Platelet-Rich Plasma as a Novel, Non-invasive Method to Treat Breast Capsular Contractures: a Case Report

Abstract

We describe the first examples of breast capsular contracture amelioration using a non-surgical, transdermal treatment with platelet-rich plasma. The treated patients did not experience any complications or significant pain. This report illustrates the potential of a non-invasive treatment option for a common complication of breast augmentation.

Introduction

Capsular contractures can be unfortunate sequelae of breast implant surgery caused by a foreign body reaction to the prosthesis and resulting in fibrous encapsulation [1,2]. The tightening of the contracture can be deforming to the breast and potentially painful. The severity of capsular contractures typically is graded by the semi-quantitative Baker system describing the breast: Grade I – Natural, normally soft; Grade II – Minimal, little firm but looks normal; Grade III – Moderate, firm and looks abnormal; Grade IV – Severe, hard, painful, and looks abnormal [3–5].

Multiple approaches for the management of capsular contractures have been described. Conventional methods involve surgery; more specifically, contractures are treated with a capsulotomy or capsulectomy [6,7]. Other surgical interventions include autologous fat transfer [8,9]. Surgery has disadvantages, which include cost, need for recovery time, and infection risk. These shortcomings are compounded if a contracture recurs.

There are also a variety of non-surgical treatments for capsular contractures. These include leukotriene antagonists (such as Zafirlukast) [10,11], botulinum toxin A [12,13], steroids [14], ultrasound [15], and low-level lasers [16]. However, such therapies have variable degrees of efficacy [17].

Herein, we describe the first published report of utilizing platelet-rich plasma (PRP) as an effective, non-surgical modality to treat breast capsular contractures.

Case presentation

Case study – 1

Patient 1 is a 36-year-old woman with a history of a prior, bilateral, dual plane breast augmentation with silicone, smooth implants (left and right-535 mL) and a subsequent, right-sided removal and replacement by a similar implant of the same volume (right-535 mL) due to asymmetry. After 9.6 months, the right breast developed a capsular contracture affecting the right areola with a Baker grade of II–III. PRP generated from the patient was applied topically to the affected area and impelled into the skin and underlying soft tissue via transdermal electroporation. After three treatment sessions with PRP over a 9-week period, the right breast contracture was reduced; and the breast was softer with a Baker grade of I–II (Figure 1).

Figure 1.

Patient 1: Pre-treatment internal subcuticular scarring causing a Baker grade II–III capsular contracture secondary to breast implant placement (a). Post-treatment reduction of capsular contracture (B).

Case study – 2

Patient 2 is a 45-year-old woman with a history of prior, bilateral breast augmentation status-post removal. She subsequently had a bilateral, dual plane breast augmentation with silicone, smooth implants (left and right-535 mL). After 6 months, the patient’s right breast developed firmness. Treatment for a potential contracture was initiated using ultrasound therapy and Zafirlukast; however, the firmness continued to progress. After 1.7 years since implantation, the right breast had a capsular contracture with a Baker grade of III; and the breasts were asymmetric with the right breast raised more superiorly than the left breast. Then, the patient elected to undergo PRP therapy. PRP generated from the patient was applied to the affected breast using transdermal electroporation. After six treatments with PRP over a 14-week period, the breast was softer and began to regain symmetry, demonstrating a Baker grade of I–II (Figure 2).

Figure 2.

Patient 2: the patient initially developed a capsular contracture of the right breast with a Baker grade of III, where the right breast migrated asymmetrically more superior than the left breast. Treatment of the right breast was initiated with PRP. Photos after one treatment (A) and after five treatments (B). The right breast had a final Baker grade of I–II with improvement of the horizontal alignment of the breasts. It should be noted that photos do not readily demonstrate the progressive softness of the right breast.

Discussion

Capsular contractures are an immune response to foreign material placed inside the human body [18], where such objects include orthopedic hardware, pacemakers, breast implants, etc. The result is the development of collagenous fibrosis around these foreign bodies.

Across many medical specialties, PRP has been used to treat a variety of indications, including fibrosis. In orthopedics, PRP has been injected into joints to treat adhesive capsulitis [19–21], which is an inflammatory condition characterized by fibroblastic proliferation and extensive scar tissue formation in the shoulder that causes stiffness, pain, and loss of passive range of motion. In dermatology, PRP has been utilized to reduce cutaneous scars [22,23]. Such therapies have reported effectiveness with a good safety profile.

Most important to plastic surgeons are capsular contractures in relation to breast implants. When dealing with any attempt to remove a capsular contracture, two important factors in the treatment are (1) to be successful and (2) to minimize any pain. In the current report, the authors describe patients whose breast capsular contractures were successfully reduced with a pain-free and safe treatment utilizing PRP. The current technique is convenient and requires no post-treatment recovery time.

In this report, PRP was generated by first harvesting patient autologous blood. Then specimens were centrifuged once at 3000–3500 revolutions per minute for 10–15 min. Platelet-rich plasma was collected with leukocytes into a separate container. The PRP was applied without activators or any significant fibrin network.

With the current method, the PRP was delivered by a novel system based on transdermal electroporation. Electroporation or electropermeabilization is the transitory, structural perturbation of lipid bilayer membranes due to the application of high voltage, short duration pulses; and this method has been used for the cutaneous delivery of drugs [24,25]. Electroporation is also capable of actively delivering large molecules through the stratum corneum of the skin [26,27], similar to this report. For the current patients, it is hypothesized that the transdermal electroporation introduces the PRP into the skin; and then the PRP subsequently diffuses deeper to disrupt the contracture. This effect is magnified after several applications of PRP over time.

The current manuscript describes the observation that PRP can reduce breast capsular contractures; however, the exact mechanism of action for contracture dissolution has not been elucidated presently. One hypothesis involves the collagenase activity of platelets [28]. Matrix metalloproteinases (MMP) have been identified within platelets, and a subset of these proteinases can degrade fibrillar collagen [29–31]. The platelets of PRP could bind to the collagen of capsular contractures and induce the release of these factors to disrupt the fibrosis. Another potential mechanism could involve the inhibition of myofibroblasts, which are found within capsular contractures, and their contractile activity that contributes to breast distortion [32–36]. The platelets of PRP may release proteins (such as fibroblast growth factor [37] or hepatocyte growth factor [38]) that are known to inhibit myofibroblasts [39,40] and, thereby, reduce breast deformation.

Conclusion

This case report introduces the potential of platelet-rich plasma as a non-surgical, relatively pain-free therapy for breast capsular contractures. In addition to inhibiting the contractures of these patients, the current PRP method yielded no significant complications; and the patients were able to immediately resume their usual activities post-treatment. In comparison to the conventional, surgical methods of treating capsular contractures, this technique with PRP is convenient, is less expensive, and does not carry the same complication risks as invasive procedures. This report also demonstrates that the introduction of PRP via transdermal electroporation and without surgery or injection is possible.

A greater patient sample size is required to confirm efficacy and an absence of significant side effects, and the authors are currently underway to evaluate these. It is plausible that the current technique may not remove a patient’s capsular contracture entirely; however, the aim here is to decrease the severity of the contracture; thereby, providing some relief without surgical treatment risks. This case report first illustrates the potential of PRP as a safe, efficacious modality that could be added to the armamentarium of managing breast capsular contractures.

Author contributions

All of the authors discussed, reviewed, and agreed with the final version of the manuscript.

Informed consent

Informed consent from the patients has been obtained for usage of their clinical details and clinical photographs for publication.

Disclosure statement

A provisional patent application for the described process has been filed.