Revisional Breast Reconstruction for Capsular Contracture - Best Option?

I went to 4 surgeons and got 4 varied recommendations. I am unable to decide the way to go....2 out of 4 would use alloderm. I am concerned about the risk for infection using that matrix-I don't want the long surgical procedure of diep or tram. I am therefore just unable to go ahead since there are obvious pros and cons using alloderm.

Doctor Answers (9)

Options for capsular contracture in breast reconstruction

+3

If you are experiencing capsular contracture following implant reconstruction, you have several options.   One option is to consider an autologous reconstructive option such as a TRAM or DIEP free flap.  If you have enough excess tissue in your lower belly, then you may be able to restore your post mastectomy breast using your own tissue without an implant.   Another option would be the latissimus flap with an implant.  If you are not interested in an autologous procedure, then revision implant surgery is the remaining option.   This would entail a total or partial capsulectomy (removal of scar tissue), your current implant and placement of a new implant.   Alloderm has shown promise in slowing the process of scar tissue. In fact, I authored a recent paper in Plastic and Reconstructive surgery on this exact topic (dec 2010).  However, it is still too premature to say definitively that alloderm prevents capsular contracture.


Houston Plastic Surgeon
4.5 out of 5 stars 117 reviews

Treatments of Recurrent Breast Implant Capsular Contractures

+1

Treatments for breast implant capsular contractures include the with or without AlloDerm, removal and replacement of the breast implant along with capsulectomy to remove the scar capsule; exchange of the breast implant and placement of a new implant in another pocket; removal of the implant and breast reconstruction with a tissue flap

Flap reconstruction of the breast makes it possible, using your own tissues, to provide a soft, natural, warm breast reconstruction.

Although more complex than implant expander breast reconstruction, flap reconstructions such as TRAM flap, or DIEP flaps may actually have less complications.   The flap reconstruction techniques once healed, last a lifetime as they are already a part of you.

Fredrick A. Valauri, MD
New York Plastic Surgeon

Revision breast reconstruction with Alloderm works.

+1

Hi.

1)  Most of the time, capsular contracture can be corrected just with your existing tissues, without the need for either Alloderm or a flap.

2)  If Alloderm is indicated for some other reason (rippling, thin tissues, etc.), I assure you that we use it all the time, that it  is very safe, and that the risk of infection is very low.  There are really no "cons" here.  And Alloderm actually lowers the risk of capsular contracture coming back.

3)  I have the feeling that your situation may be a little more complicated than it sounds, because surgeons would not be recommending complicated flaps (certainly not risk free) just to correct a capsular contracture.

George J. Beraka, MD (retired)
Manhattan Plastic Surgeon
5.0 out of 5 stars 9 reviews

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Alloderm is excellent choice for treatment of capsular contracture

+1

Sometimes it can be confusing given the fact that often there is no one great answer and therefore no consensus. It doesn't mean that there is a "wrong" answer. Given that you don't want the far more extensive procedures which is a quite reasonable decision, using Alloderm is an excellent choice and is what I like to use.

The Alloderm significantly reduces the incidence and extent of capsular contracture even in irradiated tissue though the effects are even better without previous irradiation. New implants should be placed and the capsules removed.

There is never any guarantee but this appears to be the most prudent choice given what you have, the information provided and without performing a personal examination.

Steven Turkeltaub, MD
Scottsdale Plastic Surgeon
5.0 out of 5 stars 20 reviews

Capsular contracture and implants

+1

Of course, without a physical exam by me, I am not sure what is going on for you.  However, Alloderm is being used quite often for capsular contracture  because it seems to diminish the recurrence.

Steven Wallach, MD
Manhattan Plastic Surgeon
4.5 out of 5 stars 17 reviews

Strattice acellular matrix for capsular contracture

+1

The best chance of correcting capsular contracture is probably with implant replacement, removal of the capsule, and acellular dermis graft. Alloderm is popular for this application because it was found to be associated with an extremely low incidence of CC in breast reconstruction patients. There is some theoretical concern however, because technically alloderm is aseptic, not sterile. A good alternative is a similar material called Strattice, which is sterile and works the same way as alloderm.

Richard Baxter, MD
Seattle Plastic Surgeon
5.0 out of 5 stars 23 reviews

Options for Capsular Contracture after Breast Reconstruction

+1

According to information published by one of the major manufacturers of breast implants: “Breast implants are not considered lifetime devices. You will likely undergo implant removal with or without replacement over the course of your life.”

Data published by the by the U.S. Food and Drug Administration show that:

  • Approximately 50% of women will require unplanned re-operation within 7 years of undergoing reconstruction using saline-filled implants
  • Implant removal is required by approximately 30% of women within 5 years of reconstruction with a saline-filled implant
  • Within 7 years of surgery, nearly 40 % of women will require implant removal

             Data available for silicone-filled implants shows similar trends

If radiation has been part of a woman's treatment, the incidence of capsular contracture is even higher.

Once a women has had surgery to address a complication such as a capsular contracture, she has over a 30% chance of needing additional surgery for implant related problems within just 3 years of the first revision surgery. Because there is no "sure-fire" way to cure/eliminate a capsular contracture and prevent its subsequent return, it is not surprising that different surgeons would have different approaches. 

While I can appreciate your desire to avoid a surgical procedure such as a DIEP flap that would typically take longer to perform than an implant-based reconstruction procedure, in the hands of experienced microsurgeons, a DIEP reconstruction can be completed in about 4 hours. Given the ability of natural-tissue to resolve the problems of capsular contracture and the lifetime durability of such reconstructions, you may want to consult with a surgeon who has significant experience with perforator flap procedures before totally eliminating the possibility. Surgeons who perform these procedures often have patients who are willing to talk to women considering this type of surgery; many of my patients have volunteered to speak with women confronting difficult decisions such as the one you described. Regardless of which method of reconstruction you choose, I suggest that you consult with surgeons who have significant experience dealing with capsular contracture.

I hope this is helpful.

 

David Greenspun, MD, MSc
New York Plastic Surgeon

Acellular dermal matrix is a good option for capsular contracture

+1

Acellular dermal matrix (ADM), of which Alloderm is one option, seems to be beneficial for people with capsular contracture.  It may work where previous capsulotomy or capsulectomy has failed to prevent the contracture from recurring.  Other manuevers should be used as well - implant exchange, creating a new pocket for the implant, etc.  I wouldn't be too worried about infection - although the risk might be slightly higher, it is still very low.  There is a higher rate of seroma formation with ADM, but many surgeons will place a drain, and seromas are fairly easy to deal with.

Douglas J. Mackenzie, MD
Santa Barbara Plastic Surgeon
4.5 out of 5 stars 19 reviews

Revisional breast reconstruction for capsular contracture - best option?

+1

The use of the acellular dermal matrix has grown in its applications and use in plastic & reconstructive procedures, and growing. It has truly been a remarkable addition for breast reconstruction.

The acellular dermal matrix is a tissue that is specially-prepared, which comes from cadaveric skin. It is placed on the inside, not on your skin.  It has been processed in such a way that the basement membrane and cellular matrix remain intact, while removing all other cellular components that may lead to both rejection and infection. Packages as a sterile tissue product, due to its preparation, the chance of acquiring viruses and such is nearly absent.

Its applications for breast reconstruction alone include its use in tissue expander/implant reconstruction, to act as a "hammock" at the inferior portion of the breast for which the implant lies within. This creates a natural "sling" which mimics the ptosis (sag) of the breast, while supporting it in place. By suturing this matrix to its exact position of the breast margins, the plastic surgeon is able to precisely recreate an excellent contour for your breast, especially at the inferior, medial, and lateral positions. This also minimizes migration of the implant, as sometimes seen with "bottoming out" inferiorly or its displacement into the axilla (armpit). In addition to its increased aesthetic results, the acellular dermal matrix provides additional coverage over your implant. This is especially useful in those instances of dehiscence (your incision opening up), thus protecting the implant from exposure, and threatening its necessity for removal. Furthermore, in cases where the overlying mastectomy flaps are thin or damaged, leading to partial flap necrosis, the tissue matrix again provides a coverage over your implant, which can heal over time or a graft placed over the are or simply closed. Lastly, the additional coverage lessens implant visibility and palpability and is a great adjunct for revisionary breast surgery. The use of this matrix, along with the advantages listed above, has reduced the time of the reconstructive portion of the procedure as well. There is less pectoralis muscle retraction and eliminates the need to raise any other surrounding muscles in order to achieve complete implant coverage.  It doe an excellent job for capsular contracture and is certainly a reasonable modality.  Hope that this helps!  Best wishes!

Lewis Albert Andres, MD
Scottsdale Plastic Surgeon
5.0 out of 5 stars 12 reviews

These answers are for educational purposes and should not be relied upon as a substitute for medical advice you may receive from your physician. If you have a medical emergency, please call 911. These answers do not constitute or initiate a patient/doctor relationship.