Severe Capsular Contracture Research Articles

The Effects of Postmastectomy Adjuvant Radiotherapy on Immediate Two-Stage Prosthetic Breast Reconstruction

The authors performed a systematic review of the literature on the outcome of therapy for patients with breast cancer who underwent adjuvant radiotherapy after an immediate two-stage prosthetic breast reconstruction, either following tissue expansion (stage 1) or after removal of the tissue expander and insertion of a final breast implant (stage 2). Their outcomes were compared to those of patients who had reconstruction without postmastectomy irradiation. Electronic database searches were supplemented by a full-text review of possible relevant articles on two-stage prosthetic immediate breast reconstruction and radiotherapy. Delayed or one-stage prosthetic or nonprosthetic breast reconstruction studies were excluded. The primary outcome measured was the reconstruction failure rate with prosthesis loss. Secondary endpoints were capsular contracture and aesthetic outcome. No randomized controlled trials were identified, and only one prospective, nonrandomized, multicenter trial was found. Reports with more than 15 patients were included; 12 studies had a total of 1853 patients (715 irradiated and 1138 nonirradiated). Adjuvant radiotherapy resulted in a significantly higher reconstruction failure rate in immediate two-stage prosthetic breast reconstruction compared with controls (18.6 percent versus 3.1 percent, p < 0.00001). Radiotherapy particularly increased the failure rate when given after stage 1 (expander) (29.7 percent versus 5 percent, p < 0.00001) but also stage 2 (permanent implant) (7.7 percent versus 1.5 percent, p = 0.0003). There was also an increase in severe capsular contractures and an inferior cosmetic result in the irradiated patients. Nonrandomized studies suggest that adjuvant radiotherapy results in a higher risk of reconstruction failure.

Influence of curing agent on fibrosis around silicone implants

Severe capsular contracture around silicone expander breast implants leading to pain and failure is a major clinical problem. Even though earlier studies have implicated the immunogenicity of silicone, the role of physical and chemical properties of the silicone material in excessive collagen deposition and fibrosis has been less addressed. The present study investigates whether there is any correlation between the type of curing systems i.e. addition and free radical curing and the fibrosis around silicone elastomer. The experiment carried out uses commercially available silicone ventriculo-peritoneal shunt material elastomer cured by platinum and the results are compared with results obtained in a similar study carried out by the authors using commercially available silicone tissue expander material cured by peroxide. Ultra-high molecular weight poly-ethylene (UHMWPE), the standard reference for biocompatibility evaluation, was used as the control material. The materials were implanted in rat skeletal muscle for 30 and 90 days. Inflammatory cells, myofibroblasts, cytokines, and collagen deposition at the material–tissue interface were identified by haematoxylin–eosin and Masson’s Trichrome stains and semi-quantitated based on immunohistochemical studies. Results indicate that even though the cellular response in the initial phase of wound healing was similar in both platinum and peroxide-cured materials, the collagen deposition in the proliferative phase was more around peroxide-cured material in comparison to the platinum-cured silicone elastomer. There is a need to look into the molecular mechanisms of this interaction and the possibility of using curing systems other than free radical peroxide in the manufacture of silicone elastomer expanders for breast prosthesis.

Delayed Breast Implant Reconstruction

We evaluated the association between radiation therapy and severe capsular contracture or reoperation after 717 delayed breast implant reconstruction procedures (288 1- and 429 2-stage procedures) identified in the prospective database of the Danish Registry for Plastic Surgery of the Breast during the period between 1999 and 2006. A history of radiation therapy was associated with increased risk of severe capsular contracture for 1- and 2-stage procedures, with adjusted hazard ratios (HR) of 3.3 (95% confidence interval [CI]: 0.9-12.4) and 7.2 (95% CI: 2.4-21.4), respectively. Similarly, a history of radiation therapy was associated with a non-significantly increased risk of reoperation after both 1-stage (HR = 1.4; 95% CI: 0.7-2.5) and 2-stage (HR = 1.6; 95% CI: 0.9-3.1) procedures. Reconstruction failure was highest (13.2%) in the 2-stage procedures with a history of radiation therapy. Breast reconstruction approaches other than implants should be seriously considered among women who have received radiation therapy.

Delayed breast implant reconstruction: A 10-year prospective study

Studies of complications following reconstructive surgery with implants among women with breast cancer are needed. As the, to our knowledge, first prospective long-term study we evaluated the occurrence of complications following delayed breast reconstruction separately for one- and two-stage procedures. From the Danish Registry for Plastic Surgery of the Breast, which has prospectively registered data for women undergoing breast implantations since 1999, we identified 559 women without a history of radiation therapy undergoing 592 delayed breast reconstructions following breast cancer during the period 1999 to 2006; 239 one-stage procedures and 353 two-stage procedures. The postoperative course through November 2009 was evaluated by cumulative incidence adjusting for competing risks for the selected outcomes; hematoma, infection, seroma, implant rupture, severe capsular contracture (modified Baker III and IV), extrusion of the implant, asymmetry/displacement of the implant, any complication, and reoperation. These analyses were performed both overall and separately according to type of procedure (one- or two-stage). The overall 10-year risk estimates were 68.1% for any complication, 7.7% for severe capsular contracture, 32.3% for displacement/asymmetry of the implant and 38.6% for reoperation. When comparing one- and two-stage procedures, we observed significantly higher risk estimates for infection, seroma and extrusion of the implant following two-stage procedures, whereas the risk of reoperation was significantly higher following the one-stage procedure. For both procedures, the majority of reoperations were due to asymmetry or displacement of the implant. In conclusion, non-radiated one- and two-stage delayed breast implant reconstructions are associated with substantial risks of complications and reoperation which should be taken into consideration in the planning of breast reconstruction.

Breast reconstruction with polyurethane implants: preliminary report

Today, immediate breast reconstruction is widely accepted in breast cancer surgery. There are many reconstruction procedures that combine cancer indications with patient's expectations. Improved techniques in the use of textured or polyurethane-coated implants and tissue expanders, associated with increasingly more conservative mastectomy procedures, may result in better cosmetic outcomes and less complications, even in patients that require postoperative radiotherapy. From June 2002 to December 2008, 166 unilateral breast reconstructions were performed immediately using definite prosthesis with polyurethane-coated (6) or textured (24) implants, or later, after implant of 136 tissue expanders, using polyurethane-coated (113) or textured (23) implants. Eighty-six two-stage breast reconstructions were irradiated where later 63 polyurethane-coated implants and 23 textured implants have been inserted. Results were analysed evaluating complications associated with temporary expanders and with the two definite implants, with or without RT, respectively. Excluding capsular contracture, total complication rate was 14.7% with expanders, 5.0% with polyurethane implants and 12.8% with textured implants. In this study, severe capsular contracture was reported in 21.7% of cases with textured prosthesis and in 6.3% of cases with polyurethane implants in patients receiving RT. This difference was statistically significant. As of today, no case of clinically noticeable capsular contracture was seen in non-irradiated patients receiving breast reconstruction with polyurethane-coated implants. These results allow us to establish RT, which is not a severe contraindication to breast reconstruction with implants. Polyurethane implants have provided encouraging results either in terms of lower complication rate and likelihood of capsular contracture.

The clinical course of immediate breast implant reconstruction after breast cancer

Background. The number of women suitable for breast conserving treatment as well as immediate reconstruction after breast cancer has been increasing, and studies of complications hereafter are needed. Material and methods. The cohort was identified in the prospective database of the Danish Registry for Plastic Surgery of the Breast during the period 1999 to 2006; 167 women with 189 immediate breast reconstructions (40 one-stage and 149 two-stage procedures) after breast cancer without a history of radiation therapy. The women were followed for complications until November 2009. Cumulative incidence risks were computed for infection, hematoma, seroma, severe capsular contracture (modified Baker III and IV), extrusion of the implant, implant rupture, asymmetry/displacement of the implant, any complication, and reoperation. In addition, we compared the postoperative course of immediate two-stage procedures with delayed two-stage procedures. Results. The overall eight-year risk estimates for the immediate procedures were 76.4% for any complication, 5.3% for severe capsular contracture, 29.5% for displacement/asymmetry of the implant and 40.6% for reoperation. Significantly higher risk for reoperation was observed after immediate one-stage than after two-stage procedures. For immediate two-stage procedures acute complications such as infection, seroma and hematoma were higher in the expansion period than after the second planned surgery. Higher risks for acute complications were observed after immediate than after delayed two-stage procedures. Conclusion. Immediate breast implant reconstruction was found to have substantial risks of complications in non-radiated women, which should be considered in the guidance of breast cancer patients before choosing reconstructive procedure.

Perforator Flap Breast Reconstruction After Unsatisfactory Implant Reconstruction

In 2009, 86,424 breast reconstructions were performed in the United States, with 76% being implant-based procedures. Capsular contracture and infection are the 2 most cited indications for implant explantation, resulting in a reconstruction failure. However, several patients are dissatisfied with implant reconstruction even without the aforementioned complications. We hypothesize that microvascular autologous tissue transfer with perforator free-flap breast reconstruction provides an excellent salvage modality in the face of an unsatisfactory implant reconstruction, resulting in an improved cosmetic and functional outcome, with low risk of complications. We retrospectively reviewed the charts of patients in the senior author's practice who underwent perforator flap breast reconstruction between the years 1998 through 2008, and identified all patients who had prior implant reconstruction. Indications for implant explantation, medical history, operative procedure, and postoperative complications were reviewed. During the study period, 1846 perforator flaps were performed. We found 191 patients who underwent autologous breast reconstruction after implant reconstruction with a total of 284 flaps (15.4%). The most frequent patient complaint was unnatural appearance and feel of the implants (Baker I or Baker II), and the majority of patients had not undergone radiation. Most patients were reconstructed using abdominal flaps with 164 deep inferior epigastric perforators, 50 superior gluteal artery perforators, 30 superficial inferior epigastric arteries, 35 inferior gluteal artery perforators, and 5 transverse upper gracilis. The total complication rate was 7.4%, with most complications related to wound healing at the donor site. There were 3 flap losses (1%), all of which were later successfully reconstructed with another perforator flap. Implant failures are traditionally thought to be in patients with Baker grade III/IV capsular contractures and in patients status post radiation therapy. However, in our study, the majority of patients seeking perforator flap reconstruction after implant reconstruction complained of an unnatural feel and appearance of their breasts, and did not have a severe capsular contracture deformity (Baker III/IV), nor had they undergone radiation. This suggests that implant reconstruction can lead to patient dissatisfaction severe enough to warrant removal even with Baker I/II results, and not in the setting of postradiation changes.

Local Complications after Cosmetic Breast Augmentation

Prospective long-term data on the occurrence of complications following breast augmentation are sparse and the reported frequencies differ substantially.The Danish Registry for Plastic Surgery of the Breast has prospectively registered preoperative, perioperative, and postoperative data for women undergoing breast augmentation in Denmark since 1999. From the Registry, the authors identified 5373 women with a primary cosmetic breast augmentation between 1999 and 2007. The authors calculated incidence proportions of adverse clinical outcomes within three time intervals (0 to 30 days, 0 to 3 years, and 0 to 5 years) after primary implantation. Outcomes of primary interest were capsular contracture, asymmetry/ displacement of the implant, hematoma, and infection.During the entire follow-up period (mean, 3.8 years; range, 0.1 to 8.7 years), 16.7 percent of the women were registered with an adverse event and 4.8 percent of the women were registered with a surgery-requiring complication. The most common adverse events within 30 days were hematoma (1.1 percent) and infections (1.2 percent), whereas the most common adverse events within 5 years were change of tactile sense (8.7 percent) and asymmetry/ displacement of implant (5.2 percent). Within 5 years, 1.7 percent of the women had a record of severe capsular contracture. Displacement/asymmetry and capsular contracture were the most frequent indications for reoperation with removal or exchange of the implant.Population-based complication frequencies among women with cosmetic breast augmentation in a Danish nationwide implant registry were generally lower than those reported in other studies, although frequencies of complications increased with length of follow-up.

Refractory Elbow Arthrofibrosis

Most patients with elbow stiffness have contractures proportional in severity to the initial insult. However, there is a subset of individuals who have stiffness after relatively minor events and who experience repeated early recurrences after soft-tissue contracture release. The purpose of the present report was to describe the clinical features and outcomes for patients presenting with such a condition, which we term refractory elbow arthrofibrosis. The elbow has a certain propensity for the development of stiffness after injuries or surgery1,2. Contracture of the capsule with extensive fibrosis is a central pathologic element in most stiff elbows, but the severity of capsular fibrosis varies considerably from patient to patient. There is some association between the severity of the initial insult to the joint and the intensity of the fibrotic capsular response. Several studies have documented predictable and permanent improvements in motion when the abnormal capsule is surgically removed3-6. Over the last few years, we evaluated and managed a subset of individuals who had a severe capsular contracture that was out of proportion to the relatively benign nature of the initial insult and who had a persistent tendency to experience recurrent contractures despite repeated treatment attempts. We are unaware of other reports of this condition. We used strict criteria to include patients in this report, recognizing that there is a spectrum of severity of this condition. Although the intimate biologic mechanisms underlying this fibrotic response are yet to be elucidated, the purposes of this study were to describe the clinical features and treatment outcome of this condition, to caution against multiple surgical attempts in this patient population, and to stimulate the exploration of alternative diagnostic and potential biologic treatment modalities. Institutional review board approval was obtained. The patients were informed that data concerning their …

Modification of Cysteinyl Leukotriene Receptors Expression in Capsular Contracture

Periprosthetic capsular contracture represents a specific iatrogenic phenomenon with different side effects. Recently, interesting data have disclosed a potential role of leukotrienes as important mediators of inflammation in the reactivation process of capsular contracture. Some preliminary studies have assessed the efficacy of leukotriene antagonists in the prevention and treatment of capsular contracture. These clinical data are still lacking of a potential biomolecular basis. The aim of our present study was to evaluate the expression of the protein receptor cysteinyl leukotriene receptors (CysLTR). We included 50 patients with severe capsular contracture (Baker III-IV) and a control group consisting of healthy patients who underwent an implant replacement. In both groups, we performed the protein extraction and semiquantitative analysis for the determination of protein concentration on myofibroblasts and macrophages. Western Blot analysis of protein levels shows a significant increase in the expression of CysLTR in patients with capsular contracture. Our final results show that the increase in the levels of mRNA coding for CysLTR actually translates into an effective increase in protein levels of these mRNA transcripts. These findings could at least partially provide a biomolecular basis that justifies the use of specific antileukotriene drugs in the treatment of this disease.

Experience with the Mentor Contour Profile Becker-35 expandable implants in reconstructive breast surgery

Round expander-implants (Beckers 25 and 50) and anatomical expander-prostheses filled with firm cohesive gel (McGhan Style 150) are established choices for single-stage expander breast reconstruction. Because of their drawbacks we selectively adopted the anatomical Becker-35 expander-implant filled with soft cohesive gel from January 2005. All patients undergoing reconstructive breast surgery using the Contour Profile Becker-35 expandable implant over a two-year period were retrospectively reviewed with respect to indication, implant sizes, inflation details, complications and outcomes. 36 patients, mean age 48.9 years (r=14-69), received 39 anatomical Becker-35 expanders (three bilaterally). Three quarters of these implants (29) were used for immediate breast reconstruction while the remainder were equally divided between delayed postmastectomy reconstruction (5) and correction of congenital breast asymmetry (5). Half of the patients had simultaneous latissimus dorsi myocutaneous flap coverage of the implants. The median numbers of inflations and deflations needed to achieve the target expansion size and shape were 3 (r=0-7) and 0 (r=0-4), respectively. The mean time from expander insertion to completion of reconstruction was 4.6 months (r=0-13 months). Four patients required surgical intervention for haematoma, implant infection, severe capsular contracture, and palpable rippling. Additionally there were three injection port adjustments, giving a 20% overall revisional surgery rate (8/39 breasts) after a median follow-up of 20 months (r=6-38 months). Four implants (10%) developed significant but asymptomatic rippling. The significant capsular contracture rate was 21% (8/39 breasts), which was related to chest wall radiotherapy. In this short-term study, the Becker-35 expander was successfully used for single-stage prosthetic breast reconstruction with an incidence of early complications comparable to alternative prostheses. Although it has expanded the range of implants available to the breast surgeon, its exact role in reconstructive breast surgery has yet to be established.

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.

Effects of an Autologous Flap Combined with an Implant for Breast Reconstruction: An Evaluation of 1000 Consecutive Reconstructions of Previously Irradiated Breasts

The goal of the authors' study was to determine whether an autologous tissue flap, when combined with an implant for breast reconstruction, reduces the incidence of implant-related complications in previously irradiated breasts. The authors reviewed 1000 consecutive cases of implant-based breast reconstructions performed in 706 patients at the authors' institution. The median age was 49.5 years, and mean follow-up was 22.2 months. Eighty-six patients (8.6 percent) received preoperative radiation therapy and 43 patients (4.3 percent) received postoperative radiation therapy to the reconstructed breast. Breast reconstructions were performed using an expander/implant alone in 776 cases, a latissimus dorsi flap/implant in 146 cases, and a free transverse rectus abdominis musculocutaneous (TRAM) flap/implant in 78 cases. Implant-based reconstructions were considered to have failed if an implant was lost because of extrusion, infection, or rupture or if implant exchange was required because of a severe capsular contracture. In patients who had undergone preoperative irradiation, patients with free TRAM flap/implant reconstructions had a significantly lower implant loss rate than patients with expander/implant-only reconstructions (5.0 percent versus 30.3 percent, p < 0.04). Also, significantly fewer reconstructions failed in patients with latissimus dorsi flap/implant reconstructions or TRAM flap/implant reconstructions than in patients with expander/implant-only reconstructions (15.2 percent or 10.0 percent versus 42.2 percent, p < 0.03). An autologous flap, when combined with an implant for breast reconstruction, appears to reduce the incidence of implant-related complications in previously irradiated breasts.

O-74 Comparison of the incidence of severe capsular contracture following implant-based immediate breast reconstruction with or without postoperative chest wall radiotherapy using 40 Gy in 15 fractions

O-74 Comparison of the incidence of severe capsular contracture following implant-based immediate breast reconstruction with or without postoperative chest wall radiotherapy using 40 Gy in 15 fractions

The Infected Breast Prosthesis after Mastectomy Reconstruction: Successful Salvage of Nine Implants in Eight Consecutive Patients

The use of tissue expanders and permanent implants has an established role in breast reconstruction after mastectomy. Periprosthetic infection, however, represents a known complication. The most conservative approach to severe or recalcitrant prosthetic infection remains removal of the device. However, removal makes subsequent reinsertion and reexpansion more difficult, with less predictable cosmetic results. The authors believe that timely surgical intervention directed toward salvage of infected breast prostheses can be successful, without demonstrating increased capsular contracture. The authors present nine consecutive cases of infected breast implants (nine implants in eight patients). All patients had previously undergone mastectomy for malignancy and immediate expander/implant reconstruction. Six patients had localized infections that failed to respond to oral antibiotics and two women initially presented with systemic infection. All patients were placed on intravenous antibiotics followed by drainage of fluid, manual debridement and curettage of the infected pocket, device exchange, and postoperative antibiotics. All nine infected breast prostheses responded to this approach and currently remain intact and without recurrent infection. Mean time to follow-up for all patients was 14.6 months (range, 10 to 25 months). In patients with severely infected breast prostheses, timely operative intervention can salvage the previously "unsalvageable" implant; in addition, the surgically replaced implants did not develop severe capsular contractures. Surgical salvage of severely infected breast prostheses after mastectomy is a treatment option that should be considered when dealing with severe or recalcitrant infection in a suitable patient.

Modification of Cysteinyl Leukotriene Receptor Expression in Capsular Contracture

The development of a fibrotic capsule around foreign material in the body is a physiologic reaction undertaken by the body to protect itself from a material it does not recognize. The periprosthetic capsule can pathologically contract, pressing on the implant; it can cause pain, firmness, and sometimes implant extrusion. The pathogenesis of capsular contracture is still unclear, but most reports indicate a multifactorial explanation. The aim of this study is to investigate the role of cysteinyl leukotriene receptors (cysLTR) on the inflammatory cells involved in the development of the capsular contracture. We recruited 20 patients affected by severe capsular contracture (Baker III-IV) and a control group composed of normal patients who had undergone implant substitution. In both groups, we performed a semiquantitative analysis of mRNA encoding for cysLTR1, cysLTR2, tumor necrosis factor-alpha (TNF-alpha) and interleukin 10 (IL-10) on myofibroblasts and macrophages of the periprosthetic capsular tissue. The molecular analysis showed an increase in the cysLTR2, TNF-alpha gene expression but no change in the cysLTR1 and IL-10 genes in patients affected by capsular contracture. These preliminary findings suggest a primary role for cysteinyl leukotrienes in the activation and up-regulation of capsular contraction mechanisms.

Male body contouring

Richard A. Mladick, MD Joseph P. Hunstad, MD Gerald H. Pitman, MD Peter A. Vogt, MD Dr. Mladick: The first patient is a 27-year-old male athlete who would like to correct his pectus excavatum (funnel chest) (Figure 1). Dr. Hunstad, how would you approach this problem? Figure 1 This 27-year-old athlete wishes to correct his pectus excavatum. Dr. Hunstad: His degree of pectus excavatum is not severe enough to cause cardiovascular embarrassment, so this problem can be resolved with a purely cosmetic procedure. I use a moulage kit to create a customized semi-solid silicone implant to correct the pectus deformity. Dr. Mladick: When you have sculptured the implant with your moulage, assuming it needs to have tapered edges that do not stand out and create a noticeable ridge, how do you keep the edges of the implant flat? Dr. Hunstad: I have not had severe capsular contracture in my patients. If one of the implants gets a contracture, particularly along the thin edges, there is the risk that the edges might roll up and, perhaps, become palpable and visible. You cannot allow the edges of the new implant to be too thin, or it will actually fold and buckle with the natural healing forces. I lay Saran wrap (SC Johnson, Racine, WI) on the patient's skin (after marking the areas of deformity) so that the moulage does not stick to the skin. The moulage can be especially irritating for a man with chest hair. Dr. Mladick: Have you tried putting fixation patches on the undersurface of the implants to keep them in place and prevent edge “rollup?” Dr. Hunstad: Classically, with early breast implants, fixation patches were common. But I have not used these and have actually tried to place a slightly textured implant because of my concern about deformity from capsular …

Analysis of 30 Breast Implant Rupture Cases

The detection and evaluation of implant ruptures have been an issue for many years. If a ruptured implant is not removed, noncohesive silicone gel may spread to surrounding tissue, causing granuloma, redness of the affected skin, firmness of the breast tissue and skin, or distant migration [2]. When a ruptured or leaking saline type prosthesis is not removed or replaced with a new one, severe deformity of the breast may result. Once this occurs, I have found that many cases present difficulty in the reconstruction of the deformity to breasts with a symmetric appearance. The authors state that when they encountered rupture of a hydrogel breast implant, the gel had adhered to surrounding tissue, accompanied by inflammation and granuloma formation. Also, they state that the surgical procedure required removal of the granuloma and extensive debridement of the affected skin. Diagnostic methods used to detect implant rupture include a squeeze test, mammography, sonography, computed tomographic scan, and magnetic resonance imaging (MRI). Among these, MRI is reported to be the most reliable method for detecting rupture of the implant [1], which the authors article supports. Sonography is a valuable adjunct in the evaluation of only anterior breast parenchymal pathology. Furthermore, the sensitivity and specificity of sonography may vary depending on the experience of the attending radiologist. Mammography itself may cause implant rupture [3]. Also, patients with severe capsular contracture are unable to receive mammography. Recently, a patient in Japan noticed her breast implant rupture during the course of mammography. She subsequently sued the doctor, which raised the issue of how breast cancer should be checked among those with implants. In my opinion, mammography should not be used for patients with breast implants unless either a rupture or breast cancer are strongly suspected, as evidenced by other types of evaluations. At this point, however, MRI seems to be the most reliable imaging method for evaluating patients with breast implants. No diagnostic technique offers 100% accuracy in finding an early rupture or leak of saline, noncohesive silicone, or hydrogel breast implants. Probably the best way to check these conditions is to use a battery of techniques, which means checking local symptoms such as pain, mass, swelling, redness, and firmness; noting a change in the shape and size of the breasts; and administering the squeeze test, sonography, and MRI. Among these diagnostic procedures, the authors demonstrated that the linguine sign of the MRI is the most reliable for detecting signs of rupture or leaking of the implant. Because hydrogel implants are not so popular throughout the world, it is important to know what happens if ruptured implants are not removed after many years. The authors reviewed only one case of this type in their report. Further study is required to detect early signs of rupture or leaking hydrogel implants. With regard to the silicone type prosthesis, cohesive silicone implants currently are available in many countries. These cohesive silicone implants may rupture or leak. Furthermore, the degree of silicone cohesivity varies depending on product types or companies. More studies are required to determine whether the ruptured or leaking cohesive silicone breast implantmust be removed or replacedwith a new one. If this type of condition requires treatment, the question arises as to the best way of finding the leak or rupture of the cohesive silicone prosthesis. Because cohesive silicone implants are relatively new products becoming popular in the world, it is necessary to learn more information about this type of implant. As professional doctors, once we use breast implants for our patients, we are obligated to ensure that they are always happy with their breasts. Correspondence to: Email: info@mega-clinic.com Aesth. Plast. Surg. 29:470 471, 2005 DOI: 10.1007/s00266-005-0061-9

Dual-plane implant positioning for capsular contracture of the breast in combination with mastopexy

This study aims at combined surgical therapy options concerning patients with a clinically relevant and long-established capsular contracture following subglandular breast augmentation in a glandular ptotic breast. This is a review of 23 patients with capsular contracture. Three patients had a revision surgery for capsular contracture and implant dislocation before. The mean implant duration in the case of the twenty patients without any previous revision was 96 months. A revision implant has been re-located in a dual-plane position and further corrective surgery was carried out to adapt the glandular ptotic breast. Between 2001 and 2003, a chart review was performed on all patients for capsular contracture and ptotic breast by using the technique presented in this study. In each case, the operation was performed as a one-stage procedure. The procedure included the following steps: Removal of the implant and total capsulectomy, preparation of an inferior de-epithelialised skin pedicle above the inframammary crease, release of the inferior origins of the pectoralis major muscle, creation of a new implant pocket by continuous connection of the inferior muscle border with the cranial edge of the inferior skin pedicle (dual-plane), adaptation of the soft-tissue/skin envelope by closing the cranial V over the implant coverage, preservation of the areola by creating a cranial or cranial medial pedicle. There was a follow-up for a period of up to 48 months, and any complication that occurred was documented. At follow-up period, all patients who had been implanted with a new implant pocket were free of a clinically relevant capsular contracture. In the cases of a severe capsular contracture and glandular-ptotic breasts, we presented the surgical corrections of the parenchyma/skin envelop as a one-stage procedure following the establishment of a new implant pocket.

Die autologe Gewebetransplantation (TRAM/DIEP) als Therapieoption bei Kapselfibrose der Brust

Free microvascular abdominal tissue transfer (TRAM/DIEP) has become standard in breast reconstruction after mastectomy. A new indication for abdominal tissue transfer is severe capsular contracture after augmentation by implants. Capsular contracture following aesthetic or reconstructive augmentation mammaplasty occurs in only a small percentage of cases, but warrants adequate therapy. Between 1999 and 2003, six patients with an average age of 35 years with symptomatic capsular contracture after augmentation mammaplasty underwent autologous tissue transfer with the free TRAM/DIEP flap. The flap was harvested either with a perforator of the deep epigastric artery (DIEP) or as muscle sparing flap (TRAM) and was anastomosed to vessels of the subscapular system. Operation time was reduced by operating with two teams. Besides minor dog-ear deformities at the donor sites, no complications were noted. Postoperatively, neither, instability of the abdominal wall nor flap loss was seen. In some cases, a secondary mastopexy was necessary. Aesthetic results concerning natural feeling and breast symmetry were graded as excellent. In our experience, the free microvascular transfer of abdominal tissue (TRAM/DIEP flap) offers a treatment option for patients seeking alternatives other than repeated capsulectomies and implant changes for severe capsular contracture.