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Breast implantation either for cosmetic or reconstructive e purposes is one of the most common procedures performed in plastic surgery. Biofilm infection is hypothesised to be involved in the development of both capsular contracture and anaplastic large cell lymphoma ALCL. Capsular contracture is one of the principal reasons for breast revision surgery and is characterised by the tightening and hardening of the capsule surrounding the implant, and ALCL is an indolent lymphoma found only in women with textured implants.

The pathogenesis of Bikini photo south actresses contracture is thought to be due to biofilm formation on the implant, which results in on-going inflammation. We describe the current research into breast implant associated ALCL and how implant properties may affect its pathogenesis, with ALCL only occurring in women with textured implants.

Breast implantation, either for cosmetic or reconstructive purposes, is one of the most common procedures performed in plastic surgery. Inin the United States of America alone, more thanwomen had breast enlargement surgery and an estimatedbreast cancer patients underwent post-mastectomy breast reconstruction, which often involved insertion of implantable medical devices [ 1 ]. Basic designed silicone breast implants were first introduced in the early s [ 2 ].

Modern breast implants can be divided into categories based on implant filling silicone or salinesurface texture textured or smoothand shape round or anatomiceach of which have slightly different properties [ 34 ]. Saline implants are sold as empty silicone elastomer shells and are filled to the appropriate volume with sterile saline in the operating room. The cohesive gel increases form stability and correlates with better shape retention when compared with saline or fluid form silicone filled implants [ 6 ].

Smooth breast implants move within the breast Pa natural breast augmentation clinical trials pocket to give a more natural movement [ 5 ], while aggressive texturisation of the implant surface improves integration between the living host and the implant by enhancing tissue adhesion, growth and proliferation of the host blood supply, enhancement of cellular migration, and fibroblast adhesion [ 78 ].

Texturisation is thought to increase device stability as it helps prevent rotation in the breast pocket or migration of implants [ 5 ]. Figure 1 describes the implant surface classification system and representative scanning electron Pa natural breast augmentation clinical trials pictures of breast implants.

The first textured implant, released inincorporated Pa natural breast augmentation clinical trials 1. However, polyurethane PU coated silicone implants were voluntarily removed from the USA market indue to reporting of an association between polyurethane and the carcinogen 2,4-toluenediamine TDA [ 12 ]. This withdrawal lead to the development of alternative technologies to modify the outer silicone shell, including bonding the PU foam coating to the silicon surface, e.

This implant has been classified as surface type 4 Figure 1 [ 9 ]. The salt-loss technique of producing a textured surface is produced by adding salt crystals to the silicone before curing, which are then washed from the surface leaving behind a pitted surface with randomly sized and arranged interconnected pores [ 13 ]. The pores promote adherence to the surrounding tissue [ 141516 Pa natural breast augmentation clinical trials and make these devices relatively immobile [ 16 ].

Negative contact imprinting, such as with Mentor Siltex, creates a less aggressive textured silicone surface by pressing the uncured silicone mandrel into PU foam. In contrast to Silimed Pa natural breast augmentation clinical trials and Biocell, Siltex does not adhere to the surrounding tissue and is not immobile [ 10 ].

Motiva, using a propriety method of negative imprinting, manufacture the nanotextured SilkSurface and the micro-textured VelvetSurface Figure 1. Along with smooth implants, nanotextured implants are classified as surface type 1 Figure 1 [ 9 ]. Complications of breast augmentation include hematoma, seroma, infection, altered nipple sensation, asymmetry, scarring, swelling, rupture, leakage and capsular contracture CC but CC is thought to be the most common complication and frequently requires surgical revision [ 19 ].

CC is a common reason for reoperation in Australia, being responsible for Surgical revisions following CC result in poorer aesthetic outcome and a high rate of recurrence of CC [ 2223 ]. Upon insertion of a breast implant, a foreign body reaction is induced, which is essentially an excessive fibrotic response that encloses the implant.

CC is contracture of the peri-prosthetic capsule, which is characterised by the tightening and hardening of the tissue capsule around the breast implant. CC eventually leads to distortion of the implant [ 2425 ]. Individual studies have reported incidence rates of CC ranging from 1. The wide range of CC rates is attributed to differences in follow-up times, as CC rate increases with time following implantation, as well as different type of implants and differing surgical techniques being used throughout the various studies [ 4 ].

The degree of CC is classified using the Baker clinical grading system which divides CC into four grades [ 31 ].

A grade I breast looks and feels natural, while grade II breasts have minimal contracture where the surgeon can tell surgery has been performed but there are no clinical symptoms. Grade III and IV are clinically significant Naked family at home symptomatic, where grade III describes moderate contracture with some firmness felt by the patient, and grade IV describes severe contracture that is obvious from observation and symptomatic in the patient [ 31 ].

With each new implant generation, the incidence of CC has decreased, although whether this is Pa natural breast augmentation clinical trials to implant design or better surgical technique, or a combination of both, is unclear. Historically, the type of fill was thought to influence the development of CC. Older generation silicone gel devices were characterised by higher gel bleeds and rupture rates compared to current generation implants [ 53233 ].

The rates of CC were six-fold higher with these older devices than with devices containing low-bleed silicone gel fillings [ 34 ] or cohesive silicone gel fill implants [ 223536373839 ]. The benefits of textured implants in reducing CC remains controversial. Systematic reviews of comparative clinical studies concluded texturisation may reduce the incidence of early capsular contracture if the implant was placed under the breast glandular tissue, but had no significant effect if placed under the pectoral muscle [ 2940 ].

Smaller comparative or split breast studies, inserting one smooth and one textured implant in the same patient, are evenly divided as to the benefit of texturisation [ 4142434445464748 ]. Many of these published reports lack adequate description of implant type, surgical technique, outcome assessment, and have short follow-up or the time period of follow-up is not stated. Several early randomised controlled trials reported textured implants had lower rates of clinically significant CC compared to smooth surface implants [ Pa natural breast augmentation clinical trials45 ].

Similarly, some later prospective trials and metanalysis of 16 randomised controlled trials combined with two case-control studies, involving patients, have shown that smooth implants are more likely to develop CC [ 404849 ]. However, the follow-up of most of these studies has been less than five years. When of these patients were followed for 10 years there was no difference in the rate of CC [ 23 ].

It is likely Pa natural breast augmentation clinical trials the effect of surface technology is of some benefit but is one of many factors that impact on clinical outcome, and the aetiopathogenesis of CC is likely to be multifactorial. InBurkhardt and co-workers [ 50 ] were the first to propose that subclinical infection led to CC. However, the lack of culture positivity in many clinical studies of CC delayed the acceptance of this hypothesis.

The detection of a Staphylococcus epidermidis biofilm in a patient with Slut in saint- hyacinthe CC led to the hypothesis that the proposed subclinical infection is due to biofilm formation on the breast implant [ 51 ].

The presence of biofilm on implants obtained from CC patients was confirmed using scanning electron microscopy [ 25 ]. The likelihood of bacterial isolation was increased by mincing, sonication, and broth culture of a piece of implant or tissue, rather than using a swab Pa natural breast augmentation clinical trials collect samples. Subsequently, the degree of Baker grade CC has been shown to directly correlate with the number of bacteria in humans [ 52 Pa natural breast augmentation clinical trials and in the porcine model [ 53 ].

The biofilm hypothesis helps explain the lack of culture positivity in older studies where sonication was not employed, as biofilm bacteria are notoriously difficult to culture [ 54 ].

An alternative, to the biofilm hypothesis is that CC is purely an immunological response reviewed in Headon [ 4 ]. The principal cell type within the capsule include activated macrophages, lymphocytes, and fibrocytes, and the number of lymphocytes and fibrocytes correlate with Baker grade [ 4 ].

Pa natural breast augmentation clinical trials, the trigger for activating these cells is unknown. The presence of silicon particles has been postulated as a trigger. The amount of silicon in capsular macrophages is greater in higher grade CC and is associated with increased inflammation [ 55 ]. In contrast, the biofilm hypothesis proposes that the immunological response is activated by biofilm infection. Once in contact with the Pa natural breast augmentation clinical trials, they attach to the prosthetic surface and form a biofilm.

If implants are contaminated with only low numbers of bacteria, the host can contain the biofilm to a level that produces minimal inflammation [ 53 ]. However, once bacterial numbers reach a critical point, the host response is overwhelmed, and the bacteria continue to proliferate and trigger a chronic inflammatory response, leading to subsequent fibrosis and accelerated CC [ 53 ]. Frequently, organisms that are part of the microflora of the skin or the breast, such as Cutibacterium acnes formally Proprionibacterium acnes and coagulase-negative Pa natural breast augmentation clinical trials, particularly S.

Further evidence for bacterial involvement in CC aetiopathogenesis is provided by artificial inoculation of implants, resulting in increased CC development in animal models [ 566061 ].

In the porcine model, breast pocket inoculation of S. Additional evidence to support the subclinical biofilm hypothesis is that strategies to prevent breast implant infection appear to be effective. Animal studies have shown that antimicrobial coated implants can significantly reduce the genesis of biofilm and subsequent CC [ 62Pa natural breast augmentation clinical trials ], whilst clinical studies utilising antibiotic or antiseptic breast implant pocket irrigation at time of surgery have shown a significant reduction in CC [ 2464 ].

Other strategies to prevent bacterial contamination of the implant by modifying surgical technique have resulted in decreased CC rates reviewed by Deva et al. These include modification of implantation site subpectoral position reduces access of breast flora to the implant through the natural musculofascial barrier ; avoiding periareolar and Pa natural breast augmentation clinical trials incisions, which have higher rates of CC compared to submammary incisions; use of a nipple shield; and use of an introductory shield to prevent the implant touching the skin surface [ 19 ].

The occurrence of unilateral contracture following bilateral insertion of identical breast implants means that systemic or implant material-related causes are also less likely [ 52 ].

Thus, although contracture remains poorly understood, it is likely to be multifactorial in origin, and of all the theories on the potential aetiology of CC, the subclinical infection hypothesis remains the leading theory.

It was recognised as a distinct cancer by the World Health Organisation in [ 20 ]. As ofover cases were reported worldwide, and recent epidemiological studies suggest that the number will continue to rise [ 697071 ]. However, the true incidence of BIA-ALCL Pa natural breast augmentation clinical trials likely to be higher due to under reporting and the lack of accurate breast implant sales figures.

Treatment for the majority of patients consists of complete surgical excision of diseased tissue, implants, and the surrounding fibrosis capsule, while adjuvant chemotherapy is only recommended for patients with advanced disease reviewed by Clemens and co-workers [ 76 ]. The aetiopathogenesis of BIA-ALCL is unknown, but it is thought that chronic inflammatory stimulus leads to T-cell dysplasia in patients that are genetically susceptible.

It is postulated that a milieu rich in immune stimulatory cytokines, which promotes rapid division of host lymphocytes, may cause the initial tumorigenic changes that lead to BIA-ALCL in some patients. Autocrine production of IL-6 has been identified as a driver of tumorigenesis in some diffuse large B-cell lymphomas, as well as solid tumours, including breast, lung, and ovarian carcinomas [ 838485 ].

Therefore, it is plausible that chronically infected breast implants may mediate similar inflammatory and neoplastic processes resulting in the development of a T cell lymphoma. In support of biofilm being the chronic inflammatory stimulus, significantly more bacteria attach to textured implants compared to smooth implants [ 9 ].

The strongest support for the role of bacterial biofilm in the aetiopathogenesis of BIA-ALCL was the detection of biofilm in clinical samples using qPCR, with visual confirmation of biofilm presence using fluorescent in situ hybridisation and scanning electron microscopy [ 88 ].

Analysis of the microbiome bacterial community genetic profileusing next generation sequencing, showed a significantly greater proportion of Gram-negative bacteria in BIA-ALCL specimens compared with non-tumour CC Pa natural breast augmentation clinical trials Figure 3suggesting that different bacterial species may preferentially trigger lymphocyte activation [ 88 ].

Writing—Original Draft Preparation, M. He has previously coordinated industry-sponsored research for these companies relating to both biofilms and breast prostheses. National Center for Biotechnology InformationU. Journal List Materials Basel v. Materials Basel. Published online Nov Author information Article notes Copyright and License information Disclaimer. Received Nov 5; Accepted Nov This article has been cited by other articles in PMC.

Abstract Breast implantation either for cosmetic or reconstructive e purposes is one of the most common procedures performed in plastic surgery. Introduction Breast implantation, either for cosmetic or reconstructive purposes, is one of the most common procedures performed in plastic surgery.

Breast Implants Basic designed silicone breast implants were first introduced in the early s [ 2 ]. Silicone or saline implant filling: Saline implants are sold as empty silicone elastomer shells and are filled to the appropriate volume with sterile saline in the operating room. Textured or smooth outer surface: Smooth breast implants move within the breast implant pocket to give a more natural movement [ 5 ], while aggressive texturisation of the implant surface improves integration between the living host and the implant by enhancing tissue adhesion, growth and proliferation of the host blood supply, enhancement of cellular migration, and fibroblast adhesion [ 78 ].

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