Late and Long-Standing Capsular Hematoma After Aesthetic Breast Augmentation with a Saline-Filled Silicone Prosthesis: A Case Report

Late capsular hematoma is an extremely rare complication after the implantation of silicone breast prostheses for aesthetic or reconstructive objectives. We present a unique case of late capsular hematoma in an aesthetic breast augmentation with a saline-filled, textured silicone implant, which remained for a year after formation.     

An Improved Method of Removing Polyurethane Foam-Covered Gel Prostheses

One of the advantages of polyurethane foam-covered prostheses has been that in the first 5 to 10 years after their use, the amount of capsular contraction was found much less than when similar ``slick' prostheses were used. Another advance was their fixation to the surrounding tissue thus giving a more natural appearance and movement with the muscles when the arms were moved in any direction. The formation of a thick capsule also acted as a protection against gel granuloma due to rupture of the prosthesis and has been thought to be a factor in the lower capsule contraction rate. The greatest disadvantage has been that its removal was extremely difficult and this has continued up until the technique described in this paper has been introduced.     

A biochemical evaluation of the restraints to posterior shoulder dislocation

The biomechanics of posterior dislocation of the shoulder was evaluated using nine cadaver shoulders. Each was arthroscoped, roentgenograms were obtained, and then each was dislocated in a testing device. Force displacement data was obtained during testing, and posttesting roentgenograms, arthroscopic evaluation, and subsequent open dissections were performed to evaluate the pathology created. Although instability was created in all cases with displacement of the humerus to the diameter of the humeral head, force displacement of the humerus to the diameter of the humeral head, force displacement curves did not show an inflection point, implying a continuum between subluxation and dislocation. All shoulders had posterior Bankart lesions or posterior capsular lesions, or both. Anterior pathology was not seen. Posterior instability is most likely a continuum between subluxation dislocation with progressive injury to the posterior capsule and attachments such as the labrum as the principal restraint to posterior displacement.     

Inflammatory Reaction and Capsular Contracture Around Smooth Silicone Implants

Histologic studies were performed on capsular tissue resected from 21 patients who were implanted with smooth silicone prostheses filled with gel. The results disclosed a non-uniform response to the implants. The granulomatous reaction to the silicone showed important variations along the same surface of the implants, between the plane and the concave surfaces, between equivalent points at the right and left sides, and among the patients. Also, a significant difference was observed between reactions and capsules in early and late stages. The author believes these variations of the capsular inflammatory reaction promote different sites of contraction between cell-to-cell, or cell-to-collagen-to-cell. These adding forces result in vectors of different intensities and directions around the implants which explains the various clinical grades of capsular contracture.     

Immediate Reaugmentation of the Breasts Using Bilaterally Divided TRAM Flaps After Removing Injected Silicone Gel and Granulomas

The authors present eight cases of reconstruction of the breasts using bilaterally divided TRAM flaps after removing the injected silicone gel and granulomas. In Japan, we have the opportunity to examine many patients who have had foreign substance injections to the breasts for purposes of augmentation, however, most of them are now suffering from delayed complications. Until now we have reconstructed breasts such cases by use of silicone bag prostheses after removal of granulomas; however, now it is difficult to obtain silicone prostheses. Thus, we have decided to reconstruct by the use of autogenous cutaneous and adipose tissue flaps as presented by us in this article.     

A Review of the Literature on the Etiology of Capsular Contracture and a Pilot Study to Determine the Outcome of Capsular Contracture Interventions

The etiology of capsular contracture is unclear and probably multifactorial. This review covers the literature on several proposed contracture factors, including filler material, implant placement, surface texture, and bacterial infection. The pilot study's goal was to test the feasibility of a data collection form, which could be used in a scaled-up study analyzing multiple surgeon's records. The goal of the expanded version of this study will be to determine the efficacy of available interventions for capsular contracture, including surveillance. The Breast Implant Public Health Project, LLC (BIPHP), piloted a retrospective review of outcomes in women who had interventions to relieve capsular contracture or had chosen a wait-and-watch approach. An evaluation of the efficacy of various treatments can help women decide if they want to pursue treatment at all and, if so, which treatment might offer them the best solution. BIPHP researchers (E.E.A., M.E.) developed a data collection form after reviewing records of three surgeons (B.C., W.P., V.L.Y.). During the data collection using the same records, we tested a randomization process to identify women with capsular contracture who underwent various interventions, including a wait-and-watch strategy, and those who had no mention of any intervention or waiting approach. Data were gathered on a total of 90 breasts with capsular contracture (scored Baker I–IV or qualitatively), of which 45 underwent a total of 102 interventions for capsular contracture. Interventions were classified as ``closed capsulotomy,' ``surgical,' or ``watchful waiting.' Closed capsulotomy was performed most often (47%), followed by surgery (29%) and watchful waiting (21%). Presurgical Baker scores averaged higher in breasts that underwent surgery (3.1) than for watchful waiting (2.5) or closed capsulotomy (2.3). Though closed capsulotomies had 100% of outcomes scoring ``improved' or ``same,' 58% of the breasts underwent the procedure more than once, suggesting that the favorable outcome was short-lived. The wait-and-watch approach resulted in scores of either ``same' or ``worse'; surgery (open capsulotomy, repsoitioning, or capsulectomy) resulted in 79% improved, 16% same, and 5% worse outcomes in breasts with outcomes listed. In all intervention procedure categories, outcomes were frequently unavailable; they were noted only 60% of the time (52/87). The missing 40% may have resulted from the doctor's failure to note it in the chart, satisfied patients not returning for additional treatment, or dissatisfied patients seeking treatment elsewhere. Generally, the data collection forms and procedures were workable; however, we uncovered issues to address in the scale-up of this pilot study: (1) the outcome report rate was 60%; (2) though Baker scores are commonly used to evaluate the degree of capsulaar contracture, it seems that grade I may have different meanings for different surgeons, which would need to be clarified; (3) participating surgeons will need to divulge standard-of-care items that they may not have included in medical records, but routinely performed (e.g., patient massage, use of prophylactic antibiotics); and (4) records were initially separated by ``implant,' then researchers realized that a more useful collection would be by ``breast.' The latter approach captures the history of the breast in one record, which may be more important to contracture than the differences in implants. With the modifications discussed, the study can be scaled up to encompass as many records as necessary to achieve robust statistical power. These data will add to the existing literature regarding factors associated with capsular contracture and identify factors that affect the successful outcome of capsular contracture interventions.     

Shoulder prosthesis]

In our department, 25 shoulder prostheses were laid in 24 patients. The main indication remains omarthritis with or without necrosis (13). Fifteen Neer's prostheses (13 total, 2 simple humeral ones) were laid. The posterior approach was chosen in 14 cases. Out of the 20 shoulders reviewed, 8 presented with preoperative muscle atrophy, 8 with no postoperative muscle atrophy, including 8 with posterior approaches. In 4 cases of posterior approach, postoperative atrophy of the infraspinatus muscle was noted, but these four patients were all satisfied or very satisfied. The analysis was carried out according to our grading (0 to 20) of Neer's prostheses. The overall results are excellent for simple humeral prostheses on traumatic lesions. In the other cases, the main benefit is obtained for shoulders in a stable state. The improvement remains poor for the mobility and function of the shoulder. The patients are satisfied on a whole, especially with the improvement of pain.     

Nose Surgery (Rhinoplasty) Without External Immobilization and Without Internal Packing: A Review of 812 Cases

In a review of 812 cases of rhinoplasty, none of our patients had early bone or septal displacement; swelling, bruising, and pain were almost nonexistent. This confirms that an external split would not have been of any benefit in these cases. Packing should help prevent epistaxis, synechiae, and early bone and septal displacement. Not using any packing, we have not encountered these complications. Besides, we have not seen a single submucosal hematoma or a septal necrosis. Therefore, we doubt the value of packing in our patients. The inconveniences and complications of external splits and internal packing are described. Early postoperative photographs show the reduced swelling and bruising, and late photographs show the final results. Difficult primary and secondary rhinoplasty cases are demonstrated.     

Prospective Study of Clinical Findings and Changes in 56 Trilucent Implant Explantations

Between 1995 and 1998 we implanted 88 Trilucent? implants in 48 patients. The experience of 56 explantations in 30 patients are presented in this prospective study. Of 48 patients, 32 returned for review after we wrote to them. Twenty-seven elected to have their implants exchanged immediately for a fourth-generation cohesive silicon implant and three decided to have the implants removed and not replaced. In 14 patients it was clinically obvious that the volume of the implant had changed, although not all patients realized this. The absence of capsular contraction was notable (unanimously Baker II), so that most patients were asymptomatic and had to be convinced of the need for explantation. However, perioperatively, 55% of the implants had thickening or color change caused by the peroxidation of the triglyceride content. Typically the implant capsule was adherent to the surrounding tissues, especially pectoralis major. This prolonged operative time (184 min, on average) and hemostasis was a problem. During the study we developed a standardized operative technique, which enabled us to reduce operative times. Special attention had to be paid to the selection of the new implant volume, because many patients had become accustomed to the increase in the size of their breasts caused by the peroxidation of the implant content. Forty-three percent of patients preoperatively expressed the wish to have even bigger breasts than before. Nearly all of our patients at the three-month postoperative follow-up were happier with the new implants than before. It became apparent that after only two to three years there were obvious oxidative changes in the implants in asymptomatic patients. Based on our study result, the recommendations regarding explantation of Trilucent? implants seem justified.     

Operative results of the inferior capsular shift procedure for multidirectional instability of the shoulder

BACKGROUND: Neer and Foster previously described the inferior capsular shift procedure for treating multidirectional instability of the shoulder and reported preliminary results that were quite satisfactory. The purpose of our study was to perform a longer-term follow-up evaluation of the efficacy of the inferior capsular shift procedure for treating multidirectional instability of the shoulder. METHODS: An inferior capsular shift procedure was used to treat multidirectional instability of the shoulder in forty-nine patients (fifty-two shoulders). All patients had failed to respond to an exercise program. In this series, the operative approach (anterior or posterior) was based on the major direction of the instability, as determined by the preoperative history and physical examination and as verified by examination with the patient under anesthesia. In all of the patients, the inferior capsular shift was the primary attempt at operative stabilization. The repair consisted of a lateral-side (or humeral-side) shift of the capsule to reduce capsular redundancy and, when necessary, a reattachment of the avulsed labrum to the anteroinferior aspect of the glenoid. RESULTS: A redundant capsular pouch was seen in all of the shoulders in this series. In addition, detachment of the anteroinferior aspect of the labrum was found in ten shoulders and an anterior fracture of the glenoid rim was seen in two shoulders. At an average of sixty-one months (range, twenty-four to 132 months), results were available for forty-nine shoulders (forty-six patients). Thirty shoulders (61 percent) had an excellent overall result, sixteen (33 percent) had a good result, one (2 percent) had a fair result, and two (4 percent) had a poor result. Forty-seven (96 percent) of the forty-nine shoulders remained stable at the time of follow-up. Two of the thirty-four shoulders that had been repaired through an anterior approach began to subluxate anteroinferiorly again. None of the fifteen shoulders that had been repaired through a posterior approach had recurrent instability. Full function, including the ability to perform strenuous manual tasks, was restored to forty-five shoulders (92 percent). A return to sports was possible after thirty-one (86 percent) of the thirty-six procedures done in athletes; however, a return to the premorbid level of participation was possible after only twenty-five (69 percent) of the thirty-six procedures. CONCLUSIONS: The results in this series demonstrate the efficacy and the durability of the results of the inferior capsular shift procedure for the treatment of shoulders with multidirectional instability. The procedure directly addresses the major pathological feature - a redundant joint capsule. Similar results were seen with either an anterior or a posterior approach, and we continue to approach shoulders with multidirectional instability on the side of greatest instability. A postoperative brace was reserved for patients in whom a posterior approach had been used or in whom an anterior approach had involved extensive posterior capsular dissection (ten of the thirty-four shoulders treated with the anterior approach).     

Augmentation Mammoplasty: Personal Evolution of the Concepts Looking for an Ideal Technique

The purpose of this paper is to report our personal experience in the field of augmentation mammoplasty. This experience is based on over 15 years in practice and working with more than 400 cases using different types of prostheses (single-lumen gel-filled, single-lumen saline-filled, double-lumen, smooth or texturized surfaces), different routes (submammary, periareolar, transaxillary), and different locations of the implant (complete submuscular, subglandular, subpectoral). Our present preference is for a partial submuscular (subpectoral) augmentation mammoplasty through an inferior periareolar route. The results of 91 consecutive patients operated on with this technique from January, 1990 to December, 1994, during the blow-up of the controversy on silicone, are reported.     

Splenic rupture from colonoscopy

Splenic injury after colonoscopy is rare. Only 15 cases previously have been reported in the English literature. Partial capsular avulsion is the proposed mechanism of injury. Any condition causing increased splenocolic adhesions may be a predisposing factor to splenic injury. Two cases of splenic injury following colonoscopy are reported in addition to a complete review of the literature. Received: 21 September 1995/Accepted: 11 November 1995     

External Ultrasonic Treatment of Capsular Contractures in Breast Implants

The authors report their experience on the nonsurgical treatment of capsular contractures due to breast implant augmentation mammaplasty. External ultrasonic repeated applications have been applied to 24 patients after closed capsulotomy procedures in order to reduce the recurrency rate. The new ultrasonic device used was based on a 2-MHz generator with a timing adjustable power emission connected to eight transducers designed for breast anatomy. The authors report significant improvement of the closed capsulotomy technique demonstrating a persistent stability of the achieved results in 82% of the treated contractures, even in severe cases (Baker's IV), after a minimum follow-up period of 12 months. Methods of application, technical features of the ultrasonic device, experimental charts, and results obtained on 34 breast implant capsular contractures are reported and discussed.     

Subfascial Endoscopic Transaxillary Augmentation Mammaplasty

Video endoscopy for breast hypoplasia and glabellar frown lines has been used since 1996 at our private clinic. Breast augmentation with an S-shape incision for transaxillary access is utilized to introduce the implant, in a submuscular or subglandular and, recently (since October 1998), in a subfascial location. From August 1998 through January 1999, 62 patients underwent endoscopic surgeries; 49 were submuscular, 5 subglandular, and 8 subfascial. McGhan 410, anatomical biodimensional implants 155 to 235 g, were used. We observed three cases of complications, two of them malpositioning (rotation), needing reoperation, and one hematoma, treated with drainage. Patient satisfaction was high, especially regarding the axillary incision. There have been no capsular contractions to date.     

双平面法假体再置入在隆乳术后包膜挛缩治疗中的应用

目的 探索假体隆乳术后并发包膜挛缩的有效治疗方法.方法 选取自2007-2009年在我科就诊的25例胸大肌下假体隆乳术后并发包膜挛缩的患者,在完整切除挛缩的包膜后应用双平面法置入乳房假体.结果 对25例患者随访3 ～ 12个月,其中2例乳房变硬,为BakerⅡ级,经保守治疗后痊愈;术后乳房柔软,更富弹性,形态美观,无乳房下垂及假体上移等并发症发生.结论 双平面法隆乳术是治疗假体隆乳术后并发包膜挛缩的有效方法.     

Radiofrequency capsular shrinkage for voluntary shoulder instability

We report a prospective study of 13 consecutive shoulders treated exclusively with radiofrequency capsular shrinkage for voluntary instability. Before surgery, voluntary instability had ceased in all patients with physiotherapy, but involuntary shoulder instability continued. The mean follow-up was 45 months (range, 32-57 months). According to the system of Rowe et al, the results were excellent in 3 shoulders (23.1%), fair in 1 (7.7%), and poor in 9 (69.2%). All 4 shoulders that had previous stabilization surgery had a recurrence of instability. Of the 6 shoulders with fair and poor Rowe ratings that had no previous stabilization surgery, 4 had a repeat capsular shrinkage. Two of these four shoulders had an excellent Rowe rating at final review. Overall, 5 of 9 patients (55.6%) with no previous surgery achieved stability by radiofrequency stabilization. In conclusion, results of radiofrequency capsular shrinkage in voluntary shoulder instability are poor. Results are improved with repeat capsular shrinkage. Radiofrequency capsular shrinkage is not recommended for patients who have had previous stabilization surgery.     

Biomechanical evaluation after five and ten millimeter anterior glenohumeral capsulorrhaphy using a novel shoulder model of increased laxity

Anterior instability of the shoulder is classically treated with a capsulolabral repair, but in cases of capsular redundancy, shortening or shifting of the capsule is added. This study compared glenohumeral translations in intact shoulders after rotational stretching of the capsule and after progressive increasing of anterior-inferior capsular shifts. Seven cadaveric shoulders were mounted on a custom biomechanical testing apparatus. Rotational range of motion and glenohumeral translations were measured. To create laxity, the shoulders were rotationally stretched an additional 30% from the intact rotational range of motion about the axis of the humerus in external and internal rotation. Anterior-inferior capsular shifts of 5 and 10 mm were performed. Rotational stretching of the shoulder capsule created anterior laxity. A 5 mm capsular shift was ineffective, but a 10 mm shift restored anterior and total anteroposterior translation to the intact condition.     

不同类型乳房假体隆乳术后并发症的临床分析

目的 统计不同类型的乳房假体置人人体后，远期并发症发生的几率，并分析其原因。方法 总结1993年至2002年间假体隆乳573例，随访到手术方法相同、假体放置位置相同、同一医生组手术的隆乳妇女427例共852只乳房，使用4种不同类型乳房假体：毛面硅凝胶、光面硅凝胶、毛面生理盐水充注式、光面生理盐水充注式乳房假体。出现的远期并发症有纤维包膜挛缩、假体破裂渗漏、疼痛移位等，对各种假体并发症发生率进行统计分析，比较各类假体的优劣。结果 427例852只中803只效果满意，无明显并发症，占94．24％。发生并发症者42例49只乳房，占5．76％。并发症中乳房硬化属Baker‘s分级Ⅲ～Ⅳ级的有26只，缩小变形24只，移位疼痛10只，经手术取出发现假体破裂渗漏的有30只。其中纤维包膜挛缩引起乳房硬化多发生于硅凝胶假体，假体渗漏引起乳房缩小变形多发生于生理盐水充注式假体；假体在体内放置时间越长，发生并发症的几率越高。结论 经统计学处理发现，光面生理盐水假体并发症明显少于光面硅凝胶假体，毛面硅凝胶假体和毛面生理盐水假体并发症发生率没有明显差异。49只有不同并发症的乳房假体中有30只假体破裂渗漏，占61．22％，假体破裂渗漏后又容易引发其它并发症，说明假体质量的提高是减少并发症的关键，长期留置体内假体的老化是目前的难题。     

Thermal capsular shrinkage for shoulder instability. Mid-term longitudinal outcome study

We present the short- and medium-term clinical results of thermal shrinkage in selected groups of patients with multidirectional or capsular stretch-type instability. We treated 56 patients (61 shoulders) by laser-assisted capsular shrinkage (LACS) and 34 patients (38 shoulders) by radiofrequency (RF) capsular shrinkage. The two groups were followed for mean periods of 40 months and 23 months, respectively. In the LACS group the mean Walch-Duplay score improved to 90 points 18 months after the operation, but then declined to a plateau of about 80 points; 59% of patients considered their shoulders to be 'much better' or 'better' but there was a failure rate of 36.1%. For the RF group the mean Walch-Duplay and Constant scores were 80 points at the various follow-up times; 76.3% of patients considered their shoulder to be 'much better' or 'better'. RF failed in nine shoulders (23.7%). These results match some clinical series of patients with multidirectional instability, undergoing open inferior capsular shift, with a similar rate of failure. We believe that the minimal morbidity involved makes thermal shrinkage a viable alternative to open capsular shift in this difficult group of patients.     

Transgastrostomal endoscopic surgery for early gastric carcinoma and submucosal tumor

Background: Laparoscopic intraluminal surgery of the stomach is now widely used for a lesion on the posterior wall. However, this procedure has some technical limitation related to the intricate introduction of the surgical instruments into the gastric lumen. In this article, we report our newly developed technique of transgastrostomal endoscopic surgery that overcomes this limitation and is also suitable for full-thickness gastric wall resection of a lesion in the wall. Methods: After making a 4-cm-long temporary gastrostomy, a Buess-type endoscope is inserted into the gastric lumen through the gastrostomy. The operation is performed inside the gastric lumen under video camera guidance using electrocautery, scissors, and forceps. After resection, the wound in the mucosa or the wound after full-thickness resection is endoluminally sutured. Mucosal resection was performed in six cases of early gastric carcinoma, two cases of atypical epithelium, and one case of ectopic pancreas. Full-thickness wall resection was performed in four cases of a leiomyoma. Results: In all 13 cases, the lesion could be precisely located by the video camera. All lesions were then resected endoluminally. The mean duration of the operation was 148 min. The postoperative course in all cases was uneventful. Conclusions: Transgastrostomal endoscopic surgery is minimally invasive and an efficient tissue-preserving technique for the removal of early gastric carcinoma or submucosal tumor. Received: 7 September 1996/Accepted: 27 January 1997