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André Camirand, M.D. and Jocelyne Doucet, R.N.
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Montréal, Canada.
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Abstract
If we insert a foreign body into a human being, physiologically,we get a capsular contracture because a periprosthetic scar contracts to give the implant a spherical shape,the smallest surface area for a given volume.To antagonize this contracture,one must stretch the periprosthetic scar and this can be accomplished with compression.
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Key words : Compression-Capsular contracture
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After a breast augmentation, a scar forms around an implant and contracts in a centripetal direction in an effort to conform to a spherical shape, which as the smallest surface area for the given volume of the implant.If the implant itself is spherical,the contracture will not change the shape of the implant but will exert the same pressure, resulting in hardness.A spherical implant will become oval-shaped when it is placed behind the pectoral muscle.(Table1). In certain circumstances such as the presence of blood, bacterial contamination, necrotic tissue, silicone,talcum powder or any other irritant, this scar formation can be exagerated to the point that the periprosthetic scars thicken and contract very strongly.This will result in a hard, spherical, distorted,fixed, and painful breast: a capsular contracture. (Table 2)
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Capsular contracture
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Capsular contracture results from myofibroblast, and as the scar matures,collagen forms, resulting in a spherical capsular contracture.Capsular contractures can appear anytime after surgery.However, in our experience, most of them manifest within 2 to 3 months and rarely more than 1 year after surgery.We stressed to our patients the importance of compressing the implant to increase its surface area, thereby stretching the periprosthetic contracting scar to prevent its contracture, and we instructed them to compress their implants for at least 3 months.At follow-up, we foundthat none of them had developed capsular contracture.There was no scientific reasoning behind chosing 3 months for compression, but it seemed a reasonable lenght of time to expect patients to cary out our instructions, which they did, and the results were conclusive.It may be interesting to determine if less compression time would yield the same results.
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The Role of Compression
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The Encyclopedic Dictionary of Mathematics states the following:
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Specifically, if an ovaloid and a sphere have the same volume then the surface area of the ovaloid is greater than or equal to the surface area of the sphere with equality only when the ovaloid is a sphere.
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Rephrasing, if an ovaloid and sphere have the same volume but the ovaloid is not a sphere then the surface area of the ovaloid must be strictly greater than the surface area of the sphere. If the volume of the ellipse is kept fixed, then the surface given as a function of the axes a and b (Fig.1).In three dimensions, ther is a third radius, c which lies enteroposterior (depth), but for sake of simplicity, we will assume that we deal with a uniform compression and the resulting c has the same dimension as a .
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These formulas show that the surface area is, for a fixed volume, inversely proportional to the magnitude of b and directly proportional to the magnitude of the square root of a (Fig.1). To simplify, the more we compress the implant, the more we reduced the radius b and augment the radius a ; therefore, the more we augment the surface area. In other words, it is a mathematical and a physical fact that the smallest surface area for a given volume is the sphere. Figure 1 shows that the radius in a sphere is the same in all three dimensions.As we compress the sphere,we augment the radius a and reduce the radius b and we get a flattened ellipse or an oval. There is also a formula that can give us the percentage increase in surface area (Fig.2) we get with compression.If the radius a becomes 8 times as long as the radius b, we double the surface area for the given volume, or increase it by 100 %. We believe this ratio is easily attainable as one sleeps on a prone position.
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| Fig.1 The larger a and the smaller b, the more the surface area is augmented. |
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| Fig.2 The formula of the percentage of augmentation of the surface area the following compression. |
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The Importance of Compression in Preventing Capsular Contracture
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We believe that the best way to explain to patients the importance of compression is to explain the physical and mathematical fact that the smallest surface area for a given volume is the sphere.Crushing a spherical balloon (Fig.3 and 4) will stretch the surrounding rubber (which thins and become transparent), and if too much pressure is applied, the ballon will burst. This happens not because the volume of air is greater but simply because the shape has changed from spherical to oval-shaped,overstretching the rubber to the point of rupture.Patients easily understand that (a)if the implant is crushed, the scar surrounding the implant wil stretch like the rubber balloon, and (b) after 2 or 3 months, the body adapts,the scar ceases to contract around the implant, and the breast remains soft.
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The Difference Between Compressing an Air-Filled Sphere and Compressing a Liquid-Filled Sphere
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In both cases, the outer surface area will increase, but less so in the air-filled (Fig.3) balloon because air is compressible and its volume will decrease.
In the case of water-filled sphere or balloon (Fig.4),the surface area will increase much more because the volume remains constant and the pressure applied with the crushing hand distributed equally in all directions and entirely around the periphery.In the air-filled balloon, the compressing hand will not distribute pressure equally on the outside of the balloon. Instead, a large amount of pressure will be applied immediately under and around the crushing hand, overstretching the rubber and tearing it.This explains why it is so much easier to burst an air-filled balloon than a water-filled balloon.
Using the crushed air-filled balloon as an example is the simplest way to convince our patients that compressing the implant for a few months is the best way of preventing capsular contracture.
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Fig.3 Air-containing balloon.As one crushes the balloon, the spherical shape of the balloon becomes an ovaloid and the surface area increases the more we crush the balloon, explaining the stretching ,thinning,and transparency of the rubber. If the crushing is excessive,the surface area will become so increased that there will not be enough rubber to cover it: it will tear and the balloon burts. This shows that the smallest area for a given volume is the sphere, and the purpose of the capsular contracture is to attain the sphere;the shape with the smallest surface area for a given volume,that of the foreign body.This same capsule will stretch like the rubber if the implant is crushed.Compression is the only scientific way, we feel, to stretch the capsule and oppose its contracture. Note that the hand sinks a lot more into the air-containing balloon (compared to the water-filled balloon) beacause of the local excessive stretching, facilitating its bursting.
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| Fig.5. Demonstrating what part of the pectoral muscle is strectched and what part is incised in relationship with the implant. |
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| Fig.6 .Demonstrating what part of the pectoral muscle is strectched and what part is incised in relationship with the implant. |
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| Fig.7. The undetached upper pectoral muscle compresses the upper part of the implant and we get a teardrop shape. |
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Table I : Advantages of subpectoral implantation |
| Continuous compressing (tonus) and repeated milking action of the muscle. |
| Less bleeding because the vessels are located between the muscle and the breast . |
| No anesthesia of the arcola (nerve between muscle and the gland). |
More vascular medium increases against presence of bacteria:
(1) Y-Globulin
(2) Leuckocytes
(3) Antibiotics |
Muscle prevents palpation of the implant in thin patients,especially if there
is wrinkling of the prothesis. |
| No noise from air in the prothesis or fro liquid in the megacavity at first. |
| If there is capsular compression, palpate the muscle instead of the capsular contracture. |
| Dissection is easier and faster and draws less blood. |
In the presence of ptosis,the muscle
- compresses the prothesis (reducing the suprareolar projection)
- produces a better axilliary projection |
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Table II : Factors to Prevent Capsular Contracture |
| Subpectoral location creates compression |
| Compress the implant |
| Lie on stomach |
| Compress for 1 second each hour |
| Wear a compressive brassiere |
| Less bleeding |
| Subpectoral(blood vessels between the gland and the muscle) |
| Meticulous hemostasis |
| If the patient is under general anesthesia we used propofol because it is antemetic |
| Stop smoking;coughing leads to bleeding |
Avoidance :
ASA
Garlic
VitamineE
Red wine |
| Inframammary incision : bettrer exposure for coagulation |
| Absence of bacteria |
| Asepsis and shampoo,spay OpSite on areola |
| Antibiotics |
| 10 cc of Betadine in the cavity |
| Inframammary incision :less contamination from axillary swearing or areolar duct manipulation |
| Megacavity or cavity larger than the implant eliminates tension |
| Clean talcum powder from gloves |
| Eliminate silicone bleed (quality implant or saline-inflated implant) |
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| Fig.8 Preoperative (A) and postoperative (B) pictures of a patient who had subpectoral breast augmentation 1 year ago.Preoperative (C) and postoperative (D) pictures of another patient who had subpectoral augmentation 1 year ago. |
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Preoperative Protocol
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During consultation, after a complete medical questionnaire, physical examination, psychological evaluation,and laboratory investigation,we advise our patients verbally and on paper to avoid aspirine,oral vitamin E, garlic,black Chinese mushrooms,alcohol (especially red wine ), and exposure to smoke (postoperative cougching can cause bleeding ) for 2 weeks before and after surgery. We give patients a thorough written documentation on intervention, convalescence,pain,scarring, and possible complications such as hematoma, infection, extrusion, rupture, asymmetry, rippling, palpability,and hypertropics scars.We advise them to come back for another consultation before they make a decision. Pictures of results and of scars are shown to the patients preoperatively.
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On the night before and morning of surgery, patients must shower and clean their upper chest and axilla with an antiseptic soap.They ust avoid shaving their axilla for 1 week before surgery to avoid folliculitis. We prescribe antibiotics :cephalosporin 500 mg given every 6 hours beginning 24 hours preoperatively, continuing on the day of surgery until 24 hours postoperatively. If the patient is allergic to penicillin, we recommend the same dosage of Cipro ( Bayer,Inc.Etobicoke,Ontario,Canada ) 500 mg twice a day.
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Technique
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We spray OpSite (Smith& Nephew, Lachine,Québec) on the areolae to prevent contamination from mammary ducts. We then infiltrate an anesthetic solution around the gland,horizontally at the level of the inframammary crease, along the parasternal and anterior axillary lines, and then above, at the level of the second rib into the pectoral muscle.We also infiltrate from the inframammary crease orizontally and parallel to the ribs in a cephalic direction.This infiltration is always done, even if general anesthesia is used.The solution used is 50 ml of1% Xylocaine with adrenaline and 25 ml of 0.25 % bupivacaine mixed in 250 ml of saline.Anasthetic infiltration is carried out before scrubbing, allowing 20 minutes for vasoconstriction. We rinse our gloves with water to remove talcum powder (talcum is a cause of granuloma, and any irritant could enhance capsular contracture).We then make a 3 cm incision approximately 7.5 cm from the nipple.We believe that an incision at the inframammary crease gives us a better exposure for hemostasis when necessary, there is less contamination,i.e.,axillary sweating or mammary duct contamination (Table 2), and symmetry is achieved more easily.
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With a finger ,we stretch the lower sternal attachment (Figs.5 and 6) of the pectoral muscle.We feel that we get less medial rippling than when it is sectioned. The stretched muscle fibers will heal by fibrosis without interference of function. This will give a teardrop profile because as the upper part remains attached, it will compress the upper pole of the implant (Fig.7). This explains why we use the round implant instead of the oval anatomic or teardrop-shaped implant. The implant is a plastic structure and it takes the shape of the cavity that was dissected and is available.We free the pectoral muscle attachment from the sixth rib (Figs.5-7). Because of the absence of the lower muscular contracture, this reduces the risk of an upward movement of the implant on muscular contracture.
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Although the majority of patients do not require cauterization, we use a bipolar electrocautery if necessary : a bloodless field is essential. After dissecting a cavity, we explore to make sure there is no bleeding.We then inject 20 ml of Xylocaine, adrenaline, and bupivacaine solution (the same as for the infiltration ) and 10 ml of proviodine into each cavity.We insert the prothesis,inflate it using a closed system (Table 2) for sterile saline inflation to minimize the risk of contamination, and suture the deep dermal layer, including the subcutaneous fat to obtain a good eversion of the closure, and the intradermal layer with Vicryl 4-0. We apply Steri-Strips, compresses, and Elastoplasts or a compressive brassiere.
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Postoperative Protocol
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After 1 week, we encourage patients to gradually lie on their stomach at night. If they cannot, we ask them to watch television in the evening in the prone position for a few hours, on a hard surface, such as carpeted floor, and we advise them to compress their implants for 1 second each hour.This is accomplished by simultaneously touching each ear with the opposite hand, forcing compression by the elbows.
These compressive maneuvers are recommended for 3 months,after which time the stretched capsule would rarely if ever contract in our “series” and did not contract in any of our smooth-surfaced, saline implants.Without steroids with a normal-functioning endocrine system, compression will not displace the implants laterally unless the dissection was excessive. If enough pressure could dissect the tissues, it would be as painful as surgical dissection without anesthesia and would be intolerable, so it would be very unlikely.
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Conclusions
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By keeping bacterial contamination and the presence of blood to a minimum, and by placing the implant behind the muscle(Table1 ), we have few capsular contractures.However, since we began recommending compression for 3 months, none of our approximately 1000 smootht-sufaced, saline-inflatable implants required surgical treatment for a capsular contracture.(Fig.8) We never considered using textured saline implants.
Obviously the pathophysiology of a capsular contracture manifests itself by a centripetal contracture of the periprosthetic scar to reduce the surface area of the foreign body---the breast implant .We end up with a hard, spherical implant. In our opinion, the only logical way to counteract this condition is compression,which will give the implant an oval shape with a resulting larger surface area and will cause the inevitable stretching of the capsule, eliminating contracture. Understanding the scientific and mathematical explanation of this evidence and considering the findings of our study, we are convinced that compression is the most important factor in preventing capsular contracture.Giving the example of the rubber balloon was our best tool to convince our patients of the importance of compression in preventing capsular contraction.
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