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Since the development of the breast implant in 1962, capsular contracture has been the #1 complication of aesthetic and reconstructive breast surgery [1]. It is also the most common causes of re-operation following implantation.

In addition to operative complications of capsular contracture, there is an eco­nomic impact as well. Approximately 1.5 million breast augmentation are done each year outside the US and 300,000 in the US with contracture rate overall between 7 and 15%, resulting in a staggering 180,000 women affected by capsular contracture each year globally.

There have been numerous theories and treatment strategies for the management of capsular contracture although the subclinical infection etiology has come to the forefront of the science. Other theories include hypertrophic scar hypothesis, acti­vated myobroblasts, silicone gel bleed, hematoma, or infection related inamma­tion. Since 1981 [2], Burkhardt demonstrated a connection of sub-acute periprosthetic infection to capsular contracture. In a follow-up prospective study by the same author usingrandomized clinical split breast design [3], prophylactic treatment of the implants with antibiotic solution demonstrated an 85% reduction in capsular contracture as compared to the opposite untreated side. Although the Burkhardt

As capsular contracture remains the most common complication, surgeons see patients for revision of this malady very often and it is the #1 most common reason for revision breast augmentation. Although this chapter will concentrate on the sur­gical treatment of contracture, surgeons should keep in mind thatthe best defense of contracture is a good offense. We will start with prevention as these concepts are critical to the management of existing capsular contracture.

vs. textured implants [23, 24]. All of these studies underscore the issue that many surgeons have followed for years mistakenly believing textured implants cause less capsular contracture. This reduction is not supported by data consistently and the increase surface area of the texture increases the amount of bacteria which may cause an increased risk for capsular contracture and also other bacterially mediated processes, specically BIA-ALCL [24].

With the science of capsular contracture rmly implicating subclinical infection as the major cause, groups began to investigate optimal means of reducing bioburden. An animal study by Tamboto, et al. inoculating porcine mammary pockets with Staph epidermidis demonstrated capsular contracture with bacterial inoculation, consistent with the studies mentioned above. However, the study also suggested that that below a certain bacterial threshold, capsular contracture may not occur [11]. There is merit in reducing to the best of our ability the bacterial burden at the time of surgery. A easy means for surgeons to do this would be minimizing bacterial loadin the breast pocket with antimicrobial breast pocket irrigation that would bring the critical bacterial threshold to a low enough point to minimize the infectious contribution to capsular contracture. Given the polymicrobial nature ofdevice asso­ciated infection (capsular contracture, BIA-ALCL, seroma etc). The ideal breast irrigant would maximally reduce bacterial numbers (broad spectrum), minimally cytotoxic, have relatively available ingredients, be easy to create. While surgeons were recognizing the role of bacterial contamination and capsular contracture, there was no standardization in the practice of breast pocket preparation that was clini­cally proven to reduce bacterial numbers and reduce capsular contracture. Adams etal [25] sought to optimize and standardize breast pocket irrigation. Their concern was that surgeons were conscious of the importance of antibiotic irrigation (at least for the reduction of acute infection) but there was no gold standard nor standardiza­tion of technique. They evaluated various antibiotic combinations in vitro that would neutralize the most common bacterial species cultured from implants and implicated in capsular contracture (P. acnes, S. epidermidis, E. coli) as well as spe­cies implicated in more acute infections (S. aureus, P. aeruginosa) [5]. The result wasa recommendation of eitherBetadine Triple(BT) (50ml of povidone-iodine, 1g of cefazolin, and 80mg of gentamicin in 500mL)or 50% Betadine [25] and then a year later after betadine was label-restricted in the FDA saline implant PMA hearings, a non-betadine triple antibiotic (NB-TAB) (50,000 U Bacitracin, 1 g cefazolin, 80mg gentamicin, 500cc NS) [26]. Thesame irrigations BT, 50% beta­dine, and NB-TAB were then evaluated clinically in a 6-year prospective study that examined the rate of capsular contracture in breast augmentation, reconstruction, and augmentation mastopexy. Capsular contraction rates were 1.8% (5x lower),

Deva,Adams andVickery and [30] suammarized recommendations that address the clinical data regarding breast implants and minimization of bacterial load. These recommendations are summarized in a “14 point plan” that aim to ultimately mini­mize and prevent capsular contracture formation. Each point uses data to support its inclusion on the list. The points are as follows:

7. Perform pocket irrigation with triple antibiotic solution or betadine.

8. Minimize skin-implant contamination.

9. Use new instruments and drapes, and change surgical gloves prior to handling

Historically, there is a generalized dogma for capsular contracture: capsulec­tomy, site change, and implant exchange; however, there are multiple factors that should be assessed when evaluating a surgical candidate. These include implant site, presence of malposition, tissue quality, and implant type. Management should be geared toward the patient’s personal clinical scenario. We present decision points in management. With regard to the data in breast surgery, we nd much of it to be, while good intentioned, non-specic in surgi­cal technique and not transferrable. Vastly varying recurring contracture rates can be found in the literature. There are some studies that do offer insights into management of capsular contracture and we include some here to help us in our decision-making.

the prevention of recurrent capsularcontractureandtime will tell on its true ef­cacy. Cost with these adjuncts[50]. Cost is also a factor for these adjuncts.