Best Ways Pre and Post Surgery to Avoid Capsular Contracture?
- Asked by Miller in los angeles county
- 4 years ago
can a doctor take to prevent capsular contraction with a high risk patient for cc? (I have had several cc.) Are there doctors who have a very low incident rate of cc due to the way they medically treat the patient before, during and after surgery? I am considering one last try at this, but am very unsure. Currently have no implants in to allow my body to heal. I have very little of my own breast tissue and my chest is caved in from 20+ years of implant use.
I would have to agree with most of the comments made previously.
No matter what is done during surgery, this is a biological process and no once can ever predict the outcome or necessarily prevent capsular contracture. It is a highly controversial topic for which we still have many unanswered questions.
As stated, the two most popular theories relate to either:
- blood around the implant
- low grade bacterial contamination around the implant, called a biofilm
In the first case doing all you can do to minimize bleeding requires:
- meticulous control of bleeding during surgery some surgeons feel it is best performed with a bipolar cautery but this is not proven
- limited/controlled postoperative activity
- avoidance of aspirin, etc.
- ice compresses
- some feel compression is useful
In regards to the second, options to potentially minimize biofilm include:
- Perioperative antibiotics
- Triple antibiotic irrigation during surgery
- Multiple glove changes
- Use of a nipple shield, tegaderm, and insert sleeve during surgery
- The use of silicone vs saline implants is controversial in regards to capsular contracture.
- Placement under the muscle seems to be correlated with lower capsular contracture
- Placement throught the breast crease is believed to be the source with the least potential of contamination
Postoperatively: options include::
- Breast implant displacement excercises
- The use of accolate is controversial
- The use of Vitamin E is generally felt to be of little benefit
In cases of recurrent capsular contracture at the time of implant exchange it is probably best to perform a complete capsulectomy (not partial or capsulotomy) and use a completely new implant.
The risk of capsular contracture can be minimized with good technique.
Hi! Of course, there are no guarantees, but here are some important points:
1) Even a few drops of blood increase the risk, so for you, I would recommend using suction drains to remove every little bit of blood around the implants.
2) Even a few bacteria increase the risk (without having obvious infection). So you should be done with a "super sterile" no-touch technique, antibiotic irrigation of the wounds, and high doses of intravenous antibiotics.
3) Gentle technique that avoids bruising the breast tissue is important.
4) Avoiding very large implants is important.
5) I don't think that what you do before and after surgery makes much difference. Massage does not help. (I know this is controversial, but I have a lot of experience.) So never blame yourself. It's what happens DURING surgery that's critical, and the unpredictable biological factor in your tissues.
Nothing can guarantee
Some people are just prone to form contractures around the implant, despite optimizing all conditions.
Be sure that you do not have any active infections. You may also want to be on preoperative antibiotics that are powerful for skin bacteria, like say augmentin?. You will want to take an antimicrobial shower just before you go to the hospital. Your doctor may hav a few tricks for after surgery, but as I said in the teaser, no guarantees. I feel for you and wish you luck.
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Extremely difficult problem with no easy answers but some hope
Capsular contracture is still the number one complication in breast implant related surgery for cosmetic augmentation, revision surgery and reconstruction alike. It also is more likely following a first time contraction.
The main theories for CapCon development are blood and fluid in the pocket around the implant and a low grade bacteria or BioFilm that can surround the implant inside the implant pocket or space. At the time of surgery most plastic surgeons do everything possible to decrease the chance of CapCon. These mainly include meticulous surgery with bloodless pocket preparation and what we call "prospective hemostasis" -- stopping the blood vessels encountered from bleeding before they are cut, and no trauma to the ribs or tissue with blunt instruments, and then antibiotic irrigation to minimize the chance for this low grade bacteria.
Other things we do that may also lower the possiblility of development include: placement of the implant deep to the muscle, and heavy texturing or a Biocell surface on the implant -- a "textured" implant, and creating a pocket that is higher or taller than the implant diameter to allow the patient to displace or push the implant vertically in the pocket (the only thing you can do and it's benefit is ?), and finally a "No Touch" technique to minimize any contamination or contact of the implant with any drapes, towels, sponges.
Recurrent capsular contracture is a very difficult problem. We do all the things above to try and minimize the recurrence again.
The "hope" in the equation is a new material called Strattice or Alloderm among others, but these are the gold standards. This material is called an Acellular Dermal Matrix (ADM) which is in essence human or pocine/pig skin where the epidermis and any infectious or cells that our body may react to are removed. This material has many uses including supporting implants like a hammock or sling internally, providing covergae to help prevent visible wrinkling and rippling and also helps to decrease or eliminate capsular contracture.
In order to have a CapCon, the body has to form scar tissue completely around the implant. For some reason, the capsule does not form beneath this material. It comes to the edge and stops so there is no complete or circumferential capsule that forms.
I have used this material now for this purpose specifically in ~ 20 patients without capsular contraction recurrence. We are starting a research project to document this further but the preliminary findings are very exciting (I presented this early experience at Atlanta Breast Symposium, Feb-2009). You may want to find a surgeon in your area with ADM experience and go in for a consult.
You are wise however to venture into any future surgery with trepidation.
All my best!
Capsular Contracture always a risk
Capsular Contracture is always a risk with any breast augmentation, and in your case, given your history, it is likely a higher risk than in the average patient. As the other doctors have written, 2 things we know increase the risk of capsular contracture are blood around the implant or a low grade infection. With this in mind, I think it's important to pick a surgeon who prides him or herself on meticulous techinque, not just fast technique. Given what we know about what increases the risks of contracture, namely blood around the implant or infection around the implant, I think it's crucial to pick a surgeon that will take his time and do everything possible to avoid these problems.
That being said, the risk always exisits, and the surgeon may do everything right and you could still end up with a contracture. I also agree with the idea of not choosing implants that are too big, and perhaps placing the implants under the muscle, in particular if they are not there already. Some surgeons really believe in this, others think there is no great data to support this, but in your case, I would try everything possible to give you the best result.
Web reference: http://www.drsalemy.com
Preventing Capsular Contracture
Because of a number of techniques I use during breast augmentation surgery that are outlined below, I see very few capsular contractures in my breast augmentation patients. However, the reality is that if you are a breast augmentation patient with a capsular contracture, the incidence - at least to you - feels like 100%. A well-established capsular contracture can be corrected, but doing so involves a return to the operating room, removing and discarding the implant, removing or excluding the contracted capsule, creating a completely new implant space, and putting in a new breast implant (that statement may be somewhat controversial, but I believe the procedure just described is what is what provides a patient with the lowest risk of recurrent contracture). So I think that surgeons should feel obliged to do everything possible to limit the likelihood that a patient develops this frustrating postoperative problem.
Studies have shown that a bacterium called Staph epidermidis can be cultured from as many as 70% of capsule specimens obtained during surgical procedures for capsular contracture. So I employ a number of measure that address the possibility that skin bacteria or nipple duct bacteria may adhere to the implant surface during the augmentation procedure. We prep the skin using potent antiseptic solutions prior to draping the surgical site with sterile drapes, however the microscopic surface of the skin is full of peaks and valleys, and `nooks and crannies' - like sweat glands, hair follicles and sebaceous glands - that may harbor bacteria despite thorough application of an antiseptic prep solutions.
After prepping, we apply a new skin sealant product called InteguSeal to the skin surface where the incision is to be made. This effectively seals off all of the `nooks and crannies' that may harbor bacteria, and the sealant lasts for several days postop. We also apply it over the nipple and areola to seal off the nipple ducts which may also harbor bacteria.
Over the course of the surgery, we irrigate the implant space several times with a large volume of a saline solution containing three antibiotics (which can be modified in patients with an allergy to any of the antibiotics in the solution). Prior to implant placement, we irrigate the implant space with full-strength Betadine, a potent topical antiseptic that has been shown in clinical studies to reduce the incidence of capsular contracture.
I think one of the greatest advances in reducing the possibility of implant contamination by skin bacteria during breast augmentation surgery is the development of a soft, sterile, paper funnel for insertion of silicone gel implants into the implant pocket. This simple yet clever device actually looks much like a pastry chef's bag. It allows me to introduce the implant into the subpectoral pocket without ever touching it with my gloves, and without the implant ever contacting the patient's skin surface. The implant package is opened, the implant is irrigated with antibiotic solution then `poured' into the funnel, the small end of the funnel is inserted in to the skin excision which is held open with retractors, and I gently `squirt' the implant into the pocket. Before this was available, there was a great deal of implant contact with the patient's skin, under great pressure, as a pre-filled gel implant is forced into the pocket through a relatively small incision. The implant insertion funnel completely eliminates what I think has been the most concerning aspect of breast augmentation surgery in regards to the potential contamination of the implant with bacteria during the procedure.
There is no breast augmentation practice with a capsular contracture rate of zero. Yet there are obviously a number of measures that can be taken to make the rate of contracture as low as possible. I think it is important for patients to have confidence that their surgeon is focused not only on providing a breast enhancement that is beautiful and natural-appearing, but also on maximizing the likelihood that their aesthetically pleasing result will remain beautiful and natural-appearing over the long term.
Web reference: http://www.naturalbreastnc.com
You can't eliminate the risk
If your body has shown a tendancy to multpile capsular contractures, you will probably make more no matter what any doctor does. Proper technique, reasonable implant size, submuscular placement, implant massage, and maybe vitamin E are your best bet but no doctor can eliminate the history you have.
Key points to avoid capsular contracture
Reccurent capsular contraction is a difficult problem to overcome as no surgeon can guarrantee a complete remisssion.
The key points are:
1. Complete capsulectomy.
2. Irrigation with a triple antibiotic solution.
3. Submuscular position.
4. Gel implant.
5. Accolate as a medication is controversial due to the side effects.
6. Good surgical technique to avoid bleeding.
7. Early implant massage.
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.