to being skin contaminants in the field. As originally described, these bacteria are present in the presumed-sterile surgical field (after skin sterilization) and are consistently identified across sample subjects. Although their exact location has yet to be proven, it is reasonable to imagine that they reside in the ducts, paths that are in fact exposed to the outside world in a similar fashion to the gastrointestinal and urogenital tracts. Even if the ducts harbor similar bacteria to that found on the skin, if that flora is remote from routine skin preparation, then the …

Prosthetic breast reconstruction: indications and update.

Despite 82% of patients reporting psychosocial improvement following breast reconstruction, only 33% patients choose to undergo surgery. Implant reconstruction outnumbers autologous reconstruction in many centres. A systematic review of the literature was undertaken. Inclusion required: (I) Meta-analyses or review articles; (II) adult patients aged 18 years or over undergoing alloplastic breast reconstruction; (III) studies including outcome measures; (IV) case series with more than 10 patients; (V) English language; and (VI) publication after 1(st) January, 2000. After full text review, analysis and data extraction was conducted for a total of 63 articles. Definitive reconstruction with an implant can be immediate or delayed. Older patients have similar or even lower complication rates to younger patients. Complications include capsular contracture, hematoma and infection. Obesity, smoking, large breasts, diabetes and higher grade tumors are associated with increased risk of wound problems and reconstructive failure. Silicone implant patients have higher capsular contracture rates but have higher physical and psychosocial function. There were no associations made between silicone implants and cancer or systemic disease. There were no differences in outcomes or complications between round and shaped implants. Textured implants have a lower risk of capsular contracture than smooth implants. Smooth implants are more likely to be displaced as well as having higher rates of infection. Immediate breast reconstruction (IBR) gives the best aesthetic outcome if radiotherapy is not required but has a higher rate of capsular contracture and implant failure. Delayed-immediate reconstruction patients can achieve similar aesthetic results to IBR whilst preserving the breast skin if radiotherapy is required. Delayed breast reconstruction (DBR) patients have fewer complications than IBR patients. Implant reconstruction is a safe and popular mode of post-mastectomy reconstruction. Evidence exists for the settings in which complications are more likely, and we can now more reliably predict outcomes of reconstruction on an individual basis and assess patient suitability.

Nipple-Sparing Mastectomy via an Inframammary Fold Incision with Implant-Based Reconstruction in Patients with Prior Cosmetic Breast Surgery.

Nipple-sparing mastectomy through an inframammary fold incision (NSM-IMF) with implant-based reconstruction (IBR) is a cosmetically preferable approach to breast cancer treatment in appropriate candidates. However, patients who have undergone prior cosmetic breast surgery (CBS) may be at increased risk for postoperative complications secondary to existing surgical scars. To assess whether prior CBS increases the risk of complications following NSM-IMF with IBR. A retrospective chart review was conducted for 398 NSM-IMFs with IBR performed between July 2006 and December 2013. CBS cases were identified. Outcomes were reviewed. Of 398 NSM-IMF cases, 41 had prior CBS: 24 augmentations, 12 reductions, three mastopexies, and two augmentation mastopexies. NSM-IMF was performed an average of 8 years following CBS. CBS cases had lower BMIs (P = .040), more breast tissue resected (P = .021), wider breast bases (P = .0002), more single-stage reconstructions (P < .0001), more ADM use (P < .0001), and larger permanent implants (P = .0051) than those without CBS. Postoperatively, CBS cases had higher rates of mastectomy flap ischemia (P = .0392) and hematoma (P = .0335). Among CBS cases, single-stage reconstruction was associated with increased full-thickness flap ischemia (P = .0066). Compared to prior augmentation cases, prior reduction/mastopexy cases had higher rates of capsular contracture (P = .0409) and seroma (P = .0226). This series is the largest to date to evaluate the success of NSM-IMF with IBR in CBS patients. These women should be cautiously considered for IBR, particularly in the setting of single-stage reconstruction. 4 Therapeutic.

Radiation Therapy and Expander-Implant Breast Reconstruction

The optimal timing of expander-implant exchange in the setting of postmastectomy radiation therapy (PMRT) remains unclear with prior reports yielding inconsistent and variable results. The purpose of this study was to characterize complications associated with the sequencing of expander-implant breast reconstruction before or after PMRT and to compare the outcomes between early (<4 months) and late (>4 months) expander-implant exchange in the subset of patients who received PMRT before exchange. The medical records of all patients PMRT in the setting of tissue expander-implant breast reconstruction between June 2004 and June 2011 at our institution were reviewed retrospectively. Patients were first classified as having undergone expander-implant exchange before the initiation of PMRT or after the completion of PMRT. Patients who underwent expander-implant exchange after PMRT were then classified as having undergone exchange early (<4 months after PMRT) or late (>4 months after PMRT). All complications requiring additional surgery or hospitalization were recorded. Fifty-five eligible patients were identified as having undergone 56 two-stage tissue expander-implant breast reconstructions. Twenty-two reconstructions underwent exchange before PMRT and 34 reconstructions underwent exchange after PMRT. There was no significant difference in overall complication rate (54.55% vs 47.06%, P = 0.785) or reconstruction failure rate (13.64% vs 20.59%, P = 0.724) between the 2 cohorts. Twenty reconstructions underwent exchange less than 4 months after PMRT and 14 underwent exchange more than 4 months after PMRT. There was no significant difference in overall complication rate (40% vs 57.14%, P = 0.487) or failure rate (25% vs 14.29%, P = 0.672) between the 2 groups. Trends suggest a higher rate of infection in patients who underwent exchange earlier (30% vs 14.29%, P = 0.422) and a higher rate of capsular contracture in patients who underwent exchange later (5% vs 21.43%, P = 0.283); however, statistical significance was not reached. Our findings suggest that neither the sequencing nor timing of expander-implant exchange in the setting of PMRT affects overall complication or reconstruction failure rate. However, the timing of exchange may impact the type of complication encountered. Further investigation is necessary to determine an optimal time for expander-implant exchange.

Capsular Contracture with Breast Implants in the Cosmetic Patient: Saline versus Silicone–A Systematic Review of the Literature

Capsular contracture is one of the most common and trying complications associated with the placement of breast prostheses. The authors hypothesized that silicone implants have a higher rate of capsular contracture than saline implants when used for cosmetic, nonreconstructive breast augmentation. This was based on several previous studies and the experience of the senior author (R.J.R.). The authors objectively evaluated this hypothesis using a systematic review of the literature, specifically examining the incidence of capsular contracture with saline and silicone cosmetic breast implants. A review of the PubMed, OVID, and Cochrane databases for prospective studies using these implants and having at least 1-year follow-up on all implants was performed. Reference articles of the articles meeting these inclusion criteria were also included. Two independent reviewers performed the same systematic review with the same a priori criteria, and discrepancies were settled by the senior author. The systematic review was performed in March of 2009. One thousand six hundred ninety-six articles were identified as potentially inclusive based on the search term "breast augmentation." When filtered for "saline or silicone" search terms, 583 articles were found. In the end, 16 articles met inclusion criteria. There is a lack of current prospective data comparing saline and silicone breast implants in the literature, thereby interfering with the ability of physicians to make data-driven recommendations to patients based on the best medical evidence. The authors were unable to accept or reject their null hypothesis definitively based on this review.

Effect of Tissue Inhibitors of Metalloproteinases and Matrix Metalloproteinases on Capsular Formation Around Smooth and Textured Silicone Gel Implants

Capsular contracture is one of the most distressing complications after cosmetic breast augmentation. Evidence suggests that matrix metalloproteinases (MMPs) and tissue inhibitors of metalloproteinases (TIMPs) may play a key role in the onset or progression of several fibrotic disorders. In this study we used quantitative reverse-transcription PCR methodology to profile the expression of TIMP-1, TIMP-2, MMP-2, and MMP-9 in the tissue of patients with capsular contracture after breast augmentation with smooth and textured silicone breast implants. The study included 20 female patients (average age = 37 +/- 15 years) with capsular contracture after bilateral subglandular cosmetic breast augmentation with smooth silicone implants. Ten patients developed grade II capsule contracture, 8 grade III contracture, and 1 grade IV contracture. Twenty other female patients (average age = 41 +/- 9 years) with capsular contracture after breast augmentation with textured silicone implants were also included (Baker grade II = 10 patients, grade III = 8, grade IV = 2). Expression of mRNA in capsular tissue was calculated using a relative quantification method (Pfaffl). Statistical analysis was performed using the Mann-Whitney test. The level of significance was considered to be p < 0.05. The expression of MMP-2 was significantly increased in tissue of patients with textured implants and capsular contracture grades II and III/IV in comparison to grade I (p < 0.05). In comparison to grade I, the capsular tissue from patients with Baker II and III/IV fibrosis showed a significant increase for TIMP-1 and TIMP-2 (p < 0.05) in both smooth and textured silicone implants. The expression was significantly higher in tissue from patients with severe contracture (Baker III/IV) and smooth silicone implants compared with that in tissue from patients with textured implants (p < 0.05). The decrease in MMP-to-TIMP expression can cause increased synthesis and deposition of collagen surrounding alloplastic breast implants, leading to a profibrotic state. The higher expression of TIMPs in capsular tissue of patients with smooth silicone gel implants might be a reason for the observed higher rates of capsular contracture. In the future, a nonoperative treatment that decreases TIMPs but increases the activity of MMPs may be an appropriate therapy for patients with capsular contracture.

Incidence of Capsular Contracture in Silicone Versus Saline Cosmetic Augmentation Mammoplasty: A Meta-Analysis

Capsular contracture after augmentation mammoplasty occurs at a rate of 15% to 45%. The purpose of the present study was to determine the effect of implant core type (silicone versus saline) on the rate of capsular contracture in augmentation mammoplasty. A systematic review was conducted through a search of three electronic databases. Two reviewers independently scanned titles yielded by the search and identified potentially relevant papers. Inter-reviewer variability and the scientific quality of the articles were assessed. Meta-analysis was performed. Eighty-eight titles of potential relevance were selected from the 393 articles yielded by the search. Inter-rater agreement for selection of potentially relevant articles was 84% (kappa=0.54). Four comparative studies were included in the analysis. Scientific quality scores of the included studies ranged from 5 of 14 to 9 of 14. Three of the four studies reported a higher rate of capsular contracture in patients with silicone implants. A combined odds ratio calculated on two of the studies found a 2.25-fold increased risk of capsular contracture in patients who received silicone implants. Eight series of patients who received cohesive gel silicone implants reported rates of capsular contracture from 0% to 13.6%. Higher rates of capsular contracture were found in patients who received silicone implants when compared with those who received saline implants. However, the scientific quality of the comparative studies to date on this subject is poor. Recent series evaluating cohesive gel implants report relatively low rates of capsular contracture. A randomized controlled trial comparing rates of capsular contracture in cohesive gel and saline implants is recommended.

Transareolar Incision with Geometric Broken Line for Breast Augmentation: A Novel Approach

Along with implant location and size, incision location is an important variable that influences the final result of breast augmentation. The transareolar approach is not popular because of reported lactational difficulties, higher rates of capsular contracture, visibility of scars, and potential changes in nipple sensation. We describe a geometric zigzag transareolar incision for breast augmentation that can achieve imperceptible scarring. We believe that in selected patients the transareolar zigzag incision has its place among the different approaches used in breast augmentation today.