Plastic & Reconstructive Surgery | 2021
Discussion: Postirradiation Capsular Contracture in Implant-Based Breast Reconstruction: Management and Outcome.
Abstract
From Virginia Commonwealth University, Inova Branch, National Center for Plastic Surgery. Received for publication June 14, 2020; accepted July 2, 2020. Copyright © 2020 by the American Society of Plastic Surgeons DOI: 10.1097/PRS.0000000000007456 T purpose of the authors’ study was to explore the role of capsular release and autologous fat grafting for the treatment of Baker grade III to IV capsular contracture in the setting of prosthetic breast reconstruction and radiation therapy.1 Of the 48 breasts included in the study, all had a textured subpectoral device. Management strategies included an implant exchange, myotomy, and capsular release [48 of 48 (100 percent)], with the addition of autologous fat grafting [15 of 48 (31.3 percent)]. Capsular release included either a capsulotomy or capsulectomy, depending on the thickness of the capsule. Fat was injected into the subcutaneous, muscular, and supracapsular planes. Of the 15 breasts that had fat grafting, eight of 15 (53.3 percent) resolved following one session of fat grafting and five of 15 (33.3 percent) resolved following an additional fat grafting procedure, resulting in a total resolution rate of 86.6 percent. Of the 33 breasts that did not undergo fat grating, 16 of 33 (48.5 percent) had resolution of capsular contracture following the primary operation and six of 33 (18.2 percent) had resolution following a secondary procedure of fat grafting, resulting in a total resolution rate of 66.7 percent. The authors concluded that radiation-related capsular contracture can be successfully managed by the various capsular release procedures and autologous fat grafting in the majority of patients. It is important to appreciate the clinical appearance of grade III to IV capsular contracture and the structural changes associated with it.2 The changes are the result of skin contracture, subcutaneous fat atrophy, muscle fibrosis, and progressive periprosthetic fibrosis. The clinical manifestations include hyperpigmentation and telangiectasias of the skin, progressive shrinkage of the breast caused by subcutaneous fat atrophy, progressive distortion of the breast caused by periprosthetic capsule formation, and cephalad migration of the device caused by foreshortening of the pectoralis major muscle. The latter point is important because the changes resulting from the irradiated pectoralis major muscle are a major contributor to how we perceive and make the diagnosis of capsular contracture. The radiation-induced damage to the pectoralis major muscle is permanent and irreversible. This is evident when placing implants under the pectoralis major muscle in patients that received radiation therapy before subpectoral reconstruction or augmentation. The outcomes are predictable and suboptimal because of early capsular contracture and the cephalad migration of the implant that is primarily attributable to foreshortening of the pectoralis major muscle and secondarily attributable to periprosthetic fibrosis.3 The firmness of the breast is attributable to the fibrotic changes associated with the adipocutaneous layer, the pectoralis major muscle, and the periprosthetic tissues. Although the authors are very optimistic about their results, this discussant does not share the same degree of optimism. This is based on the observation of personal outcomes following capsular release with or without fat grafting in the setting of radiation-induced grade III to IV capsular contracture that have not been encouraging. The reasons for this are multifactorial and will be elaborated on. The technical aspects and difficulty associated with injecting fat into the atrophied and fibrotic subcutaneous compartment are underappreciated. Often, the subcutaneous fibrosis is so severe that it is difficult to advance the cannula and inject the fat, especially in the area around the nipple-areola complex. Percutaneous aponeurectomy as described by Khouri et al. is occasionally effective but sometimes results in excessive undermining, pooling of fat, resorption, and nodularity.4 In the patient with radiation-induced grade III to IV capsular contracture who desires to continue Discussion: Postirradiation Capsular Contracture in ImplantBased Breast Reconstruction: Management and Outcome