Closed Capsulotomy for capsular contracture is controversial. Many plastic surgeons refuse to perform the maneuver and the manufacturers of implants don’t want their implants exposed to it. Nevertheless, I continue to offer it and have never really had any problems over many years. Let me make the case why closed capsulotomy should at least be considered.
Capsular contracture occurs when the capsule that forms around each and every breast implants shrinks around the prosthesis and squeezes it, making it feel firm and sometimes even distorting the appearance. We really don’t know what triggers this aesthetic problem although there are some interesting theories that have spawned new and controversial therapies. Here are some of the possible courses to take if capsular contracture occurs.
Nothing-capsular contracture is not a medical problem and some patients are content to live with firm implants.
Accolate– a drug of doubtful benefit that is intended for use in asthmatics. The drug relaxes smooth muscle which contracts during an asthmatic attack. Smooth muscle is also found in the capsules of patients who suffer from capsular contracture. It generates the vector of force on the implant. It is proposed that this drug can cause relaxation of the smooth muscle in the capsule and ameliorate the hardening. When the drug should be administered, the dosage, and the duration are all speculative.
Re-operation-obviously expensive and associated with the risks and side effects of an operative procedure. There is also no guarantee that the contracture will not recur. Some advocate the use of acellular dermal matrix as part of the procedure which really drives up the cost and comes with no guarantee. The manufacturers insist that new implants should be used regardless of their age.
Removal of the impants-no implant, no capsular contracture
Closed capsulotomy– this is an office maneuver that takes a couple of minutes. I don’t charge my patients for the service.
Critics of closed capsulotomy point out that it may weaken or even break the prosthesis. In this maneuver, the plastic surgeon applies pressure to the afflicted breast which transmits that pressure to the breast implant. As the implant expands away from the area of applied pressure (picture squeezing a water balloon) it applies pressure to the capsule. The capsule fractures, increasing the surface area and relieving the force it delivers to the breast implant. Complications might arise as a result of the force applied to the breast that would require an operation eg.,hematoma (I’ve never seen one). The recurrence rate is high. Manufacturers may invalidate on the breast implant warranty if they find closed capsulotomy has been performed. Let me take these one at a time.
The manufacturers brag about the resiliency of breast implants. I have had closed capsulotomy demonstration implant in my office that I have forcefully squeezed (to duplicate the forces on the prosthesis)almost daily for years. It’s doing just fine. A closed capsulotomy is perfomed in less than a minute. Furthermore, I have never experienced a failure of an implant secondary to closed capsulotomy in 30 years of practice.
The worst complication I have experienced is a bruise of the breast. I have never been forced to perform an operation as a result of closed capsulotomy.
The recurrence rate is high, probably greater than 50%. So what? If it recurs immediately, it’s time to go to another option. If it takes 6 months or longer to recur, why not just repeat it? It only takes a couple of minutes and it’s free.
Manufacturers frown on the maneuver and might invalidate the warranty when closed capsulotomy is performed on their implant. However, that same warranty does not cover capsular contracture. A revisional procedure for capsular contracture demands purchase of new implants. Whether a closed capsulotomy was perfomed or not prior to the operation, the patient still has to pony up for a new implant. Reoperation using the old implants (not a good idea) invalidates the warranty on those implants in the same way a closed capsulotomy does.
Closed capsulotomy does not always work and is not for everyone. It is not comfortable but most patients find it tolerable. The sensation of the capsule breaking up is more discomfiting than the pain most of the time. However, it certainly should be a part of the capsular contracture treatment algorithm.
Breast implants can be placed through 5 possible incisions. It can be confusing for the patient picking the best approach for their situation. I offer 4 of the 5 but prefer the inframammary ( in the crease below the breast) for reasons to be discussed.
The 5 potential incisions:
Axillary(through the armpit). In this approach (which is sometimes assisted by an endoscope) a tunnel has to be created to permit development of the pocket. It would be considered a “remote” approach. Obtaining symmetrical pockets is a bit harder and occasionally the implants can fall into the tunnel when the patient is recumbent if it persists after healing.
Periareolar (through the nipple). An incision along the border of the areola (usually about 180 degrees on the bottom side) is used for access. In this technique, the implants is dragged through breast tissue for placement in the pocket. I will discuss the importance of this in a minute.
Inframmary (through the breast crease). The most direct approach and allows development without disturbing breast tissue.
Periumbilical (through the umbilicus). This is another remote technique and is limited to saline implants. It is seldom used anymore and shares the difficulty of making the pockets symmetrical with the axillary approach.
Transabdominoplasty. In the occasional patient undergoing an abdominoplasty concurrent with breast augmentation the implant can be placed under the breast without an incision using access available by the dissection of the abdominoplasty.
Although I am willing to place implants by any of the incisions save for the transumbilical, I prefer the inframmary. Here is my reasoning:
The major significant aesthetic problem after breast augmentation is capsular contracture (hardening of the implant). The problem dwarfs any other cosmetic side effect including the post-op scar. A year after an augmentation almost no patient even considers the scar as all yield consistently near invisible results. The development of a capsular contracture, however is a real aesthetic issue if it occurs. Anything to reduce the incidence is worthy of consideration.
Plastic surgeons don’t really know what causes capsular contracture. One emerging theory which looks more plausible by the day is the formation of a “biofilm”. A biofilm known to all of us is plaque on the teeth. Certain types of bacteria can generate a substance that is used as a structure in which to hide out-the biofilm. It’s presence can cause local problems, gingivitis in the case of plaque. That’s why the hygienist scrapes it off at the time of dental cleaning.
Biofilms may play a role in capsular contracture. Two of the approaches expose the implants to contamination, the axillary and the periareolar. There is one published study (not enough yet to consider the case closed) showing that the inframmary approach has a lower incidence of capsular contracture than the inframmary . This suggests, but certainly does not prove, that contamination of the implant might be reason for the difference.
In my opinion, the aesthetics of the scars is of very minor importance. I think capsular contractures are a big deal. If it’s possible that a given approach has a lower incidence of capsular contracture, it makes sense to me to prefer that choice. As I mentioned above, this is why I prefer the inframmary approach.
Rhinoplasty (nosejob) is again becoming a popular procedure. The nose is front and center on the face and even small adjustments can significantly change the harmony of the face. In most cases, results are predictable and patients now can get an idea of what to expect by way of video imaging.
There was a fall off in popularity of the procedure over the past few years. Most of this decline was probably due to the economy. However, the media made exaggerated coverage of really bad nose jobs (think Michael Jackson) that probably scared many who were considering the surgery.
Nose surgery is outpatient, physiologically not hard on the patient, and not very painful. Nasal packing, if it is used at all, comes out within 24 hours so is not the issue it used to be. Again, with the benefit to video imaging, patients have a pretty good idea of how things are going to turn out once healing is complete.
Rhinoplasty is probably the hardest of all aesthetic operations to get consistently good results. Each nose provides the surgeon with it’s own anatomy that has to be adjusted to create harmony on the specific face. It takes a lot of practice to understand how an adjustment in anatomy below the skin will translate into a very specific visual change on the face.
Some noses are harder than others and the expectations of the patients have to be in line with the capabilities of the operation. This, again, is where video imaging can educate the patient and sometimes even the surgeon.
As summer draws to a close it may be time to consider erasing some of the unwanted blemishes produced or exacerbated by sun exposure. Specific treatment is dependent upon the magnitude of the problem and the skin type involved. There are a number of approaches to consider.
Topical creams-modest improvement if any. Hydroquinone is a bleaching agent that sometimes works.
Chemical peels-different formulations allow for different levels of treatment. In our office we offer the Vipeel and the Vipeel precision. These are painless treatments that can be used on any skin type.
For an elective aesthetic procedure it is crucial that negative side effects are few and minor. With breast augmentation, the worry at one time was that the implants might increase the risk of the disease. There was also concern that the presence of a breast implant might compromise the diagnostic capabilities of mammograms. Women with implants might be further along in the disease at the time of detection. Fortunately, none of this is true. Nevertheless, many women remain misinformed.
There are lots of published studies related to breast cancer and breast implants. Some are contradictory. In distilling the information there is a preponderance of evidence supporting the safety of breast implants relative to the development and detection of breast cancer.
Here are facts:
Breast cancer is detected at the same stage with or without breast implants. Implants do create an obstacle to visualization of breast tissue, but modifications in mammography technique allow for proper evaluation of breast tissue with implants in place. The test might be a bit more complicated with implants but it is not less accurate. It has been suggested that in small breasted patients, the implants might actually be able to deliver more breast tissue for evaluation by moving it away from the chest wall.
Submuscular placement has no advantage over subglandular placement relative to diagnosis by mammogram. Subglandular placement may obscure more breast tissue than submuscular but this does not result in a change in cancer detection.
The presence of breast implants slightly decreases the risk of breast cancer. Studies point to a slight decrease in risk for breast cancer development in women with breast implants. This is a small reduction and certainly not a reason by itself to consider breast implants. The important point is that breast implants do not increase the risk of breast cancer. Why implants might be protective in speculative. One possibility is enhanced immune surveillance created by the presence of the prosthesis.
When comparing women who develop breast cancer with and without breast augmentation, the tumors are a bit smaller in women who have breast augmentation. This means that breast cancer is detected at an earlier stage in women with breast implants. This probably has to do with vigilance on the part of the women with breast implants who are more attentive to self-examination and so forth.
A procedure that is increasing in popularity is the “Brazilian Butt Lift” which is a trade name of sorts for buttock volume enhancement using autologous fat. As fat grafting in general becomes better understood and predictable, patients are getting better and better results.
The procedure is a lot more than just adding fat to the buttock region. Almost always excess fat in peripheral areas such as the lower back (love handle) is reduced. The idea is to properly frame the gluteal area. This fat then becomes a source of material for the areas to be augmented.
Areas remote for the gluteal area are suctioned to collect the necessary fat for a good result. It’s clear that a fairly large volume of fat needs to be injected. Studies suggest that anywhere from 50% to 70% of injected fat remains permanently. The abdomen is commonly a good source of fat for grafting.
Because of the need for a generous volume for a good result, thin individuals are not really good candidates. General anesthesia is not necessary for the operation for most individuals.
Xeomin (incobotulinumtoxinA) is the “new kid on the block” competitor of Botox (onabutulinumtoxinA) for treatment of facial aging resulting from muscular generation of expression lines. As with all new products, the question is how well it stands up to the standard-in this case Botox.
It turns out that it stacks up favorably (J Drugs in Dermatol. 2012:11(6):731-736). In equal dosages the effects are essentially the same. Xeomin actually was slightly better but not in a statistically significant way.
We are introducing Xeomin into our practice along side of Botox. On August 26th and 29th it will be discounted to 8$ per unit as an introductory offer.
Any operation can yield a complication and facelift is no exception. Fortunately, these are usually minor and seldom does the patient suffer significantly. Major complications are just not acceptable in elective cosmetic surgery cases.
Hematoma-bleeding can sometimes begin after the operation is over and accumulate under the skin. The blood needs to be evacuated and the bleeding stopped. Occasionally this will require a return to the operating room. Smaller hematomas can be drained at the bedside. The incidence is about 5% of cases. When properly dealt with hematomas do not effect the outcome of the operation.
Seroma-serum is a protein rich fluid normally accumulating in a wound as a component of healing. If enough accumulates in an area it needs to be drained. This is always a minor office procedure and has no effect on the outcome of the case.
Wound healing issues-almost always these are small and heal by themselves without significant sequellae. The most likely location is behind the ear which is fortunate since it is well hidden. Seldom is a surgical revision of the area needed. Major wound problems requiring surgical intervention are almost unheard of.
Infection-very, very rare.
Nerve damage-permanent injury to a motor nerve (governs muscle function of the face) is extremely rare and really shouldn’t happen. Temporary motor nerve malfunction happens occasionally due to indirect trauma but will return in time.
Unsightly scars-very unlikely with a facelift. They can be improved with a surgical scar revision.
There are unusual complications reported after facelifts which are decidedly rare and will not be discussed here. It is important to keep in mind that a properly executed facelift has a very low complication rate and will deliver a predictably good result. Unfortunately, there are “surgeons” out there that do not properly execute the operation.
First of all, anti-aging creams do not reverse aging-period. At best, they can only camouflage some of the stigmata of aging. The question is whether they even do that. Much money is spent on these products. Are they worth the money?
All of the ingredients that supposedly combat aging are placed in emollients as a vehicle for delivery to the surface of the skin. By themselves, emollients hold in skin moisture and protect a bit against mechanical trauma. So that’s good.
Beyond the emollients, let’s look at the ingredients that are offered in the vast array of available products.
Acids are added to some topical creams for exfoliation. Acids can irritate the skin and cause swelling. The swelling can plump out wrinkles and make the skin appear younger.
Collagen is a protein within the dermis (the deep layer of the skin).The collagen content of the skin decreases with age. Collagen is sometimes injected into the skin to enhance volume. As an ingredient in a skin cream, however, it cannot possibly make it’s way through the epidermis (the shallow skin layer that covers the dermis) to have any effect on the dermis.
Hyaluronic acid is a large molecule that is a component of the dermis referred to as “ground substance”. Aging skin loses ground substance. As an ingredient in a cream, however, these molecules are incapable of penetrating the epidermis to make it to the dermis (same as collagen). They can, however, be effectively injected for temporary volume enhancement.
Hydroquinone is a bleaching agent that interrupts the production of melanin by the melanocytes. It can diminish the color variegations in sun damaged skin making it appear more youthful.
Peptides are small chains of amino acids that are components of proteins. They also are incapable of penetrating the epidermis to produce any benefit in the dermis.
Retinol is a biologically active compound that can penetrate the epidermis and increase the metabolism of the dermis. This can increase the generation of epidermis and create a volume increase in the dermis which can make the skin look younger.
Sunscreen is worthwhile in a topical cream but don’t overpay for it.
Vitamin C is an acid that, if concentrated enough, can irritate the skin causing swelling which can blunt shallow wrinkles.
Anti-aging creams, depending on their composition, can camouflage some features of aging. Creating some swelling in the dermis can plump out shallow wrinkles. Bleaching agents can provide more color homogeneity. They do not, however, have any real effect on the aging process.
Inexpensive products work just as well as the expensive ones. Check to see what active ingredients are in the cream. Consider working with a skin care specialist to choose the right prescription for your specific skin.
b-The breast is given a “lift” by repositioning the areola and reshaping the breast each and every time.
c-The areola, which is almost always excessively large in diameter, is resized
d-Excess skin is removed. The amount of excess skin determines the ultimate length of the incisions and resulting scars
2.Breast reduction is most often a functional procedure. Most women are seeking a reduction of weight in their breasts to ameliorate the common symptoms of shoulder, back, and neck pain. Younger women who are athletic often find large breasts get in the way and want them smaller.
3.Women who have had breast reductions most often go on to lose additional weight. Many years ago I did a retrospective study on my own patients. We found that after reduction, the average patient went on to lose and additional 14 pounds. When we explored the possible reasons it became clear that because of the reduced weight on the chest, the women became more active and with that the ability to lose unwanted pounds.
4.Breast reduction will reduce the risk of breast cancer. This might seem intuitive but it is really not. For the longest time plastic surgeons were concerned that trama to the breast might actually increase the risk. It turns out to be the opposite. The rate of reduction is loosely linked to the amount of tissue removed.
5. Younger women who have reductions are still able to breast feed. This does not mean that all women undergoing reduction are capable of breast feeding. Rather the amount of breast tissue remaining and the intact milk delivery anatomy allows the possibility to breast feed which most women find they can co.