December 28th, 2022 | Categories: Breast, Breast Reconstruction, Uncategorized
This video is age-restricted and only available on YouTube. Watch on YouTube – Orange County Plastic Surgery Capsular Contracture
Capsular contracture is one of those concepts that everyone thinks they know, and fears, despite it being so poorly understood. This applies to both patients and providers. Although there are surgical techniques, devices and medications that can reduce the risk for capsular contracture, so many factors remain out of a surgeon’s control that the incidence of capsular contracture after breast augmentation is unlikely to ever approach 0%. In fact, the use of textured breast implants was shown to reduce risk. However, textured implants have been implicated in increasing the risk for diseases like BIA-ALCL, and so they are seldom used anymore. Known risk factors include minor infections, perioperative bleeding, placement of implants above the muscle, and patient demographics. The greatest risk factor is a prior history of capsular contracture. Of course, sloppy surgical technique, excessive bleeding, and surgeon inexperience are modifiable risk factors that are equally or more significant.
In the simplest terms, capsular contracture can be thought of as scar tissue encasing a surgical implant, causing that implant to become firmer, distorted, and even painful. Although it can affect any implanted device or material, we typically associate it with breast implants. Capsular contracture is usually observed years after breast augmentation but can occur much sooner. Fortunately, strategies to mitigate or even reverse capsular contracture exist. Preventing the evolution of this disease can often eliminate the need for surgery to correct it. At the Zelken Institute for Aesthetic Medicine, asthma medications like Singulair (montelukast) or Accolate (zafirlukast) are offered to high-risk patients and those showing early signs of contracture.
Dr. Zelken expects capsular contracture rates to far exceed what is reported in community and the scientific literature, particularly because most patients and their providers fail or refuse to recognize capsular contracture when it exists- especially in the absence of patient awareness or concern. After all, capsular contracture does not require corrective surgery when a patient is unaware of it, or it does not bother her. This is because surgical intervention carries its own risk, expenses, and again, up to a 50% chance of recurrence. Case in point: as seen in this video, Dr. Zelken treated a patient with right-sided capsular contracture after breast augmentation 20 years ago, but it turns out she had bilateral capsular contracture.
Furthermore, capsular contracture can be mistaken for an intentionally “made” look, “botched” breast augmentation (think Tori Spelling), or intentionally high placement of breast implants. Alternatively, when large implants are placed above the muscle in thin women, the “bolt-on” appearance may look like capsular contracture when it does not actually exist. But the diagnosis is never more clear than direct intraoperative observation of the implant and its investing capsule. Hence this video. In this video, Dr. Zelken intends to provide a rare look at capsular contracture from the inside out. By visualizing various degrees of capsular contracture (Baker IV on right, Baker II on left) in a single patient, you will better understand how and why an implant can get constricted and scar down to the underlying chest wall.
In advanced cases, such as the patient’s right breast shown in this video, the capsule is not only thick, but it is calcified with a chalky lining. The capsule can become so thick and robust that it becomes impenetrable to a fine surgical blade and holds its shape like an eggshell when the implant is removed. Although this must have been uncomfortable for the patient treated in this video, it also speaks volumes to the woman’s capacity to wall off any foreign bodies that impose an unnecessary threat. In this case, and in most advanced cases of capsular contracture surgery, Dr. Zelken relies on en bloc capsulectomy. En bloc capsulectomy not only releases the thick scar capsule but preserves the force field that was divinely designed and crafted by the patient’s surrounding tissues.
By waiting until surgery is over to study the intact specimen, Dr. Zelken will not expose the body to whatever substance or organism was contained within it that may have caused the capsular contracture to develop in the first place*. Next, the soft tissue envelope was cleansed with specialized acids, antibiotics, and detergents designed to eliminate pathogens to ensure a truly sterile environment for healing. Finally, Dr. Zelken will line the new implant with the patient’s own breast tissue (auto augmentation) or cadaver tissue (allograft, acellular dermal matrix) when indicated and desired by the patient.
*Note: en bloc capsulectomy is not for everyone. Please note: en bloc capsulectomy can be risky, painful, and is simply not necessary for all patients who have capsular contracture. Neither is it the standard of care, nor has it been shown to reduce the risk of recurrence in most women. It has been popularized more by social media more than scientific evidence.
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