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.
1.Placement of implants deep to the pectoralis muscle hurts more and has a longer convalescence.
2.Using the pectoralis muscle will distort the implant temporarily while the muscle is engaged.
3.”Bottoming out” is more likely when implants are under the muscle. The vector of force from the pectoralis muscle referred to in no.2 over time can stretch the soft tissues and create a situation where there is too much breast implant volume in the bottom half of the breast.
4. Closed capsulotomy, although frowned upon by the manufacturers, is often impossible in submuscular implants. Closed capsulotomy is a non-operative release of capsular contracture performed in the office (takes about a minute). In many patients it can avoid a trip to the operating room.
5. Patients with modest ptosis (droopiness) desiring breast augmentation often do not need a concurrent breast lift as the enhanced volume will camouflage the slightly droopy breast. Subglandular placement is a better choice in this clinical situation.
Gynecomastia is breast development in a male. Since breasts are composed of both glandular and fatty tissue, the relative contribution of each determines the proper treatment. Most gynecomastia is idiopathic (it just happens). Occasionally, medications or medical conditions can be responsible for the problem. These are sorted out before surgical treatment. You can also read more about gynecomastia here.
About 30% of teenage boys develop some modest gynecomastia as they pass through puberty. Almost always it disappears without treatment although it’s complete resolution may take a couple of years. The small breast bud can be tender which is an occasional indication for earlier treatment as would be persistent increase in size of the breasts.
Some medications, such as those used to treat breast cancer, have been successful at getting rid of gynecomastia. These medications are controversial and have not specifically been approved by the FDA to treat gynecomastia.
A plastic surgeon has the choice of liposuction, excision, or a combination of the two to treat gynecomastia. Liposuction is indicated when the breast mound is substantially fat. Excision is indicated when the breast is mostly glandular. Excisional treatment requires, in most cases, an incision that is short. Persistent gynecomastia is almost always treated with surgery. In about 90% of patients, liposuction alone will yield a satisfactory result.
In conclusion, although gynecomastia is an embarrassing condition, it is treatable. First, it is necessary to visit a physician to exclude treatable causes of gynecomastia.A treatment plan is based on the cause of the breast enlargement and its anatomic makeup.
Breast augmentation is an operation so naturally there is some post-operative pain. Patients experience pain differently after any operation because of personal differences. Nevertheless, there is a fairly predictable range of discomfort after the procedure.
Post-operative pain is greatly influenced by whether the implants are placed above or below the pectoralis muscle. Implantation above (subglandular) is much less painful since the pectoralis muscle is undisturbed. Women describe subglandular pain as an uncomfortable “fullness” or, for those that have experienced both, “feels like I need to breastfeed”.
In a submuscular placement, the pectoralis is not cut but it is stretched and partially released. Patients experience this pain as a very uncomfortable tightness similar to a pulled muscle. If the muscle is not being used, the discomfort is quite tolerable.
Regardless of position of placement, the recovery is fairly quick. Most patients are going about basic daily activities (not athletic) in a few days. Almost all patients drive themselves to the office for suture removal in 5-7 days.
Athletic activity is permitted as soon as the patient wishes provided it does not disturb the healing breasts. Full athletic activity may be resumed in 4 weeks. That is, a long walk can be taken the next day if the woman is up for it, but jogging is out for 4 weeks.
Texturized implants were introduced to decrease the rate of capsular contracture “hardening” of the breast. It turns out, however, that the capsular contracture rate with texturized implants is the same as that of smooth walled implants. Furthermore, the failure rate of texturized implants is greater than that of smooth implants. Therefore, I see no reason to ever use them.
About 30 years ago there were implants available covered in polyurethane sponge that were purported to have a lower capsular contracture rate than conventional smooth walled implants. The sponge covering was irregular and thought to play a role in the way that capsules formed around implant, in this case favorable relative to capsular contracture. They were eventually taken off the market for a variety of reasons. I doubt they had much influence on the capsular contracture rate anyway.
Implant manufacturers thought that mimicking the surface characteristics of the polyurethane sponge covered implants on to silicone walled implants might favorably affect the capsular contracture rate. For this reason these implants were brought to market. I used them preferentially for a number of years.
After a while I noticed I was witnessing a much higher incidence of failed implants from the texturized family. Somewhat later a study reviewing the performance of texturized implants demonstrated that they indeed did have a higher failure rate.
Implants fail most of the time from silicone shell fatigue as a paperclip will fail if you bend the metal back-and-forth a number of times. When one opens the pocket housing a smooth walled implant there is no connection between the capsule in the implant. When one opens the pocket of texturized implant there is adherence of the capsule to the texturized silicone shell. This attachment puts more stress on the shell of the implant leading to higher failure rate.
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