Capsular contracture after performing reconstructive plastic surgery in patients with breast cancer

Reconstructive breast surgery, including the use of silicone endoprostheses after radical mastectomy, is an integral part of the comprehensive treatment of breast cancer patients. One of the serious long‑term complications of reconstructive surgery is capsular contracture (CC).

Purpose of the study. To analyze the literature data on the etiopathogenesis of periprosthetic capsule (PC) defects and the possibilities of reducing the risk of CC after breast reconstructive surgery.

Materials and methods. The literature was searched using PubMed, eLibrary, Cyberleninka databases. The following keywords were used: "breast reconstruction", "capsular contracture", "radiation therapy", "polyurethane", "breast implant", "mesh implant". Original studies, meta‑analyses, randomized controlled trials and systematic reviews were used.

Results. The exact etiology of the development of CC has not yet been established. The main pathogenetic mechanism of CC development is chronic inflammation followed by the formation of capsular fibrosis. Radiation therapy significantly increases the risk of developing CC due to the development of fibrotic changes not only in the PC, but also the occurrence of fibrosis of the pectoralis major muscle. The frequency of CC is higher when using adjuvant radiation therapy, compared with neoadjuvant or no radiation therapy, as well as with dual‑plane reconstruction compared with pre‑pectoral placement of the endoprosthesis. The use of a polyurethane endoprosthesis in simultaneous pre‑pectoral breast reconstruction significantly reduces the risk of developing CC in the case of adjuvant radiation therapy, in comparison with textured endoprostheses. One of the ways to reduce the risk of developing CC in breast cancer can be considered the installation of mesh implants, which contributes to the augmentation of the integumentary tissues and improves the stability of the breast endoprosthesis in conditions of tissue deficiency.

Conclusion. Simultaneous pre‑pectoral breast reconstruction based on polyurethane endoprosthesis and mesh implants can be considered as a promising technique for reducing the risk of developing CC. There is a positive trend towards reducing the risk of developing CC against the background of adjuvant radiation therapy. Further research is needed related to the reduction of the risk of developing CC.

1. Malignant neoplasms in Russia in 2023 (morbidity and mortality). Edited by Kaprin AD, Starinsky VV, Shakhzadova AO. Мoscow: P. Hertsen Moscow Oncology Research Institute – Branch of the National Medical Radiology Research Centre of the Ministry of Health of the Russian Federation, 2024, 276 p. (In Russ.). Available at: https://oncology-association.ru/wp-content/uploads/2024/08/zis-2023-elektronnaya-versiya.pdf

2. Fortunato L, Loreti A, Cortese G, Spallone D, Toto V, Cavaliere F, et al. Regret and Quality of Life After Mastectomy With or With‑out Reconstruction. Clinical breast cancer. 2021 Jun; 21(3):162–169. doi: 10.1016/j.clbc.2019.11.005

3. Timoshkina EV, Tkachev SI, Glebovskaya VV, Trofimova OP, Chernykh MV, Ivanov SM. Impact of hypofractionated adjuvant radiotherapy on complication rate in breast cancer patients with implant‑based immediate reconstruction. Medical Alphabet. 2023;(10):18–24. (In Russ.). doi: 10.33667/2078‑5631‑2023‑10‑18‑24

4. Pool SMW, Wolthuizen R, Mouës‑Vink CM. Silicone breast prostheses: A cohort study of complaints, complications, and explantations between 2003 and 2015. J Plast Reconstr Aesthet Surg. 2018 Nov;71(11):1563–1569. doi: 10.1016/j.bjps.2018.07.010

5. Berestok TS, Zikiryakhodzhaev AD, Ermoshchenkova MV, Ablitsova NV, Onofriychuk IM, Vlasova MYu, Troshenkov EA. Complications after simultaneous one‑stage and two‑stage reconstruction with implants in patients with breast cancer during combined/combination treatment. P.A. Herzen Journal of Oncology. 2023;12(3):54–61. (In Russ.). doi: 10.17116/onkolog20231203154

6. Safran T, Nepon H, Chu CK, Winocour S, Murphy AM, Davison PG, et al. Current Concepts in Capsular Contracture: Pathophysiology, Prevention, and Management. Seminars in plastic surgery. 2021 Aug;35(3):189–197. doi: 10.1055/s‑0041‑1731793

7. Mohan AS, Sullivan J, Tenenbaum MM, Broderick KB, Myckatyn TM. Toward a Consensus Aproach for Assessing Capsular Contracture Severity and Progression : A Systematic Review. Plast Reconstr Surg. 2024 Jan 1;153(1):7–22. doi: 10.1097/prs.0000000000010573

8. de Bakker E, Rots M, Buncamper ME, Niessen FB, Smit JM, Winters HAH, et al. The Baker Classification for Capsular Contracture in Breast Implant Surgery Is Unreliable as a Diagnostic Tool. Plast Reconstr Surg. 2020 Nov;146(5):956–962. doi: 10.1097/prs.0000000000007238

9. 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 Dec;42(6):1485–1491. doi: 10.1007/s00266‑018‑1211‑1

10. Scarpa C, Borso GF, Vindigni V, Bassetto F. Polyurethane foam‑covered breast implants: a justified choice? Eur Rev Med Pharmacol Sci [Internet]. 2015 [cited 2024 Aug 9];19(9). Available from: https://pubmed.ncbi.nlm.nih.gov/26004599/

11. Shin BH, Kim BH, Kim S, Lee K, Choy YB, Heo CY. Silicone breast implant modification review: overcoming capsular contracture. Biomater Res. 2018 Dec 20;22:37. doi: 10.1186/s40824‑018‑0147‑5

12. Bachour Y, Poort L, Verweij SP, van Selms G, Winters HAH, Ritt MJPF, et al. PCR Characterization of Microbiota on Contracted and Non‑Contracted Breast Capsules. Aesthetic plastic surgery. 2019 Aug;43(4):918–926. doi: 10.1007/s00266‑019‑01383‑9

13. Walker JN, Pinkner CL, Pinkner JS, Hultgren SJ, Myckatyn TM. The Detection of Bacteria and Matrix Proteins on Clinically Benign and Pathologic Implants. Plastic and reconstructive surgery. Global open. 2019 Feb 8;7(2):e2037. doi: 10.1097/gox.0000000000002037

14. Hallab NJ, Samelko L, Hammond D. The Inflammatory Effects of Breast Implant Particulate Shedding: Comparison With Orthopedic Implants. Aesthet Surg J. 2019 Jan 31;39(Suppl_1):S36–S48. doi: 10.1093/asj/sjy335

15. Tanner B. Low rate of capsular contracture in a series of 214 consecutive primary and revision breast augmentations using microtextured implants. JPRAS Open. 2017 Dec 27;15:66–73. doi: 10.1016/j.jpra.2017.10.007

16. Galdiero M, Larocca F, Iovene MR, Francesca M, Pieretti G, D'Oriano V, et al. Microbial Evaluation in Capsular Contracture of Breast Implants. Plast Reconstr Surg. 2018 Jan;141(1):23–30. doi: 10.1097/prs.0000000000003915

17. Loreti A, Siri G, De Carli M, Fanelli B, Arelli F, Spallone D, et al. Immediate Breast Reconstruction after mastectomy with polyurethane implants versus textured implants: A retrospective study with focus on capsular contracture. Breast. 2020 Dec;54:127–132. doi: 10.1016/j.breast.2020.09.009

18. Hammond JB, Kosiorek HE, Cronin PA, Rebecca AM, Casey WJ 3^rd, Wong WW, Vargas CE, Vern‑Gross TZ, McGee LA, Pockaj BA. Capsular contracture in the modern era: A multidisciplinary look at the incidence and risk factors after mastectomy and implant‑based breast reconstruction. Am J Surg. 2021 May;221(5):1005–1010. doi: 10.1016/j.amjsurg.2020.09.020

19. Dzhabrailova DSh, Zikiryakhodzhaev AD, Usov FN, Bagdasarova DV, Duadze IS, Kaprin AD. Autologous dura mater grafts in reconstructive surgeries for breast cancer: surgical and aesthetic outcomes. Tumors of female reproductive system. 2023;19(4):43–53. (In Russ.). doi: 10.17650/1994‑4098‑2023‑19‑4‑43‑53

20. Ulrikh DG, Krivorotko PV, Bryantseva ZhV, Pesotskiy RS, Bondarchuk YI, Amirov NS, et al. Reconstructive plastic surgery in combined treatment of breast cancer: predictive risk factors of complications and reconstruction failure. P.A. Herzen Journal of Oncology. 2024;13(3):13 19. (In Russ.). doi: 10.17116/onkolog20241303113

21. Olinger TA, Berlin NL, Qi J, Hamill JB, Kim HM, Pusic AL, Wilkins EG, Momoh A, et al. Outcomes of Immediate Implant‑Based Mastectomy Reconstruction in Women with Previous Breast Radiotherapy. Plastic and reconstructive surgery. 2020 Jun;145(6):1029e–1036e. doi: 10.1097/PRS.0000000000006811

22. Hansen TC, Woeller CF, Lacy SH, Koltz PF, Langstein HN, Phipps RP. Thy1 (CD90) Expression Is Elevated in Radiation‑Induced Periprosthetic Capsular Contracture: Implication for Novel Therapeutics. Plastic and reconstructive surgery. 2017 Aug;140(2):316–326. doi: 10.1097/PRS.0000000000003542

23. Woeller CF, O'Loughlin CW, Roztocil E, Feldon SE, Phipps RP. Salinomycin and other polyether ionophores are a new class of antiscarring agent. J Biol Chem. 2015 Feb 6;290(6):3563–3575. doi: 10.1074/jbc.m114.601872

24. Antoszczak M, Huczyński A. Salinomycin and its derivatives ‑ A new class of multiple‑targeted "magic bullets". Eur J Med Chem. 2019 Aug 15;176:208–227. doi: 10.1016/j.ejmech.2019.05.031

25. Prantl L, Momeni A, Brebant V, Kuehlmann B, Heine N, Biermann N, Brix E. Recommendations for the Use of Antibiotics in Primary and Secondary Esthetic Breast Surgery. Plast Reconstr Surg Glob Open. 2020 Jan 24;8(1):e2590. doi: 10.1097/gox.0000000000002590

26. Luvsannyam E, Patel D, Hassan Z, Nukala S, Somagutta MR, Hamid P. Overview of Risk Factors and Prevention of Capsular Contracture Following Implant‑Based Breast Reconstruction and Cosmetic Surgery : A Systematic Review. Cureus. 2020 Sep 9;12(9):e10341. doi: 10.7759/cureus.10341

27. Samargandi OA, Joukhadar N, Al Youha S, Thoma A, Williams J. Antibiotic Irrigation of Pocket for Implant‑Based Breast Augmentation to Prevent Capsular Contracture : A Systematic Review. Plast Surg (Oakv). 2018 May;26(2):110–119. doi: 10.1177/2292550317747854

28. Awad AN, Heiman AJ, Patel A. Implants and Breast Pocket Irrigation: Outcomes of Antibiotic, Antiseptic, and Saline Irrigation. Aesthet Surg J. 2022 Jan 12;42(2):NP102–NP111. doi: 10.1093/asj/sjab181

29. Ngaage LM, Elegbede A, Brao K, Chopra K, Gowda AU, Nam AJ, et al. The Efficacy of Breast Implant Irrigant Solutions: A Comparative Analysis Using an In Vitro Model. Plast Reconstr Surg. 2020 Aug;146(2):301–308. doi: 10.1097/prs.0000000000007028

30. Wang Y, Tian J, Liu J. Suppressive Effect of Leukotriene Antagonists on Capsular Contracture in Patients Who Underwent Breast Surgery with Prosthesis: A Meta‑Analysis. Plast Reconstr Surg. 2020 Apr;145(4):901–911. doi: 10.1097/PRS.0000000000006629

31. Pașca A, Bonci EA, Chiuzan C, Jiboc NM, Gâta VA, Muntean MV, et al. Treatment and Prevention of Periprosthetic Capsular Contracture in Breast Surgery With Prosthesis Using Leukotriene Receptor Antagonists: A Meta‑Analysis. Aesthet Surg J. 2022 Apr 12;42(5):4831–494. doi: 10.1093/asj/sjab355

32. Eichler C, Schulz C, Thangarajah F, Malter W, Warm M, Brunnert K. A Retrospective Head‑to‑head Comparison Between TiLoop Bra/TiMesh® and Seragyn® in 320 Cases of Reconstructive Breast Surgery. Anticancer Res. 2019 May;39(5):2599–2605. doi: 10.21873/anticanres.13383

33. Choi YS, You HJ, Lee TY, Kim DW. Comparing Complications of Biologic and Synthetic Mesh in Breast Reconstruction : A Systematic Review and Network Meta‑Analysis. Arch Plast Surg. 2023 Feb 6;50(1):3–9. doi: 10.1055/a‑1964‑8181

34. Zikiryahodzhaev AD, Shirokikh IM, Ablitsova NV, Ermoshenkova MV, Khakimova ShG, Khakimova GG, Tukmakov AYu. Effect of radiation therapy on breast immediate reconstruction in breast cancer patients. Problems in Oncology. 2019;65(3):374–385. (In Russ.). doi: 10.37469/0507‑3758‑2019‑65‑3‑374‑385

35. Tevlin R, Borrelli MR, Irizarry D, Nguyen D, Wan DC, Momeni A. Acellular Dermal Matrix Reduces Myofibroblast Presence in the Breast Capsule. Plastic and reconstructive surgery. Global open. 2019 May 17;7(5):e2213. doi: 10.1097/gox.0000000000002213

36. Kim IK, Park SO, Chang H, Jin US. Inhibition Mechanism of Acellular Dermal Matrix on Capsule Formation in Expander‑Implant Breast Reconstruction After Postmastectomy Radiotherapy. Ann Surg Oncol. 2018 Aug;25(8):2279–2287. doi: 10.1245/s10434‑018‑6549‑8

37. Lardi AM, Ho‑Asjoe M, Junge K, Farhadi J. Capsular contracture in implant based breast reconstruction‑the effect of porcine acellular dermal matrix. Gland Surg. 2017 Feb;6(1):49–56. doi: 10.21037/gs.2017.01.02

38. Hong HK, Kim YH, Lee JS, Lee J, Park HY, Yang JD. Prepectoral breast reconstruction with complete anterior implant coverage using a single, large, square‑shaped acellular dermal matrix. BMC Surg. 2022 Jun 20;22(1):234. doi: 10.1186/s12893‑022‑01683‑z

39. 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 Jun;44(3):735–742. doi: 10.1007/s00266‑019‑01603‑2

40. Wagner RD, Braun TL, Zhu H, Winocour S. A systematic review of complications in prepectoral breast reconstruction. Journal of Plastic, Reconstructive & Aesthetic Surgery: JPRAS. 2019 Jul;72(7):1051–1059. doi: 10.1016/j.bjps.2019.04.005

41. Bassetto F, Pandis L, Azzena GP, De Antoni E, Crema A, Scortecci L, et al. Complete Implant Wrapping with Porcine‑Derived Acellular Dermal Matrix for the Treatment of Capsular Contracture in Breast Reconstruction: A Case‑Control Study. Aesthetic Plast Surg. 2022 Aug;46(4):1575–1584. doi: 10.1007/s00266‑022‑02826‑6

42. 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 Apr;145(4):686e–696e. doi: 10.1097/prs.0000000000006654

43. Baichorov EA, Zikiryakhodzhaev AD, Ismagilov AKh, Vanesyan AS. Comparative analysis of health‑related quality of life in patients with breast cancer after immediate prepectoral breast reconstruction. Plastic Surgery and Aesthetic Medicine. 2022;2:25–32. (In Russ.). doi: 10.17116/plast.hirurgia202202125

44. Hansson E, Burian P, Hallberg H. Comparison of inflammatory response and synovial metaplasia in immediate breast reconstruction with a synthetic and a biological mesh: a randomized controlled clinical trial. J Plast Surg Hand Surg. 2020 Jun;54(3):131–136. doi: 10.1080/2000656X.2019.1704766

45. Dzhabrailova DSh, Zikiryakhodzhaev AD, Usov FN, Starkova MV, Bagdasarova DV, Duadze IS. Autologous dura mater grafts in reconstructive surgeries for breast cancer patients. Tumors of female reproductive system. 2021;17(3):44–50. (In Russ.). doi: 10.17650/1994‑4098‑2021‑17‑3‑44‑50

46. Du F, Liu R, Zhang H, Xiao Y, Long X. Post‑mastectomy adjuvant radiotherapy for direct‑to‑implant and two‑stage implant‑based breast reconstruction: A meta‑analysis. J Plast Reconstr Aesthet Surg. 2022 Sep;75(9):3030–3040. doi: 10.1016/j.bjps.2022.06.063

47. Ricci JA, Epstein S, Momoh AO, Lin SJ, Singhal D, Lee BT. A meta‑analysis of implant‑based breast reconstruction and timing of adjuvant radiation therapy. J Surg Res. 2017 Oct;218:108–116. doi: 10.1016/j.jss.2017.05.072

48. Plachinski SJ, Boehm LM, Adamson KA, LoGiudice JA, Doren EL. Comparative Analysis of Prepectoral versus Subpectoral Implant‑based Breast Reconstruction. Plast Reconstr Surg Glob Open. 2021 Jul 27;9(7):e3709. doi: 10.1097/GOX.0000000000003709

49. Sobti N, Weitzman RE, Nealon KP, Jimenez RB, Gfrerer L, Mattos D, Ehrlichman RJ, Gadd M, Specht M, Austen WG, Liao EC. Evaluation of capsular contracture following immediate prepectoral versus subpectoral direct‑to‑implant breast reconstruction. Sci Rep. 2020 Jan 24;10(1):1137. doi: 10.1038/s41598‑020‑58094‑4

50. 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 Oct;25(10):2899–2908. doi: 10.1245/s10434‑018‑6602‑7

51. Vlasova MYu, Zikiryakhodzhaev AD, Reshetov IV, Usov FN, Saribekyan EK, Shirokikh IM, et al. Complications after simultaneous prepectoral breast reconstruction using polyurethane‑coated implants in patients with breast cancer. Tumors of female reproductive system. 2020;16(4):12–20. doi: 10.17650/1994‑4098‑2020‑16‑4‑12‑20

52. Sbitany H, Gomez‑Sanchez C, Piper M, Lentz R. Prepectoral Breast Reconstruction in the Setting of Postmastectomy Radiation Therapy: An Assessment of Clinical Outcomes and Benefits. Plastic and reconstructive surgery. 2019 Jan;143(1):10–20. doi: 10.1097/prs.0000000000005140

53. de Vita R, Buccheri EM, Villanucci A, Pozzi M. Breast Reconstruction Actualized in Nipple‑sparing Mastectomy and Direct‑to‑implant, Prepectoral Polyurethane Positioning: Early Experience and Preliminary Results. Clin Breast Cancer. 2019 Apr;19(2):e358–e363. doi: 10.1016/j.clbc.2018.12.015

54. Acea Nebril B, García Novoa A, García Jiménez L, Díaz Carballada C, Bouzón Alejandro A, Conde Iglesias C. Immediate breast reconstruction by prepectoral polyurethane implant: Preliminary results of the prospective study PreQ‑20. Cir Esp (Engl Ed). 2023 Mar;101(3):187–197. doi: 10.1016/j.cireng.2022.09.021

55. Ribuffo D, Berna G, De Vita R, Di Benedetto G, Cigna E, Greco M, et al. Dual‑Plane Retro‑pectoral Versus Pre‑pectoral DTI Breast Reconstruction: An Italian Multicenter Experience. Aesthetic Plast Surg. 2021 Feb;45(1):51–60. doi: 10.1007/s00266‑020‑01892‑y

56. 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 Sep;71(9):e29–e48. doi: 10.1016/j.bjps.2018.05.022

57. Ozgur I, Kurul S, Bademler S, Karanlik H. Comparison of subpectoral versus dual‑plane implant based immediate breast reconstruction after nipple‑areola sparing mastectomy. Ann Chir Plast Esthet. 2021 Dec;66(6):447–458. doi: 10.1016/j.anplas.2020.10.002

58. King CA, Masanam MK, Tousimis EA, Salzberg CA. Literature review and guide for optimal position in implant‑based breast reconstruction. Gland Surgery. 2023;12(8):1082–1093. doi: 10.21037/gs‑23‑78

59. Hamdi M. Association Between Breast Implant‑Associated Anaplastic Large Cell Lymphoma (BIA‑ALCL) Risk and Polyurethane Breast Implants: Clinical Evidence and European Perspective. Aesthetic surgery journal. 2019 Jan 31;39(Suppl_1):S49‑S54. doi: 10.1093/asj/sjy328

60. Lo Torto F, Relucenti M, Familiari G, Vaia N, Casella D, Matassa R, et al. The effect of postmastectomy radiation therapy on breastimplants: Material analysis on silicone and polyurethane prosthesis. Ann Plast Surg. 2018;81(2):228–234. doi: 10.1097/SAP.0000000000001461

61. Vlasova MYu, Zikiryakhodzhaev AD, Reshetov IV, Sukhotko AS, Saribekyan EK, Usov FN, et al. Prepectoral reconstruction with polyurethane‑coated implant after skin‑sparing mastectomy in patients with breast cancer. Research and Practical Medicine Journal. 2020;7(3):63–73. (In Russ.). doi: 10.17709/2409‑2231‑2020‑7‑3‑6

62. Headon H, Kasem A, Mokbel K. Capsular Contracture after Breast Augmentation: An Update for Clinical Practice. Archives of plastic surgery. 2015 Sep;42(5):532–543. doi: 10.5999/aps.2015.42.5.532

63. Caplin DA, Calobrace MB, Wixtrom RN, Estes MM, Canady JW. MemoryGel Breast Implants: Final Safety and Efficacy Results after 10 Years of Follow‑Up. Plastic and reconstructive surgery. 2021 Mar 1;147(3):556–566. doi: 10.1097/PRS.0000000000007635

64. Zugasti A, Hontanilla B. The Impact of adjuvant radiotherapy on immediate implant‑based breast reconstruction surgical and satisfaction outcomes : a systematic review and meta‑analysis. Plast Reconstr Surg Glob Open. 2021;9(11):e3910. doi: 10.1097/gox.0000000000003910