Colchicine and capsular contracture around breast prostheses

Capsular contracture around the prosthetically reconstructed, breast is a very common problem which often leads to an unacceptable result. Colchicine, a drug known to inhibit contracture activity, was studied in an animal model of capsular contracture. Twenty-four 130 cc silicone gel breast prostheses were implanted subcutaneously into twelve rabbits. Colchicine was given daily in oral doses to half of the animals; the other half were used as controls. The prostheses were maintained insitu for two months. The degree of capsular contracture, as measured by applanation tonometry, was significantly less in the colchicine treated groups. The difference was often visually apparent. This study appears to be the first to demonstrate a significant inhibition of capsular contracture in an animal model by colchicine, an oral medication commonly used in the treatment of gout.Hospital where the work was done: Providence Hospital Southfield, Michigan, USA Correspondence to: C.B. Kelly     

Silicon in human breast tissue surrounding silicone gel prostheses. A scanning electron microscopy and energy dispersive X-ray investigation of normal, fibrocystic and peri-prosthetic breast tissue

Implanted silicone breast prostheses leak silicone gel through the intact membrane. In order to determine the exact location and to achieve a semiquantitative estimation of the amount of silicone in the surrounding tissue, a method involving scanning electron microscopy (SEM) and energy dispersive analysis of X-rays (EDAX) was used. By this method we were able to demonstrate the presence of the element silicon (Si) (main component of silicone, a polymer with a general formula e.g. (CH3[Si(CH3)2O]n Si(CH3)3 along the inner border of vacuoles corresponding to the light microscopic localization of droplets and in macrophages. The tissue adjacent to the prostheses had a higher silicon content than the control tissue.     

Immediate breast reconstruction with tissue expanders

Primary breast reconstruction with expander devices provides a safe, simple, and rapid method that is most cost-effective and should usually be the method of choice in these cases.     

Fluid retention in Bioplasty Misti Gold II breast prostheses with development of capsular contracture.

We compared the incidence of capsular contracture in an implant (Bioplasty Misti Gold II) which has a textured surface and is filled with polyvinyl-pirrolidone (PVP)-hydrogel, with that in saline-filled implants with textured surfaces when the implants are placed subcutaneously during immediate reconstruction after subcutaneous mastectomy. In 41 patients, mean age 55 years (range 30-81), with breast cancer that was not suitable for breast conservation, 20 patients had 22 Misti Gold II prostheses inserted (two patients bilaterally) and 21 patients had saline-filled prostheses (one patient bilaterally). The development of capsular contracture was assessed using Baker's classification and applanation tonometry. Fourteen patients with Misti Gold II implants were classified one year postoperatively as Baker 2 and 3 compared with five with saline-filled implants (p = 0.01). On applanation tonometry 16 of the Misti Gold II group had an operative:postoperative ratio of < or = 0.75, compared with 50% in the saline-filled group (p = 0.096). In the 12 Misti Gold II prostheses that were removed because of capsular contracture between 13-40 months postoperatively, the volume in the prostheses had increased by 48%. The poor results obtained with the Misti Gold II prosthesis can be explained by the volume that they gained after implantation as a result of osmosis.     

Post-mastectomy breast reconstruction by tissue expanders: technical note

The aim of post-mastectomy breast reconstruction by tissue expanders is the mammary symmetry. The Authors report a personal experience in immediate (55 pts) and delayed (12 pts) breast reconstruction with implants. The technique is simple and safe with good aesthetical and functional results.     

Steroid and benzyl alcohol diffusion through tissue expanders and double lumen breast implants.

The rate of diffusion of benzyl alcohol (the bacteriostatic agent in the provided diluent) and methylprednisolone 21-hemisuccinate and related rearrangement and hydrolysis products ("steroid") through tissue expanders was examined. The rate of diffusion of steroid through double lumen breast implants was also studied. It was found that benzyl alcohol rapidly diffused through tissue expanders into a saline bath. By 24 hours, one-half of the benzyl alcohol had diffused through the expander. The steroid was much slower to diffuse out of the expander. By 141 days, only 2% of the steroid was found in the bath. This rate was comparable for both the tissue expander and double lumen implants. In addition, a significant amount of the steroid is located in the expander wall, associated with the surface of the expander or precipitated out of solution or both. The clinical significance of these findings is discussed.     

硅凝胶乳房假体的临床应用及并发症研究进展

1962年,美国德克萨斯州整形医师Cronin和Gerow[1]发明了一种新的摸起来感觉自然的隆乳假体,他们改进的假体为有弹性的固体硅胶包膜内充注凝胶,这种假体成为现在使用的各种假体的原型。但在硅凝胶乳房假体使用的安全性上一直有争议。1992年,美国食品与药物管理局(FAD)[2]颁布了禁止硅胶用于隆乳美容的决定,并严格限制其在临     

Infusion port dislodgement of bilateral breast tissue expanders after MRI

Tissue expanders are placed routinely for breast reconstruction, and magnetic resonance imaging (MRI) is a common diagnostic procedure. Many studies have reported on the safety of MRI in patients with nonferromagnetic implants; however, many tissue expanders contain ferromagnetic components. The authors present a case of bilateral tissue expander infusion port dislodgment after MRI. A 56-year-old woman underwent bilateral mastectomy and immediate reconstruction with McGhan BIOSPAN tissue expanders. These implants contain integral nonferromagnetic infusion ports, as well as small, powerful Magna-Site magnets. Several weeks postoperatively the patient underwent MRI of her spine, which was ordered by her primary physician for back pain. Subsequently, the infusion ports could not be located with the finder magnet. A chest radiograph was obtained, which demonstrated bilateral dislodgment of the infusion ports. Surgical removal and replacement of the tissue expanders were required. Safety considerations of MRI have been discussed extensively in the literature, and data on MRI with various implanted devices have been obtained. The potential risks of performing MRI on patients with metallic implants include conduction of electrical currents, heating of the implant, misinterpretation resulting from artifact, and the possibility of movement or dislodgment of the implant. The small magnet integral to many tissue expanders may be overlooked by patients and physicians during pre-MRI screening. All patients undergoing tissue expansion with implants that contain integral ports should be thoroughly warned about the potential hazards of MRI.     

Development of the inframammary fold and ptosis in breast reconstruction with textured tissue expanders

Tissue expansion has become the most important method for postmastectomy breast reconstruction. However, well-defined inframammary fold and ptosis are difficult to achieve with this technique. This study was performed to evaluate the inframammary fold and ptosis achieved in breast reconstruction using a textured tissue expander, later replaced by a textured implant. In ten postmastectomy patients, a textured tissue expander was inserted into a submuscular pocket. Every two to three weeks the volume of the expander was increased by about 30%. About three months after the last filling, the expander was removed and replaced with a permanent textured, gel-filled implant. The profile of the reconstructed breast was recorded before and after the tissue expansion, as well as before and after the change of the implant. The results showed that the inframammary fold did not move significantly upwards or downwards during the expansion period when a textured tissue expander was used. Waiting three months after the last inflation of the expander before replacing it with the permanent implant resulted in a more ptotic breast mound. Usually, however, no real ptosis was achieved, meaning that the angle between the lower part of the breast and the lower chest wall was more than 90 degrees. These findings indicate that a textured expander could help create a pronounced inframammary fold, but without ptosis. A three-month waiting period before inserting the permanent implant may improve the development of an inframammary fold.     

The use of tissue expanders in immediate breast reconstruction following mastectomy for cancer

From April 1985 to March 1987, 50 women had 56 mastectomies for documented cancer. A tissue expander was used for immediate reconstruction in each case. The patient records were used to determine morbidity and mortality, as well as to examine the effect of reconstruction on adjuvant therapy, cancer surveillance, adequacy of cancer surgery and patient satisfaction. The patients were followed up for an average of 13 months. Fifty-two of 56 expanders were successfully replaced with a permanent prosthesis. Forty-seven women remain alive. Local or regional recurrence did not occur in any women within the study period. Complications, of which superficial skin necrosis was most common, occurred in 35% of reconstructions and were investigated critically. Patient satisfaction was high. Dissatisfaction was not related to the incidence of complications but rather appeared to reflect the success of the patient's cancer treatment.     

Microbiological evaluation of tissue expanders in patients who had first stage breast reconstruction

Abstract

Capsular contracture is one of the most common complications associated to the use of foreign materials in reconstruction after mastectomy and aesthetic breast augmentation. Many risk factors, causes, and conditions seldom associated with capsular contracture have been identified but none of these have been confirmed by published data. Among these, subclinical infections (particularly those caused by Staphylococcus epidermidis) seem to be one of the most likely. In the present study we analysed the correlation between capsular contracture and the incidence of periprosthetic subclinical infection in two groups of patients who had first-stage breast reconstruction: one group of patients who were not having adjuvant or neoadjuvant radiotherapy for breast cancer (n = 25) and a second group of patients who had had quadrantectomy and radiotherapy (QUART) and successive radical mastectomy for recurrent disease (n = 25). Patients who had radiotherapy had a significantly higher incidence of subclinical infection (n = 13) than patients who did not (n = 1), but there was no statistical correlation between subclinical infection and capsular contracture. Subclinical infections seemed to present at a later stage and under certain local and systemic circumstances that favoured bacterial growth, such as radiotherapy.     

The suspension technique to avoid the use of tissue expanders in breast reconstruction

BACKGROUND: Immediate or delayed breast reconstruction is usually performed using expansion techniques or pedicled or free flaps. The suspension technique hereby described can reduce the number of surgical stages, as well as donor-site sequelae. TECHNIQUE: The authors describe a new technique of breast reconstruction with implants using a nonabsorbable mesh to create a superior abdominal cutaneous flap, which contributes to the skin envelope of the reconstructed breast. The advantage of this technique is the opportunity to use immediately a definitive prosthesis also in cases requiring a mastectomy with the resection of a large amount of skin, consequently reducing the indications of tissue expanders or myocutaneous flaps. RESULTS: We performed the "suspension technique" in 67 cases of immediate reconstruction and in 6 cases of delayed reconstruction. No further surgery under general anesthesia was necessary in 56 patients (76.7%). In 14 cases (19.2%), a second operation under general anesthesia was necessary for implant replacement, capsula revision, and nipple and areola (NAC) reconstruction. In 3 cases (4.1%), implant removal was necessary due to implant exposition or infection. In 33 patients, only NAC reconstruction was performed under local anesthesia. In our series, capsula contracture was graded as Baker I in 24 cases, grade II in 16 cases, grade III in 9 cases, and grade IV in 1 case. Breast symmetry, patient's satisfaction, and surgeon cosmetic evaluation were respectively scored 7.56, 7.75, and 7.60 (range from 1 to 10). CONCLUSION: In conclusion, this technique can be applied in cases requiring a large skin resection at the time of mastectomy and refusing a reconstruction with myocutaneous flaps or a second surgery, necessary if a reconstruction with tissue expanders is planned.     

Microbiological evaluation of tissue expanders in patients who had first stage breast reconstruction

Capsular contracture is one of the most common complications associated to the use of foreign materials in reconstruction after mastectomy and aesthetic breast augmentation. Many risk factors, causes, and conditions seldom associated with capsular contracture have been identified but none of these have been confirmed by published data. Among these, subclinical infections (particularly those caused by Staphylococcus epidermidis) seem to be one of the most likely. In the present study we analysed the correlation between capsular contracture and the incidence of periprosthetic subclinical infection in two groups of patients who had first-stage breast reconstruction: one group of patients who were not having adjuvant or neoadjuvant radiotherapy for breast cancer (n = 25) and a second group of patients who had had quadrantectomy and radiotherapy (QUART) and successive radical mastectomy for recurrent disease (n = 25). Patients who had radiotherapy had a significantly higher incidence of subclinical infection (n = 13) than patients who did not (n = 1), but there was no statistical correlation between subclinical infection and capsular contracture. Subclinical infections seemed to present at a later stage and under certain local and systemic circumstances that favoured bacterial growth, such as radiotherapy.     

Soft tissue expanders in hand reconstruction

Eight cases in which soft tissue expanders have been used as an adjunct to reconstruction in the hand are reported. Cases involved reconstruction after skin grafting for burns and crush injuries as well as skin resurfacing in the management of the painful hand. Patient tolerance was excellent and the final result was significantly aided by the use of this technique. The technical details of expansion as well as complications are discussed.     

皮肤软组织扩张术在面颈部瘢痕修复中的应用

目的：通过对临床资料的回顾,总结皮肤软组织扩张术在面部瘢痕修复中的应用经验及教训。方法：系统回顾自2001年以来54例面颈部瘢痕应用皮肤软组织扩张术治疗的病例,通过对术前设计、扩张器置入技巧、皮瓣应用、修复效果和并发症等资料的总结。探讨颜面部扩张术治疗的经验和教训。结果：临床应用54例,发生血肿2例,感染和切口外露各1例,所有并发症经及时对症处理后未影响手术效果。随访6—36个月,48例患者满意,6例患者主诉切口瘢痕增生明显,需进行二期瘢痕整形术。结论：应用扩张器修复面颈部瘢痕,虽然可以获得良好的效果,但对并发症的预防不可忽视。     

3D analysis of tissue expanders

This article reviews some of the phenomena associated with tissue expansion that are amenable to study with 3D imaging and presents selected cases from the literature where the technology has been used to answer clinical questions and plan procedures. The authors discuss implant selection, remodeling, contraction, and 3D analysis. Future directions and limitations of the use of this technology in the head and neck are also described.     

Role of connective tissue growth factor in breast implant elastomer capsular formation

Transforming growth factor-beta (TGF-beta) has been demonstrated to be a mediator in scar formation and in multiple fibrotic disorders such as in Dupuytren contractures and in pulmonary fibrosis. Recently, it has been demonstrated that connective tissue growth factor (CTGF) is a downstream mediator of TGF-beta and acts to stimulate wound contraction and fibrosis. The purpose of this study is to assess the role of CTGF in the development of breast implant elastomer capsule formation over time and to evaluate the effects of TGF-beta and CTGF antisense (AS) oligonucleotides on capsule formation. Fifteen Sprague-Dawley rats were randomly assigned to treatment (n = 12) and control (n = 3) groups. Four 2- x 2-cm pockets were created on the dorsum deep to the panniculus carnosus in each rat. A 1- x 1-cm smooth breast implant elastomer was placed. Each rat in the treatment group received 1 ml vehicle, AS-TGF-beta, AS-CTGF, or scramble antisense oligonucleotide (AS-scramble). Control rats received either 1 ml vehicle or 1 ml saline in each pocket. At weeks 1, 3, and 5, four treatment rats and one control rat were randomly selected and killed. Tissue blocks were harvested for determination of CTGF levels using the enzyme-linked immunosorbent assay technique and for hematoxylin and eosin slides to evaluate capsule formation. Levels of CTGF in capsular tissue treated with vehicle or AS-scrambled were similar and progressively increased in tissues on weeks 1, 3, and 5, compared with normal skin. At weeks 1 and 3 after surgery, levels of CTGF were suppressed in capsules treated with AS-CTGF or AS-TGF-beta compared with normal skin and with tissues treated with vehicle or AS-scramble (p = 0.002). At week 5, levels of CTGF were similar to levels in normal skin. Histological analysis revealed reduced capsular formation in samples treated with AS-CTGF or AS-TGF-beta compared with the two other treated sites. In conclusion, a single and local treatment with AS-CTGF or AS-TGF-beta at the time of surgery reduced CTGF levels in tissue and correlated with reduced capsular formation in a rat model. These data suggest a new therapeutic strategy to reduce early capsular formation based on local application of antisense oligonucleotides targeting CTFG and TGF-beta.     

Activity of antimicrobial-impregnated silicone tissue expanders

Because bacterial colonization of medical devices may result in clinical infection, it is conceivable that antimicrobial impregnation of tissue expanders may reduce the rate of infection. The objective of this in vitro study was to examine the spectrum, durability, and shelf-life antimicrobial activity of minocycline/rifampin-impregnated silicone tissue expander shells. The impregnated devices exhibited zones of inhibition at baseline against Staphylococcus epidermidis, Staphylococcus aureus, and Escherichia coli. The impregnated devices exhibited strong residual activity against S. epidermidis and S. aureus after suspension in serum at 37 degrees C for 4 weeks. There was no significant decrease in the size of zones of inhibition after storing the impregnated devices at room temperature for 1 year. These results indicate that minocycline/rifampin-impregnated tissue expander shells provide broad-spectrum and durable antimicrobial activity and that the shelf-life antimicrobial activity exceeds 1 year. These findings prompt future exploration of the anti-infective efficacy of these antimicrobial-impregnated devices.