Defining the Relationship between Pocket and Breast Implant Surface Area as the Basis for a New Classification System for Capsular Contracture

 

by Hammond, Dennis C.; Chaudhry, Arif 

 

Plastic and Reconstructive Surgery: September 2022 - Volume 150 - Issue 3 - p 496-509

 

Background: 

The precise cause of and treatment for capsular contracture remains uncertain, at least partially because there is no reliable quantitative measurement tool. To address this, it is postulated that the surface area of an implant as defined by the surrounding pocket may provide a quantifiable variable that can be measured to evaluate the degree of capsular contracture.

Methods: 

A bench model for capsular contracture was developed. The surface area of a series of spherical test objects and noncontracted and contracted breast implants was measured using a wax-coating technique and three-dimensional reconstructions created from computed tomographic scan images.

Results: 

Comparison of the mathematically calculated surface areas to the wax and computed tomographic scan results for spheres of known dimension provided nearly identical values, documenting the accuracy of the two experimental methods. Comparison of the surface area measurements between the test groups showed that the average decrease in surface area for all implants was 20 percent, ranging from a high of 30.9 percent for a low-profile implant to a low of 14.1 percent for a high-profile implant. The anatomically shaped devices demonstrated nearly uniform degrees of surface area change over three different heights with volume and projection held relatively constant.

Conclusions: 

The described bench model provides a useful tool for the study of capsular contracture. Surface area is a descriptive variable that can assess the degree of capsular contracture that is present. A classification system based on surface area is presented.

 

 

The Baker Classification for Capsular Contracture in Breast Implant Surgery Is Unreliable as a Diagnostic Tool

 

The Baker Classification for Capsular Contracture in Breast Implant Surgery Is Unreliable as a Diagnostic Tool

 

by de Bakker, Erik; Rots, Mathijs; Buncamper, Marlon E.; Niessen, Frank B.; Smit, Jan Maerten; Winters, Henri A. H.; Özer, Müjde; de Vet, Henrica C. W.; Mullender, Margriet G.

Plastic and Reconstructive Surgery: November 2020 - Volume 146 - Issue 5 - p 956-962

 

Background:

Breast implants are frequently used in cosmetic and reconstructive breast surgery. Capsular contracture, the most common long-term complication, is usually graded using the Baker classification. Despite its widespread use, the reliability of the Baker classification has never been established. The aim of this study was to determine the interobserver reliability and agreement of the Baker classification.

Methods:

Sixty women who had undergone cosmetic breast augmentation were included. They were examined independently by two plastic surgeons from an observer pool. The Baker score was determined, along with firmness, dislocation, symmetry, and pain using four-point scales. Patients were asked to complete the BREAST-Q postaugmentation module. The interobserver reliability and agreement were calculated for all variables with a quadratic weighted kappa.

Results:

The interobserver reliability of the Baker classification was poor (kappa, 0.55; 95 percent CI, 0.37 to 0.72). Interobserver reliability of the clinical parameters firmness (0.64; 95 percent CI, 0.49 to 0.79), dislocation (0.49; 95 percent CI, 0.26 to 0.73), and symmetry (0.61; 95 percent CI, 0.34 to 0.88) was also poor. Pain scores seemed more reliable (0.72; 95 percent CI, 0.56 to 0.89); however, most patients had no pain. The interobserver agreement for the Baker score was 48 percent; in 43 percent, the observers differed one category; and in 12 percent, the difference was more than one category.

Conclusions:

Interobserver reliability and observer agreement of the Baker classification for capsular contracture were poor. Consensus about how to adequately rate the symptoms of capsular complaints is lacking. A more reliable method of measurement or description is needed, especially for scientific research purposes, to assess the long-term problems associated with breast implants. CLINICAL QUESTION/LEVEL OF EVIDENCE: Diagnostic, IV.

The Functional Influence of Breast Implant Outer Shell Morphology on Bacterial Attachment and Growth

The Functional Influence of Breast Implant Outer Shell Morphology on Bacterial Attachment and Growth

by Jones, Phoebe; Mempin, Maria; Hu, Honghua; Chowdhury, Durdana; Foley, Matthew; Cooter, Rodney; Adams, William P. Jr; Vickery, Karen; Deva, Anand K.  

Plastic and Reconstructive Surgery: October 2018 - Volume 142 - Issue 4 - p 837–849

Background: The introduction of texture to the outer shell of breast implants was aimed at increasing tissue incorporation and reducing capsular contracture. It has also been shown that textured surfaces promote a higher growth of bacteria and are linked to the development of breast implant–associated anaplastic large cell lymphoma.

Methods: The authors aimed to measure the surface area and surface roughness of 11 available implants. In addition, the authors aimed to subject these implant shells to an in vitro bacterial attachment assay with four bacterial pathogens (Staphylococcus epidermidis, S. aureus, Pseudomonas aeruginosa, and Ralstonia pickettii) and study the relationship among surface area, surface roughness, and bacterial growth. Results: Surface area measurement showed grouping of implants into high, intermediate, low, and minimal. Surface roughness showed a correlation with surface area. The in vitro assay showed a significant linear relationship between surface area and bacterial attachment/growth. The high surface area/roughness implant texture grew significantly more bacteria at 24 hours, whereas the minimal surface area/roughness implant textures grew significantly fewer bacteria of all types at 24 hours. For implants with intermediate and low surface areas, some species differences were observed, indicating possible affinity of specific bacterial species to surface morphology.

 Conclusions: Implant shells should be reclassified using surface area/roughness into four categories (high, intermediate, low, and minimal). This classification is superior to the use of descriptive terms such as macrotexture, microtexture, and nanotexture, which are not well correlated with objective measurement and/or functional outcomes.

Is the Right Research Being Conducted to Advance Knowledge about Breast Reconstruction? An Analysis of the Research Pipeline

Title: Is the Right Research Being Conducted to Advance Knowledge about Breast Reconstruction? An Analysis of the Research Pipeline

Author: Checketts, Jake X. B.S.; Gordon, Joshua D.O.; Crawford, Julia H. M.L.I.S., A.H.I.P.; Adams, Haley D.O.; Duckett, Laurie D.O.; Vassar, Matt Ph.D.

Publication: Plastic and Reconstructive Surgery: March 2018 - Volume 141 - Issue 3 - p 566–577

Abstract:

Background: Capsular contracture around breast implants is a severe and unpredictable complication experienced by up to 50 percent of patients after breast augmentation and reconstruction, and represents a major cause leading to reoperation. Several lines of evidence point to the involvement of subclinical infections and of bacterial biofilm formation.

Methods: To reduce the incidence of capsular contracture following mammaplasty, the authors studied the correlation between contamination by exogenous and endogenous bacterial flora and the capacity to develop bacterial biofilm in mammary implants. The authors performed a microbiological study assessing microbial growth of swabs from breast skin, nipple-areola complex, and mammary gland biopsy specimens. Furthermore, the authors compared the results with the data resulting from cultural experiments from biopsy specimens of periprosthetic capsule, contracted or not, and from the surfaces of the relative prosthesis.

Results: Between July of 2012 and July of 2013, a series of 65 female patients from the area of Naples, Italy, and its province, who underwent breast plastic surgery with the use of implants for aesthetic or reconstructive reasons, were included in the study. The authors noticed that there is a greater tendency for capsular contracture to form in oncologic patients who received radiotherapy, patients with precedent capsular contracture, and patients with cutaneous contamination by biofilm-producing microbes.

Conclusions: Although all of the new technical procedures tend to reduce the amount of bacterial charge that comes into contact with the prosthesis at the time of its introduction, a minimal amount must always be taken for granted. This is the rationale for a preventative personalized antibiotic therapy.

CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.

Microbial Evaluation in Capsular Contracture of Breast Implants

Microbial Evaluation in Capsular Contracture of Breast Implants

Galdiero, M et al

Plastic and Reconstructive Surgery: January 2018 - Volume 141 - Issue 1 - p 23–30

Background: Capsular contracture around breast implants is a severe and unpredictable complication experienced by up to 50 percent of patients after breast augmentation and reconstruction, and represents a major cause leading to reoperation. Several lines of evidence point to the involvement of subclinical infections and of bacterial biofilm formation. Methods: To reduce the incidence of capsular contracture following mammaplasty, the authors studied the correlation between contamination by exogenous and endogenous bacterial flora and the capacity to develop bacterial biofilm in mammary implants. The authors performed a microbiological study assessing microbial growth of swabs from breast skin, nipple-areola complex, and mammary gland biopsy specimens. Furthermore, the authors compared the results with the data resulting from cultural experiments from biopsy specimens of periprosthetic capsule, contracted or not, and from the surfaces of the relative prosthesis. 
Results: Between July of 2012 and July of 2013, a series of 65 female patients from the area of Naples, Italy, and its province, who underwent breast plastic surgery with the use of implants for aesthetic or reconstructive reasons, were included in the study. The authors noticed that there is a greater tendency for capsular contracture to form in oncologic patients who received radiotherapy, patients with precedent capsular contracture, and patients with cutaneous contamination by biofilm-producing microbes. 
Conclusions: Although all of the new technical procedures tend to reduce the amount of bacterial charge that comes into contact with the prosthesis at the time of its introduction, a minimal amount must always be taken for granted. This is the rationale for a preventative personalized antibiotic therapy.

Role of Mitomycin C in Preventing Capsular Contracture in Implant-Based Reconstructive Breast Surgery: A Randomized Controlled Trial

Role of Mitomycin C in Preventing Capsular Contracture in Implant-Based Reconstructive Breast Surgery: A Randomized Controlled Trial

Nava, M B et al

Plastic & Reconstructive Surgery: April 2017 - Volume 139 - Issue 4 - p 819–826

Background: Capsular contracture represents the most frequent complication after implant-based breast reconstruction. An experimental study on mice demonstrated that capsule formation around breast implants is considerably diminished after topical application of mitomycin C. The authors conducted a randomized controlled clinical trial investigating the efficacy of mitomycin C in reducing capsular contracture rates following implant-based breast reconstruction after mastectomy for breast cancer. 
Methods: The authors randomized all women older than 18 years scheduled for the second stage of an implant-based breast reconstruction after mastectomy for breast cancer at the National Cancer Institute in Milan from October of 2005 to February of 2010 to receive or not receive the topical application of mitomycin C during surgery. The authors assessed capsular contracture, major postoperative complications, and aesthetic outcome.
 Results: The authors randomized 322 patients to receive mitomycin C or not at the second stage of implant-based breast reconstruction. One hundred sixty-two patients were allocated to the mitomycin C group and 160 patients were allocated to the control group. The relative risk of capsular contracture in the mitomycin C group was 0.92 (95 percent CI, 0.60 to 1.41). Major complications leading to reintervention, oncologic outcomes, and aesthetic outcomes were comparable between the two groups. 
Conclusions: This is the first trial reporting data about the use of mitomycin C in breast reconstructive surgery in a clinical setting. Mitomycin C seems not to significantly affect capsular contracture rate and severity following implant-based reconstructive breast surgery at the tested doses. 

Revisiting the Management of Capsular Contracture in Breast Augmentation: A Systematic Review

Revisiting the Management of Capsular Contracture in Breast Augmentation: A Systematic Review

Plastic & Reconstructive Surgery: March 2016 - Volume 137 - Issue 3 - p 826–841 doi: 10.1097/01.prs.0000480095.23356.ae


Wan, D, Rohrich, R



Background: Capsular contracture is a complication of breast augmentation that frequently requires revision surgery. “Capsulectomy, site change, and implant exchange” has been referred to as the gold standard treatment of clinically significant contractures. However, the actual clinical evidence behind this algorithm remains elusive at best. A systematic review of the literature was performed to clarify the true evidence behind the surgical management of capsular contracture. Methods: A search of the MEDLINE database was performed for clinical studies involving the surgical treatment of capsular contracture following breast augmentation. Resulting articles were reviewed using a priori criteria. Results: The systematic review was performed in April of 2015. The primary search for “breast augmentation” yielded 9490 articles. When filtered for “treatment of capsular contracture,” 461 articles resulted. Review of these articles and pertinent references using a priori criteria yielded 24 final articles. No controlled trials met final inclusion criteria. Conclusions: There is limited clinical evidence behind the surgical management of capsular contracture. Site change and implant exchange are associated with reduced contracture recurrence rates and likely play a beneficial role in treating capsular contracture. The data on capsulectomy are less conclusive. Acellular dermal matrix may be a useful adjunct but still requires long-term data.