We are doing a capsulectomy today. This lady has a Baker IV capsular contracture. These implants are hard like a rock. You can see them. They are subglandular and subglandular breast augmentation is associated with much higher incidents of capsular contracture. As the implant contracts with the capsule around, the implant contracts... it turns them from a slightly flatter or [inaudible 00:00:32] shape into a spherical shape. That's what gives the spherical appearance, and they are very, very hard as you can see on both sides. I am going to be making an incision in the inframammary fold, go in and shell out this implant, hopefully get it all with the capsule around it, so the implant material does not leak, but if it leaks, we can clean that up. Then I'll be lifting up the muscle, tacking it to the overlying breast tissue and inserting a new more modern silicone gel [inaudible 00:01:00] silicone gel implant. Sometimes, we can do it from a small incision, but we have to cut the capsule and remove the implant, but if we have preoperative diagnosis that the implant is leaking, sometimes it's better to try and take it out with the entire capsule intact around the implant, and I've been able to dissect around the entire capsule and here it is, but it's sometimes very hard to get it out of the pocket and it's very tedious operation to dissect around this whole thing. I dissect around the whole thing, all the way around, and I am going to try and deliver this implant and capsule out of this incision [inaudible 00:01:38] little bit. I don't think I am going to be able to, so we may have to just open it.

Give me a towel please. Here, this one is good. We have to decompress it so we can get the implant material out of here and sometimes, these capsules are actually calcified. This one has been in for 24 years. This is the old style implant that it did have a problem with leaking. There is the capsule breaking open. This is a textured implant so it's adhered to the pocket, but here it is, get it out. There we go. It was leaky. You can see it's tacky. Sometimes, they are more droopy than that. There's the pocket and we are taking it all out without contaminating the pocket at all. This is it. This is the capsule that forms around it. It's actually calcified. When you press on it, it crackles. This has got calcium in it. What we do is we take a graduated cylinder and we fill it to a certain volume, so this is filled to 400 cc. If we take this implant capsule combination and drop it in there with all that sticky stuff around there, we can see it goes up to 720 cc. Now, we know we've got about a 300 cc or 325 cc implant. That's how we figure out what size to put in here new. Of course we'll have to lift up the muscle, irrigate the pocket, lift up the muscle and tack it to the overlying tissue. Then, we will put our new implant in, approximately 325 to 350. I will go over a little bit because when you get a capsular contracture and it gets spherical, it has a lot more projection.

Our new implant is going to sit down more. It will look a lot smaller. We have lifted up the pectoralis major. We are going to lift it up some more, but basically if lifted up under here to make the new pocket, and this has to be sewed to the overlying muscle all along here, so that's what I am going to be doing here. Lifted it up all through here and that's where the new pocket will be, but I won't put this muscle way down here. That won't allow the lower pole to open up. I am going to put muscle here and simulate a dual plane breast augmentation. I will be suturing it up with multiple sutures along the lower edge of the pectoralis major. The implant we took out and just placed was 325 cc. Typically, to give you the same volume, you have to go up about 20% when going from saline to silicone because saline stand up a bit more. You want it to be the same volume but of course it will sit down a bit more, so I put a sizer in. Likely, the 325 [inaudible 00:04:48] so this is a real implant of 325. I'm going to insert it and that's what we're going to look like. These little puckers here where we put the sutures to hold the pectoralis major up, those will relax over a few weeks, but that's what you are going to look like and of course nice and soft compared to rough hard.


Inside the Operating Room: What Does a Capsular Contracture Surgery Look Like?

Dr. Clayton Moliver removes an old implant that has developed a very hard capsule and inserts a brand new implant.