The role of bacteria/biofilm on breast implant surfaces in potentiating the development of capsular contracture has been well established.1–3 Interestingly, there are strong data that chronic inflammation from bacteria/biofilm is also responsible for the development of breast implant–associated anaplastic large-cell lymphoma (ALCL).4,5 To date, all confirmed cases have been of textured devices or patients with multiple implants including at least one textured device.6,7 Originally, Brody pointed to a cause specific to Biocell macrotextured implants7; however, implant demographics have demonstrated this to occur in multiple different types of textured devices. This is a logical observation, given that textured devices harbor exponentially more bacteria than smooth implants,2 and this is associated with greater lymphocyte stimulation.4 Implant surface texturing varies by manufacturer, and can generally be classified as macrotextured, including polyurethane and Biocell (Allergan plc, Dublin, Ireland), intermediate-textured (TRUE Texture; Sientra, Santa Barbara, Calif.), or microtextured (Siltex; Mentor Worldwide, Santa Barbara, Calif.).8,9 More aggressive macrotextured implants (polyurethane and Biocell) demonstrate higher bacterial counts than those with less aggressive texturing (Siltex and Poly Implant Prothèse), and a greater T-cell response.4 Chronic T-cell activation in response to the implant bacteria/biofilm may be the inciting factor in implant-associated ALCL, and may explain why it has only been reported in association with textured implants. Recent reports in Australia have indicated a significantly higher calculated incidence in macrotextured implants (one in 2400 to one in 4500).10
Techniques to reduce the number of bacteria around implants have minimized the occurrence of capsular contracture to very low levels, less than 1 percent.1,3,11–13 Similar to cutaneous ALCL, which has a pathway of transformation through a bacterial superantigen,14 breast implant–associated ALCL is hypothesized to undergo a similar process. Furthermore, the same techniques that reduce the bacterial load/contamination around implants—specifically, the 14-point plan (Table 1)—will likely reduce the risk of implant–associated ALCL. The purpose of this study was to look at a global experience in macrotextured devices with regard to implant–associated ALCL among a group of surgeons who use similar surgical technique, including the 14-point plan.
PATIENTS AND METHODS
Eight plastic surgeons in five countries collected their prospective macrotextured implant experience looking at technique and the incidence of breast implant–associated ALCL. Patients were followed according to the protocol of the individual practice; however, this included yearly documented follow-up as standard practice. The data for the total number of macrotextured implant (Biocell, polyurethane) patients were combined for all surgeons, total number of implants placed, mean follow-up, type of case performed, total number of cases of breast implant–ALCL that has developed among their patients, and adherence to each component of the 14-point plan used in their practices (Table 1).
The overall experience is reported in Table 2. A total of 42,035 Biocell implants were placed in 21,650 patients, with a mean follow-up of 11.7 years (range, 1 to 14 years). A total of 704 polyurethane-covered implants were used in 352 patients, with a mean follow-up of 8.0 years (range, 1 to 20 years). All surgeons reported using Biocell implants; six (75 percent) had also placed polyurethane implants. The majority of these implants were used in primary breast augmentation (77.9 percent), followed by augmentation mastopexy (9.9 percent), revision augmentation (8.2 percent), and breast reconstruction (4.0 percent). The overall capsular contracture rate was 2.2 percent. There were no cases of implant–associated ALCL.
All surgeons routinely performed all perioperative components of the 14-point plan at the time of implant placement. Six of the surgeons adhered to all 14 steps during placement of 10,359 implants (24.2 percent). The remaining two surgeons followed 13 of the steps in 32,380 cases (75.8 percent), but did not routinely use or recommend antibiotic prophylaxis for subsequent procedures that breach skin or mucosa such as dental procedures.
Bacterial/biofilm primarily forms on the implant surface dependent on the presence of initial bacterial contact with the implant surface at the time of surgery.1 The extracellular slime provides relative isolation from antibiotics and limits exposure to the host immune response. Although theoretically designed to promote periprosthetic capsular tissue ingrowth to increase adherence to the capsule and limit implant mobility, the irregular surface and increased surface area of textured implants provide a harbor for bacterial growth and biofilm formation. Hu et al.4 demonstrated that a chronic immune response is elicited by bacterial biofilm, characterized by a predominant T-cell lymphocytic infiltrate. They found that textured implants harbored significantly more bacteria than smooth implants, and are associated with significantly greater lymphocytic infiltrate. The most popular macrotextured breast implants, Biocell and a smaller percentage of polyurethane devices, have the greatest bacterial growth and lymphocytic response compared with less textured (microtextured) implants. This is logical, given that more aggressive texturing provides a space for bacterial growth. Although breast implant–associated ALCL is likely a separate entity from systemic ALCL, and shares many similarities to primary cutaneous ALCL, they are all characterized by T-cell derivation.15,16 Further supporting bacterial biofilm as the inciting cause of implant–associated ALCL, Hu et al.5 recently identified the unique microbiome of Ralstonia spp. in ALCL specimens compared with normal and contracture capsule specimens (primarily Gram-positives), and in the breast implant--associated ALCL subgroup who also had contralateral non--breast implant--associated ALCL capsular pathology found significantly lower bacterial concentration in normal contralateral capsule specimens. Furthermore, all reported cases of implant-associated ALCL to date have been in association with textured implants.6
Chronic stimulation by bacterial antigens, a sustained T-cell response, and genetic transformation appear to constitute the basic model for development of implant-associated ALCL (Fig. 1).16 Interestingly, the same pathogenesis is seen in primary cutaneous ALCL.14 Although there is now very compelling evidence for a chronic immune response to bacterial/biofilm as the primary mechanism of transformation to breast implant–associated ALCL, there is growing controversy over the classification of this disease.7,17 Although the initial classification of ALCL by the World Health Organization originally took a conservative approach, the “decision makers” were primarily not people who treat breast implant patients. The consensus from many international breast implant experts is that it is very obvious that this entity behaves not like an ALCL but rather like a lymphoproliferative disorder. Specimens isolated from implant capsules consistently demonstrate anaplastic cytology and CD30+ antigen expression, consistent with ALCL. However, systemic ALCL typically expresses anaplastic lymphoma kinase especially in younger patients, whereas breast implant--associated ALCL is anaplastic lymphoma kinase–negative in the majority of cases.18 In most cases of implant-associated ALCL, the tumor is confined to the seroma fluid only and/or implant capsule, but axillary and/or mediastinal metastases and disseminated disease have been reported.7 It is typically characterized by a more indolent course, and is frequently treated by capsulectomy alone. Breast implant-associated ALCL shares many similarities to primary cutaneous ALCL, which is also anaplastic lymphoma kinase–negative and commonly presents with localized lesions with infrequent spread to lymph nodes and overall excellent prognosis.15,16 Breast implant–associated ALCL appears to be a distinct entity from systemic ALCL, with many features in common with primary cutaneous ALCL, and likely will warrant a new classification as a lymphoproliferative disorder. Nevertheless, minimizing contamination at the time of surgery and the load of bacteria that lead to biofilm formation (the 14-point plan)1 reduces the known sequelae of bacteria/biofilm and breast implants. The “14-point effect” has been proven for capsular contracture.1,3,11–13,19,20
In light of recent evidence that implicates a higher incidence of breast implant–associated ALCL in macrotextured devices,10 the data in this article demonstrate that technique is a critical factor in the use of textured implants, and most importantly macrotextured implants. Although the extrapolation is not fully valid, as not all of the patients in this series were treated in Australia, the expected number of implant–associated ALCL cases would be between eight and nine diagnoses; however, there were no cases in this series. The series approaches 43,000 macrotextured implants, with a mean follow-up of 11.7 and 8.0 years in patients with Biocell and polyurethane implants, respectively, and provides adequate average follow-up to comment on implant–associated ALCL. Polyurethane was included, because it is the other main macrotextured implant type.
As with capsular contracture, where the 14-point plan techniques have reduced capsular contracture rates to 1 percent or less,11–13 this study seeks to specifically review the experience with breast implant–associated ALCL in macrotextured implants from a group of international surgeons using similar techniques. Supporting this logic is the capsular contracture rate of 2.2 percent in the same group of patients. This study was not meant to be an exhaustive analysis of the relationship of implant placement technique and ALCL, but was intended simply to demonstrate that surgeons using systematic, defined, and evidence-based principles have achieved a low rate of implant-associated ALCL (specifically, zero cases) in a large number of implants at highest risk.
Although debate remains over the cause and classification of breast implant–associated ALCL, mounting evidence clearly implicates a prominent and likely key role of implant bacteria/biofilm and associated host immune response. Using the principles of the 14-point plan to minimize the bacterial load at the time of surgery, the development and subsequent sequelae of capsular contracture and breast implant–associated ALCL may be reduced, especially with higher risk textured implants.
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