Enlarging mammoplasty: capsular contracture

The formation of a connective tissue capsule around any foreign body entering the body tissues is a biologically determined process that lasts for several months after surgery.

Fibrous capsular contracture is understood as a contraction, compaction and thickening of the fibrous tissue of the capsule, resulting in compression of the endoprosthesis, compaction and deformation of the mammary gland. This objectively worsens the results of endoprosthetics of the mammary glands, and therefore the development of capsular contracture is considered a late complication of this type of surgery. The frequency of its occurrence, according to various authors, can reach 74%.

Macroscopically, the capsule of the prosthesis is a fibrous, smooth, shiny, grey tissue surrounding the prosthesis. Morphologically, the capsule has three layers. The inner layer is dense fibrous tissue with a small number of fibroblasts and macrophages. The middle layer consists of collagen fibers and myofibroblasts, elongated cells that have features in common with both fibroblasts and smooth muscle cells. [ 1 ]

The outer layer is thicker and consists of fibrous tissue, mainly fibroblasts.

The accumulated experience has allowed us to identify four groups of causes that influence the occurrence of capsular contracture:

• reasons directly related to surgical intervention (hematoma formation, insufficient pocket size, rough handling of tissues by the surgeon, infection of the formed cavity);
• reasons related to the implant (insufficient inertness of the material from which the endoprosthesis is made, the nature of its surface, the type of filler and its ability to bleed through the wall of the prosthesis);
• Patient-related reasons include an individual tendency to develop coarser scars;
• exogenous factors (macro and microtrauma, chronic intoxication, such as smoking).

However, according to numerous studies, none of the above mentioned reasons have a statistically significant correlation with the formation of a dense fibrous capsule. Therefore, it is generally accepted that capsular contracture develops under the influence of many factors.

Currently, the most popular theory of capsular contracture pathogenesis is the fibroblastic theory. According to it, the key moment in the development of capsular contracture is considered to be the contraction of myofibroblasts and hyperproduction of fiber structures oriented in one direction. It is for this reason that the use of endoprostheses with a textured surface has led to a decrease in the incidence of this complication.

With the development of capsular contracture, the mammary gland gradually becomes more and more dense. In advanced cases, it takes on an unnatural spherical shape. In some cases, patients are bothered by unpleasant sensations and even pain. Fibrous compression of the prosthesis capsule can begin several weeks or years after surgery, but most often capsular contracture develops within the first year after the intervention. The process can be bilateral, but more often it develops only on one side.

Currently, the generally accepted clinical scheme for assessing the severity of the capsule surrounding the prosthesis according to Baker is:

1. degree - the mammary glands are as soft as before the operation;
2. degree - the gland is denser, the implant can be felt;
3. degree - the gland is significantly compacted, the implant can be felt as a dense formation;
4. degree - visible deformation of the glands is often noted. The gland is hard, tense, painful, cold to the touch.

In general, when using the Baker subjective scale, only contractures of grades III and IV are defined as clinically significant.

Prevention of capsular contracture

The following areas of prevention of capsular contracture development are identified.

Choosing an implant

It has now been established that the use of textured mammoprostheses, according to many authors, has reduced the incidence of fibrous compression of the implant capsule to an acceptable minimum (from 30% to 2%). Prostheses filled with non-flowing gel, as well as implants filled with isotonic sodium chloride solution, also reduce the likelihood of this complication.

Localization of prostheses in tissues

Most surgeons note a lower percentage of capsular contracture development when placing prostheses under the large pectoral muscles compared to the localization of implants directly under the glandular tissue. This difference can be explained, on the one hand, by a better blood supply to the capsule of the prosthesis located under the muscle, as well as by the constant stretching of the capsule under the influence of muscle contraction. On the other hand, the intermuscular space can be considered "cleaner", since the possibility of microflora from the glandular tissue getting into the pocket formed for the prosthesis is practically excluded. The influence of this flora on the development of capsular contracture is recognized by many surgeons.

Prevention of infection development by using antibiotics significantly reduces the incidence of capsular contracture. Thus, B. Burkhardt et al. (1986) filled prostheses with isotonic sodium chloride solution with antibiotics and washed the formed cavity with an antiseptic solution containing steroids. Then, using a polyethylene "sleeve" irrigated with a solution of providone iodide, the prosthesis was inserted into the formed pocket. The results of this study showed that capsular contracture developed in 37% of cases in patients in the control group (without antibiotic therapy) and only in 3% of patients operated on using the method described above.

Steroid therapy

Local and general use of steroids is based on the well-known fact of their ability to inhibit scarring processes during wound healing. Indeed, the introduction of steroids both into prostheses together with the filler and into the tissues surrounding the prosthesis leads to a decrease in the incidence of capsular contracture or to a decrease in its severity. However, the use of this method can also lead to the development of serious complications - atrophy and thinning of the tissues surrounding the implant, displacement of the prosthesis and even an increase in contracture.

Quality of bleeding control

For a long time, the presence of a hematoma around the prosthesis was considered the main reason affecting the frequency of formation and severity of capsular contracture. This opinion is confirmed by many experimental and clinical studies devoted to this problem. Although a clear correlation between the thickness of the capsule and the presence of a hematoma has not been identified, high-quality bleeding control and wound drainage are essential requirements for the technique of performing endoprosthetics of the mammary glands.

Treatment of capsular contracture

The incidence of capsular contracture has been significantly reduced by the use of cohesive gel and thick-shelled implants. Submuscular placement is also an important factor in this regard. If a capsule does form and the implant is placed subglandular, it can be replaced with a textured implant in the submuscular plane. [ 2 ]

Treatment of fibrous capsular contracture can be conservative and surgical.

The most common method of conservative treatment is closed capsulotomy, which is now finding fewer and fewer supporters. The technique of this procedure comes down to various options for squeezing the gland with the surgeon's hands until the fibrous capsule of the prosthesis ruptures. As a result, the breast becomes soft. The significant trauma of the manipulations often leads to rupture of the implant, the formation of a hematoma, and migration of the gel into soft tissues. Incomplete rupture of the capsule and even dislocation of the prosthesis are possible. The frequency of relapses of capsular contracture after closed capsulotomy, according to different authors, varies from 30% to 50%. [ 3 ]

Surgical treatment involves open capsulotomy and capsulectomy, as well as endoscopic dissection of the capsule.

Open capsulotomy allows visual determination of the condition of the prosthesis, the thickness of the capsule, correction of the position of the prosthesis, and, if necessary, change the size of the pocket.

Open capsulotomy is performed under general anesthesia from an approach along the old scar. After removing the prosthesis, the capsule is dissected from the inside with an electric knife along the entire circumference of its base, and then additional radial incisions are made from the periphery to the center. The previous prosthesis can be used. If necessary, it is replaced with a more modern model. The subsequent stages of the operation are no different from the primary prosthetics. [ 4 ]

If possible, it is advisable to change the localization of the prosthesis in the tissues. For example, if during the first operation the implant was placed directly under the breast tissue, then during re-endoprosthetics it is better to install it in the intermuscular space. In this case, it is necessary to drain both the "old" and newly formed pockets.

Endoscopic capsulotomy is possible, but this technique excludes the possibility of replacing the prosthesis and correcting its position. [ 5 ]

Capsulectomy can be partial or complete and is a rather traumatic intervention. Indications for capsule excision may be its significant thickness or calcification. With simultaneous excision of the capsule and re-endoprosthetics, the implant is placed in obviously unfavorable conditions, therefore, if possible, it is advisable to perform delayed prosthetics with a change in the localization of the implant in the tissues. According to a number of surgeons, relapses of capsular contracture after capsulectomy reach 33%.