Добавил:
Sekretar
kiopkiopkiop18@yandex.ru
t.me/Prokururor I Вовсе не секретарь, но почту проверяю
Опубликованный материал нарушает ваши авторские права? Сообщите нам.
Вуз:
Предмет:
Файл:Ординатура / Хирургия / @xirurgi_2025 / @xirurgi_2025 - 310 - файл
.pdf
23 Breast Implant Infections
https://t.me/medicina_free
371
a
c
b
d
Fig. 23.9 (a, b) 32-year-old lady who had undergone breast augmenta-
tion 12 weeks ago and then to Bali for a vacation. She used a local
herbal treatment for scar reduction which was kept in place with injury
to the suture line. She noticed a small boil like lesion on the inferior
aspect of left breast which showed sign of infection into the implant
pocket. (c) Explantation was done with cleaning of the implant pocket
23.10 Tips andTricks forPrevention
ofInfection inAugmentation
Mammaplasty Using Implants
• Scrubbing using sterile water or no use of water at all by
using chlorhexidine hand rub (3M-Avaguard). (The
scrubbing is done with standard disinfectants; we
recommend the use of sterile water to rinse off the disinfectant as tap water is more likely to harbour atypical
organisms transmitted through water.)
and closure of the incision in two layers. Fluid and tissue were sent for
culture which turned out to be atypical mycobacterium. She was treated
for 3months on triple antibiotics and was taken up for surgery after a
further cooling off period of 3months. (d
on the left side in a new implant pocket
) 6months after re- implantation
• The nipple area needs to be cleaned and isolated with a
sterile impermeable dressing (Tegaderm).
• Gas sterilization of instruments is preferred. (Autoclaving
does not eradicate the atypical mycobacteria.)
• Sharp pocket dissection with good haemostasis.
• Use powder-free gloves and change them prior to implant
placement.
• Minimal touch procedure for implant insertion. Can use a
“Keller Funnel” for implant placement.
372
https://t.me/medicina_free
M. Thomas and J. D’silva
• Antibiotics for 7days starting the day of surgery. The rst
IV injection should be given 30min. Before the surgical
incision.
• Use drains judiciously. (If there is a chance of blood collection, it is safer to use a drain rather than fear that the
drain may be a route for implant infection.)
• Always tell patients about risk of infection to the implants
and hence if any invasive procedure is undertaken (even
dental), then prophylactic antibiotics should be taken.
References
Barr SP, Topps AR, Barnes NLP, Henderson J, Hignett S, Teasdale RL,
etal. Infection prevention in breast implant surgery – a review of
the surgical evidence, guidelines and a checklist. Eur J Surg Oncol.
2016;42(5):591–603. https://doi.org/10.1016/j.ejso.2016.02.240.
Boustany AN, Elmaraghi S, Agochukwu N, Cloyd B, Dugan AJ, Rinker
B. A breast prosthesis infection update: two-year incidence, risk
factors and management at single institution. Indian J Plast Surg.
2018;51(1):7–14. https://doi.org/10.4103/ijps.IJPS_215_17.
Cordeiro PG, McCarthy CM. A single surgeon’s 12-year experience
with tissue expander/implant breast reconstruction: part I. a prospective analysis of early complications. Plast Reconstr Surg.
2006;118:825–31.
Costerton J, Montanaro L, Arciola C. Biolm in implant infec-
tions: its production and regulation. Int J Artif Organs.
2005;28(11):1062–8.
Lalani T.Breast implant infections. Infect Dis Clin N Am. 2018;32:877.
https://doi.org/10.1016/j.idc.2018.06.007.
Laveaux C, Pauchot J, Loury J, etal. Acute periprosthetic infection
after aesthetic breast augmentation. Report of three cases of implant
“salvage”. Proposal of a standardized protocol of care. Ann Chir
Plast Esthet. 2009;54(4):358–64.
Newman M, Swartz K, Samson M, etal. The true incidence of near-
term postoperative complications in prosthetic breast reconstruction
utilizing human acellular dermal matrices: a meta-analysis. Aesthet
Plast Surg. 2011;35(1):100–6.
Ooi AS, Song DH.Reducing infection risk in implant-based breast-
reconstruction surgery: challenges and solutions. Breast Cancer
(Dove Med Press). 2016;8:161–72. https://doi.org/10.2147/BCTT.
Pittet B, Montandon D, Pittet D.Infection in breast implants. Lancet
Infect Dis. 2005;5:94–106.
Spear SL, Howard MA, Boehmler JH, Ducic I, Low M, Abbruzzesse
MR.The infected or exposed breast implant: management and treatment strategies. Plast Reconstr Surg. 2004;113:1634–44.
Wallace RJJ, Brown-Elliott BA, Ward SC, Crist CJ, Mann LB, Wilson
RW.Activities of linezolid against rapidly growing mycobacteria.
Abstr ICAAC. 2001;45:764–7.
Washer LL, Gutowski K.Breast implant infections. Infect Dis Clin N
Am. 2012;26(1):111–25. https://doi.org/10.1016/j.idc.2011.09.003.
Capsular Contracture: Etiology
https://t.me/medicina_free
andTreatment Options
JacobHaiavy
24
24.1 Introduction
Cosmetic breast augmentation has one of the highest satisfaction rates of any surgical procedure performed with
reports ranging from 95% to 98%. Notably, removal and/or
replacement of breast implants saw a 15% increase compared to 2018, with over 33,764 cases performed in 2019.
(American Society for Aesthetic Plastic Surgery (ASAPS)
2019)
Capsular contracture is a troublesome complication of
breast implants which may require revision surgery. Capsular
contracture is also one of the most common reasons for dissatisfaction with breast augmentation which initially presents with rmness of the breast and can progress to pain and
distortion of the breast shape and volume. When an implant
is placed, a brous capsule forms around it. In a normal
breast, the capsule is thin and soft, with no effect on the
appearance of the breast. In a contracted breast, the capsule
becomes thick and hard and shrinks in a way which alters the
contour of the breast and the position of the implant. (Araco
etal. 2009; Wan and Rohrich 2016) Contracture is thought to
be due to a chronic inammatory process in the implant
pocket, which converts a normal foreign body response to a
pathologic response. The process is not completely understood but seems to be affected by bacterial contamination or
biolm, blood, silicone gel leakage, and tissue trauma. (Wan
and Rohrich 2016; Adams 2009; Berry etal. 2010)
24.2 Classication ofCapsular Contracture
The Baker classication describes four grades of capsular
contracture (Table 24.1), with grade I being a normal, soft
breast; grade II being a minimally rm breast; grade III being
a moderately rm breast with some visible deformity
(Fig. 24.1); and grade IV being a painful, hard, and obviously distorted breast. (Wan and Rohrich 2016; Spear and
Baker 1995) (Fig. 24.2) Typically grade III and grade IV
capsular contracture require surgical management. (Araco
Table 24.1
Grade Description
I Normal breast
II Minimally rm breast
III Moderately rm breast with some visible deformity
IV Painful, hard, and obviously distorted breast
Baker classication of capsular contracture
Supplementary Information The online version contains supplementary material available at
J. Haiavy (*)
Inland Cosmetic Surgery, Rancho Cucamonga, CA, USA
© The Author(s), under exclusive license to Springer Nature Singapore Pte Ltd. 2023
M. Thomas, J. D‘silva (eds.), Manual of Cosmetic Medicine and Surgery, https://doi.org/10.1007/978-981-99-3726-4_24
https://doi.org/10.1007/978- 981- 99- 3726- 4_24.
Fig. 24.1 An example of right breast grade III capsular contracture
with superior displacement of right implant
373
374
https://t.me/medicina_free
Fig. 24.2 An example of bilateral grade IV capsular contracture with
obviously distorted breasts, which were hard and painful
etal. 2009; Wan and Rohrich 2016; Lee etal. 2011; Handel
etal. 2006)
Reported rates of capsular contracture vary widely from 1
to 30 percent of patients who receive implants. (Araco etal.
2009; Wan and Rohrich 2016; Handel et al. 2006; Araco
et al. 2007) The strongest data comes from premarket
approval studies. The rates of capsular contracture in these
studies range from 2 to 15 percent after primary breast augmentation and from 5 to 22 percent after revision breast augmentation with a 3- to 7-year follow-up. (Cunningham and
McCue 2009; U.S. Food and Drug Administration n.d.-a,
n.d.-b, n.d.-c, n.d.-d, n.d.-e, n.d.-f, n.d.-g; Spear etal. 2007;
Hammond etal. 2012; Maxwell etal. 2012; Bengston etal.
2007) Capsular contracture is often cited as one of the most
common reasons for reoperation after breast augmentation.
(Wan and Rohrich 2016)
J. Haiavy
24.3.2 Radiological Diagnosis (Wan
andRohrich 2016)
24.3.2.1 Mammography
Mammography is the commonest breast monitoring investigation done worldwide and is ideal for breast parenchymal
evaluation and any obvious extracapsular rupture of the
implant but is not very consistent in detecting ruptures of
implant intracapsularly. Mammography has limitations in
assessing breasts with severe capsular contractures hence it
is only helpful for early stage capsular contractures.
24.3.2.2 Ultrasound Scan
A well trained sonologist can accurately decipher a normal
breast nding from those found in patients with capsular
contracture. The normal breast implant is anechoic with an
echogenic shell and may show small radial folds with little
periprosthetic uid. Normally, there is a three-layered
appearance with two echogenic lines and an anechoic line
between them, a nding which has been named the “Oreo
cookie sign.”
Three ndings which are prominently seen in patients
with capsular contracture include thickening of the brous
capsule, increase in number of radial folds and deformity of
the implant out of which appearance of new radial folds indicated progressive shrinkage.
24.3.2.3 Magnetic Resonance Imaging (MRI)
MRI has been crowned the “gold standard” for imaging of
the breasts especially after implant surgery. The shell of the
implant is seen intact with a thin brous capsule and small to
moderate amount of periprosthetic uid in normal implants.
Some infoldings of the shell may also be visible.
MRI scan is benecial in screening of the breast post
implant surgery for the following reasons:
24.3 Diagnosis
24.3.1 Clinical Diagnosis
Clinical examination is the best way to diagnose early stages
of capsular contracture as early on it only presents with mild
breast induration which is only felt on palpation of breasts.
Progressive increase in the thickness of the capsule causes
the breast to become harder and distorted causing symptoms
varying from local tenderness to severe pain (Araco etal.
2009).
1. Possible capsular contracture ndings may include alter-
ation of implant contour, irregular surface, spherical in
shape with shell indentations and possible coarse periimplant calcication.
2. Can detect herniation of implant through the “rat tail
sign.”
3. MRI has the highest sensitivity and specicity for implant
rupture detection compared with ultrasound and
mammogram.
4. MRI was found to be the most sensitive to diagnose
implant associated anaplastic large cell lymphomas (BIA
ALCL).
24 Capsular Contracture: Etiology andTreatment Options
https://t.me/medicina_free
375
24.4 Treatment ofCapsular Contracture
Treatment of capsular contracture is divided in to nonsurgical and surgical techniques. Best policy as with any
complication is prevention.
24.4.1 Prevention ofCapsular Contracture
Measures to try and prevent capsular contracture are well
described in the literature. Most surgeons agree that as with
any surgical procedure a dose of IV antibiotics administered
prior to surgery is key to prevention of infection. We use
2.0g of Ancef (Cefazolin) or 600mg of Clindamycin prior to
start of operation. Other factors include careful hemostasis,
sterile and atraumatic techniques, and local antimicrobial
agents. (Wan and Rohrich 2016; Pajkos etal. 2003)
In addition we use a funnel for insertion of the implants
(Fig.24.3). Funnels have been shown to reduce skin contact
and thus potential contamination by 27-fold (P=0.00059) in
a cadaver model. (Moyer etal. 2012) In addition, Flugstad
etal. demonstrated that with the use of the funnel for insertion, the patients experienced a statistically signicant reduction in the incidence of reoperations performed due to
capsular contracture within 12 months of primary breast
augmentation (Flugstad etal. 2016).
re
Various irrigation solutions have been advocated over the
years. In our practice we follow the triple antibiotic irrigation
of the pocket advocated by Adams et al.(Adams Jr et al.
2006). Adams and his coauthors demonstrated that the triple
antibiotic irrigation solution decreased the incidence of capsular contracture and infection. The solution consists of
50,000units of Bacitracin, 1g of Cefazolin, and 80 mg of
gentamycin in 500cc of normal saline. Since Bacitracin has
Fig. 24.3 Use of a funnel for “no touch” technique for insertion of a
silicone gel implant
been difcult to obtain after the Covid-19 pandemic we have
replaced that with Betadine solution added to the antibiotics.
We use 50cc of Betadine in patients that are not allergic to
Iodine.
Textured implants (Wan and Rohrich 2016; Barnsley
etal. 2006; Wong etal. 2006; Asplund etal. 1996) and a submuscular pocket (Wan and Rohrich 2016; Blout etal. 2013;
Vazquez et al. 1987) had classically been associated with
decreased incidence of capsular contracture following primary breast augmentation. We do not use textured implants
for primary breast augmentation due to higher rate of
reported rippling and the recall of the Allergan Biocell textured implants and possible association with anaplastic large
cell lymphoma (ALCL) (Gidengil etal. 2015; Duvic etal.
1995; Cohen and Brooks 1991; U.S. Food and Drug
Administration n.d.-h; FDA n.d.).
Once capsular contracture has occurred, literature on nonsurgical and surgical management is much less clear.
Conservative or non-surgical options consist of breast exercises, high doses of vitamin E, use of prescription medication such as zarlukast (Accolate) or montelukast (Singulair),
pentoxifylline (Trental), use of herbal medication such as
silymarin (Milk Thistle), Turmeric, low-level light laser therapy, and external ultrasound. Surgical options of treatment
are open capsulotomy, capsulectomy (partial or full), site
change, implant exchange, and possible use of Acellular
Dermal Matrix.
24.5 Current Approach toCapsular
Contracture
Our current approach to capsular contracture has evolved
over the last 20years based on current literature and research
and our understanding of this pathologic process. Since the
etiology of capsular contracture can be multifactorial our
approach to treatment is multimodal as well. We discuss the
risk of capsular contracture with our patients during consultation and review the treatment options.
Postoperatively we start breast displacement exercises on
postop day one. Although there is no published study on the
effects of breast exercises and capsular contracture, I believe
that it helps maintain the pocket dimensions, promotes settling of the implants, relaxes the pectoralis muscle, and helps
guide the early capsule formation. We also recommend that
our patients take 1500–2000mg of Milk Thistle (Silymarin)
daily for the rst 6–12weeks. This can be divided into two
doses of 750–1000mg per day. Milk thistle, a natural herb
that has antioxidant and anti-inammatory properties, is
commonly used to detoxify the body, especially the liver.
The active complex of milk thistle is a lipophilic extract from
the seeds of the plant and is composed of three isomer avo-
376
https://t.me/medicina_free
J. Haiavy
nolignans (silybin, silydianin, and silychristin) collectively
known as silymarin (Abenavoli etal. 2010). The antioxidant
properties of milk thistle are similar to Vitamin E, Vitamin C,
and bioavonoids to reduce and slow down oxidative damage. We prefer Milk Thistle to prescription medication due to
low incidence of side effects, tolerability, and liver protective
prole. The most common side effects of milk thistle are gastrointestinal in nature with GI upset and loose bowels. The
incidence is low and similar to placebo effect in studies,
whereas Zarlukast (Accolate) has been associated with a
few incidences of liver failure. (Gryskiowicz 2003)
At the earliest sign of rmness or capsular contracture we
recommend that the patients start low-level light therapy
(LLLT). Low-level light therapy has been shown to reduce
pain, inammation, and edema, promote healing of wounds,
deeper tissue, and nerves, and prevent tissue damage.
Mitochondria are thought to be a likely site for the initial
effects of light, (Yu etal. 1997; Silviera etal. 2009; Pastore
etal. 1994; Karu and Kolyakov 2005) leading to increased
ATP production, modulation of reactive oxygen species, and
induction of transcription factors. These effects in turn lead
to increased cell proliferation and migration, modulation of
levels of cytokines, growth factors and inammatory mediators and increased tissue oxygenation. The results of these
cellular changes in animals and humans include such benets as increased healing of chronic wounds, improvement in
sports injuries, pain reduction in arthritis, and neuropathies.
There are multiple critical parameters that promote the biological responses described; however, the most critical are
the wavelength, energy density, and duration of treatment.
Generally, the clinical literature demonstrated that treat-
ments delivered multiple times a week over several weeks
result in greater efcacy. In addition, pulsing of light pulsing
of light is known to increase penetration depth. (Hashmi
etal. 2010) Some known parameters are that wavelengths in
the 600–700nm range are chosen for treating supercial tissues, and wavelengths between 780 and 950nm are chosen
for deeper tissues, due to longer optical penetration distances
through tissue.
There are many light emitting diodes (LED) devices on
the market. The device that we use is called the Celluma
from BioPhotas (BioPhotas, Inc. Anaheim, CA). Celluma is
a safe, affordable, and easy to use exible LED array. The
Celluma has been FDA approved for multiple indications
such as arthritis, muscle spam, muscle and joint pain, muscle
tissue tension, joint and muscle stiffness, diminished local
circulation, and inammatory acne vulgaris. The Celluma
has 345 light emitting diodes that emit energy at blue
(465nm), red (640nm), and near infrared (880nm) wavelengths with frequencies of 80 Hz, 680 Hz, and 800 Hz,
respectively, for duration of 30min per treatment. The device
comes programmed with multiple operating modes for each
clinical application (Fig.24.4).
For capsular contracture we recommend the Aches and
Pains mode as it favors the infrared wavelengths. Two key
clinical advantages to this device are the exibility (Fig.24.5)
and ease of adaptation for optimal tting to the contours of
the body and the fact that it offers longer duration of treatment. Properly tting the contours of the body is key to optimal energy absorption. A longer treatment duration time
allows the body more time to respond to the therapeutic
effects of LLLT.
Fig. 24.4 The Celluma
console interface showing
different modes
24 Capsular Contracture: Etiology andTreatment Options
https://t.me/medicina_free
377
Fig. 24.5 Patient during a Celluma treatment for capsular contracture
showing the exibility of the device in conforming to the patient’s body
24.6 Non-surgical Management Protocol
At rst sign of capsular contracture the patients start on the
following protocols:
Table 24.2
tion with implant removal (Florin and Haiavy 2018, Prantl et al. (n.d.))
• No replacement of an explanted implant or tissue expander
• Exchange of an existing implant in one tissue plane for a new
implant in a different tissue plane
• Capsular contracture (Baker grades III and IV)
• Calcied or thick, brous capsule
• Removal of a ruptured implant, especially one lled with silicone
gel
• Removal of silicone granulomas
• Exchange of an implant for one with a larger volume
• Replacement of a smooth implant with a textured implant
(regardless of ller material in existing or new implant)
Table 24.3
and Haiavy 2018)
• Subcutaneous implant after mastectomy
• Thin capsule in a submuscular plane
• Capsule that extends deep into the axilla
• Submuscular capsule that is adherent to the chest wall and ribs
• Patients with thin tissues and inadequate support
Indications for partial or total capsulectomy in conjunc-
Conditions that may preclude total capsulectomy (Florin
sulotomy in preventing recurrence of capsular contracture.
Total or partial capsulectomy may be indicated in the following conditions (Table24.2):
Furthermore, the benet of capsulectomy must outweigh
the risk to the patient. There are certain conditions that preclude the ability to perform a total capsulectomy as detailed
below (Table24.3):
We allow the clinical scenario to guide our management
of the capsule.
1. Milk Thistle 1000mg twice a day for 3–6months
2. Low-level light treatment with the Celluma daily for
6–12weeks
3. Ultrasound treatments at 1week, 3weeks, 6weeks, and
3months postop.
The patients are followed closely and if after 6weeks of
this protocol they do not respond we offer the option of adding Montelukast (Singulair) 10mg nightly to the protocol.
24.7 Surgical Management Options
If the patient fails 3months of conservative management or
longer, then they are offered surgical intervention. Surgical
options of treatment are: capsulotomy, capsulectomy,
implant exchange, and site change. A systematic review of
24 observational articles published by Wan and Rohrich
(Wan and Rohrich 2016) in 2016 found that there is no denitive evidence that capsulectomy is more effective than cap-
24.8 Our Technique ofCapsulectomy
We rst perform an injection of dilute solution of local anesthetic for hemostasis, analgesia, and anesthesia. Our solution
usually contains 500 cc of Normal Saline, 50 cc of 1%
Lidocaine, 1 ampule of 1:1000 Epinephrine. For capsulectomies we add 1000mg of Tranexamic acid to promote hemostasis. About 150–200 cc in total are injected in to each
breast along the incision, medial and lateral breast tissue and
along the inferior border.
Capsulectomy is usually performed through existing
periareolar or inframammary incisions on the breast.
Moreover, adequate exposure for capsulectomy may require
a larger incision than if implantation alone was being performed. We prefer to remove the implant and capsule
together if possible in what is called an “en bloc capsulectomy,” especially in the case of a ruptured silicone implant
that is intracapsular without entering the implant capsule.
The thought is that this technique results in a more complete
removal of silicone gel. To facilitate this dissection we care-
378
https://t.me/medicina_free
fully inject additional local anesthetic around the implant
capsule. This helps with hydrodissection and hemostasis.
Using blunt and sharp dissection with an Iconoclast spreader
and Bovie cautery we carefully dissect around the implant
capsule until it is fully free. This dissection has to be done
carefully with an experienced assistant retracting on the
implant to expose the plane of dissection between the capsule and normal breast tissue or muscle. This dissection is
easier around a calcied implant capsule (Fig.24.6) but may
be difcult in a capsule that is tightly adherent to the surrounding tissue and muscle.
On occasion the capsule may still be entered despite the
best efforts of the surgeon. Thus, ruptured silicone material
enters the extracapsular space and must be manually
removed. In such cases, the surgeon has to make an effort to
remove the free silicone material and the implant shell in its
entirety. Then the capsule edges are grasped with a Kocher
clamp and the capsule is dissected and removed as a whole
or in pieces as safely as possible (Fig.24.7). A Jackson Pratt
Fig. 24.6 Calcied capsule and ruptured silicone implants removed en
bloc
J. Haiavy
Fig. 24.7 An example of ruptured silicone implants and fragments of
the capsules, which were removed bilaterally
drain is placed especially in cases where a ruptured silicone
implant was removed. The patient stays on antibiotics until
removal of the drains.
After the capsulectomy the patient is placed back on the
conservative treatment protocol with Milk Thistle 1000 mg
BID and use of LED light therapy daily for 6–12weeks. We
performed a retrospective analysis of our results over the last
2years (2018–2020) for our current protocol in management
of capsular contracture. We measured success as prevention of
another surgical procedure to treat capsular contracture. In the
post-surgical group the success rate was 96% and in the conservative management group success rate was 76%. We found
these to be quite signicant as the recurrence rate for capsular
contracture from previous studies was shown to be as high as
20–50% (Araco etal. 2009; Wan and Rohrich 2016). Capsular
contracture is a complex problem that remains a challenge for
surgeons performing breast augmentation surgery. We continue to study our results from this current treatment protocol.
Figures 24.8 and 24.9 show examples of patients that were
treated non-surgically with our conservative protocol.
Figures24.10 and 24.11 show examples of patients that had
surgical treatment followed by conservative protocol.
Before After
Before After
24 Capsular Contracture: Etiology andTreatment Options
https://t.me/medicina_free
Fig. 24.8 52-year-old with right capsular contracture Baker III treated non-surgically with 24 sessions of LED light with Celluma and daily Milk
Thistle 1000mg BID
379
Fig. 24.9 47-year-old with left capsular contracture Baker III treated non-surgically with 21 sessions of LED light with Celluma and daily Milk
Thistle 1000mg BID and 6 ultrasound treatments
380
Before After
Before After
https://t.me/medicina_free
J. Haiavy
Fig. 24.10 50-year-old with right capsular contracture Baker IV
treated surgically with full capsulectomy and implant exchange followed by use of LED light with Celluma QOD and daily Milk Thistle
1000 mg BID, Montelukast 10 mg nightly, and 18 ultrasound treat-
ments over 3months. Although right breast was softer we classied as
Baker III but she did not want additional surgery and opted to continue
conservative management
Fig. 24.11 40-year-old with right capsular contracture Baker III treated surgically with full capsulectomy and bilateral re-augmentation followed
by use of LED light with Celluma QOD and daily Milk Thistle 1000mg BID for 3months. Both breasts remained soft Baker I
Соседние файлы в папке @xirurgi_2025