Breast implants Methods for reducing capsular contracture

Summary The aim of the paper is to establish a method of breast augmentation which will reduce capsular contracture. Since the causation of capsule contracture is probably multifactorial, a regime of pocket irrigation, prolonged drainage, a double lumen prosthesis and massage is advocated. Using this protocol, the incidence of capsule formation is 11 % and appears to be decreasing as further studies are carried out.     

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

BackgroundCapsular contracture (CC) is the most common complication following Immediate Breast Reconstruction (IBR) with breast implants. Different implant surfaces were developed aiming to reduce the incidence of CC. We evaluated the incidence and degree of CC after Direct-to-Implant (DTI) IBR with insertion of textured (TE) or polyurethane (PU) covered implants.MethodsA retrospective review of consecutive patients treated at our Institution with mastectomy and one-stage IBR and implant reconstruction between 2013 and 2018, with or without post mastectomy radiation therapy (PMRT), was conducted. Immediate breast reconstruction was performed by implanting 186 PU covered implants and 172 TE implants.ResultsThree-hundred-twelve women underwent 358 DTI IBR with PU or TE implants, were analyzed with a median follow-up time of 2.3 years (range 1.0–3.0). The overall rate of CC Baker grade III and IV was 11.8% (95%CI: 8.4–16.3), while, after PU and TE implant placement it was 8.1% (95% CI: 4.1–15.7) and 15.8% (95% CI: 4.1–15.7) [p = 0.009]), respectively. Irradiated breasts developed CC more frequently rather than non-irradiated breasts (HR = 12.5, p < 0.001), and the relative risk was higher in the TE group compared with the PU group (HR = 0.3, p = 0.003).ConclusionsAfter mastectomy and one-stage IBR, the use of PU covered implants is associated with a lower incidence of CC compared to TE implants. This advantage is amplified several folds for patients who necessitate PMRT. Footnote: Capsular contracture (CC); Immediate Breast Reconstruction (IBR); Directto- Implant (DTI); Textured (TE); Polyurethane (PU); Post mastectomy radiation therapy (PMRT); Nipple Sparing mastectomy (NSM).     

经乳晕切口综合处理假体隆乳术后包膜挛缩

目的 探讨经乳晕切口采用多种方法综合处理假体隆乳术后包膜挛缩的效果.方法 2005年2月至2011年6月,对94例168侧假体隆乳术后包膜挛缩进行治疗并置入假体,其挛缩程度均为Baker分类法Ⅲ、Ⅳ级.94例均采用乳晕切口,根据原假体置入腔隙及乳腺、胸大肌厚度等条件,采取重新剥离腔隙、去除或不去除包膜组织,甚至二期手术,于胸大肌或乳腺后间隙置入假体等方法综合处理,术中严格止血.结果 术后94例中46例获得门诊随访,其余病例均获得电话随访,时间6 ～37个月,平均9.9个月,术后包膜挛缩复发Ⅲ级者2例、Ⅳ级者1例,其余病例乳房外观均丰满、挺拔,柔软度较好,电话随访病例均对乳房塑形效果满意.本组病例均无血肿、感染、乳房假体破裂、乳房下垂及上移等并发症发生.结论 应用乳晕切口对假体隆乳术后包膜挛缩进行综合而有效地处理,术后包膜挛缩复发率较低,可以获得较满意的乳房塑形效果.     

Effect of expansion exercises on capsular constriction around silicone implants

Animal experiments were used to demonstrate that capsule expansion exercises can have a positive effect on capsular constriction around silicone implants.     

几丁糖预防硅凝胶乳房假体包膜挛缩的实验研究

目的　探讨几丁糖预防硅凝胶乳房假体置入术后包膜挛缩的效果。方法　以 18只雌性SD大白鼠为实验对象 ,随机分为 3组。于大白鼠两侧背阔肌下各置入小型模拟硅凝胶假体。左侧为实验组 ,剥离腔内注入几丁糖 ,右侧为对照组。术后 4、8、12周分组切取包膜行组织学检查 ,测量其厚度和Ⅰ、Ⅲ型胶原的面密度。结果　实验侧与对照侧包膜结构相似 ,可分为致密层和疏松层两层结构。术后 4周 ,实验侧包膜全层厚度、致密层厚度均小于对照侧 (P <0 .0 1) ,Ⅰ型、Ⅲ型胶原的面密度均低于对照侧 (P <0.0 1)。术后 8、12周 ,实验侧包膜全层厚度、致密层厚度均小于对照侧(P <0.0 5 ) ,Ⅰ型胶原的面密度低于对照侧 (P <0 0 5 ) ,Ⅲ型胶原的面密度与对照侧无差异 (P >0.0 5 )。结论　几丁糖可明显预防硅凝胶乳房假体置入术后的早期包膜挛缩     

Correction of established capsular contractures with polyurethane implants

Twelve patients with severe and recurrent capsular contractures following breast augmentation and reconstruction were improved with polyurethane-covered implants. It still has not been established whether these implants prevent or merely delay the onset of contractures, but some of these patients have been followed for over three years and all 12 were improved.Presented at the 9th Congress of the International Society of Aesthetic Plastic Surgery, New York, October 11–16, 1987     

Incidence of capsular contracture in silicone versus saline cosmetic augmentation mammoplasty: A meta-analysis

INTRODUCTION:

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.

METHODS:

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.

RESULTS:

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% (κ=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%.

CONCLUSIONS:

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.     

Influence of patient age on capsular contracture after aesthetic breast augmentation

The influence of age on capsular contracture rates remains unclear. Most studies have only investigated early capsule development and not whether a link between age at primary surgery and the later development of capsular fibrosis exists. To clarify whether patient age impacts the development of late capsular fibrosis, the authors conducted a retrospective case study involving 43 patients who presented for surgical revision of capsular contracture (Baker grade ≥III) between four and 40 years after primary breast augmentation. Possible correlations between age and implant placement were analyzed. Late presentation of capsular fibrosis occurred a mean of 15.6 years after primary augmentation, with a slightly negative, but not significant, correlation between age at primary operation and duration of implant placement. Patients <40 years of age underwent an operative revision after a mean of 18.9 years, while patients ≥40 years of age needed an operative revision a mean of 11.9 years after primary breast augmentation (P=0.0368). The results suggest that with advancing age, the average time to develop capsular fibrosis is significantly shorter in individuals who develop capsular contracture. As more data are collected, appropriate advice can be provided to patients regarding factors that influence the long-term outcomes of breast augmentation.     

积雪草甙预防隆乳术后包膜挛缩的细胞及分子机制初探

目的 初步探讨积雪草甙抑制隆乳术后包膜挛缩的细胞及分子机制.方法 将人体来源挛缩包膜组织进行体外分离培养,获得成纤维细胞,将含不同浓度积雪草甙的条件培养基作用于细胞后,采用3H-胸腺嘧啶核苷掺人法、3H-脯氨酸掺入法、Western-blot法分别检测细胞增殖、胶原合成及α-SMA蛋白表达的变化,结果采用SPSS11.0统计学软件分析,并进行t检验.结果 当积雪草甙浓度达到50 mg/L即对细胞DNA合成及胶原合成产生显著的抑制,抑制率分别为34.7%和30.1%,与空白组比较差异具有统计学意义(P＜0.05),随着药物浓度的增加,抑制作用逐渐增强;积雪草甙浓度达到25 mg/L时,α-SMA蛋白表达显著受到抑制,蛋白活化指数为1.673,与空白组比较差异具有统计学意义(P＜0.05).抑制作用与药物浓度正相关.结论 积雪草甙能有效抑制包膜来源成纤维细胞的增殖、胶原合成及向肌成纤维细胞的转分化.

Abstract：

Objective To explore the cellular and molecular mechanism of the inhibitory effect of asciaticoside on capsular contracture following breast augmentation. Methods Contractured capsule derived fibroblasts were cultured in medium with different concentration of asciaticoside. The cell proliferation, collage synthesis and α-SMA expression were detected by means of 3H-thymidine incorporation, 3H-proline incorporation, and Western-blot. The results were analyzed by SPSS 11.0 with t test. Results DNA and collagen synthesis of fibroblasts were dramatically inhibited when the asciaticoside reached the concentration of 50 mg/L. The inhibitory rate was 34.7% and 30.1%respectively, showing a significant difference from that in control group( P＜0.05 ). The inhibitory effect increased with the rise of the asciaticoside concentration in a dose-dependent manner. When the concentration of asciaticoside reached 25 mg/L, the expression of α-SMA was down-regulated with an activation index of 1. 673, showing a significant difference when compared with that in control group(P＜0.05). Conclusions Asciaticoside can effectively inhibit the DNA and collagen synthesis of capsulederived fibroblasts. The trans-differentiation of fibroblast to myo-fibroblasts is also prevented by it.     

Open capsulotomy for capsular contracture: A new procedure for the prevention of recurrence

Capsular contracture is a frequent complication after breast augmentation with alloplastic implants. A technique has been developed to correct this contracture, performed through the previous operative scar. Use of a portion of the matured capsule wall as petal flaps appears to be a contributing factor in the success of this procedure. Open capsulotomy has been performed on 23 patients with good results in 20. The procedure should be performed at least 6 months after augmentation mammoplasty has been performed.     

维生素E在隆乳手术中的应用

在研究观察了维生素Ｅ防止硅凝胶假体隆乳术后纤维囊挛缩的临床疗效中，结果显示使用维生素Ｅ组和对照组纤维囊挛缩分别为６．１４％和２０．１６％。表明维生素Ｅ可以防止纤维囊挛缩。并就维生素Ｅ防止纤维囊挛缩机制进行了讨论。     

What is new about implants: tissue reactions

Summary Current knowledge about the tissue reactions to polyethylene, Dacron, polyurethane, Proplast and silicone implants is briefly reviewed.Presented at the Fourth Congress of the European Section of the International Confederation for Plastic and Reconstructive Surgery, Athens, 10–14 May 1981     

Capsular contracture and ripple deformity of breast implants

Our surgical understanding and preference for an implant design suggests that location of the implant in the retromuscular plane gives an aesthetically better looking clinical result, there is less rippling when the chest wall is vertical, and the implant flattens when the patient is lying supine. An implant with a textured posterior wall and smooth anterior wall assists adherence of the implant at the desired level. It also induces a pseudo-bursa over its anterior surface which, being larger than the implant surface, allows it to flatten naturally when the patient is lying or raising the arm. A gel-filled implant gives the most natural quality to an implant and the contents displace less readily and therefore do not tend to cause rippling.     

Late unilateral breast enlargement after insertion of silicone gel implants: A histopathological study

Late unilateral breast enlargement after the insertion of silicone gel breast implants is a very rare phenomenon. The present study reports five women who presented with this finding over the past 20 years. Three of these patients presented with late unilateral hematomas, which developed nine, 12 and 14 years, respectively, after initial breast augmentation, in the absence of any known trauma. These patients presented for treatment one, four and 12 months, respectively, after their breast enlargements initially appeared. Two of these patients had developed chronic expanding hematomas. Extensive histopathological analyses of the capsules of all three patients provided explanations for the etiologies and progressions of the findings in these patients. In each of the three patients, the etiology of the hematoma was consistent with erosion of a capsular artery. Numerous large vessels were seen within the wall of the capsules. In each case, there was a class IV capsular contracture, which could have increased the friction of the intact implant against the capsule, and there was both old (hemosiderin deposits) and new bleeding into the pocket from the capsules. This supports the concept that numerous episodes of bleeding had occurred in each case. Histopathology also demonstrated the progression of the hematomas. After four weeks, only liquefied hematoma was present, while after four months, there were both liquefied hematoma and blood clotting. The hematoma on the surface of the capsule was becoming organized peripherally, but not centrally. After 12 months, the hematoma was becoming very well organized compared with the hematoma at four months. In one of the two remaining cases, late infection was the cause of the breast enlargement. Histopathology of this capsule showed that the involved capsule was six times as thick as the other side. It also showed edema and infiltration by scattered mononuclear cells, polymorphonuclear cells, and irregular crenated and degenerating nuclei. In the final patient, chronic inflammation appeared to be the cause of the breast enlargement. The histopathology of this capsule was unique. Its inner surface showed re-epithelialization and metaplasia of the ductal epithelium to form stratified squamous epithelium with early surface keratinization. These findings are consistent with synovial metaplasia. Several areas of the fibrous portion of the capsule showed patchy loss of cellular staining with loss of nuclei, indicative of necrosis. This produced a ‘washed out’ staining appearance. This tissue was paucivascular and fibrotic, and showed areas of fibrinoid necrosis, suggestive of mechanical abrasion and increased pressure.     

双平面法假体再置入在隆乳术后包膜挛缩治疗中的应用

目的 探索假体隆乳术后并发包膜挛缩的有效治疗方法.方法 选取自2007-2009年在我科就诊的25例胸大肌下假体隆乳术后并发包膜挛缩的患者,在完整切除挛缩的包膜后应用双平面法置入乳房假体.结果 对25例患者随访3 ～ 12个月,其中2例乳房变硬,为BakerⅡ级,经保守治疗后痊愈;术后乳房柔软,更富弹性,形态美观,无乳房下垂及假体上移等并发症发生.结论 双平面法隆乳术是治疗假体隆乳术后并发包膜挛缩的有效方法.     

内窥镜在乳房假体包膜挛缩微创治疗中的应用研究

目的依托内窥镜技术，探索微创治疗包膜挛缩的新术式，以求获得满意的手术疗效。方法根据新设计的手术步骤的要求，按切口大小，不同切口的操作需要，以及挛缩部位与乳房的位置关系，在不取出假体的情况下。将内窥镜技术应用于临床包膜松解手术中。手术采用经原隆乳手术切口或乳房下皱襞切口，完成乳房假体的显露后，对于完好的硅凝胶假体或盐水假体，不必取出假体，而在包膜内壁与假体之间，应用内窥镜电刀进行切割及分离包膜，完成包膜的松解。结果应用内窥镜技术，完成包膜松解术4例。术后随访半年，效果良好。结论本术式在保证手术操作易行性的前提下，增加了包膜松解手术切口的选择性及不更换假体完成操作的可行性。微创包膜松解术主要适应于隆乳术后乳房假体包膜挛缩的患者，无论假体内注入的是硅凝胶，还是盐水，均可以采用此方法治疗。