Afridi Abdullah

Background: Capsular contracture (CC) is a common complication following breast implant surgery, marked by the abnormal thickening of fibrotic tissue around the implant. Specifically, there is an incidence of 10.6% across all implants.¹ This condition leads to aesthetic changes, discomfort, and pain, impacting patient satisfaction and requiring surgical correction.¹ The phenomenon is driven by the foreign body response (FBR), an immune-mediated reaction to the implanted material.

Methods:  This review was conducted by searching PubMed and Google Scholar for the keywords “capsular contracture,” “breast implant,” “foreign body response,” “surface modification,” and “immunomodulation.” Relevant studies were selected based on their focus on the pathophysiology of CC and interventions designed to mitigate it, with an exclusion criteria of being published before 2019.

Results:  Studies have identified several promising strategies for preventing or reducing the severity of CC. Characterization of CC is the first hurdle to overcoming it. Kuehlmann et al. discovered that there are distinct shifts in ECM architecture, WBC infiltration, and Giant Cell formation that define capsular contracture in SEM and TEM studies.³ Karinja et al. reported that surface coating of breast implants with anti-inflammatory peptides significantly reduced fibrotic capsule thickness/increased density in a localized macrophage depletion associated mechanism.⁴ Doloff et al. found that the average surface roughness of implants was significantly associated with capsular formation, macrophage-recruitment, to the wound site, and regulatory T-cells.⁵ Doloff’s team also showed immunologically nude mice do not share the immunological privilege granted by modified surface topology, effectively proving that there is a critical immunomodulatory mechanism of FBR that extends beyond macrophages, which are thought to be the defining cell type of early stage FBR.

Conclusion:  These findings, paired with the existing strategies for local immune, suggests that surgeons have a much stronger arsenal of immunomodulatory strategies than they currently use: choosing properly textured implants, re-texturing implants, functionalizing implants with triazole groups, administering specific immunomodulatory cocktails, and more. Future research should shift toward reversing capsular contracture that has already occurred, as preventing capsular contracture is a matter of implementing pre-existing scientific advances of this decade.

Works Cited:

1. Headon H, Kasem A, Mokbel K. Capsular Contracture after Breast Augmentation: An Update for Clinical Practice. Arch Plast Surg. 2015;42(5):532-543. doi:10.5999/aps.2018.42.5.532
2. Carnicer-Lombarte A, Chen S-T, Malliaras GG, Barone DG. Foreign Body Reaction to Implanted Biomaterials and Its Impact in Nerve Neuroprosthetics. Systematic Review. Frontiers in Bioengineering and Biotechnology. 2021-April-15 2021;9doi:10.3389/fbioe.2021.622524
3. Kuehlmann B, Zucal I, Bonham CA, Joubert LM, Prantl L. SEM and TEM for identification of capsular fibrosis and cellular behavior around breast implants – a descriptive analysis. BMC Mol Cell Biol. 2021;22(1):25. Published 2021 May 3. doi:10.1186/s12860-021-00364-8
4. Karinja, Sarah J. MD1,2; Bernstein, Jaime L. MD1,2; Mukherjee, Sudip PhD, MRSC3; Jin, Julia BS1,2; Lin, Alexandra MD1,2; Abadeer, Andrew MD, MEng1,2; Kaymakcalan, Omer MD1,2; Veiseh, Omid PhD3,4; Spector, Jason A. MD1,2,5. An Antifibrotic Breast Implant Surface Coating Significantly Reduces Periprosthetic Capsule Formation. Plastic and Reconstructive Surgery 152(4):p 775-785, October 2023. | DOI: 10.1097/PRS.0000000000010323
5. Doloff JC, Veiseh O, de Mezerville R, et al. The surface topography of silicone breast implants mediates the foreign body response in mice, rabbits and humans. Nat Biomed Eng. 2021;5(10):1115-1130. doi:10.1038/s41551-021-00739-4