Capsular Contracture Part Two: Prevention
By: Oscar Ochoa, MD
Once capsular contracture is present, methods of treatment are inconsistently effective, making prevention paramount. Known factors such as tissue trauma and bleeding around the implant may be prevented through meticulous surgical technique and verification of absolute hemostasis during implant placement. In particular, surgeons must minimize over-dissection of tissue planes that are non-essential for proper implant placement in order to prevent excessive tissue trauma that may lead to an exaggerated inflammatory process around the implant. Similarly, insertion and removal of an implant multiple times into the implant pocket so as to adjust the pocket dimensions during placement should be eliminated. Not only can such repeated insertion/extraction of an implant cause unnecessary tissue trauma and implant damage, but also increases the potential of implant contamination through contact with bacteria present on the patient’s skin.
Measures to limit implant contamination are simple and cost-effective methods of minimizing capsular contracture. Placement of sterile plastic dressings over the nipples and implant insertion sites as well as exchange of sterile surgical gloves prior to manipulation of an implant are readily available methods that can used in any surgical setting. During placement of silicone gel implants, specialized plastic funnels can be utilized to perform a no-touch insertion technique minimizing contact of the implant with surrounding surfaces. In addition, use of antibiotics given before performing any skin incisions has demonstrated efficacy in decreasing implant contamination. Similarly, irrigation of the implant pocket with antibiotic solution prior to implant placement can decrease the prevalence of implant contamination and subsequent capsular contracture.
Some factors leading to capsular contracture cannot be eliminated, however. External beam radiation, if required as a part of breast cancer treatments, damages the skin and subcutaneous tissue through non-reversible cellular DNA damage that leads to a chronic low-grade inflammatory environment around the implant leading to recurring capsular contracture. In the setting of previous radiation, implant-based breast reconstruction is relatively contraindicated due to a high rate of short-term and long-term complications, namely capsular contracture. Another sporadically occurring condition causing capsular contracture is silicone gel bleed. This phenomenon is caused by hydrolysis of the silicone molecules contained in silicone gel implants over a long period of time. Hydrolysis of the molecules causes the coherent gel to liquefy and slowly diffuse out of an intact silicone shell. Free floating silicone molecules around the implant elicit a low-grade inflammatory response leading to the development of capsular contracture many years following implant placement.
Implant manufacturers have attempted to minimize the prevalence of capsular contracture as well with ongoing research into various components of implant design. Implant surface texturing was one of the initial promising advances aimed at decreasing capsular contracture. By adding micro- and nanotopographical changes to the shell surface through minute undulations and ripples, capsular contracture was minimized likely due to the disoriented alignment of myofibroblasts. Development of more cohesive gels resistant to hydrolysis has been another area of manufacturer research that may hold promise in the future.
Outside of peri-procedural antibiotic use, pharmacologic capsular contracture prevention has been unsuccessful until recently. New studies have reported reduced incidence of capsular contracture with use of a specific class of anti-inflammatory medication called leukotriene inhibitors, such as Singulair®. Leukotrienes are pro-inflammatory derivatives released in response to allergens or other stimuli that result in inflammatory cell activation and infiltration into the site of injury. By blocking the effect of leukotrienes, use of such medications have reduced the prevalence of capsular contracture in reported series. Other anti-inflammatory medications such as synthetic corticosterioid have been used sporadically in the past with variable results warranting controlled studies to determine their efficacy and safety.
Recent advancements in reconstructive medicine have popularized the use of tissue allografts in breast reconstruction. Specifically, acellular dermal matrix (ADM) is widely used in conjunction with implant-based reconstruction to achieve better definition of aesthetically sensitive subunits leading to improved cosmetic outcomes. An unintended benefit of ADM which forms a portion of the periprosthetic capsule is the reported reduced prevalence of capsular contracture. The pathophysiology of this observed characteristic of ADM is a topic of active research but is likely secondary to reduced infiltration of inflammatory cells and fibroblasts within the ADM architecture preventing laminar orientation and contracture. Use of ADM is currently limited to the reconstructive setting or cases of secondary augmentation previously complicated by capsular contracture. Prophylactic use of ADM in primary breast augmentation in order to prevent capsular contracture is not recommended due to the high cost and likely negligible benefit.