I had my first augmentation July 2011 with silicone smooth unders through the areola. Developed contacture at week 4 in my left beast that is now grade III to IV. I want revision with Strattice, since it is likely due to bacterial film around the implant. My question: would it help to decrease the chance for recurrence if I take the implants and capsule out for a few months before I put in the new set? Thank you in advance!
What is the Best Way to Approach Capsular Contracture Revision?
Doctor Answers 8
Correction of capsular contracture with Strattice
Hi Margarita 6062,
As previously mentioned there is no study that specifically addresses this question. In my opinion, unless there is an obvious infection, as opposed to what may be a biofilm, there is no reason to remove the implants for a few months. Most cases of capsular contracture, if treated appropriately with at least partial capsulectomy, will be corrected. One does not always need to use Strattice, although it may have some benefit. For my patients I do not routinely use Strattice for correction of capsular contracture. I assume the implant is subglandular? If it is subglandular, please discuss with your surgeon converting to a subpectoral pocket, which may help. Textured implants may also be beneficial. You may also want to consider taking Accolate post-operatively. I assume your plastic surgeon is taking all the possible steps in the operating room which may help prevent capsular contracture-use of triple antibiotic solution, Ioban to cover the skin prior to insertion of implant, etc. Please discuss all these things with your plastic surgeon so that you know you have done everything possible to prevent a recurrence. The good news is the treatment almost always is successful if done correctly. Hope this helps.
Tracy M. Pfeifer, MD, MS
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Capsular Contracture Revision can be assisted with ADMs
Margarita6062: sorry to hear about your predicament. Prior to the advent of ADMs (acellular cadaveric dermal matrices like Alloderm and Strattice), I would counsel women who had experienced early & symptomatic (Baker III-IV) capsular contracture that the surgical approach would include a) anterior dome capsulectomy (removal of the anterior surface of the scar capsule; b) change of the surgical approach (in your case, periareolar to inframammary fold); c) placement of a drain; d) possible change of implant; e) activity restriction & interim massage.
Generalizing from the low rate of capsular contracture in my breast cancer patients and since 2007, I have included Alloderm, as an "interposition" graft (i.e. sewn onto the inside of the breast flap), change of incision, along with either a capsulotomy (i.e. scoring the scar capsule), formal drainage and activity restriction for patients who were "early" (within 1-3months post-op) scar capsule formers. All patients were informed that although it wasn't possible to guarantee "improvement", the only alternative would be removal of the implants. As you can imagine, most patients were not enthusiastic about explantation or the cost of the ADMs. Although my series is small, none of the 6 patients have recurred or required further surgery. In my experience, interval explantation isn't going to improve your chances for nonrecurrence of capsular contracture.
Certainly the appraoch you mentioned to remove the implants and the capsule and wait 3-4 months before putting new implants in would be the ideal best chance to minimize recurrence. However, with a first go round with a CC often changing the pocket to under the muscle, changing the implants, and removing as much of the capsule as possible is a reasonable first attempt. Some suggest using Strattice as well.
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What is the Best Way to Approach Capsular Contracture Revision?Answer:
So far there is early evidence that contracture can be successfully treated with Strattice and I think the timing can be anytime you and your surgeon feel that you have given it enough time and are sure that it is not going to change..I would not do a full capsulectomy at that time, but instead would suture Strattice as an interposition material into the capsule....It really seems to work!!!
Capsular contracture and staging the correction.
The reason for your contracture is most likely unknown at this point. Assuming you did not have a clinical infection of the breast, the contraction could just have easily been from a small hematoma. The bottom line is that most capsular contracture is idiopathic (meaning we don't know why it happened). Strattice is an excellent choice to help prevent recurrence of contracture and in most cases it is not necessary to stage the capsulectomy and the Strattice. However, if you did have a clinically apparent infection, it would be prudent to perform the capsulectomy and implant removal several months prior to replacement of an implant with or without Strattice.
Breast implant contracture revision with Strattice
Most of the time it is not necessary to remove the implants and wait before using Strattice, though sometimes that is recommended for capsular contracture when not using it. Unfortunately there are no specific studies to answer your question definitively. What I can sayis that every case where I have used Strattice along with implant replacement for capsular contracture it has been successful.
Revision for contracture
these are difficult questions.. unless you had an extreme infection.. this is probably not necessary. the implant should be changed. the entire capsule removed and acellular dermis added.. you still will have a 25-40% chance of some problems.
Capsular contracture following breast augmentation
The incidence of capsular contracture following breast augmentation approaches 8%. The etiology is unclear and may relate to a low grade infection which does not become clinically apparent or a small amount of blood left in the pocket at the time of surgery. In most cases it is a Grade II capsule with firmness and minimal displacement. Recent evidence suggests asthma medications which are strongly anti-inflammatory such as Accolate may slow or stop a recently identified capsule form worsening. When patients develop more significant encapsulation, it is best to wait 6 months for maturity of the scar before revision. There are several options for revision. These include removal of the implants and replacement after a delay such as an additional six months. Capsulectomy with immediate implant replacement can be performed. The addition of an acellular dermal matrix such as Strattice has been shown to decrease the recurrence risk. Certainly, evidence suggests that changing sites from subglandular to submuscular may also reduce encapsulation recurrence.