Semin Plast Surg 2021; 35(03): 189-197
DOI: 10.1055/s-0041-1731793
Review Article

Current Concepts in Capsular Contracture: Pathophysiology, Prevention, and Management

Tyler Safran
1   Division of Plastic Surgery, McGill University, Montreal, Quebec, Canada
,
Hillary Nepon
2   Division of Experimental Surgery, McGill University, Montreal, Quebec, Canada
,
Carrie K. Chu
3   Department of Plastic Surgery, MD Anderson Cancer Center, Houston, Texas
,
Sebastian Winocour
4   Division of Plastic Surgery, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, Texas
,
Amanda M. Murphy
1   Division of Plastic Surgery, McGill University, Montreal, Quebec, Canada
,
Peter G. Davison
1   Division of Plastic Surgery, McGill University, Montreal, Quebec, Canada
,
Tassos Dionisopolos
1   Division of Plastic Surgery, McGill University, Montreal, Quebec, Canada
,
Joshua Vorstenbosch
1   Division of Plastic Surgery, McGill University, Montreal, Quebec, Canada
› Author Affiliations

Abstract

Over 400,000 women in the United States alone will have breast implant surgery each year. Although capsular contracture represents the most common complication of breast implant surgery, surgeons continue to debate the precise etiology. General agreement exists concerning the inflammatory origin of capsular fibrosis, but the inciting events triggering the inflammatory cascade appear to be multifactorial, making it difficult to predict why one patient may develop capsular contracture while another will not. Accordingly, researchers have explored many different surgical, biomaterial, and medical therapies to address these multiple factors in an attempt to prevent and treat capsular contracture. In the current paper, we aim to inform the reader on the most up-to-date understanding of the pathophysiology, prevention, and treatment of capsular contracture.



Publication History

Article published online:
13 July 2021

© 2021. Thieme. All rights reserved.

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  • References

  • 1 Domanskis E, Owsley Jr JQ. Histological investigation of the etiology of capsule contracture following augmentation mammaplasty. Plast Reconstr Surg 1976; 58 (06) 689-693
  • 2 ASPS 2018 Plastic Surgery Report. https://www.plasticsurgery.org/documents/News/Statistics/2018/plastic-surgery-statistics-full-report-2018.pdf . Accessed June 29, 2021
  • 3 Sinnott CJ, Persing SM, Pronovost M, Hodyl C, McConnell D, Ott Young A. Impact of postmastectomy radiation therapy in prepectoral versus subpectoral implant-based breast reconstruction. Ann Surg Oncol 2018; 25 (10) 2899-2908
  • 4 Shen Z, Chen X, Sun J. et al. A comparative assessment of three planes of implant placement in breast augmentation: a Bayesian analysis. J Plast Reconstr Aesthet Surg 2019; 72 (12) 1986-1995
  • 5 Ribuffo D, Berna G, De Vita R. et al. Dual-plane retro-pectoral versus pre-pectoral DTI Breast reconstruction: an Italian multicenter experience. Aesthetic Plast Surg 2021; 45 (01) 51-60
  • 6 Li S, Mu D, Liu C. et al. Complications following subpectoral versus prepectoral breast augmentation: a meta-analysis. Aesthetic Plast Surg 2019; 43 (04) 890-898
  • 7 Bachour Y, Bargon CA, de Blok CJM, Ket JCF, Ritt MJPF, Niessen FB. Risk factors for developing capsular contracture in women after breast implant surgery: a systematic review of the literature. J Plast Reconstr Aesthet Surg 2018; 71 (09) e29-e48
  • 8 Wan D, Rohrich RJ. Revisiting the management of capsular contracture in breast augmentation: a systematic review. Plast Reconstr Surg 2016; 137 (03) 826-841
  • 9 Hidalgo DA, Weinstein AL. Surgical treatment for capsular contracture: a new paradigm and algorithm. Plast Reconstr Surg 2020; 146 (03) 516-525
  • 10 Klopfleisch R, Jung F. The pathology of the foreign body reaction against biomaterials. J Biomed Mater Res A 2017; 105 (03) 927-940
  • 11 Shin BH, Kim BH, Kim S, Lee K, Choy YB, Heo CY. Silicone breast implant modification review: overcoming capsular contracture. Biomater Res 2018; 22: 37
  • 12 Wolfram D, Rainer C, Niederegger H, Piza H, Wick G. Cellular and molecular composition of fibrous capsules formed around silicone breast implants with special focus on local immune reactions. J Autoimmun 2004; 23 (01) 81-91
  • 13 de Bakker E, van den Broek LJ, Ritt MJPF, Gibbs S, Niessen FB. The histological composition of capsular contracture focussed on the inner layer of the capsule: an intra-donor Baker-I versus Baker-IV comparison. Aesthetic Plast Surg 2018; 42 (06) 1485-1491
  • 14 Bachour Y, Poort L, Verweij SP. et al. PCR characterization of microbiota on contracted and non-contracted breast capsules. Aesthetic Plast Surg 2019; 43 (04) 918-926
  • 15 Tamboto H, Vickery K, Deva AK. Subclinical (biofilm) infection causes capsular contracture in a porcine model following augmentation mammaplasty. Plast Reconstr Surg 2010; 126 (03) 835-842
  • 16 Hallab NJ, Samelko L, Hammond D. The inflammatory effects of breast implant particulate shedding: comparison with orthopedic implants. Aesthet Surg J 2019; 39 (Suppl. 01) S36-S48
  • 17 Walker JN, Pinkner CL, Pinkner JS, Hultgren SJ, Myckatyn TM. The detection of bacteria and matrix proteins on clinically benign and pathologic implants. Plast Reconstr Surg Glob Open 2019; 7 (02) e2037
  • 18 Anderson JM, Rodriguez A, Chang DT. Foreign body reaction to biomaterials. Semin Immunol 2008; 20 (02) 86-100
  • 19 Moore LB, Kyriakides TR. Molecular characterization of macrophage-biomaterial interactions. Adv Exp Med Biol 2015; 865: 109-122
  • 20 Bygd HC, Forsmark KD, Bratlie KM. The significance of macrophage phenotype in cancer and biomaterials. Clin Transl Med 2014; 3 (01) 62
  • 21 Sadtler K, Singh A, Wolf MT, Wang XK, Pardoll DM, Elisseeff JH. Design, clinical translation and immunological response of biomaterials in regenerative medicine. Nat Rev Mater 2016; 1 (07) 16040
  • 22 Wolfram D, Rabensteiner E, Grundtman C. et al. T regulatory cells and TH17 cells in peri-silicone implant capsular fibrosis. Plast Reconstr Surg 2012; 129 (02) 327e-337e
  • 23 Chung L, Maestas Jr DR, Lebid A. et al. Interleukin 17 and senescent cells regulate the foreign body response to synthetic material implants in mice and humans. Sci Transl Med 2020; 12 (539) 12
  • 24 Siggelkow W, Faridi A, Spiritus K, Klinge U, Rath W, Klosterhalfen B. Histological analysis of silicone breast implant capsules and correlation with capsular contracture. Biomaterials 2003; 24 (06) 1101-1109
  • 25 Basu CB, Leong M, Hicks MJ. Acellular cadaveric dermis decreases the inflammatory response in capsule formation in reconstructive breast surgery. Plast Reconstr Surg 2010; 126 (06) 1842-1847
  • 26 Gaster RS, Berger AJ, Monica SD, Sweeney RT, Endress R, Lee GK. Histologic analysis of fetal bovine derived acellular dermal matrix in tissue expander breast reconstruction. Ann Plast Surg 2013; 70 (04) 447-453
  • 27 Tevlin R, Borrelli MR, Irizarry D, Nguyen D, Wan DC, Momeni A. Acellular dermal matrix reduces myofibroblast presence in the breast capsule. Plast Reconstr Surg Glob Open 2019; 7 (05) e2213
  • 28 Yu D, Hanna KR, LeGallo RD, Drake DB. Comparison of histological characteristics of acellular dermal matrix capsules to surrounding breast capsules in acellular dermal matrix-assisted breast reconstruction. Ann Plast Surg 2016; 76 (05) 485-488
  • 29 Galdiero M, Larocca F, Iovene MR. et al. Microbial evaluation in capsular contracture of breast implants. Plast Reconstr Surg 2018; 141 (01) 23-30
  • 30 Bachour Y, Ritt MJPF, Heijmans R, Niessen FB, Verweij SP. Toll-like receptors (TLRs) expression in contracted capsules compared to uncontracted capsules. Aesthetic Plast Surg 2019; 43 (04) 910-917
  • 31 Burkhardt BR, Demas CP. The effect of Siltex texturing and povidone-iodine irrigation on capsular contracture around saline inflatable breast implants. Plast Reconstr Surg 1994; 93 (01) 123-128 , discussion 129–130
  • 32 Burkhardt BR, Dempsey PD, Schnur PL, Tofield JJ. Capsular contracture: a prospective study of the effect of local antibacterial agents. Plast Reconstr Surg 1986; 77 (06) 919-932
  • 33 Virden CP, Dobke MK, Stein P, Parsons CL, Frank DH. Subclinical infection of the silicone breast implant surface as a possible cause of capsular contracture. Aesthetic Plast Surg 1992; 16 (02) 173-179
  • 34 Netscher DT, Walker LE, Weizer G, Thornby J, Wigoda P, Bowen D. A review of 198 patients (389 implants) who had breast implants removed. J Long Term Eff Med Implants 1995; 5 (01) 11-18
  • 35 Drinane JJ, Bergman RS, Folkers BL, Kortes MJ. Revisiting triple antibiotic irrigation of breast implant pockets: a placebo-controlled single practice cohort study. Plast Reconstr Surg Glob Open 2013; 1 (07) e55
  • 36 Barker JC, Khansa I, Gordillo GM. A formidable foe is sabotaging your results: what you should know about biofilms and wound healing. Plast Reconstr Surg 2017; 139 (05) 1184e-1194e
  • 37 Adams Jr WP. Commentary on: surgical site irrigation in plastic surgery: what is essential?. Aesthet Surg J 2018; 38 (03) 276-278
  • 38 Dunne Jr WM. Bacterial adhesion: seen any good biofilms lately?. Clin Microbiol Rev 2002; 15 (02) 155-166
  • 39 Donlan RM. Biofilms: microbial life on surfaces. Emerg Infect Dis 2002; 8 (09) 881-890
  • 40 Costerton JW, Stewart PS. Battling biofilms. Sci Am 2001; 285 (01) 74-81
  • 41 Kim L, Castel N, Parsa FD. Case of late hematoma after breast augmentation. Arch Plast Surg 2018; 45 (02) 177-179
  • 42 Headon H, Kasem A, Mokbel K. Capsular contracture after breast augmentation: an update for clinical practice. Arch Plast Surg 2015; 42 (05) 532-543
  • 43 Dower R, Turner ML. Pilot study of timing of biofilm formation on closed suction wound drains. Plast Reconstr Surg 2012; 130 (05) 1141-1146
  • 44 Moyer HR, Ghazi BH, Losken A. The effect of silicone gel bleed on capsular contracture: a generational study. Plast Reconstr Surg 2012; 130 (04) 793-800
  • 45 Bray FN, Simmons BJ, Wolfson AH, Nouri K. Acute and chronic cutaneous reactions to ionizing radiation therapy. Dermatol Ther (Heidelb) 2016; 6 (02) 185-206
  • 46 Sobti N, Weitzman RE, Nealon KP. et al. Evaluation of capsular contracture following immediate prepectoral versus subpectoral direct-to-implant breast reconstruction. Sci Rep 2020; 10 (01) 1137
  • 47 Moyer HR, Pinell-White X, Losken A. The effect of radiation on acellular dermal matrix and capsule formation in breast reconstruction: clinical outcomes and histologic analysis. Plast Reconstr Surg 2014; 133 (02) 214-221
  • 48 de Bakker E, Rots M, Buncamper ME. et al. The Baker classification for capsular contracture in breast implant surgery is unreliable as a diagnostic tool. Plast Reconstr Surg 2020; 146 (05) 956-962
  • 49 Spear SL, Baker Jr JL. Classification of capsular contracture after prosthetic breast reconstruction. Plast Reconstr Surg 1995; 96 (05) 1119-1123 , discussion 1124
  • 50 Gylbert LO. Applanation tonometry for the evaluation of breast compressibility. Scand J Plast Reconstr Surg Hand Surg 1989; 23 (03) 223-229
  • 51 Zahavi A, Sklair ML, Ad-El DD. Capsular contracture of the breast: working towards a better classification using clinical and radiologic assessment. Ann Plast Surg 2006; 57 (03) 248-251
  • 52 Wixtrom RN, Stutman RL, Burke RM, Mahoney AK, Codner MA. Risk of breast implant bacterial contamination from endogenous breast flora, prevention with nipple shields, and implications for biofilm formation. Aesthet Surg J 2012; 32 (08) 956-963
  • 53 Wiener TC. Relationship of incision choice to capsular contracture. Aesthetic Plast Surg 2008; 32 (02) 303-306
  • 54 Namnoum JD, Largent J, Kaplan HM, Oefelein MG, Brown MH. Primary breast augmentation clinical trial outcomes stratified by surgical incision, anatomical placement and implant device type. J Plast Reconstr Aesthet Surg 2013; 66 (09) 1165-1172
  • 55 Santorelli A, Rossano F, Cagli B, Avvedimento S, Ghanem A, Marlino S. Standardized practice reduces complications in breast augmentation: results with the first 290 consecutive cases versus non-standardized comparators. Aesthetic Plast Surg 2019; 43 (02) 336-347
  • 56 Li C, Du X, Ouyang YY, Liu C. Does standardized practice reduce complications in breast augmentation compared with non-standardized one?. Aesthetic Plast Surg 2019; 43 (05) 1415-1416
  • 57 Adams Jr WP, Culbertson EJ, Deva AK. et al. Macrotextured breast implants with defined steps to minimize bacterial contamination around the device: experience in 42,000 implants. Plast Reconstr Surg 2017; 140 (03) 427-431
  • 58 Flugstad NA, Pozner JN, Baxter RA. et al. Does Implant Insertion with a Funnel Decrease Capsular contracture? A preliminary report. Aesthet Surg J 2016; 36 (05) 550-556
  • 59 El-Sheikh Y, Tutino R, Knight C, Farrokhyar F, Hynes N. Incidence of capsular contracture in silicone versus saline cosmetic augmentation mammoplasty: a meta-analysis. Can J Plast Surg 2008; 16 (04) 211-215
  • 60 Jewell ML, Hariri S, Lantz EE, Jewell HL, Strickland AD, Leung BK. In vitro evaluation of common antimicrobial solutions used for breast implant soaking and breast pocket irrigation—part 1: efficacy against planktonic bacteria. Aesthet Surg J 2020; (e-pub ahead of print) DOI: 10.1093/asj/sjaa309.
  • 61 Jewell ML, Bionda N, Moran AV. et al. In vitro evaluation of common antimicrobial solutions used for breast pocket irrigation-part 2: efficacy against biofilm-associated bacteria. Aesthet Surg J 2021; (e-pub ahead of print) DOI: 10.1093/asj/sjaa308.
  • 62 Mirzabeigi MN, Mericli AF, Ortlip T. et al. Evaluating the role of postoperative prophylactic antibiotics in primary and secondary breast augmentation: a retrospective review. Aesthet Surg J 2012; 32 (01) 61-68
  • 63 Sood A, Xue EY, Sangiovanni C, Therattil PJ, Lee ES. Breast massage, implant displacement, and prevention of capsular contracture after breast augmentation with implants: a review of the literature. Eplasty 2017; 17: e41
  • 64 Weissler JM, Banuelos J, Alsayed A. et al. Topical tranexamic acid safely reduces seroma and time to drain removal following implant-based breast reconstruction. Plast Reconstr Surg Glob Open 2020; 8 (Suppl. 09) 9-10
  • 65 Munhoz AM, Clemens MW, Nahabedian MY. Breast implant surfaces and their impact on current practices: where we are now and where are we going?. Plast Reconstr Surg Glob Open 2019; 7 (10) e2466
  • 66 Walker PS, Walls B, Murphy DK. Natrelle saline-filled breast implants: a prospective 10-year study. Aesthet Surg J 2009; 29 (01) 19-25
  • 67 Barnsley GP, Sigurdson LJ, Barnsley SE. Textured surface breast implants in the prevention of capsular contracture among breast augmentation patients: a meta-analysis of randomized controlled trials. Plast Reconstr Surg 2006; 117 (07) 2182-2190
  • 68 Wong CH, Samuel M, Tan BK, Song C. Capsular contracture in subglandular breast augmentation with textured versus smooth breast implants: a systematic review. Plast Reconstr Surg 2006; 118 (05) 1224-1236
  • 69 Hakelius L, Ohlsén L. A clinical comparison of the tendency to capsular contracture between smooth and textured gel-filled silicone mammary implants. Plast Reconstr Surg 1992; 90 (02) 247-254
  • 70 Montemurro P, Tay VKS. Transitioning from conventional textured to nanotextured breast implants: our early experience and modifications for optimal breast augmentation outcomes. Aesthet Surg J 2021; 41 (02) 189-195
  • 71 Han SE, Lee KT, Bang S. Comprehensive comparison between shaped versus round implants for breast reconstruction: a systematic review and meta-analysis. Aesthet Surg J 2021; 41 (01) 34-44
  • 72 Lee KT, Kim S, Jeon BJ. et al. Association of the implant surface texture used in reconstruction with breast cancer recurrence. JAMA Surg 2020; 155 (12) 1132-1140
  • 73 Buonomo OC, Morando L, Materazzo M. et al. Comparison of round smooth and shaped micro-textured implants in terms of quality of life and aesthetic outcomes in women undergoing breast reconstruction: a single-centre prospective study. Updates Surg 2020; 72 (02) 537-546
  • 74 Swanson E. Open capsulotomy: an effective but overlooked treatment for capsular contracture after breast augmentation. Plast Reconstr Surg Glob Open 2016; 4 (10) e1096
  • 75 Namnoum JD, Moyer HR. The role of acellular dermal matrix in the treatment of capsular contracture. Clin Plast Surg 2012; 39 (02) 127-136
  • 76 Salzberg CA, Ashikari AY, Berry C, Hunsicker LM. Acellular dermal matrix-assisted direct-to-implant breast reconstruction and capsular contracture: a 13-year experience. Plast Reconstr Surg 2016; 138 (02) 329-337
  • 77 Liu J, Hou J, Li Z, Wang B, Sun J. Efficacy of acellular dermal matrix in capsular contracture of implant-based breast reconstruction: a single-arm meta-analysis. Aesthetic Plast Surg 2020; 44 (03) 735-742
  • 78 Wagner RD, Braun TL, Zhu H, Winocour S. A systematic review of complications in prepectoral breast reconstruction. J Plast Reconstr Aesthet Surg 2019; 72 (07) 1051-1059
  • 79 DeLong MR, Tandon VJ, Bertrand AA. et al. Review of outcomes in prepectoral prosthetic breast reconstruction with and without surgical mesh assistance. Plast Reconstr Surg 2021; 147 (02) 305-315
  • 80 Safran T, Al-Halabi B, Viezel-Mathieu A, Boileau JF, Dionisopoulos T. Direct-to-implant, prepectoral breast reconstruction: a single-surgeon experience with 201 consecutive patients. Plast Reconstr Surg 2020; 145 (04) 686e-696e
  • 81 Veras-Castillo ER, Cardenas-Camarena L, Lyra-Gonzalez I. et al. Controlled clinical trial with pirfenidone in the treatment of breast capsular contracture: association of TGF-β polymorphisms. Ann Plast Surg 2013; 70 (01) 16-22
  • 82 Graf R, Ascenço ASK, Freitas RDS. et al. Prevention of capsular contracture using leukotriene antagonists. Plast Reconstr Surg 2015; 136 (05) 592e-596e
  • 83 Persichetti P, Segreto F, Carotti S, Marangi GF, Tosi D, Morini S. Oestrogen receptor-alpha and -beta expression in breast implant capsules: experimental findings and clinical correlates. J Plast Reconstr Aesthet Surg 2014; 67 (03) 308-315
  • 84 Caffee HH. Vitamin E and capsule contracture. Ann Plast Surg 1987; 19 (06) 512-514
  • 85 Acuner B, Baser NT, Aslan G. et al. The effects of colchicine-impregnated oxidized regenerated cellulose on capsular contracture. Surg Innov 2017; 24 (05) 417-422
  • 86 Irkoren S, Ozkan HS, Ceylan E, Sivrioglu N, Tataroglu C, Durum Y. The effect of botox on the implant stabilization and capsular formation: an experimental study. Ann Plast Surg 2015; 75 (01) 91-97
  • 87 Li S, Ren L, Xu H. et al. Effects of medical chitosan on capsular formation following silicone implant insertion in a rabbit model. Aesthetic Plast Surg 2016; 40 (04) 613-624
  • 88 Diehm YF, Jost Y, Kotsougiani-Fischer D. et al. The treatment of capsular contracture around breast implants induced by fractionated irradiation: the collagenase of the bacterium clostridium histolyticum as a novel therapeutic approach. Aesthetic Plast Surg 2021; 45 (03) 1273-1281
  • 89 Lombardo GAG, Tamburino S, Magano K. et al. the effect of omega-3 fatty acids on capsular tissue around the breast implants. Plast Reconstr Surg 2020; 145 (03) 701-710
  • 90 Baker JE, Seitz AP, Boudreau RM. et al. Doxycycline-coated silicone breast implants reduce acute surgical-site infection and inflammation. Plast Reconstr Surg 2020; 146 (05) 1029-1041