Putting Back the Same Implant After Capsulectomy?

Question

I had a Brachioplasty and Breast Lift with implants this past Septemeber. My right breast now has a painful Grade IV contracture resulting from a hematoma. To make matters worse, the particular model of Mentor cohesive gel implants that I have are not yet approved in the US.
My local surgeon wants to perform a capsulectomy and just replace with the SAME implant. I mentioned to him that everything I read indicated standard practice was to replace with a new implant. He said that I would be fine since I hadn't had the implant in very long. I am very indebted to him because he was willing to consult with me when other surgeons blasted me for going overseas. They could care less that I had lost 169 lbs and had debilitating excess skin. My Costa Rica surgeon told me to come back so he can perform the capsulectomy and replace it with a new implant, however, I'd like to avoid travelling back to Costa Rica if at all possible.
What should I do at this point? Any advice would be helpful! I am almost positive this hematoma occurred as a result of strain and is not ruptured. Yet and still, should I be leery of my US surgeon wanting to replace with the SAME implant?

Brent Moelleken, MD · Answer

I would personally not agree to perform surgery on a patient unless I had backup implants available.  That is not to say it is wrong, just my opinion.
What if during surgery an infection was discovered?  Or a damaged implant?  Or something bizarre, like an inferior quality implant?  All these things are possible, and have happened.  Now the patient is asleep and the surgeon is faced with an insoluble problem.
If you are enamored with the implant shape, and cannot find an implant shape in this country that is satisfactory, it would be best to seek a surgeon who is on the study and is capable of replacing the implant if necessary.
It would also be advisable to obtain the operative note of the foreign doctor, if at all possible, to maximize the chance that the right implant is "on deck"... just in case.

Lewis Albert Andres, MD · Answer

Hello! Thank you for your question!  It is a matter of surgeon 
preference as well as what is seen during your procedure that will 
determine whether or not a complete capsulectomy is performed. If 
significant capsule formation is seen intraoperatively, a full capsule 
removal may be warranted with a drain in order to completely remove all 
of the tissue and allow better adherence of your breast back to its 
normal anatomic position down on your chest wall. If minimal contracture
 is seen, it may be possible to leave the capsule, or place cuts within 
the capsule to allow better adherence. It truly is dependent on what is 
seen with your capsule and the issues that may be causing you to have 
such a procedure (e.g., contracture from ruptured implant vs pain vs 
simple pocket adjustment, etc).  Implants mayor may not be replaced depending on your discussion and reason for capsulectomy.   I typiclly replace the implant to new one.Without
 knowing your issues and
 without an examination, it is difficult to tell you what may be the 
best thing for you. I tend to favor performing capsulectomies (in an en 
bloc fashion) in order 
to create a fresh pocket, reshape the pocket, allow better shape and 
adherence of the overlying breast. I would discuss your issues with your
 plastic surgeon who will assist you in determining the right modality 
for you. Most patients tolerate this procedure very well with minimal 
downtime.  It is typically an outpatient procedure with most being able 
to resume activities within a few days along with restrictions for a 
week or so.  Many surgeons will recommend a postoperative garment for 
several weeks postop as well.  Hope that this helps! Best wishes!

Jerome Edelstein, MD · Answer

It is highly advised that the same implant not be used. You may want to insist on getting a replacement, although you'll probably have to cover the cost for it. If you disagree with your surgeon, please express your concerns with them. You may also want to seek the advice of another experienced board certified surgeon. Best of luck.

Siamak Agha, MD, PhD, FACS · Answer

WIth grade IV capsular contracture, many insurnace companies will actually pay towarsd your treatment. I would personally perform a capsulectomy with use of new implants. I would not use old implants again since they may harbor a biofilm of bacteria around them that can result in capsular contracture again.

Otto Joseph Placik, MD · Answer

The real problem is we really cannot definitively identify the cause nor can we provide a consistent recommendation regarding the management of capsular contracture.
In my mind you have a few options and of course some of this is based on my personal practice experience over 15 years now:

My most consistent and reliable method of treating capsular contracture is capsulectomy and implant replacement with a NEW implant.
Capsulotomy/partial removal and replacement with the EXISTING implant can be successful but not on a consistent basis.
Regardless of any technique capsular contracture may recur.
Cohesive gels are not available for widespread use at this time as you know. I know you are attempting to save money but you may want to consider replacing both implants with similar ones to assure a more symmetric outcome.
You may find that returning to Costa Rica is the most economical solution but there are no guarantees this will solve the problem.

In terms of mix/match it really depends how much tissue you have and how big the implants are which is difficult to guess over the internet. Let me give you an oversimplified example which provides some insight:

IF you take a football and a volleyball the difference in shape will be very obvious if you cover them with a silk sheet. Howevery you may barely notice the difference if you cover them with a thick comforter. What do you have: silk sheets or comforters?

I hope this helps!

Steven H. Williams, MD · Answer

I agree with Dr. Moelleken that any surgery around an intact implant where the end result includes having an intact implant in place should have implants available.
In my practice we believe that a major cause of capsular contracture (hard or firm breast implants) comes from subclinical bacterial contamination. 
To reduce the possibility of this happening again, we would recommend the implants being replaced (the biofilm on the old implants may be impossible to sterilize).  That is not to say that re-using the old implant is improper, but in our experience, it may increase the possibility of recurrent capsular contracture.
To answer your new questions - mixing the implants (as long as they are both silicone for consistent feel) should be ok.  Be sure to remember that the sides may feel different even if the same implant is used because of the additional surgery on the breast with the capsular contracture.  Depending on the extent of the capsulectomy - your old implant may not be enough to give you symmetry.
Be sure to discuss all these issues with your surgeon before your surgery.
I hope this helps!

Sanjay Grover, MD, FACS · Answer

It is possible that the hematoma did lead to your capsular contracture; however, there are other possible causes as well. 
A subclinical (non-obvious) bacterial infection around the implant could have contributed.  If this is the case, a film (thin layer) or coating may exist on your implant and potentially induce another capsular contracture if you replace the same implant.  
Although the cohesive gel implants are not yet FDA approved in the U.S. and available to all surgeons, there are some surgeons who are enrolled in several ongoing studies with Allergan and Mentor to implant them.  You may wish to contact several.

David L. Kaufman, MD FACS · Answer

Revision breast surgery is challenging, especially in the setting of a rapid onset severe contracture.  Without examining you personally, offering a specific recommendation is not realistic... given that, here are a few thoughts.
Given the rapid onset of your contracture, changing implants would be indicated (in my opinion).  Start with everything fresh.
Performing a complete capsulectomy as opposed to capsulotomy is important.  That means removing all of the capsule (scar tissue) as opposed to just opening it up.
Change planes if you are above the muscle.  Some studies (although there are a fair number of contradictory ones as well) find that capsular contractures is less with implants placed below the muscle.
I hope this helps.  At a minimum, get a couple of opinions... and listen to your instincts.  You should not feel indebted to any surgeon - we're here to help you.
Dr. Kaufman

Kris M. Reddy, MD, FACS · Answer

Your consulting surgeon would be in the best position to recommend the best course of action for you. However, we would opt for a new implant.

Scott E. Kasden, MD, FACS · Answer

I agree that there is no "standard" practice in this situation.  I feel that the hematoma led to the contracture.  It is probably better to use a new implant with the capsulectomy.  Mentor also likely has a suitable legal replacement as well.
If your surgeon feels that it would be ok, he does have the benefit of examining you. 
If you are concerned about a ruptured silicone implant, MRI will answer the question.
If you doubt your surgeon, please, by all means, seek a second opinion- you will do yourself and the doctor a favor- you need to have conficenc and trust.
Remeber this: although you are not hapy with your contracture, it is not life or health threatening, so you have the luxury of time to make the right choices for yourself. 
Finally, I am wondering why you had to go to Costa Rica for your surgery when many highly qualified and sensitive plastic surgeons are here in the USA? Cosmetic Rehab of the massive weight loss patient is in fact one of my professional passions.