Smooth Operator: Nanotextured Breast Tissue Expanders Are Associated with Lower Rates of Capsular Contracture

Abstract

Background: Continuous research on breast implant-associated anaplastic large cell lymphoma (BIA-ALCL) has introduced a focus on surface texturizations and a shift towards smooth breast devices, yet outcomes comparing the complication profiles of differently textured tissue expanders (TEs) remain conflicting. The study aim was to compare the complication profile of a new nanotextured and MRI-compatible TE to micro- and macrotextured TEs and to identify possible predictors for complications. Methods: A retrospective analysis of women undergoing expander-based breast reconstruction after mastectomy between January 2016 and March 2022 was conducted. The primary endpoint was the development of capsular contracture. Possible predictors were analyzed in a mixed-effects model using the least absolute shrinkage and selection operator (LASSO). Moreover, a comparison of complications and an evaluation of predictors were carried out. Results: A total of 147 breasts, encompassing 82 nanotextured, 43 microtextured and 22 macrotextured TEs, were analyzed. Breasts with nanotextured TEs were less likely to develop capsular contracture overall (OR, 0.12; 95%CI 0.05-0.28, p < 0.001). Post-mastectomy radiotherapy (PMRT) was identified as a predictor for capsular contracture (OR, 4.67; 95%CI 1.86-11.71, p < 0.001). Breasts with nanotextured TEs showed a higher rate of seroma, but lower rates of malposition and pain. Predictors for developing postoperative complications included higher mastectomy weight (p = 0.008). Conclusions: Breasts with nanotextured TEs exhibited the lowest rate of capsular contracture compared to micro- and macrotextured TEs. Together with its MRI-compatibility and improved oncologic follow-up, the nanotextured TE seems to be a favorable device for expander-based breast reconstruction.

Keywords: BIA-ALCL; biocompatibility; breast reconstruction; capsular contracture; mastectomy; surface texturization; tissue expander.

Figure 1

Capsular contracture marginal effects plot of TE without (−) and with (+) post-mastectomy radiotherapy (PMRT).

Figure 2

Unilateral first stage BR with TEs without PMRT. Patient images capture signs of progressive capsular formation over time, showing the preoperative condition (A,E,I), follow-up at 1 months (B,F,J), at 6 months (±1 month; C,G,K) and at 1 year (±2 months; D,H,L). Row 1 shows a patient following SSM of the right breast with vertical access and prepectoral implantation of a nanotextured TE. This patient demonstrates good lower pole expansion and adequate breast projection, showing minimal capsular contraction over a year (grade IA). Row 2 shows a patient following non-radical tumorectomy and periareolar mastopexy requiring complementary SSM of the right breast with horizontal access and pre-pectoral implantation of a microtextured TE and the use of ADM developing asymptomatic, intermediate capsular contracture (grade II). Row 3 shows a patient following NSM of the left breast and sub-pectoral implantation of a macrotextured expander and an absorbable mesh between the lower boarder of the pectoral muscle and the inframammary fold. She developed intermediate capsular contraction (grade II). Meanwhile, the patient underwent prophylactic NSM of the right breast and sub-pectoral implantation of a macrotextured TE, followed by infection with subsequent TE explant (K) and secondary prepectoral implantation of a microtextured TE (L). ADM: acellular dermal matrix; BR: Breast reconstruction; SSM: skin-sparing mastectomy; NSM: nipple-sparing mastectomy; PMRT: post-mastectomy radiation therapy.

Figure 3

Unilateral first-stage BR using TEs with PMRT. Patient images capture signs of progressive capsular formation over time, showing preoperative condition (A,E,I), follow-up at 1 months (B,F,J), at 6 months (±1 month; C,G,K) and at 1 year (±2 months; D,H,K). Row 1 shows a patient following NSM of the left breast and contralateral mastopexy and subpectoral implantation of a nanotextured TE. A progressive cranialization of the TE associated with non-painful, yet visible capsular contraction (grade III). Row 2 shows a patient following SSM of the left breast with horizontal access and subpectoral implantation of a microtextured TE and an absorbable mesh between the lower boarder of the pectoral muscle and the inframammary fold. This patient demonstrates a progressive thinning of the skin and cranialization of the TE, as well as painful symptomatic capsular contracture (grade IV). Row 3 shows a patient following bilateral SRM and pedicled nipple–areolar complexes’ implantation of a macrotextured TE and an absorbable mesh between the lower boarder of the pectoral muscle and the inframammary fold demonstrating progressive thinning of the skin and shrinkage of the soft-tissues on the left (K,L), as well as cranialization of the expander developing asymptomatic capsular contraction on the right (grade II) and painful contracture on the left (K,L: grade IV). BR: Breast reconstruction; NSM: nipple-sparing mastectomy; SRM: skin-reducing mastectomy; SSM: skin-sparing mastectomy; PMRT: post-mastectomy radiation therapy.