Cases Of Capsular Contracture Research Articles

MAMAS (mastopexy–augmentation made applicable and safer): A standardized template of pre-operative marking and step-by-step surgical procedure

Simultaneous breast augmentation with mastopexy is growing in popularity. It is a complex procedure that can lead to post-operative complications, patient dissatisfaction, and increased risk of litigation. The aim of this study is to describe an approach for the inverted-T augmentation-mastopexy technique, which limits intraoperative modifications, minimizes errors, and decreases post-operative complications and patient dissatisfaction.The study included 107 patients with Regnault's grade I and II ptosis and severe pseudoptosis. All patients were marked according to our novel technique, Mastopexy Augmentation Made Applicable and Safer (MAMAS), and operated by a single surgeon. All patients underwent simultaneous breast augmentation with Siltex Mentor Round Silicone Gel breast implants and mastopexy. Pre-operatively and post-operatively, patients filled the BREAST-Q. The mean follow-up was 24 months.Hundred and seven women received treatment in this study. Sixteen presented with post-operative complications, eleven in the early stage of recovery, and five in the late stage. There were eight cases of minor wound healing complications, all treated conservatively. Two cases of infection were noted, both were treated with oral antibiotics. One patient experienced post-operative bleeding after 13 days, which required surgical revision. In the late stage of recovery, five cases of implant displacement occurred and required revision surgery. No cases of capsular contracture and seromas were reported. According to Breast-Q, all patients were satisfied.MAMAS surgical technique, focusing on precise pre-operative marking for augmentation-mastopexy, is simple and easily reproducible. The procedure has a low complication rate and high patient satisfaction. It provides predictable and stable results over time.

Excessive fibrosis and non-function after ATOMS (adjustable transobturator male system): A case of capsular contracture?

The adjustable transobturator male system (ATOMS) treats post-prostatectomy urinary incontinence by compression of the proximal bulbous urethra. It reminds of the Kaufman prosthesis described in 1978. We describe a case where an excessive fibrotic reaction occurred around the cushion. Furthermore, the bulbous urethra underneath, developed severe atrophy devoid of any visible blood supply. We suspect ongoing shear forces around the cushion while sitting resulting in a chain reaction of acute through chronic inflammation and progressive fibrosis and encapsulation. Does the encapsulation lead to capsular contracture resulting in non-function?

A multi-center, retrospective, preliminary observational study to assess the safety of BellaGel\xae after augmentation mammaplasty

BackgroundBellaGel® is the only cohesive silicone gel-filled breast implant from a Korean manufacturer, and it was first developed in 2005. It was approved by the CE in 2008, thus becoming the first Asian breast implant available in the EU. We conducted this study to assess the safety of BellaGel® in patients receiving augmentation mammaplasty.MethodsWe evaluated a consecutive series of 239 patients (478 breasts) who received esthetic augmentation mammaplasty using the BellaGel® (round smooth, round textured, round nanotextured, and anatomical textured types of implant) (HansBiomed Co. Ltd., Seoul, Korea) at three clinics in Korea (JW Plastic Surgery Center, BS The Body Plastic Surgery Clinic and Grace Plastic Surgery Clinic) during a period from December 1, 2015 to January 31, 2018.ResultsA total of 239 patients with a mean age of 33.1 ± 8.5 years old were followed up during a mean period of 399.58 ± 232.71 days, where there were no cases of capsular contracture in our clinical series of the patients. Other complications include one case (0.4%) of seroma, three cases (1.3%) of hematoma, and one case (0.4%) of infection. Moreover, there were no significant differences in the cumulative incidences of complications between the four types of the BellaGel® (χ2 = 2.322, df = 3, P = 0.508). Furthermore, the cumulative Kaplan-Meier survival rate was estimated at 0.979 (95% CI 0.961–0.997).ConclusionsOur results indicate that the BellaGel® is such a safe breast implant that surgeons might consider using it for esthetic augmentation mammaplasty.Level of evidence: Level III, risk/prognostic study.

SMS-Split Muscle Support: A Reproducible Approach for Breast Implant Stabilization.

Recent concerns regarding the association between macrotextured breast implants and anaplastic large cell lymphoma (ALCL) have led to renewed interest in the use of devices with less texturing. Smooth implants appear to have a decreased risk of ALCL; however, low implant adherence has led to questions about implant stabilization and bottoming-out. The senior author has used a split muscle support (SMS) technique to help support the implant infero-laterally in over 380 breast augmentations and augmentation-mastopexy using smooth implants, with a low complication and reoperation rate. A retrospective chart review of 387 consecutive breast augmentation and augmentation-mastopexy patients operated on by the senior author over 24months was performed. The SMS technique was classified in three grades according to amount of implant support by the pectoralis major muscle. Patients were followed for an average of 13months. Major complications occurred in seven (1.9%) patients, of which five (1.4%) were considered implant-related. There were one case of implant rotation and three cases of malposition during the transition from microtexture to nanotexture implants and one case of capsular contracture in a previously irradiated breast. Three post-massive weight loss patients required reoperation for further skin adjustment, and one patient requested upsizing of her implants at 3months. The SMS technique is easily reproducible, adjustable intraoperatively according to patient characteristics, and helps stabilize breast implants. With increasing patient awareness regarding ALCL, the association of smooth implants along with the varying degrees of implant support afforded by SMS can help achieve a low complication and reoperation rate. This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266.

Simple prosthesis versus prosthesis plus titanium-coated polypropylene mesh for implant-based immediate breast reconstruction after total mastectomy for breast cancer.

Our study compares the cosmetic effects, postoperative complications, and quality of life of immediate breast reconstruction with simple prosthesis or prosthesis plus titanium-coated polypropylene mesh (TCPM) after total mastectomy for breast cancer. In total, 69 patients who underwent total mastectomy, sentinel lymph node biopsy, and immediate prosthetic breast reconstruction from January 2015 to December 2018 in our hospital were selected, and their cosmetic effects, complications, and quality of life after reconstruction were recorded immediately after surgery and 6 months after surgery. Of these 69 patients, 29 were in the simple prosthesis group and 40 in the prosthesis + TCPM group. The incidence of surgical complications was 17.2% in the simple prosthesis group (5/29; including 4 cases of capsular contracture and 1 case of infection) 15.0% in the prosthesis + TCPM group (6/40; 1 case of flap necrosis, 2 cases of poor wound healing, 2 cases of hematomas, and 1 case of inadequate blood supply to nipple). The complications were successfully managed after symptomatic treatment in both groups. No prosthesis loss was noted. The incidence of postoperative complications showed there to be no significant differences between these two groups (P=0.06, χ2=0.80). The satisfaction rate of patients on cosmetic effects was 95.0% (38/40) in the prosthesis + TCPM group, significantly higher than that in the simple prosthesis group (75.90%, 22/29) (P=0.05, χ2=3.87). The quality of life in the simple prosthesis group at 2 weeks and six months after the operation was significantly lower than that in the prosthesis + TCPM group. The incidence rate of arm pain and fatigue at 2 weeks after operation was significantly higher than that in the prosthesis + TCPM group (P=0.04, χ2=4.42). The satisfaction of family life and sexual interest 6 months after the operation was also significantly lower in the simple prosthesis group than in the prosthesis + TCPM group (P=0.03, χ2=4.95). Breast reconstruction with prosthesis combined with TCPM does not increase surgical complications and has a good cosmetic effect and high patient satisfaction. Thus, it is a safe and reconstruction method.

Does Implant Surface Texture Affect the Risk of Capsular Contracture in Subglandular Breast Augmentation and Breast Augmentation-Mastopexy?

Previous studies have reported decreased rates of capsular contracture associated with the use of textured surface breast implants placed in the subglandular plane during breast augmentation. However, since the publication of these studies, our understanding of the pathophysiology of capsular contracture, as well as the surgical techniques utilized to minimize bacterial contamination of the implant, have advanced considerably. The purpose of this study was to re-evaluate the relation between implant surface texturization and capsular contracture rates for breast implants placed in the subglandular plane during primary breast augmentation. Retrospective chart review was performed of all primary subglandular breast augmentation procedures involving the use of either smooth or textured round silicone gel implants, with or without simultaneous mastopexy. The primary outcome measures included clinically significant capsular contracture (Baker grade III/IV) and revision surgery for capsular contracture. Between 2010 and 2017, 526 patients underwent primary subglandular breast augmentation with either smooth (n = 212) or textured (n = 314) round silicone gel implants; 248 patients underwent breast augmentation, whereas 278 underwent breast augmentation-mastopexy. Average follow-up was 756 days in the textured group and 461 days in the smooth group. Five cases of capsular contracture were observed in the textured group, and 7 cases of capsular contracture were observed in the smooth group (P = 0.20). Smooth surface implants placed in the subglandular plane were not at a significantly increased risk of capsular contracture compared with textured surface implants. We suggest that adherence to a surgical technique focused on minimizing bacterial contamination of the implant is of greater clinical significance than implant surface characteristics when discussing capsular contracture.

Correction of animation deformity with subpectoral to prepectoral implant exchange

Breast animation deformity is a known complication associated with submuscular prosthetic breast reconstruction. Patients often will present months to years after their initial reconstruction complaining of chronic pain and visible contraction deformity of their chest, with minimal voluntary activation of their pectoralis musculature. This is aesthetically displeasing and physically uncomfortable. Our preferred method for addressing existing animation deformity and alleviating patients' symptoms involves reoperation, with implant pocket conversion to the prepectoral plane, with acellular dermal matrix (ADM) coverage. We performed a retrospective review of all patients who underwent prepectoral conversion of their breast reconstruction for correction of animation deformity with the senior author (HS) between March 2016-April 2018. Demographics, operative details, and post-operative outcomes were assessed. Thirty-one patients underwent 55 revision breast reconstructions for a history of significant animation deformity following their initial submuscular breast reconstruction. All initial breast reconstructions were done with partial muscular coverage of their implant at the time of reconstruction. All patients experienced complete resolution of animation deformity without recurrence. Unplanned return to the operating room occurred in 14.5% of reconstructions. This was four cases of capsular contracture, three infections and one hematoma evacuation. Overall rate of infection requiring intravenous antibiotics was 14.5%. One patient lost both of her reconstructed breasts for an overall implant loss rate of 1.8% implant coverage with ADM was performed in 83.6% of cases, whereas 16.4% of reconstructions were performed with implant pocket change alone. The cohort that did not use ADM had a 44.4% instance of capsular contracture requiring reoperation, compared to a 0% rate of capsular contracture when ADM was used (P<0.01). Implant pocket change from the submuscular plane to the prepectoral plane is a safe and effective means of addressing submuscular associated breast animation deformity. The application of preoperative fat grafting and intraoperative ADM coverage contributes towards lower rates of complications and decreases the need for revisionary procedures.

Trans-Vertical Mastectomy With Immediate Implant-Based Reconstruction: A Retrospective, Observational Study

BackgroundIn women with large and ptotic breasts who require a mastectomy and immediate, implant-based reconstruction, long flaps pose a high risk for flap ischemia and necrosis. A new trans-vertical incision for skin-reducing mastectomy is described, which reduces the skin envelope and lifts the breast.ObjectivesThe authors sought to describe the new mastectomy access incision and assess its efficacy and safety when followed by immediate implant-based reconstruction.MethodsThis retrospective analysis included 70 consecutive patients (101 breasts) with large and ptotic breasts who underwent a unilateral (n = 39; 55.7%) or bilateral (n = 31; 44.3%), skin-reducing mastectomy utilizing the trans-vertical approach for either breast cancer or risk reduction. All received immediate one- (n = 86; 85.5%) or two-stage (n = 15; 14.5%), implant-based reconstruction utilizing acellular dermal matrix.ResultsMean age was 50.1 years and mean body mass index was 25.6 kg/m2. After a median follow-up of 4.9 years, the number of breasts with minor and major complications was 21 (20.8%) and 26 (25.7%), respectively. The most common major complications were skin-flap necrosis (n = 12; 11.9%) and infection (n = 8; 7.9%). All occurred within 3 months postsurgically. There were 7 cases of capsular contracture (6.9%) and 5 reconstruction failures (5.0%). Higher body mass index (P < 0.01) and breast weight (P < 0.05) were associated with increased complication rates. According to BREAST-Q, 55/64 patients (85.9%) were somewhat or very satisfied with the aesthetic outcome.ConclusionsThe trans-vertical approach is an effective, reproducible, and safe alternative to conventional skin-reducing mastectomy, with favorable aesthetic outcomes, in patients with large and ptotic breasts.Level of Evidence: 4

Does the Use of Intraoperative Breast Sizers Increase Complication Rates in Primary Breast Augmentation? A Retrospective Analysis of 416 Consecutive Cases in a Single Institution.

Background. Is the use of intraoperative breast sizers beneficial for plastic surgeons or do they result in higher complication rates? Methods. This is a retrospective study of 416 consecutive cases of primary breast augmentation with silicone implants at the Plastic Surgery Service of Professor Ivo Pitanguy at the 38th Infirmary Santa Casa Misericórdia Hospital, Rio De Janeiro, from January 2011 to March 2014. 212 cases (51%) were carried out with use of intraoperative breast sizers with 204 cases (49%) without the use of implant sizers. This study compares the outcome of cases that employed the use of intraoperative implant sizers versus those that did not in terms of infection, hematoma/seroma formation, and capsular contracture. Results. Of 416 primary breast augmentation cases, there were 5 cases of infection (1.2%), 4 cases of seroma (1%), 3 cases of hematoma (0.7%), and 7 cases of capsular contracture (Baker's Grade III/IV)(1.7%). Total complication rate limited to infection, seroma, hematoma, and capsular contracture was 1.15% (95% CI 0.96–1.93%). There was a significant difference in the scores for breast sizers (M = 4.3, SD = 1.4) and no breast sizers (M = 2.3, SD = 0.87) conditions, t(8) = 2.79, p = 0.018. The use of implant sizers was correlated with a higher complication rate. Conclusion. Good results could be obtained without the use of breast sizers in primary breast augmentation with use of a biodimensional tissue based planning system while eliminating risks of infection and reducing intraoperative time. Notwithstanding, in a residency program breast sizers can be an excellent training tool to shorten the learning curve in the novice surgeon.

Morpho-elasticity of inflammatory fibrosis: the case of capsular contracture.

Inflammatory fibrosis is a wound-healing reaction of the immune system in mammals against aggression. After a signalling cascade, fibroblasts and potentially myofibroblasts make a stiff collagenous tissue inside the body that modifies the original healthy tissue. We focus here on the implant-induced fibrosis that aims to encapsulate the implant with a typical fibrous tissue called the capsule. Focusing on breast capsules, we aim to understand the mechanical properties of these tissues, to test the validity of fibre models that have been established in other contexts such as arteries. For this purpose, we perform force–extension experiments and show that mechanical constitutive laws of these tissues are especially difficult to derive, because models are sensitive to fibre orientation and dispersion, independently of the variation between individuals. In addition, fibre breakdown, and possibly remodelling, occur during the extension experiments. However, the high stiffness of the capsular tissue, compared with the healthy tissue, added to the fact that an inflammatory process has no reason to cease, is at the origin of large compressive stresses in vivo, which explains the pain and unaesthetic deformity. We evaluate the stresses responsible for the pain and the buckling instability, which have no reason to stop if the inflammation persists.

Outcomes of Arthroscopic Hardware Removal Following Locked Plating of Proximal Humerus Fractures: A Prospective Study

the Visual Analog Scale (VAS), DASH questionnaire, American Shoulder and Elbow Surgeons Shoulder score (ASES), as well as the Constant score as outcome measures. Patients were examined by a non-treating physician to determine shoulder motion and strength of both the injured and contralateral upper extremity. A radiograph of the operated shoulder was obtained at the time of final follow up to measure the head-neck angle as well as to determine the presence or absence of post traumatic arthritis and avascular necrosis (AVN) in the humeral head. Results: The mean age of our patients at the time of surgery was 66.8 years (40.5 to 85.4). There were no intra-operative complications. Mean estimated blood loss (EBL) was 109 ml (10 to 300) and the mean operative time was 119 min (70 to 236). All patients were able to return to their pre-injury level of activity and all were satisfied with their result. The mean follow-up time was 5.9 years (1 to 13.5). The mean external rotation of the injured versus uninjured shoulder was 49 deg (25 to 85) vs. 59 deg (20 to 90) p1⁄40.003, internal rotation was to T10 (L5 to T6) vs. T9 (L1 to T4) p1⁄40.65, forward flexion was 143 deg (90 to 180) vs. 158 deg (110 to 180) p1⁄40.019, and abduction was 113 deg (60 to 180) vs. 120 deg (85 to 180) p1⁄40.07. The mean ASES score was 88.2 (33 to 100), DASH score 13.9 (0 to 73.3), and Constant score 68.9 (37.9 to 86.3). The mean head-neck angle was 129 deg (106-140). Post-operative complications included one case of subacromial impingement, 2 cases of avascular necrosis, one of which involved less than twenty-five percent of the articular segment with no collapse, and one with articular collapse that required revision to hemiarthroplasty. There was one case of capsular contracture requiring manipulation under anesthesia and arthroscopic capsular release 38 months after the index procedure. There were two cases of heterotopic ossification of which one required excision 5 months after the index procedure. There was one pin tract infection that resolved with oral antibiotics. Conclusion: The use of coral as a strut allograft is a simple, safe, and effective technique for the surgical treatment of 3 and 4-part valgus-impacted proximal humerus fractures leading to consistently high patient satisfaction.

Conservative mastectomies and immediate reconstruction with the use of ADMs.

In recent years, a novel approach to immediate breast reconstruction has been introduced with the advent of acellular dermal matrix (ADM). In the setting of conservative mastectomies where the native skin envelope is preserved, placement of ADM at the lower pole in continuity with the pectoralis major muscle (PMM) provides additional support, allowing direct-to-implant breast reconstruction. The following manuscript presents the senior author's experience with ADM-assisted reconstruction and provides a detailed description of surgical technique along with a comprehensive discussion of patient selection and potential complications. A retrospective chart review of patients undergoing direct-to-implant breast reconstruction following skin sparing or nipple sparing mastectomy with the use of ADM (AlloDerm; LifeCell Corp., Branchburg, USA) was conducted at Women's College Hospital in Toronto over a 5-year period [2008-2013]. Demographic data, previous radiation therapy and post-operative complications were recorded. A total of 72 patients representing 119 breasts were identified. Average follow-up was 16 months (range, 3-51 months). Twenty-seven complications were recorded for a complication rate of 22.7% (27/119). Complications included six cases of capsular contracture (Baker III/IV), five cases of red skin syndrome, four cases of rippling, three cases of dehiscence and two cases of seroma. Overall, direct-to-implant reconstruction was successfully completed in 97.5% of breasts (116/119). One case of infection was treated with explantation and conversion to autogenous reconstruction. Two breasts with tissue necrosis or dehiscence had the implants removed and replaced with tissue expanders. Overall reoperation rate was 9.7% (7/72 patients). ADM assisted direct-to-implant breast reconstruction has been shown to be a safe option for women who are candidates for skin sparing or nipple sparing mastectomies. Judicious patient selection, effective collaboration between the oncologic and reconstructive surgeon, careful evaluation of post-mastectomy skin flaps and precise surgical technique are paramount to the success of this technique.

Immediate Definitive Prosthetic Reconstruction in Patients With Ptotic Breasts

Immediate reconstruction of medium/large ptotic breasts can be performed by using expanders, definitive implants, or autologous flaps. If a skin-sparing mastectomy is feasible, excellent results can be achieved by planning Wise pattern incisions, using definitive implants. The authors suggest the use of a dermal-adipose flap, harvested from the ptotic part of the breast, rotated laterally, and interposed between the serratus fascia and the pectoralis muscle to close the inferolateral part of the pocket. We performed 23 immediate unilateral single-stage breast reconstructions, with simultaneous contralateral reduction. Preoperatively, all breasts showed grade II or III ptosis. There was no case of implant infection or failure of the reconstruction. The median follow-up was 21 months; however, some patients followed up for >4 years; in this period, no case of capsular contracture was observed. This technique has provided good shape, acceptable ptosis consistent with the healthy breast and symmetric scars.

One stage rescue procedure after capsular contracture of breast implants with autologous fat grafts collected by water assisted liposuction ("BEAULI Method").

With increasing number of patients with silicone implants for breast augmentation or reconstruction we are confronted with more and more cases of capsular contracture. Not every case is resolved by resection of the capsule and exchange of implants. Many patients rather bear the consequences of severe fibrosis than to have their implants removed. The one stage procedure of implant removal and lipofilling proved to be highly efficient with good to excellent results and high patient satisfaction. Between January 2008 and October 2012 a total of 64 patients (124 breasts) with capsular fibrosis Baker III to IV were treated with autologous fat grafts collected with the body-jet® by water-assisted liposuction (“BEAULI Method”). Magnetic resonance imaging (MRI) of the breasts was performed in 5 patients preoperatively and 6 month postoperatively, a clinical examination and photo documentation of all patients was done on day 1 and after 4 weeks, 12 weeks and 6 months postoperatively. The procedure included implant removal and lipofilling of the subcutaneous and intramuscular space in a single procedure by means of the BEAULI Method. The average gross amount of grafted fat was 260 ml. The average drainage time was one day. The shape of the breast changed to a more natural and ptotic form. Negative side effects like oily cysts or infections were not observed. The time of the overall procedure including liposuction was 70±15 min. Reoccurring capsular contracture is one of the hazards in plastic surgery. Until now the treatment of choice after more than two failed implant changes combined with resection of the capsule is usually the final removal of implants with or without possible additional autologous tissue transfer (microvascular flaps). We could add a relatively simple and efficient procedure to resolve and improve those cases by autologous fat transfer using water-assisted liposuction and the BEAULI Method.

Incidence of severe capsular contracture following implant-based immediate breast reconstruction with or without postoperative chest wall radiotherapy using 40 Gray in 15 fractions

Purpose To determine the incidence of capsular contracture (CC) requiring revisional surgery in patients receiving postoperative radiotherapy (RT) or no RT following mastectomy and immediate breast reconstruction. Material and methods One hundred and seventy-eight immediate breast reconstructions performed at the Cambridge Breast Unit between 1.1.2001 and 31.12.2005 were identified. RT was delivered using a standard UK scheme of 40 Gray in 15 fractions over 3 weeks. The influence of hormones and chemotherapy as well as postoperative RT on time to development of severe CC after implant-based reconstruction was explored in univariate and multivariate analysis. Results One hundred and ten patients had implant-based reconstructions with a median follow-up of 51 months. In the RT group (41 patients), there were 8 patients with severe CC requiring revisional surgery, a crude rate of 19.5%, with actuarial rates of 0%, 5%, 5%, 21%, 30% and 30% at 1, 2, 3, 4, 5 and 6 years follow-up. In the unirradiated group, there were no cases of severe CC. This difference is highly significant ( p < 0.001). Hormones and chemotherapy were not significantly associated with severe CC. Conclusions This series showed a significantly higher rate of severe CC with postoperative RT. This finding has important clinical implications, when counselling patients for immediate breast reconstruction.

Endoscopic transaxillary breast augmentation: Clinical evaluation of a series of 306 patients over a 9-year period

Transaxillary breast augmentation was described in the early 1970s. While the traditional blind operation continues to be advocated, the use of endoscopic assistance has been gaining acceptance since its first presentation about 12 years ago. This clinical study presents a series of 306 consecutive patients, who underwent endoscopic transaxillary breast augmentation over a 9-year period between 1996 and 2005-the largest series reported to date for this procedure. An initial 4- to 5-cm incision was made high in the axilla. Dissection was carried out to create an adequate tunnel for insertion of the implant. A subglandular, subfascioglandular, or submusculofascial pocket, depending on the individual case, was developed with endoscopic assistance. Injections of methylene blue through the different anatomic planes proved useful in the dissection of the pocket at the inframammary fold. In our series of 306 patients, we were able to achieve a hidden scar without compromising the aesthetic result. Complications included 3 hematomas, 5 cases of capsular contracture, 1 case of postoperative infection, and a 6.2% reoperation rate to correct implant malposition. Endoscopic transaxillary breast augmentation makes it possible to treat the same deformities, with the same refinements, as the more traditional approaches. The absence of scar in the breast aesthetic unit explains patients' interest in this operation. The technique has withstood the test of time. It has been found to be safe, has a relatively easy learning curve, and produces consistent results.