Magnifying mammoplasty: capsular contracture

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

Fibrous capsular contracture is understood as the contraction, thickening and thickening of the fibrous tissue of the capsule, as a result of which the endoprosthesis is compressed, the compaction and deformation of the mammary gland. This objectively worsens the results of mammary arthroplasty, and therefore the development of capsular contracture is considered as a later complication of operations of this type. The frequency of its occurrence, according to different authors, can reach 74%.

Macroscopically, the prosthesis capsule is a fibrous smooth, shiny gray tissue surrounding the prosthesis. Morphologically, the capsule has three layers. The inner layer is represented by a dense fibrous tissue with a small amount of fibroblasts and macrophages. The middle layer consists of collagen fibers and myofibroblasts, elongated cells having common features with both fibroblasts and smooth muscle cells.

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

The accumulated experience made it possible to distinguish four groups of causes that affect the emergence of capsular contracture: 1) causes directly related to surgical intervention (formation of a hematoma, insufficient pocket size, rough handling of the surgeon with tissues, infection of the formed cavity); 2) the reasons associated with 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 sweat through the wall of the prosthesis); 3) for reasons related to the patient, there is an individual tendency to form coarser scars; 4) exogenous factors (macro and microtraumas, chronic intoxication, for example, smoking).

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

Currently, the most popular fibroblastic theory of the pathogenesis of capsular contracture. In accordance with her, the key factor in the development of capsular contracture is the reduction of myofibroblasts and hyperproduction of fiber structures oriented in the same direction. It is for this reason that the use of endoprostheses with a textured surface has reduced the incidence of this complication.

With the development of capsular contracture, the breast is gradually becoming more dense. With a far-reaching process, it takes an unnatural spherical shape. In some cases, patients are concerned about unpleasant sensations and even pain. Fibrous compression of the capsule of the prosthesis can begin in a few weeks or years after surgery, but most often the capsular contracture develops within the first year after the intervention. The process can be two-sided, but often develops only on one side.

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

1. degree - the mammary glands are as soft as before surgery;
2. degree - iron more dense, the implant can be probed;
3. the degree - the gland is considerably densified, the implant is probed as a dense formation;
4. degree - often there is a visible deformation of the glands. The gland is hard, tense, painful, cold to the touch.

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

There are the following areas of prevention of capsular contracture development.

Choosing an implant. It is now established that the use of textured mammoprostheses, according to many authors, has reduced the frequency of fibrous compression of the implant capsule to an acceptable minimum (from 30% to 2%). Prosthes 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 in comparison with the localization of implants directly under the gland 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, and by the constant stretching of the capsule under the influence of muscle contraction. On the other hand, the intermuscular space can be considered more "clean", since the possibility of microflora from entering the glandular tissue in the pocket formed for the prosthesis is virtually excluded. The influence of this flora on the development of capsular contracture is recognized by many surgeons.

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

Steroid therapy. Local and general use of steroid drugs is based on the well-known fact of their ability to inhibit scarring processes during wound healing. Indeed, the introduction of steroids both into the interior of the prosthesis together with the filler and into the surrounding tissue of the tissue leads to a reduction in the incidence of capsular contracture or to a decrease in its severity. However, the use of this method can lead to the development of serious complications, such as atrophy and thinning of tissue surrounding the implant, displacement of the prosthesis and even strengthening of the contracture.

Quality of bleeding stopping. For a long time, the presence of a hematoma around the prosthesis was considered the main reason for the frequency of formation and severity of capsular contracture. This view confirms the many experimental and clinical studies devoted to this problem. Although there is no clear correlation between the thickness of the capsule and the presence of a hematoma, a qualitative stop of bleeding and drainage of wounds is an indispensable requirement for the technique of performing mammary gland endoprosthetics.

Treatment of fibrous capsular contractures 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 is reduced to various variants of compression of the gland by the hands of a surgeon until the fibrous capsule of the prosthesis ruptures. As a result, the breast becomes tender. Significant traumatism of manipulation often leads to rupture of the implant, formation of a hematoma, migration of the gel into soft tissues. An incomplete rupture of the capsule and even the dislocation of the prosthesis is possible. The frequency of recurrence of capsular contracture after closed capsulotomy, according to different authors, varies from 30% to 50%.

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

Open capsulotomy allows you to visually determine the condition of the prosthesis, the thickness of the capsule, correct the position of the prosthesis, and if necessary, change the size of the pocket.

An open capsulotomy is performed under general anesthesia from access through the old scar. After removal of the prosthesis, the capsule is dissected from the inside with an electron knife along the entire circumference of its base, and then further radial incisions are made from the periphery to the center. The previous prosthesis can be used. If necessary, it is changed to a more modern model. The subsequent stages of the operation do not differ from the primary prosthetics.

If there is such an opportunity, it is advisable to change the location 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-prosthesis it is better to install it into 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.

Capsulectomy is partial or complete and is a rather traumatic intervention. Indication for excision of the capsule may be its significant thickness or calcification. With the simultaneous dissection of the capsule and re-prosthesis, the implant falls into deliberately unfavorable conditions, therefore, it is advisable to perform delayed prosthetics with the replacement of implant localization in tissues if possible. According to a number of surgeons, recurrences of capsular contracture after katssullectomy reach 33%.

[1], [2], [3], [4], [5], [6]