Olle Asplund

Capsular Contracture after Breast Reconstruction with Silicone-Gel and Saline-Filled Implants: A 6-Year Follow-Up

A major problem after breast reconstruction with augmentation mammaplasty is contracture of the fibrous capsule around the prosthesis. In a series of 72 breasts in 65 women, silicone-gel and saline-filled implants were randomly selected prior to breast reconstruction. The results were judged with respect to consistency, tenderness, wrinkles, and sounds by two independent plastic surgeons according to the breast augmentation classification (BAC) and by the patients themselves. Capsular contracture was found by the surgeons in 50 percent of the gel implant group and in 16 percent of the saline implant group, which is in conformity with the results of the follow-up 5 years earlier. The incidence of deflation was 16 percent in the saline group and occurred in different sizes of both overinflated and underinflated prostheses. The degree of slow leakage from saline implants will be discussed. Despite the high rate of contractures in the gel group, 85 percent of all patients were satisfied with the result of the reconstruction.

Textured or smooth implants for submuscular breast augmentation : A controlled study

&NA; Capsular contracture consistently has been the most frequently noted complication of submuscular and subglandular breast augmentation. The etiology of this complication is still unknown, although silicone bleed, hematoma, infection, foreign bodies, and surgical trauma have been implicated. In this prospective, double‐blind study, 61 women undergoing submuscular breast augmentation were randomized between Dow Corning textured and smooth‐walled silicone gel implants. Any consequent capsular contracture was assessed by an independent plastic surgeon and also by the patients themselves. Objective evaluation was made by applanation tonometry. It was found that depending on doctors, patients, and objective method used, 3 to 9 percent grade III and IV encapsulation followed submuscular augmentation with textured implants and 10 to 20 percent with smooth‐walled implants after 1 year. The differences were significant according to both patient assessment and applanation tonometry but not according to the physicians’ evaluations. There was no correlation of capsular contracture with the age of the patient, duration of the operation, or degree of blood loss. There was a small but inconclusive difference in capsular contracture rate that favored the placement of textured rather than smooth implants in the submuscular pocket. (Plast. Reconstr. Surg. 97: 1200, 1996.)

Preoperative Antibiotics and Capsular Contracture in Augmentation Mammaplasty

The main drawback with augmentation mammaplasty using implants is capsular contracture. The cause of this complication is still unknown. Silicone particles, hematoma, and bacterial contamination are some of the etiologic factors discussed. In this randomized, double-blind study on 76 breast-augmented women, 50 percent of the patients had preoperative prophylaxis with benzylpeni-cillin and dicloxacillin. Bacteria samples were taken intra-operatively. The number of negative cultures increased significantly with antibiotic prophylaxis. In four follow-ups during the first postoperative year, the rate of contractures was evaluated by subjective and objective methods. The results showed no statistically significant difference between the placebo and the antibiotic group with respect to the incidence of capsular contracture.

Results of Subglandular Breast Augmentation Using a new Classification Method—18-Year Follow-UP

The main problem after augmentation mammaplasty is the formation of capsular contractures. The frequency of this complication varies in different reports. In this study the results in 60 women 15-21 years after subglandular breast augmentation are presented. The patients completed a questionnaire and the breasts were judged according to a new Breast Augmentation Classification (BAC) scale. Of all breasts examined 79% had grade III or IV, but 77% of the patients were satisfied with the final result. However, 84% thought that their breasts were too hard. Breast cancer had not developed in any patient. Rheumatoid arthritis developed in one patient 4 years after the operation. Capsular contracture and unacceptable results after subglandular breast augmentation were found in the major portion of the patients in this study.

Bacteria in the Female Breast

Subclinical infection may play a role in capsular formation around silicone breast implants. To assess the possibility of antibiotic prophylaxis for prevention of capsular formation, knowledge of bacteria present in the female breast tissue and the resistance pattern of these bacteria is needed. Samples were taken from 25 patients (49 breasts) peroperatively during reduction mammaplasty with an impression pad method. The samples were placed in agar plates and incubated both aerobically and anaerobically. In more than 90% of the samples bacteria were found. The species of bacteria found were mainly Staphylococcus epidermidis and propionibacteria. These bacteria were sensitive to penicillin G and/or isoxapenicillin. It remains to be shown that prophylactic antibiotic treatment will decrease capsular formation following augmentation mammaplasty.

Nipple and Areola Reconstruction: A Study in 79 Mastectomized Women

Seventy-nine patients of 100 desired a nipple-areola reconstruction. In nipple-areola reconstruction, skin from the upper inner thigh gives the best results as areola replacement, except perhaps in women with very large contralateral areola. Nipple-sharing was the most favourable method for reconstruction of the nipple. Mushroom nipple plasty could give satisfactory results when nipple sharing was not feasible. There were no early complications of nipple-areola reconstruction, which often can be done on an out-patient basis. Most of a series of women who underwent breast reconstruction thought that nipple-areola reconstruction was important and were satisfied with the result.

Interobserver Variation and Cosmetic Result of Submuscular Breast Reconstruction

Four experienced plastic surgeons judged the results of 6 different variables in 99 breast reconstructed women. In the range good to poor the observers assessed symmetry of size, position of the submammary fold, symmetry of shape, nipple-areola reconstruction and scars. The grand mean for total cosmetic results was 2.16 (2 = good, 3 = acceptable). Our material shows a great variance between patients in the total cosmetic result. We considered that no variable here shown has unacceptable reliability in terms of interobserver within patients and interpatients within observers variance ratio. The strongest correlations to the total cosmetic result were shown by symmetry of shape, position of the submammary fold and symmetry of size. Thus, in order to improve the total cosmetic result it is important to focus attention on these three aspects.

Late Results Following Mastectomy for Cancer and Breast Reconstruction

A series of 100 women had been surgically treated for breast cancer and reconstructed by implantation of a submuscular prosthesis. The patients intensely desired the procedure and were supposed to have a realistic anticipation concerning the results. There was one late extrusion of prosthesis and one prosthesis was removed because of a local recurrence. Six patients had local or distant recurrences. Breast reconstruction was not a disadvantage in the treatment of these recurrences. In 48% of the cases the patients thought that the reconstructed breast was harder than desired. The corresponding figure for the independent examiner was 31%. After breast reconstruction, ipsilateral arm complications increased in number or severity by about 5%. In 82%, life-style and in 53%, social relations had improved after breast reconstruction. One of the 100 patients regretted the reconstruction and three were indifferent to it. For 14 patients it was so important as to be possibly psychologically vital.

Adjustment of the Contralateral Breast Following Breast Reconstruction

Surgery on the contralateral breast was performed in 64 of 100 patients for adjustment of size and shape or for diagnostic purposes. The patients found it more desirable to adjust size than shape asymmetry on the contralateral breast. There was only one early complication and six late ones. The former was a postoperative hematoma after a reduction mammaplasty. The latter were three cases of capsular contractures after augmentation mammaplasties. In these cases the implant was placed in a submuscular position. In three cases, patients asked for a secondary reduction mammaplasty because of poor symmetry. There were some difficulties in comparing pre- and postoperative mammography after augmentation mammaplasty. In the other adjustment procedures, there were only minor difficulties in a few cases comparing pre- and postoperative mammography. Patients with a high risk of bilateral breast cancer needing size and/or shape symmetry correction should be considered for mastectomy and immediate reconstruction.

Breast Reconstruction with Submuscular Prosthesis After Modified Radical or Simple Mastectomy : Surgical Technique and Early Complications

A series of 100 women who underwent breast reconstruction is reviewed. They had previously been treated for breast cancer with modified radical or simple mastectomy. The technique and early results of reconstruction are presented. The same surgeon performed all these operations and the technique was not varied. Emotional need for reconstruction was the main factor in patient selection. The interval between mastectomy and reconstruction was as a rule at least one year after removal of stage I cancer and 2-5 years in stage II cases. Scar correction was required significantly more often after oblique than after horizontal mastectomy incision. A submuscular pocket was created to accommodate the prosthesis and a muscle and fascia flap was used to add tissue and contour. No major early complications occurred. The submuscular implantation of prosthesis facilitated clinical follow-up. In a background population of breast cancer patients, the overall frequency of breast reconstruction was 4%. The figure for premenopausal patients with stage I breast cancer treated with modified radical mastectomy was 18%.