Symptomatic Capsular Contracture Research Articles

Passot-Type Immediate Breast Reconstruction Obviates the Use of Aceullular Dermal Matrix in Grades 2 and 3 Ptosis

Acellular dermal matrices (ADMs) are commonly used for immediate breast reconstruction after skin-sparing mastectomy (SSM). Regnault grades 2 and 3 ptotic breasts feature significant mastectomy flap redundancy that may be incorporated into the reconstruction. This allows surgeons to use patients' de-epithelialized inferior dermal pedicle instead of ADM. All consecutive SSM patients with Regnault grade 2 or 3 ptosis who underwent Passot-type immediate breast reconstruction (IBBR) with tissue expanders (TEs) and de-epithelialized inferior dermal pedicle without an ADM were included. Patient data from the electronic medical record, clinical photographs, and a comparative cost analysis of ADM versus additional operative time are provided. Thirty-eight patients with an average age of 52.7 years, weight 210.5 lb, and body mass index of 35.1 kg/m were treated (34 bilateral, 4 unilateral; 72 reconstructed breasts). Average mastectomy specimens weighed 962.8 g. Tissue expanders were filled to 265.0 mL (41.6% capacity) intraoperatively, and final implant volume averaged 710.9 ± 118.5 mL after an average of 628.6 ± 74.1-mL expansion. Operative times for Passot-type IBBR was 124.3 ± 37.7 versus 92.5 ± 27.9 minutes (P = 0.0001) for submuscular TE placement with ADM. The operative technique is described in detail. There were 8 TE explantations (21.1%) included: intractable infection (10.5%; n = 4), symptomatic capsular contracture (7.9%; n = 3), and spontaneous TE deflation (2.6%; n = 1). All but 3 patients (92.1%) successfully completed Passot reconstruction, with 2 patients declining salvage latissimus dorsi flap reconstruction and 1 patient lost to follow-up. Total cost savings in this case series was $89,724 ($2361 ± $3529/case). Additional prospective comparison studies are needed to determine whether Passot-type IBBR results in higher complication rates than conventional IBBR with ADM in this challenging patient population. Passot-type IBR after SSM is safe, demonstrates acceptable rates of successful breast reconstruction, confers cost savings by obviating the use of ADM, and provides favorable aesthetic results.

Latissimus dorsi myocutaneous reconstruction: a study of long-term outcomes in a district general hospital.

INTRODUCTION The aim of this study was to evaluate the long-term outcome and durability of both autologous and implant-assisted latissimus dorsi reconstruction in a district general hospital over a 10-year follow-up period. METHODS A prospective cohort study was carried out using a detailed database of all latissimus dorsi flap reconstructions performed by a single consultant surgeon between 2003 and 2013 at the Royal United Hospital, Bath. The long-term outcome following reconstruction was assessed by analysing all episodes of 'reconstruction-specific' operations required from 6months after the initial surgery. RESULTS The study included 110 patients with latissimus dorsi flap reconstructions, 21 autologous and 95 implant-assisted. Radiotherapy was given to 27 patients with reconstructed flaps. Mean follow-up was 69 months. Further reconstruction-specific surgery was needed in 27 (23%) cases, with 5 of these being post-radiotherapy flaps. Implant-related surgery was the most common reason for further surgery. Complications of the implant itself made up 52% of these cases, chronic sepsis being the most common. The rate of symptomatic capsular contracture requiring further surgery was 4.2%. Of these, one of four patients had undergone radiotherapy. DISCUSSION In our institution, latissimus dorsi reconstruction is durable and safe over the long term, with limited need for further substantial intervention to maintain a good outcome from the initial reconstruction. Autologous flaps were less likely to require further surgery over the long term compared with implant-based reconstructions. The low rate of symptomatic capsular contracture may be due to the protective mechanism provided by the extended harvest flap used.

Correction with autologous fat grafting for contour changes of the breasts after implant removal in Asian women

Patients who were diagnosed with symptomatic capsular contracture or with safety concerns for the implant would be often reluctant to accept the operation of implant exchange, choosing instead removal without exchange or taking other options to rebuild their breasts. These patients may benefit from augmenting the overlying soft tissue of the breasts with autologous fat grafting after removing the prosthesis. A retrospective analysis of the patients receiving fat grafting for breast augmentation after implant removal was performed in this study. Between March 2011 and November 2013, 27 patients receiving autologous fat grafting after breast implant removal. Objective evaluation was made by measuring the change in breast thickness with ultrasonography taken before and after the treatment. Aesthetic evaluation was performed using a 5-point Likert scale for patient satisfaction and comparing preoperative and postoperative digital photographs for physician satisfaction. The mean breast thickness change was 13.1 mm (SD = 3.3) which was an increment by 154% in comparison to the averaged breast thickness of 8.5 mm after implant removal. The results of patient satisfaction and physician satisfaction were 16.3 (SD = 1.2) and 16.7 (SD = 1.6). Complications included recipient site infection, fat necrosis, and small areas of induration. The overall complication rate was 22.2% (6 of 27). Autologous fat grafting is beneficial for the correction of deformed breasts after implant removal. With its preferential fill qualities, the wide cleavage and excessive upper pole fullness associated with existing implants can also be corrected.

Capsular Contracture after Breast Augmentation: An Update for Clinical Practice.

Capsular contracture is the most common complication following implant based breast surgery and is one of the most common reasons for reoperation. Therefore, it is important to try and understand why this happens, and what can be done to reduce its incidence. A literature search using the MEDLINE database was conducted including search terms 'capsular contracture breast augmentation', 'capsular contracture pathogenesis', 'capsular contracture incidence', and 'capsular contracture management', which yielded 82 results which met inclusion criteria. Capsular contracture is caused by an excessive fibrotic reaction to a foreign body (the implant) and has an overall incidence of 10.6%. Risk factors that were identified included the use of smooth (vs. textured) implants, a subglandular (vs. submuscular) placement, use of a silicone (vs. saline) filled implant and previous radiotherapy to the breast. The standard management of capsular contracture is surgical via a capsulectomy or capsulotomy. Medical treatment using the off-label leukotriene receptor antagonist Zafirlukast has been reported to reduce severity and help prevent capsular contracture from forming, as has the use of acellular dermal matrices, botox and neopocket formation. However, nearly all therapeutic approaches are associated with a significant rate of recurrence. Capsular contracture is a multifactorial fibrotic process the precise cause of which is still unknown. The incidence of contracture developing is lower with the use of textured implants, submuscular placement and the use of polyurethane coated implants. Symptomatic capsular contracture is usually managed surgically, however recent research has focussed on preventing capsular contracture from occurring, or treating it with autologous fat transfer.

Autologous Fat Grafting for Breast Augmentation in Patients after Implant Removal

Introduction: Patients diagnosed with symptomatic capsular contracture or with safety concerns for the implant are often reluctant to accept the operation of implant exchange, choosing instead removal without exchange or taking other options to rebuild their breasts. These patients may benefit from augmenting the overlying soft tissue of the breasts with autologous fat grafting (AFG) after removing the prosthesis if the aesthetic appearance of their breasts is an issue. A retrospective analysis of patients receiving AFG for breast augmentation after implant removal was performed. The outcomes in these patients were compared with those of the patients receiving AFG for breast augmentation as their first breast surgery during the same period. Materials and Methods: Between March 2011 and November 2013, 27 patients receiving AFG after breast implant removal (BIR) were assigned to group A and 325 patients who underwent AFG for breast augmentation without preexisting implant by the same surgeon were assigned to group B. Objective evaluation was made by measuring the change in the difference of breast circumference (BCD) and breast thickness measured by ultrasonography taken before and after the treatment. Aesthetic evaluation was performed using a 5-point Likert-type scale for patient satisfaction and comparing preoperative and postoperative digital photographs for physician satisfaction. Results: Relative to group B, patients in group A were older and had higher complication rates, including infection, fat necrosis, indurations, and calcifications (P < .05). The changes in BCD and breast thickness between the 2 groups were of no clinical significance. The reoperation rate in group A was significantly higher (P < .05). Conclusions: The number of postoperative complications of AFG for breast augmentation was found to be higher in patients after BIR. The optimal timing of AFG in the patients after BIR should be further studied if 2-stage augmentation with fat grafting is to be performed. Reoperation with fat grafting to the breasts should be considered if patients expect to have the original volume of their breasts restored.

Mast cells in the periprosthetic breast capsule.

Symptomatic capsular contracture occurs in about 10 % of primary breast augmentations and in more than double that rate in reconstruction after mastectomy, especially in the setting of radiation. Mast cells, traditionally associated with immune response and inflammation, secrete profibrotic mediators and may play a role in capsule formation and contracture. We analyzed the mast cell and fibroblast populations in breast capsule tissue from patients who underwent capsular excision. Capsule tissue was collected from patients who underwent exchange of tissue expanders for permanent implants, revision of reconstruction, or revision augmentation. Breast capsule tissues were prepared for histological analyses of mast cells, fibroblasts, and collagen. Mast cells and fibroblasts were isolated from capsule tissue and screened for mediators and receptor expression. In breast capsule tissue, the average numbers of mast cells and fibroblasts were 9 ± 1/mm(2) and 33 ± 10/mm(2), respectively. There were significantly more mast cells on the posterior side than on the anterior side of the capsule tissue (12 ± 2 vs. 6 ± 1/mm(2), p < 0.01). Baker grade IV capsules had an increased number of fibroblasts compared to Baker grade I capsules (93 ± 9 vs. 40 ± 19/mm(2), p < 0.001). In breast capsule tissue, mast cells contained renin, histamine, and TGF-β, and their respective receptors, AT1R, H1R, and TGF-βRI were expressed by fibroblasts. These data indicate that within breast capsule tissue mast cells contain mediators that may activate neighboring fibroblasts. Understanding the role of mast cells in pathologic periprosthetic breast capsule formation may lead to novel therapies to prevent and treat capsular contracture. This journal requires that authors assign a level of evidence to each submission to which Evidence-Based Medicine rankings are applicable. This excludes Review Articles, Book Reviews, and manuscripts that concern Basic Science, Animal Studies, Cadaver Studies, and Experimental Studies. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors http://www.springer.com/00266.

Focus on Technique

Prosthetic-based breast reconstruction commonly involves device placement in either a total submuscular pocket or a partial subpectoral position for just superior pole coverage, with various possible strategies for inferior pole coverage. Historically, the pectoralis major muscle is managed either by suturing the muscle to the inferior flap or with marionette sutures; alternatively, the device is placed under total muscle/fascia coverage (under the pectoralis major, plus the serratus anterior and rectus abdominis muscles or fascia). For many plastic surgeons, acellular dermal matrix is now used instead to function as a sling or "hammock" supporting the periprosthetic pocket and thus covering the inferior pole of the device, attached to the pectoralis major muscle above and to the inframammary fold below. In addition to its added soft-tissue support in the inferior pole, acellular dermal matrix may help to stabilize the pectoralis major muscle along its inferolateral margin, create a well-defined inframammary fold, provide the opportunity to significantly increase intraoperative fill volume of the tissue expander, and reduce the incidence or severity of significant or symptomatic capsular contracture, particularly in a patient whose breast has been treated with radiation. In addition to its indications in primary breast reconstruction, acellular dermal matrix has been increasingly used in secondary revision reconstruction cases. It can be used to buttress capsulorrhapy and capsulotomy sites and it can be used to replace periprosthetic capsule following capsulectomy. While clinical experience is accruing for these indications, acellular dermal matrix continues to be used in primary and secondary breast reconstruction.

An Illuminating No-Touch Device for Breast Augmentation

Skin contact of breast prostheses is considered by many to be a significant cause of ongoing subclinical infection leading to subsequent symptomatic capsular contracture (1–5). Many surgeons employ a no-touch technique, aiming to lower capsular contracture rates by eliminating skin contamination. One approach requires several assistants to hold retractors so that the implant can be inserted into the pocket without touching the skin (6). This is somewhat awkward and imprecise, and adds the expense of an additional assistant. Others have adopted a no-touch approach that uses a sterile tube or a simple anoscope acting as a sterile sleeve, which works quite well with a single assistant (7). The present paper describes a surgical instrument designed for the insertion of breast prostheses. The instrument can be used quite safely and efficiently by a surgeon with one nurse assistant. It has enhanced illumination, enabling good hemostasis, and is particularly easy to make at low cost. The casing of a 60 mL Toomey syringe is cut with a fine saw on an approximate 45° angle, and is used in both a long (100 mm) and short (66 mm) version (Figure 1). The tip is heat burnished with a butane torch to smooth the cut edges, and more importantly, to convert the plastic from opaque to clear. When used with a headlight, the translucent wide end of the syringe casing absorbs the light, and the clear tip, which is now within the dissected pocket, transmits the light with enhanced intensity. The amount of illumination is quite significant and beneficial, particularly when viewing the corners of a pocket with the longer casing, to ensure that there is good hemostasis (Figure 2). The shorter version works well for the insertion of the prosthesis. Figure 1) A 66 mm (top) and 100 mm (bottom) section of a 60 mL Toomey syringe that has been cut on a 45° angle Figure 2) After the tip has been heat burnished it becomes translucent, transmitting light with enhanced intensity Once hemostasis is complete, the prosthesis, partially filled with 30 mL of normal saline, is simply folded and lubricated with Bacitracin (Pfizer Canada Inc) or saline (Figures 3 and ​and4).4). It is passed as a folded tube through the lumen of the shorter casing into the pocket. This is atraumatic for the prosthesis, and completely prevents any elements of contact between the prosthesis and the skin. We have used implants as large as 400 mL that, when filled with 30 mL of saline, can simply be folded and passed through without difficulty. Figure 3) The prosthesis is passed as a folded tube through the lumen of the shorter casing into the pocket, preventing any elements of contact between the prosthesis and the skin Figure 4) The prosthesis is completely within the pocket after passing through the lumen of the shorter casing This device has many advantages over the anoscope because it transmits far more light, and its diameter fits into a 4.5 cm incision, which is quite acceptable for inframammary incisions. Its length can be determined by the surgeon’s preference. The author has not used this for axillary or periareolar incisions, but the principle to avoid the prosthesis skin contact should still exist. A no-touch sleeve device’s ability to reduce the incidence of infection and subsequent capsule formation is a question that could only be resolved by a large randomized series, which has not been done to date. The advantage of this new device in ensuring hemostasis is a significant advantage in itself. It is low cost and reusable.

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.

Experience with Soybean Oil-filled Breast Implants in a Swedish Surgical Practice

Restrictions ordered by the U.S. Food and Drug Administration on the use of silicone gel-filled breast implants, as well as patient and surgeon dissatisfaction with the aesthetic results sometimes attained with saline solution-filled implants, have prompted new interest in developing alternative implant filler materials, including triglycerides. Soybean oil-filled breast implants are now in various stages of testing and use in the United States, Europe, and Canada. This article reports on experience with Trilucent ® breast implants (prefilled with soybean oil) by one plastic surgeon in Sweden. A total of 96 patients (191 implants) underwent primary augmentation or replacement augmentation mammaplasty between October 1995 and June 1997. Data have been analyzed for all 96 patients with a mean follow-up period of 15 months and for 67 patients (133 implants) with a mean follow-up of 18 months. The significant findings of the study include the absence of systemic reactions or unusual local complications, the low incidence (2.3%) of symptomatic capsular contracture (grades III and IV) among the 67 patients at the 18-month postoperative time point, and high patient satisfaction with the aesthetic results. The mammographic radiolucency of soybean oil-filled implants was also demonstrated. At the 18-month follow-up point, the only negative observations were the presence of skin wrinkling in 3% of the breasts and implant palpability in 46% of the breasts. These findings are in general agreement with preliminary data from the European clinical trials of Trilucent ® breast implants.

Clinical relevance of positive breast periprosthetic cultures without overt infection.

The true incidence of positive breast periprosthetic cultures in the absence of overt infection is not clearly established. We retrospectively reviewed data from 389 implants that were removed for reasons other than clinical infection. Many of these patients presented with a variety of musculoskeletal ailments. Others had symptomatic capsular contracture as the presenting complaint. In a few a known implant rupture was the reason for explantation. We identified a positive culture rate of 23.5 percent from capsule tissue. Most of these organisms were coagulase-negative staphylococci and anaerobic diphtheroids, but fungi and other organisms (generally felt to be more pathogenic than the less virulent coagulase-negative staphylococci) also were cultured. In an attempt to identify the clinical relevance of these positive cultures, we statistically evaluated the culture results for associations with capsular contracture, implant rupture, type of implant, and location of implant. Of these, the only statistically significant correlation was between positive culture result and symptomatic capsular contracture (Baker class IV).

Recurrence of Breast Carcinoma Following Immediate Reconstruction

To evaluate the effect of immediate reconstruction on the incidence, location, detection, and treatment of recurrent breast cancer, a review of 306 patients operated on according to a standard protocol during the 10-year period 1979 through 1988 was performed. Reconstruction techniques included submuscular implants (207), tissue expanders (84), and musculocutaneous flaps (15). During a minimum follow-up period of 3 years with a mean of 6.4 years, 60 patients (19.6 percent) developed recurrent disease, at a mean interval to recurrence of 31 months. The first locations of recurrences were local (16), regional (11), and systemic (33). Recurrence rates by stage included stage I, 7 patients (5.2 percent); stage II, 45 patients (32.1 percent); and stage III, 8 patients (40 percent). It was not possible to include comparisons with internal control groups of patients in our institution who were not reconstructed or who had delayed reconstructions, thereby preventing conclusions based on such comparisons. Our recurrence data are similar to literature reports of recurrence rates in patients who were not reconstructed after mastectomy. Detection and treatment of recurrences were not inhibited by the reconstructions. When radiation therapy was used in the treatment of local recurrences, the development of symptomatic capsular contracture was recorded in 58 percent of the patients.