Capsulectomies are performed with scar tissue release to remove circumferentially around the implant from the underbelly surface of the pectoralis major muscle or in the retromammary plane directly from the breast tissue.
Severe encapsulation and a Baker IV capsular contracture usually requires some form of scar tissue removal through a capsulectomy. Patients who have very thin ectomorphic build and have minimal breast tissue may only be able to undergo capsulotomy with releasing the scar tissue; however, not removing much of any in order to prevent visibility and rippling of the implants.
An experienced Board Certified Plastic Surgeon should understand the difference between the scar tissue removal versus release and when to remove versus release the scar tissue only.
Two patients 2. There was no significant difference in recurrence rates comparing patients whose intact implants were reinserted Povidone—iodine irrigation did not affect the recurrence rate.
Capsular contracture was corrected with 1 procedure in Open capsulotomy is a safe and effective treatment that avoids the additional morbidity and cost of a capsulectomy. The findings challenge the infected biofilm theory of capsular contracture. Open capsulotomy deserves reconsideration by plastic surgeons. The prevailing explanation for capsular contracture is chronic inflammation caused by a bacterial biofilm.
Recurrence rates after surgical treatment are sparsely reported. Capsulectomies require greater dissection than open capsulotomies, increasing the level of difficulty, operating time, and patient discomfort. However, open capsulotomies are typically regarded as inadequate, and more disposed to recurrence of a capsular contracture. Although open capsulotomies were commonly performed in the s, 16 this procedure was largely replaced by capsulectomy 17 after investigators implicated bacterial biofilms as a cause of capsular contractures.
Clinical experience with earlier generation implants should not be relied upon when evaluating third- generation devices. A retrospective chart review was conducted from to All women who underwent an open capsulotomy by the author were included.
Three patients with extensive capsular calcification, treated with capsulectomies, were excluded. Breast reconstruction patients were also excluded. This study was determined to be exempt from institutional review board oversight by Chesapeake Institutional Review Board Services.
All patients underwent outpatient surgery using total intravenous anesthesia Fig. An inframammary approach, usually along the original scar, was used exclusively. This approach optimizes exposure.
The existing capsule was circumferentially incised either partially or totally Fig. In patients with existing subpectoral pockets, the original expanded pockets were reused, with no attempt to dissect a new tissue plane. When the original implants were subglandular, a new submuscular pocket was developed whenever possible, 5 , 7 with no attempt to remove or suture the original capsule.
New subpectoral pockets were created using sharp dissection to release the inferior pectoralis origin, and blunt dissection of the pocket. Treatment algorithm.
Implant manufacturers now provide free replacement implants for variable periods 3—10 y after implantation. This year-old woman developed a Baker III capsular contracture after her breast augmentation using Mentor smooth, round, Moderate Plus profile saline-filled implants inflated to cc. She is seen before A, D and 1 month after her breast augmentation B, E.
Two months after her breast augmentation, she underwent a right open capsulotomy with reinsertion of the same implant in the same subpectoral pocket. The hatched line indicates the capsulotomy incision. She is seen 1 month after the capsulotomy C, F. She had no recurrence. Dilute povidone—iodine solution was used before Only saline solution was used for irrigation subsequently because of probably unwarranted 21 concerns regarding the effect of antibiotics on implants.
Patients were instructed to wear a bra day and night for at least 2 weeks, not to massage their breasts, and to avoid vigorous physical activity for 1 month. A chi-square test was used to compare categorical data. The cumulative incidence of capsular contractures per patient was estimated using Kaplan—Meier analysis, calculated from the date of implant insertion to the date of the reported complication.
In 68 patients Among the 7 patients with subglandular implants, 6 were changed to a subpectoral pocket. The mean time lapse between implantation and diagnosis of a capsular contracture was 4. The mean interval between the first open capsulotomy and diagnosis of a recurrent contracture was 8. Time interval between the original breast augmentation and diagnosis of capsular contracture in 75 consecutive women treated with open capsulotomy during to Seventeen patients Fifteen women were re-treated; 2 women elected not to have additional surgery.
In 12 women including 3 bilateral contractures, only 1 of which recurred on both sides , the recurrence was on the same side, and in 5 patients the recurrence was on the contralateral side. Thirteen patients were found to have ruptured silicone gel implants or silicone bleed at surgery; 9 of these patients had recurrences Kaplan—Meier analysis: Cumulative incidence of recurrent capsular contracture in 17 consecutive women after open capsulotomy.
The most common complication was a recurrent capsular contracture Although not part of the study group, the 3 women treated with capsulectomies heavily calcified capsules during the study period did not experience recurrences. Allergan Irvine, Calif. The group sizes were insufficient for comparison of capsular contracture rates by manufacturer. In all 3 studies, second-generation devices had been implanted between and and many of the women had undergone closed capsulotomies.
Other studies of capsulectomy, all published after , 3 , 17 , 25 , 26 evaluated women with third-generation implants. Costagliola et al 25 reported no recurrences after capsulectomies, but these patients were treated with steroids. Caffee 26 reported a recurrence rate of In , Hester et al 3 reported a Silicone leakage into the tissues is known to increase the inflammatory response and increase the risk of contracture.
Improved implant design compromises any comparison of open capsulotomies performed decades ago with capsulectomies performed more recently, 7 hence the need for evaluation of open capsulotomy in women treated with third-generation devices.
A prospective cohort study comparing capsulotomy and capsulectomy would be ideal, but impractical in view of the requirement for equipoise. Infection as a factor predisposing to capsular contracture is supported by numerous microbiological studies that have cultured organisms from the capsule. Reaching beyond a correlation, some researchers now claim that bacterial biofilm infections cause capsular contracture.
There are problems with the theory of a purely infectious etiology. Positive and negative bacterial cultures from implants and capsules may be obtained from women with and without capsular contractures. Capsular contractures can occur years after implantation and the cumulative risk increases over time Fig. Capsular contractures occur more frequently after breast reconstruction using implants.
Curiously, a histological study 42 found that mast cells, the predominant inflammatory cell in hypertrophic scars, disappear as the capsular contracture becomes more severe. These investigators 43 theorize that stressful stimuli might lead independently to inflammation and a biofilm. Paradoxically, antimicrobial therapy may even induce biofilm formation to confer resistance. The limitations of an infectious etiology are evident in the clinical findings of this study.
An open capsulotomy leaves all of the capsule and biofilm in the patient, virtually guaranteeing treatment failure. Yet, this simple maneuver is The success rate is even higher in patients with intact implants, in whom free silicone gel is not a factor; Moreover, there was no change in the recurrence rate after povidone—iodine irrigation was replaced with saline irrigation. Another theory for capsular contracture is based on the mechanical action of myofibroblasts 1 , 7 , 9 , 43 , 46 , 47 and abnormal collagen deposition.
Triple antibiotic irrigation is recommended. However, as with the comparison of capsulectomy and capsulotomy, the difference in implant shell integrity is a confounding factor. An open capsulotomy in women treated in the s with second-generation implants 11 , 12 , 15 is more likely to fail in the presence of ruptured implants and silicone bleed. An open capsulotomy limits the wound area and theoretically minimizes inflammation and fibroblast activity by preserving the existing capsule.
The subpectoral location seems to be at a lower risk for capsular contracture, 1 , 5 , 6 , 16 , 56 a finding often attributed to more separation from nonsterile breast tissue, 1 , 6 , 18 , 19 although there is still plenty of contact. Plast Reconstr Surg Glob Open. Arch Plast Surg. Nahabedian, M. July Complications of reconstructive and aesthetic breast surgery.
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