Intra-operative techniques to reduce the risk of capsular contracture in patients undergoing aesthetic breast augmentation – A review

Background

Capsular contracture is a significant complication following aesthetic breast augmentation. Efforts to reduce this incidence have focused on the surgical approach, implant selection and IV antibiotics. Intra-operative methods to reduce the risk have had less investigation. This review focuses on these interventions and will document evidence to support pocket irrigation, nipple shields, drains and the use of an implant insertion funnel.

Delayed breast implant reconstruction: is radiation therapy associated with capsular contracture or reoperations?

We evaluated the association between radiation therapy and severe capsular contracture or reoperation after 717 delayed breast implant reconstruction procedures (288 1- and 429 2-stage procedures) identified in the prospective database of the Danish Registry for Plastic Surgery of the Breast during the period between 1999 and 2006. A history of radiation therapy was associated with increased risk of severe capsular contracture for 1- and 2-stage procedures, with adjusted hazard ratios (HR) of 3.3 (95% confidence interval [CI]: 0.9-12.4) and 7.2 (95% CI: 2.4-21.4), respectively. Similarly, a history of radiation therapy was associated with a non-significantly increased risk of reoperation after both 1-stage (HR = 1.4; 95% CI: 0.7-2.5) and 2-stage (HR = 1.6; 95% CI: 0.9-3.1) procedures. Reconstruction failure was highest (13.2%) in the 2-stage procedures with a history of radiation therapy. Breast reconstruction approaches other than implants should be seriously considered among women who have received radiation therapy.     

Titanium-coated polypropylene mesh (TiLoop Bra®)—an effective prevention for capsular contracture?

Background

Silicone implants have been used in breast augmentation for more than 45 years. Complications, in particular, capsular contracture, still occur with a high incidence. Titanium-coated polypropylene mesh (TCPM; TiLoop Bra®, pfm medical, Cologne, Germany) provides new opportunities for implant-based breast reconstruction. We investigated the influence of the surface of silicone implants on the formation of capsular contracture by comparing textured silicone with TCPM-covered smooth silicone implants.

Methods

Twenty textured silicone gel-filled (group A) and twenty TCPM-covered smooth silicone gel implants (group B) (Silimed®, Rio de Janeiro, Brazil) were implanted in female Wistar rats. After 60 days, the implants and capsules were extracted, and histological and immunohistochemical staining was performed. The double-blind evaluation of the capsules was performed by two examiners.

Results

We were able to detect a thinner, but stiffer, capsule and a less development of an inner synovia metaplasia layer as well as a lower vascularity in capsules around TCPM-covered silicone implants. We found a higher percentage of myofibroblasts within the capsule structure and more inflammatory cell infiltration.

Conclusions

The quality of capsule structure around both tested implants differs significantly. Although capsules around TCPM-covered implants presented were thinner, they integrated with the mesh in a rigid cage structure capsule with higher infiltration of inflammatory cells caused by a significant foreign body reaction. TCPM-covered silicone implants showed no apparent advantage in the reduction of capsular contracture. On the other hand, the indication for using this material as a supportive soft tissue structure can be confirmed. Level of Evidence: not ratable, experimental study.     

Renal capsular PEComa––a rare cause of surgically correctable renal hypertension

We report a 40-year-old lady who presented with severe headaches, persistent microscopic haematuria and hypertension requiring anti-hypertensive medication. Investigations for secondary hypertension were all normal except for a CT scan. This indicated a complex cystic lesion, measuring 2.4 × 5 × 10 cms , arising from the right kidney. She underwent an open right partial nephrectomy. The patient made an un-eventful postoperative recovery and her blood pressure returned to normal. The mass had a smooth outer surface and the cut surface showed firm whitish tissue with a few small cysts. Microscopy showed a bland spindle cell lesion staining positively for SMA, desmin, caldesmon, focally for HMB45 amd very focally for S100. The mass was reported as a Perivascular Epitheloid Cell (PEC) lesion (PEComa) arising from the renal capsule. Perivascular Epitheloid Cell tumor (PEComa), a recently defined tumor, is extremely rare. The lesion presents a distinct muscular immunophenotype (actin+, desmin+), with co-expression of the melanogenesis marker (HMB45). This combined immunophenotype is a characteristic feature of the Perivascular Epitheloid Cell (PEC) lesions. PEComa’s are usually benign, but cases have been reported in the literature which has an unfavourable outcome with metastatic dissemination. We report this case because of its rarity and also Renal Capsular PEComa should be considered as a rare cause of renal hypertension, which can be surgically cured.     

Functional outcome of collagenase injections compared with fasciectomy in treatment of Dupuytren’s contracture

Background

This study was designed to provide comparative information on the safety and efficacy of injection with collagenase clostridium histolyticum (CCH) and fasciectomy for patients with Dupuytren’s contracture (DC).

Methods

A single-center, retrospective, observational, longitudinal chart review was conducted of 25 patients treated with CCH injections and 21 patients undergoing fasciectomy. Patients were assessed at 1 week, monthly for 3 months and then yearly for a minimum of 2 years after treatment for changes in contracture and range of motion, time to return to work/normal activities, patient satisfaction, and Disabilities of Arm, Shoulder and Hand (DASH) score.

Results

Post-procedure follow-up averaged 32 months for the injection group compared with 39 months for fasciectomy group. For the CCH group, the mean postinjection contracture was 3.6° for the metacarpophalangeal and 17.5° for the proximal interphalangeal joints compared with 3.7° and 8.1° in the fasciectomy group, respectively. Patients treated with injections returned to normal activities after a mean of 1.9 days compared with 37.4 days for fasciectomy patients (p < 0.0001). DASH scores for 13 CCH and 15 fasciectomy patients were obtained. The mean DASH score was significantly lower in the injection group in the first 3 months (p < 0.01). At the 2-year follow-up visit, patients were satisfied with their outcomes following either treatment (92 % and 96 % of CCH and fasciectomy patients, respectively).

Conclusion

CCH injections are safe and effective and may be a viable alternative to fasciectomy for treating DC. It also allows earlier return to work and daily activities.     

Collagenase treatment of Dupuytren’s contracture using a modified injection method

Background and purpose — Treatment of Dupuytren’s contracture (DC) with collagenase Clostridium histolyticum (CCH) consists of injection followed by finger manipulation. We used a modified method, injecting a higher dose than recommended on the label into several parts of the cord, which allows treatment of multiple joint contractures in 1 session and may increase efficacy. We studied the occurrence of skin tears and short-term outcome with this procedure.

Patients and methods — We studied 164 consecutive hands with DC, palpable cord, and extension deficit of ≥ 20º in the metacarpophalangeal (MCP) and/or proximal interphalangeal (PIP) joint (mean patient age 70 years, 82% men). A hand surgeon injected all the content of 1 CCH vial (approximately 0.80 mg) into multiple spots in the cord and performed finger extension under local anesthesia after 1 or 2 days. A nurse recorded skin tears on a diagram and conducted a standard telephone follow-up within 4 weeks. A hand therapist measured joint contracture before injection and at a median of 23 (IQR: 7–34) days after finger extension.

Results — A skin tear occurred in 66 hands (40%). The largest diameter of the tear was ≤ 5 mm in 30 hands and > 10 mm in 14 hands. Hands with skin tear had greater mean pretreatment MCP extension deficit than those without tear: 59º (SD 26) as opposed to 32º (SD 23). Skin tear occurred in 21 of 24 hands with MCP contracture of ≥ 75º. All tears healed with open-wound treatment. No infections occurred. Mean improvement in total (MCP + PIP) extension deficit was 55º (SD 28).

Interpretation — Skin tears occurred in 40% of hands treated with collagenase injections, but only a fifth of them were larger than 1 cm. Tears were more likely in hands with severe MCP joint contracture. All tears healed without complications. Short-term contracture reduction was good.     

A systematic review of outcomes of fasciotomy, aponeurotomy, and collagenase treatments for Dupuytren��s contracture

Background  

Needle aponeurotomy and collagenase injection are alternative treatments of Dupuytren’s contracture to open partial fasciectomy; however, reported data are difficult to interpret without a formal systematic review.     

Results of the Max Page muscle sliding operation for the treatment of Volkmann’s ischemic contracture of the forearm

Background

Volkmann’s ischemic contracture is a less common but crippling condition affecting the extremities. Once the condition sets in, the prognosis always remains guarded, even after long and intensive physiotherapy and various restorative surgical techniques. This study was undertaken to evaluate the long-term functional results of the Max Page muscle slide operation in patients with Volkmann’s ischemic contracture of the forearm of moderate degree (Tsuge classification).

Materials and methods

Nineteen patients treated between 1997 and 2009 were evaluated. The functional outcome (measured as the dexterity score, hand grip strength, sensibility, and appearance) was analyzed postoperatively. The pre- and postoperative values were compared using a paired t test. The final results were graded as good, fair, and poor.

Results

The average age at the time of presentation was 18 years (range 3–25 years). Tight external splintage for injuries around elbow and forearm was the primary factor. The mean period of follow-up was 3.53 years. Fifteen patients were able to achieve good functional results. Three had fair and one had poor results. All three variables showed significant improvements postoperatively. Wound dehiscence was the most common complication. One patient needed a second surgery to restore good hand function.

Conclusion

The Max Page muscle sliding operation to treat Volkmann’s ischemic contracture of moderate degree gives good functional results. The procedure is simple and easy to perform. Adequate muscle release and proper postoperative physiotherapy are key to achieving good results.     

Minimally invasive technique for release of Dupuytren��s contracture: segmental fasciectomy through multiple transverse incisions

Background

A multitude of operative approaches have been described for treatment of Dupuytren’s contracture. A less-invasive technique of segmental fasciectomies performed through multiple small transverse incisions is presented.

Methods

Seventy-three digits in 37 patients were treated with segmental fasciectomies. The results of 34 digits in 14 patients are described with subsequent follow-up longer than 2 years.

Results

Metacarpophalangeal joint extension improved from a mean of 32.5° to 2.2°, while proximal interphalangeal joint extension improved from 22.9° to 4.1°. Patients subjectively rated their surgical outcomes as excellent or good in 91.2% of cases. No recurrence of the disease was noted, though extension of the disease to adjacent digits was observed in three patients.

Conclusions

Though this approach is technically demanding and requires the help of a skilled assistant, this preliminary study supports our contention that this less-extensive procedure allows excellent correction of contractures; results in mild postoperative pain; and permits a rapid return of finger flexion with satisfactory long-term results so far at 2-years follow-up.     

Results of total aponeurectomy for Dupuytren’s contracture in 61 patients: a retrospective clinical study

Introduction  Many surgical techniques have been advocated to treat Dupuytren’s contracture. Partial fasciectomy is often performed to treat the whole spectrum of Dupuytren’s disease. Method  We have reviewed the effectiveness of total aponeurectomy performed on 61 patients [10 women and 51 men (male:female ratio 5.1:1) with a mean age of 63.0 (range 42–79 years) and a mean follow-up of 3.45 years (range 1.03–6.39 years)]. Results  Post-operative complications including haematoma, seroma or necrosis were found in 13.8% of the patients. Recurrence of contracture occurred in 10.8% of the patients and 4.6% of the operated patients presented with a nerve lesion. Nerve irritation occurred in 6.2% of the patients. The mean DASH-score was 3.85 (range 0–52.5). Family pre-disposition was an important risk factor for Dupuytren’s disease with 44.3% of patients having a positive family history. Conclusion  We suggest that total aponeurectomy is a promising alternative to partial fasciectomy with low risk for a recurrence and slightly increased risk for a nerve lesion.     

Capsular contracture – What are the risk factors? A 14 year series of 1400 consecutive augmentations

The modern era of breast augmentation and reconstruction began in 1963, with the introduction of silicone implants by Cronin and Gerow. To date, the demand for cosmetic augmentation continues to increase exponentially. However, whilst the surgical techniques and quality of mammary prosthesis have improved dramatically in recent years, patients are still confronted with significant potential complications. We performed a retrospective study of 1400 consecutive primary breast augmentations performed between March 1995 and March 2009 by a single surgeon. We specifically examined the incidence of capsular contracture and the possible causative factors. Follow up ranged from 1 to 16 years. The mean age at the time of surgery was 32.8 years and fill volume was between 195?ml and 800?ml. Our capsular contracture rate was in the order of 26.9%. BMI >30, fill volumes >350?ml, smoking and alcohol consumption did not significantly increase capsular contracture rate. Implant type, pregnancy, infection and delayed haematoma significantly increased the risk of capsular contracture. Our series has given us a unique insight into the frequency of capsular contracture and identified several risk factors. To our knowledge, this is the first report of pregnancy having a significant effect on capsular contracture. We now counsel patients thoroughly into the detrimental effects of pregnancy on the implant.     

Modified percutaneous needle aponeurotomy for the treatment of dupuytren’s contracture: early results and complications

Background

The purpose of our study was to identify postoperative results and complications using a percutaneous approach to treat Dupuytren''s contracture in a consecutive series of patients.

Methods

A review of all patients with Dupuytren''s contracture treated with percutaneous needle aponeurotomy (NA) from 2008 to 2010 was performed. Patient demographics, digits affected, and disease severity was recorded. Pre-operative total passive extension deficit (TPED) was calculated for each affected digit. TPED in the immediate postoperative period and at the time of most recent follow-up was measured. Treatment-related complications and incidence of disease recurrence were identified. Statistical analysis was performed using paired t-test. (Statistical significance p-value <0.05).

Results

525 digits in 193 hands were treated with NA. 140 patients were male, average age was 65 years. The average preoperative TPED was 41° and the average immediate postoperative TPED was 1° (98% correction) (P=0.0001). The average TPED at 4.5 month follow up was 11 o (73% correction). Complications included infection in 3 patients and one case each of triggering, delayed flexor tendon rupture, complex regional pain syndrome and persistent numbness. Recurrence was observed in 62 digits.

Conclusion

Percutaneous needle aponeurotomy is an effective technique in the treatment of Dupuytren''s contracture. Near complete correction of contracture was achieved and few complications were observed. Longer follow-up is needed to determine if these short-term results are maintained.     

Severe contracture of the proximal interphalangeal joint in Dupuytren's disease: does capsuloligamentous release improve outcome?

This prospective study assessed whether patients with severe proximal interphalangeal joint contracture (#10878;60 degrees ) due to Dupuytren's disease which persisted after fasciectomy alone benefited from an additional capsuloligamentous release. Forty-three patients with 43 severely contracted proximal interphalangeal joints underwent operative correction followed by a standardized postoperative rehabilitation programme. All were followed for 6 months. In 11 patients correction of the proximal interphalangeal joint to 20 degrees could not be achieved by fasciectomy alone, and an additional capsuloligamentous release was performed which effectively corrected all their residual flexion contractures. There were no statistically significant differences between the capsulotomy and the non-capsulotomy group with respect to the residual proximal interphalangeal joint contracture at the end of surgery, or at their last follow-up examination.     

Proximal subscapularis release for the treatment of adduction–internal rotation shoulder contracture in obstetric brachial plexus palsy

Introduction

The purpose of this paper was to evaluate the results on shoulder function following isolated proximal subscapularis release in children with Erb’s palsy.

Methods

A retrospective study was conducted on 64 consecutive children with Erb’s palsy who underwent a Carlioz proximal subscapularis release between 2001 and 2012. Fifty children with complete records and a minimum follow-up of 2 years were included for evaluation. Age at surgery ranged from 1.3 to 4.5 years (average 2.6 years). Preoperative active shoulder abduction/anterior elevation, active external and internal rotations as well as the Mallet score were compared with those found at 6 and 24 months postoperatively using the Student paired t test, with a confidence interval of 95 %. The results were compared between children <3 years of age at surgery and those older, and between children who had an isolated C5–C6 and those with greater involvement. p < 0.05 was considered statistically significant.

Results

Active abduction improved 21° at 6 months and 31° (total) at 2 years (p < 0.01) with an overall Mallet abduction score improvement of 0.58 at 6 months and 0.6 (overall) at 2 years (p < 0.01). Active external rotation improved 52° at 6 months and 35° (total) at 2 years (p < 0.01) with an overall Mallet external rotation score improvement of 1.3 at 6 months (p < 0.01) and 0.52 (overall) at 2 years (p = 0.013). There was no statistically significant change in internal rotation (p = 0.37). We found no correlation between the child’s age or the severity of involvement at surgery and the end result.

Conclusion

Proximal subscapularis release according to Carlioz is simple and effective in improving overall shoulder function in children with obstetric brachial plexus palsy, mainly abduction and external rotation. Improvement tends to reach a plateau around 6–12 months postoperatively.