Angiotensin-Converting Enzyme Inhibitor Reduces Radiation-Induced Periprosthetic Capsular Fibrosis.

BACKGROUND: The capsular contracture is one of the main complications after radiotherapy in patients with implant-based reconstruction. The aim of this study is to evaluate the efficacy of ramipril for the prevention of radiation-induced fibrosis around the silicone implant. MATERIALS AND METHODS: Thirty Wistar rats in 5 groups were used. Group 1: implant; group 2: implant + radiation; group 3: ramipril + implant; group 4: ramipril + implant + radiation; group 5: sham. Ramipril treatment was started 5 d before surgery and continued for 12 wk after surgery. A mini silicone implant was placed in the back of the rats. A single fraction of 21.5 Gy radiation was applied. Tissues were examined histologically and immunohistochemically (TGF-ß1, MMP-2, and TIMP-2 expression). The alteration of plasma TGF-ß1 levels was examined before and after the experiment. RESULTS: After applying implant or implant + radiation, capsular thickness, percentage of fibrotic area, tissue and plasma TGF-ß1 levels significantly increased, and MMP-2/TIMP-2 ratio significantly decreased compared with the sham group. In ramipril-treated groups, the decrease in capsular thickness, fibrosis, TGF-ß1 positivity, and an increase in MMP-2/TIMP-2 ratio were found significant. In the ramipril + implant + radiation group, the alteration values of TGF-ß1 dramatically decreased. CONCLUSIONS: Our results show that ramipril reduces radiation-induced fibrosis and contracture. The results of our study may be important for the design of the clinical trials required to investigate the effective and safe doses of ramipril, which is an inexpensive and easily tolerated drug, on humans.

The Effect of Omega-3 Fatty Acids on Capsular Tissue around the Breast Implants.

BACKGROUND: One of the most common complications of the use of foreign material, in both reconstructive and cosmetic breast surgery, is capsular contracture. Historically, research on capsular contracture has focused mainly on reducing bacterial contamination through antibiotic solutions. Only secondary studies have focused on pharmacological control of the inflammation process, with particular attention paid to the main inflammation pathway, the arachidonic acid cascade. An important role in the arachidonic acid cascade is played by the omega-3 fatty acids, which are found mainly in oily fish and food supplements. The goal of the present study was to investigate the effects of omega-3 supplements on capsule contraction. METHODS: Female C57BL/6 mice were implanted with custom-made silicone gel implants and divided into two groups. The treated group received omega-3 oil daily while the control group received water daily by gavage. After mice were euthanized, samples of capsules were collected to evaluate thickness and transforming growth factor (TGF)-ß expression. RESULTS: The results showed that capsules in the omega-3 group were thinner and more transparent than those found in the control group. In addition, a significant downregulation of the TGF-ß2 gene transcript was observed in the omega-3 group. CONCLUSIONS: Omega-3 supplementation seems to be effective in reducing the occurrence of capsular formation, mainly through inhibition of the TGF-ß pathway and impairment of collagen deposit. Omega-3 supplementation is a simple and promising method that could be used to prevent or at least reduce capsular contracture after silicone implant surgery.

A meta-analysis of implant-based breast reconstruction and timing of adjuvant radiation therapy.

BACKGROUND: Implant-based breast reconstruction is the most common type of reconstruction after postmastectomy radiation therapy (PMRT). The impact of the timing of PMRT to a tissue expander or permanent implant is not well understood. The purpose of this systematic review was to evaluate outcomes in implant-based reconstruction and the timing of PMRT. METHODS: A review of the English literature in the PubMed/MEDLINE database (2000-2016) was performed to identify all articles on implant-based breast reconstruction and PMRT. Cases from each study were grouped by PMRT to a tissue expander or PMRT to a permanent implant. Outcomes of interest included reconstructive failure and capsular contracture as overall rates and associations were pooled. Effect sizes (z values), risk ratios (RRs), and heterogeneity scores (I2) were calculated on meta-analysis. RESULTS: There were 20 studies meeting inclusion criteria with 2348 patients identified. Pooled analysis revealed an overall rate of reconstructive failure of 17.6% and Baker grade III/IV capsular contracture of 37.5%. PMRT applied to tissue expanders resulted in higher rates of reconstructive failure compared with PMRT applied to permanent silicone implants (20% versus 13.4%, RR = 2.33, P = 0.0083, 95% confidence interval 1.24-4.35), but lower rates of capsular contracture (24.5% versus 49.4%, RR = 0.53, P = 0.083, 95% confidence interval 0.26-1.09). CONCLUSIONS: Regardless of timing, PMRT applied to implant-based breast reconstruction was associated with high risk of reconstructive failure and capsular contracture. Surgeons should consider alternative strategies, such as autologous tissue reconstructions, in patients requiring PMRT.

Antibiogram for Periprosthetic Infections: A Tool for Better Informed Selection of Empiric Antibiotics for Surgical Site Infections.

INTRODUCTION: Periprosthetic infection after breast reconstruction is not an uncommon complication, with incidence up to 24%. These infections are often treated empirically without knowing the causative bacteria or its sensitivities to various antibiotics. Even if cultures are obtained, results may not be available for several days. METHODS: A retrospective chart review of 553 patients at a single institution between January 2009 and July 2014 was performed, identifying patients who (1) underwent implant-based breast reconstruction and subsequently suffered an infection and (2) had cultures available with sensitivities. We reviewed patient demographics, implant characteristics, prophylactic intravenous antibiotics, oral antibiotic maintenance used, microbiologic details, and outcomes. The goal was to identify the most common causative bacteria, as well as their sensitivities to commonly used antibiotics, to help guide antibiotic decision-making. RESULTS: Of the 553 patients who underwent implant-based reconstruction, 114 (20.6%) patients suffered periprosthetic infections. Of these patients, 32 (28.1%) patients (56 reconstructions, with 33 tissue expanders and 23 implants) had cultures performed revealing 43 bacterial species, with the most common being Staphylococcus aureus (23.2%) and Pseudomonas aeruginosa (26.8%). Ceftazidime and piperacillin/tazobactam were equally effective covering 100% of Pseudomonas, enteric, and atypical organisms (P = 1), whereas vancomycin covered 100% of gram-positive organisms. Trimethoprim/sulfamethoxazole covered 100% of S. aureus, whereas clindamycin only covered 71% of S. aureus (P = 0.03). Additionally, trimethoprim/sulfamethoxazole was better able to cover atypical and enteric organisms. Ciprofloxacin covered 71% of Pseudomonas compared with 56% for levofloxacin (P = 0.14). Interestingly, cephalexin, a common choice for perioperative prophylaxis, was highly ineffective for gram-positive species in patients who later returned with infections. CONCLUSIONS: This study supports the efficacy of current intravenous antibiotics protocols but questions the efficacy of both clindamycin and levofloxacin in empirically treating periprosthetic infections and cephalexin in providing effective perioperative prophylaxis against skin flora. Because bacterial sensitivities vary by location and patient population, this study encourages other centers to develop their own antibiogram specifically tailored to periprosthetic infections to improve antimicrobial decision making and potentially improve implant salvage.

Double-Chamber Tissue Expanders Optimize Lower Pole Expansion in Immediate Breast Reconstruction Requiring Adjuvant Radiation Therapy.

INTRODUCTION: Tissue expander-based reconstruction in the irradiated breast has been associated with significant complications, including infection, skin breakdown and implant extrusion, and poor aesthetic outcome. These complications may be attributed to inadequate lower pole expansion causing increased pressure on the suture line. Achieving and maintaining adequate lower pole expansion in the reconstructed breast requiring adjuvant radiation therapy may reduce the pressure/strain on the suture line and preserve the natural appearance of the breast. We describe the effective use of a double-chamber tissue expander to control lower pole expansion in immediate breast reconstruction requiring adjuvant radiation therapy. METHODS: We performed a retrospective chart review of patients who underwent postoperative radiation therapy after immediate breast reconstruction using Sientra's double-chamber tissue expander, performed by a single plastic surgeon from 2012 to 2014. RESULTS: A total of 22 patients met our inclusion criteria. Seventeen patients had bilateral, and 5 patients had unilateral reconstruction (n = 39 total breasts). All patients were over expanded by 20% on the side affected by cancer before the start of radiation, which started by the sixth postoperative week. There was no expansion during radiation therapy. Two patients had further expansion after radiation therapy was completed. The tissue expanders were exchanged for shaped silicone gel implants 3 to 4 months after completion of radiation. A total of 2 complications occurred in 2 patients (9.0%) and 2 breasts (5.1%). These included an infection in one patient and a tissue expander leak in another. No patient developed Baker grade 3 or 4 capsular contracture, seroma, or device malposition. Good lower pole contour and projection was maintained in all breasts at 9 to 12 months of follow-up. CONCLUSIONS: The double-chamber tissue expander is effective in controlling shape, contour, and position of the breast following immediate tissue expander reconstruction requiring adjuvant radiation therapy, with decreased complication rates compared to standard expanders. These results suggest that double-chamber tissue expanders may be the preferred expander option in patients requiring adjuvant radiation therapy. Prospective clinical studies are needed to better evaluate the advantages of this reconstructive approach.