CAPSULAR CONTRACTURE
Although breast augmentation is an overwhelmingly positive experience for the majority of women, there are potential problems that can develop. The most common of these is called a capsular contracture.
Whenever a foreign body is placed within a human being whether it be a breast implant, a pacemaker, an artificial joint, etc. within the first week the body surrounds it with a layer of tissue which is called the capsule. The capsule is in fact the patient's own tissue. Normally it stays soft and pliable and moves along with whatever device it surrounds. However, it can occasionally start to constrict tightly around the object and in the case of a breast implant causes the sensation of hardening and possibly visual distortion. In its most advanced stage it can actually become uncomfortable or painful.
Plastic surgeons grade the quality of the capsule around breast implants using a system called Baker Classification. When a breast implant has a perfect result of softness and appearance it is called a Baker Class I. If the implant starts to develop a sensation of firmness but still looks completely normal it is called a Baker Grade II. If a contracture advances enough such that it not only feels firm but also now is asymmetric or drawing the implant upwards it is called a Baker Grade III. The most advanced capsular contracture is Baker Grade IV which means the implant feels hard, looks asymmetric or distorted and is now painful.
Capsular contracture developing to a stage Baker Grade III or IV, in a seven-year study was found to develop in as high as 15% of patients. It was also the most common cause for reoperation in the postoperative period if reoperation was required. Generally, patients with Baker Grade II contractures do not require any treatment. When a patient reaches Grade III or IV we call this advanced capsular contracture and treatment is generally sought.
The capsular contracture rate differs markedly for different surgeons. This is a reflection of the recognition of the various causes of capsular contracture. It is known that any irritants within the pocket will increase the chance of advanced capsular contracture. In addition, it is well known that any blood left around the implant increases the chance of capsular contracture. Increasingly, research implicates the presence of bacteria as by far the most common cause leading to capsular contracture.
Recent research is demonstrating that bacteria on a foreign body such as a breast implant behaves differently than bacteria simply floating around the body. These bacteria found on the surface of an implant interact to form what is called a biofilm, a protective layering around the bacteria that makes them resistant to a simple course of antibiotics.
Our own capsular contracture rate is far below the stated 15% over seven years. We employ numerous techniques to decrease the chances of hardening to a minimum. First, no blood is left remaining around the implant at the end of the operation. The entire operation is done with a cautery device that seals blood vessels as we move along to remove this as a possibility.
Powder-free gloves are used also so as not to introduce any irritants into the pocket, and only I, as the surgeon, handle the implants. In addition, all patients receive antibiotics through their IV, and the surgical pockets are rinsed with antibiotic solutions as is the skin around the operative site. Oral antibiotics are also prescribed for several days after surgery. Placement of the implants through the middle of the breast is discouraged as the breast always has bacteria present even when antibiotics are used and increase the chance of advanced contracture. We prefer to place the implants in the submuscular position which also has been shown statistically to lower the chance of hardening.
Despite all of these precautions, advanced contracture sometimes occurs. Traditionally it has been taught that the only treatment is to reoperate to remove the capsular tissue, but this offers no guarantee that advanced contracture will not simply recur. The search for a nonoperative solution to advanced contracture led us to the Aspen After Surgery ultrasound treatment. This is a patented device that is specific for breast capsular contracture. It is not the same as ultrasound given in a physical therapist's office for muscle aches and pains. The ultrasound heads are specifically designed for treatment to the breasts in cases of advanced capsular contracture.
The obvious question is how does it work? Most research increasingly points to bacteria contaminating the implant and forming the biofilm described above. Bacteria are always found in the breasts and may actually spread to the breast implant months after surgery. A standard course of antibiotics or even a prolonged course is often times ineffective because the biofilm prevents the antibiotics from eradicating the bacteria. It is believed that the application of ultrasound causes disruption of the biofilm and allows the antibiotics to be more effective and eradicate the bacteria as well as increase blood supply and hence antibiotic delivery to the area. The Aspen After Surgery ultrasound treatment is also combined with specific specialized massage techniques and then specialized banding techniques that we use in the interval time between each treatment. Typically, a series of 10 treatments will be administered over a three and a half week period. Each visit requires the patient spend roughly one hour in our center. For patients who travel longer distance or can only be in our proximity a shorter time we may fast track the 10 visits into a one-week or two-week period.
Along with the Aspen After Surgery ultrasound treatments we also prescribe one month of antibiotics that are specific against the bacteria most commonly found to cause capsular contracture as well as a medicine called Accolate or Singulair which was serendipitously found to also help relax the hardening in the capsular contracture.
Patients with Grade III capsular contracture generally can be very optimistic particularly when it is of recent onset with response rates around 80%. On the other hand, more well established or Grade IV contractures have a lower success rate of 1 in 3. Generally by the fifth treatment we can tell whether this is going to be successful or not and can recommend continuing the full course of 10 treatments or whether surgery would be advised instead.
At the time of this writing, we are delighted to be one of only four centers in North America that offer this nonoperative exciting and effective technique. We have been so impressed by its results and the response times that I think this is going to be in most plastic surgeons' offices one day. Our patients are very happy that we offer this as a nonoperative treatment and many choose to have their original breast augmentation with us knowing that we have the capability of handling this complication should it arise. The addition of the Aspen ultrasound treatment fits nicely with our philosophy of total patient care from start to finish in a comprehensive, caring, and professional manner at all times.
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