Subpectoral and Precapsular Implant Repositioning Technique: Correction of Capsular Contracture and Implant Malposition

Abstract

BackgroundAlthough capsule formation is a natural-healing process following breast augmentation using implants, a contracted capsule around a poorly positioned implant can act as an obstacle during the corrective procedure to reposition the implant. The ideal treatment of capsular contracture is removal of the capsule and covering the implant with a healthy envelope without scar tissue. However, total capsulectomy in the submuscular space may be difficult, especially if the capsule is firmly attached to the chest wall. This situation may require a highly skilled technique because aggressive capsulectomy could injure the intercostal muscles and vasculature and cause further complications such as pneumothorax. Therefore, the authors have developed a new, less traumatic method of leaving the capsule behind the new implant.MethodFrom February 2001 through February 2009, the authors treated 74 patients (139 breasts) using a subpectoral, precapsular implant repositioning technique. These patients suffered from capsular contracture or implant malposition after submuscular breast augmentation. The technique is composed of three parts. First, a plane was developed between the anterior wall of the capsule and the posterior surface of the pectoralis major muscle using a periareolar or inframammary approach. After removing the previous implant, the anterior wall of the capsule was fully released from the posterior surface of the pectoralis major muscle and fixed to the posterior wall of the capsule which adhered to the chest wall. The new implant was inserted into the developed subpectoral space, anterior to the capsule.ResultsThe mean age of the patients was 31 years (range = 24–52) and the time between the primary and the secondary augmentation was 42 months (range = 4 months to 12 years). The range for follow-up was from 12 months to 5 years. Median follow-up was 26 months. Postoperative complications included two cases of hematoma but no cases of infection, muscle distortion, or double-bubble deformity.ConclusionThis technique is a valid alternative treatment for capsular contracture or malpositioned implant after breast augmentation surgery. It may be less traumatic than the conventional method of total capsulectomy. In addition, this technique reduces the relapse rate of capsular contracture significantly compared to a partial capsulectomy or capsulotomy as the new implant is inserted into a scar tissue‐free environment. Good aesthetic results and patient satisfaction was achieved using this method. In our experience, this novel technique is a good alternative method of correcting complications of submuscular implant augmentation.

Eficacia del recambio de implantes mamarios y el cambio de plano quirúrgico en el tratamiento de la contractura capsular tipo Baker

“…La contractura capsular sigue siendo la complicación número uno, con una prevalencia del 15 al 39% y en algunos reportes hasta del 59%, con más de 50,000 pacientes tratadas anualmente, 7 y es la razón primaria para una revisión quirúrgica, 1 pudiendo ser tan severa que requiera cirugías adicionales para resolverla, resultando en un gasto extra para las pacientes, un potencial para resultados subóptimos y mayores probabilidades de recurrencia. 15,[19][20][21][22][23][24][25][26][27] Existen varios factores que pueden influir en la ocurrencia y el grado de formación capsular. En la actualidad, la mayoría de los cirujanos plásticos e investigadores están de acuerdo en que existen dos principales teorías de formación de la cápsula, que da como resultado la contractura: la teoría bacteriana, que implica la formación de una biopelícula y bacteriemia transitorias, y la teoría de la cicatrización hipertrófica, que involucra la presencia Cuadro III.…”

“…Con este fundamento se decidió emplear implantes de gel altamente cohesivo en todas las pacientes de este estudio. 2 En cuanto a las complicaciones, Lee y colaboradores 23 reportaron dos casos de hematoma y tres de reincidencia de contractura tipo Baker grado III, mientras que Castello 24 refirió no haber presentado algún caso de recidiva, pero reportó como complicaciones un caso de seroma que requirió exploración quirúrgica y aspiración una semana después de su cirugía y un caso de hematoma que necesitó de evacuación al quinto día del postoperatorio. A diferencia de estos reportes, en nuestro estudio no se documentó ninguna complicación postoperatoria ni temprana ni tardía.…”

Open Capsulotomy: An Effective but Overlooked Treatment for Capsular Contracture after Breast Augmentation

“…58–60 In their comparison of capsulectomy and site change versus open capsulotomy and no site change, Wan and Rohrich 7 find evidence to support a site change. However, as with the comparison of capsulectomy and capsulotomy, the difference in implant shell integrity is a confounding factor.…”

“…5 It can be technically difficult, and dangerous, to remove capsular tissue from the axilla and the chest wall. 1,60,69 Accordingly, an anterior capsulectomy may be recommended, 69 although this recommendation begs the question, is a capsulectomy really necessary if part of the capsule is left in the patient?…”

The Double-Bubble Deformity

“…Capsular contracture and upward migration of breast implants have been implicated in the genesis of the double bubble. 1 Subpectoral placement of implants in patients with significant postpartum atrophy, glandular ptosis, or "relatively large volumes of native breast tissue" also increase the risk of a double bubble. 2 Some individuals are predisposed to a double bubble, including those with tuberous breasts, a constricted inframammary fold, or a short nipple-to-inframammary fold distance.…”