1 year post op, doctor recommends a closed capsulotomy. I'm concerned the cc will return. What is the risk?

Question

I'm one year postop. My PS has recommended a closed capsulotomy, along with medication. My concern is that the cc will return. I was hoping to schedule a revision surgery to go bigger but now don't know if it's possible because of the cc on my right breast. My ps said the risk of cc is not worth a revision surgery. However aren't there risks with a closed capsulotomy? My implants are overs.

S. Larry Schlesinger, MD, FACS · Answer

Back in the day, all plastic surgeons in the 80's did closed capsulotomies.  Closed capsulotomies were ways of squeezing hard on the breast in order to tear the capsule, which then led to an immediately softer breast, with also potential bleeding which would lead to even a harder breast.  There was also the potential for ripping the cover of the implant.  I have literally done hundreds of closed capsulotomies, all of which got hard again.

	Closed capsulotomies fell out of favor in the 90's due to the high rate of return of the capsular contracture, i.e. tight scar around the implant, and also to the potential dangers of bleeding and tearing the implant covering.  The definition of insanity is doing the same thing over and over again expecting a different result. 

	Capsular contractures are a big deal and should not be taken lightly.  If you have a capsular contracture, you want to make a full court press at dealing with it the first time as each time you try and fail, the contracture gets worse and worse. 

	If you were my patient, I would switch the implant from superpectoral to subpectoral as subpectoral has a much less chance of getting a capsular contracture.  I would place ADM (a cellular dermal matrix) at various places around your implant (as this is known to decrease capsular contracture).  I would also place you on Accolate (now generic Zypherlucast), which is a medication known to decrease the chance of a capsular contracture which is an immune phenomenon, since Accolate is known to modulate the immune system and decrease capsular contractures not only around breast implants but also around artificial hips, pacemakers, etc.

Larry S. Nichter, MD, MS, FACS · Answer

Closed capsulotomy procedures are not recommended as they can cause implant rupture, internal bleeding, distortion and other complications. Off label usage of Singulair may be your best bet and if this does not work capsulectomy, change of implant and its pocket and other options are more acceptible techniques to deal with your problem. It also voids the manufacturers warranty. Discuss with a board certified plastic surgeon.

Kenneth Bermudez, MD, FACS · Answer

Definitely against closed capsulotomy to treat implant contractures. Recurrence is high, damage to the implant and your breast tissue can occur and it's not the recommended treatment.

	Medications (accolate, vit. E) and massage should be tried for 6 months and then capsulectomy, etc.

William T. Stoeckel, MD · Answer

Closed capsulotomy procedures are no longer advisable. Open capsulotomy surgery has its risks, but a much higher long term success rate. I would recommend moving your implants into a subpectoral position.

Gerald Minniti, MD, FACS · Answer

Hello,

	If what you said your PS has told you is accurate, please look for a new surgeon.  Closed capsulotomy has proven to be ineffective at treating capsular contracture, mostly because of the nearly 100% recurrence risk.  The treatment of choice is a total capsulectomy and implant replacement.  This, and no touch implant delivery, closed suction drainage, and post operative antibiotics, Singulair, and high dose vitamin E offers the lowest risk of recurrence. This will also allow the surgeon to change the size of your implants, or make other adjustments to the implant pockets as necessary. 

	Best of luck!

Jed H. Horowitz, MD, FACS · Answer

closed capsulotomy for capsular contracture


	this has generally fallen out of favor

	massage and singulair is more common.

	revisiosn with capsulectomy and implant exchange to a size you want is reasonable but may have risks of cc again

Angela Champion, MD · Answer

If you didn't want to go through another surgery, I can see a closed capsulotomy being an option to start off with and seeing if you could achieve any improvement, baby steps. But you stated that you were hoping to change your implants so it is reasonable to do an implant exchange with capsulectomy. I would consider changing planes (going under the muscle) as that reduces the risk of developing a capsular contracture. Keep in mind that even doing everything possible to reduce your risks, because you have already had one, your risks are higher. Talk with your surgeon about your options, recovery and take time to fully understand your risks. ac

Joseph L. Grzeskiewicz, MD, FACS · Answer

I'm sorry to be so short here, but closed capsulotomy is "old school," and in my opinion it no longer has a place in the treatment of capsule contracture. In addition to being very painful and risking injury to breast tissue or rupture of the implants - in fact, it voids the warranty of most implant manufacturers - it really isn't that successful at long term control of capsule contracture, especially in the subglandular position. This is likely one factor in your development of capsule contracture, and if you are inclined to treat your capsules and have the best chance to avoid recurrent contracture, I suggest that you consider open capsulectomy with repositioning of your implants below the muscle. This is an opportune time to change your implants to a different size, and it is reasonable to do this if you wish, you'll just have to have both breasts operated on at the same time instead of just the right. In the event of recurrent capsule contracture, or if you just want to be maximally aggressive and proactive in preventing the chance for recurrence, consideration can be given to using an acellular dermal matrix, like Strattice, to line your pocket after capsulectomy. I do this routinely, and I have very good success at preventing recurrent capsule contracture. If your surgeon is not on board with these concepts, I hate to say it, but you should seek a second opinion with an experienced board certified surgeon who is, because that surgeon will be the one offering you the most state of the art solutions. Good luck.

Jeffrey Zwiren, MD · Answer

Your plastic surgeon may have a good deal of experience with closed capsulotomy.  However there is little evidence of the benefit of this technique and the recurrence rate is very high.

Steven Wallach, MD · Answer

Closed capsulotomies do not work, and it is best to perform an open capsulectomy and exchange the implants.

1 year post op, doctor recommends a closed capsulotomy. I'm concerned the cc will return. What is the risk?

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