Aesthetic Surgery Journal http://aes.sagepub.com/
Thermal Capsulorrhaphy: A Modified Technique for Breast Pocket Revision Ryan Harris, Peter Raphael and Scott W. Harris Aesthetic Surgery Journal 2014 34: 1041 originally published online 15 July 2014 DOI: 10.1177/1090820X14542650 The online version of this article can be found at: http://aes.sagepub.com/content/34/7/1041
Published by: http://www.sagepublications.com
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542650 research-article2014
AESXXX10.1177/1090820X14542650Aesthetic Surgery JournalHarris et al
Breast Surgery
Thermal Capsulorrhaphy: A Modified Technique for Breast Pocket Revision
Aesthetic Surgery Journal 2014, Vol. 34(7) 1041–1049 © 2014 The American Society for Aesthetic Plastic Surgery, Inc. Reprints and permission: http://www. sagepub.com/ journalsPermissions.nav DOI: 10.1177/1090820X14542650 www.aestheticsurgeryjournal.com
Ryan Harris, BA; Peter Raphael, MD; and Scott W. Harris, MD, FACS
Abstract Background: Scant attention has been paid to breast capsule revision after augmentation mammaplasty. Dissatisfaction with traditional techniques prompted the senior authors to develop a thermal capsulorrhaphy (TC) technique to obliterate excess breast pocket space using ball cautery followed by barbed suture closure. Objectives: The authors propose a new periprosthetic technique for pocket closure, present a corresponding guide for surgical and postoperative management, and provide results of their retrospective review. Methods: Medical records were reviewed for all patients who underwent TC after cosmetic augmentation mammaplasty during a 5-year period, for whom clinical photographs were available from at least 1 year postoperatively. Operating details and complications were documented. Outcomes were rated a success, partial success, or failure, based on analysis of the photographs. Results: Of the 157 TC cases (41 unilateral, 58 bilateral) with a mean follow-up of 2 years, 141 (90%) outcomes were successful, 4 (2%) were partially successful, and 12 (8%) had failed. There were 16 complications: 10 over- or undercorrections and 1 episode each of hematoma, capsular contracture, slight deformity, nipple sensitivity, exposed suture knot, and suture abscess. Conclusions: The efficacy of TC derives from the symbiosis of stitches and heat: capsulorrhaphy reinforces apposition of the damaged walls, and cautery contracts and thickens the capsule, thus reducing dead space and improving suture purchase. Initially popularized in shoulder surgery, TC is even better suited for breast pocket closure due to superior visibility and maneuverability, more aggressive practices, and the lack of similar complications. Postoperative stabilization and guideline compliance are essential to successful revision. Level of Evidence: 4 Keywords breast implant, pocket, capsule, revision, thermal capsulorrhaphy, ball cautery, quill, symmastia, displacement, malposition Accepted for publication January 8, 2014. Breast pocket defects after augmentation mammaplasty may be iatrogenic (eg, symmastia, malposition, overdissection) or result from chronic pressure on the capsular wall by the prosthesis. In some cases, pocket revision is indicated in implant replacement procedures or in patients who simply desire a rejuvenated appearance. Given the popularity of augmentation mammaplasty and the inevitability of associated complications,1 it is surprising that few authors have addressed the management of breast pocket defects.2 Perhaps capsulorrhaphy is underutilized and thus seldom studied because pocket imperfections so often go undiagnosed.3 By contrast, revisional procedures are not unusual in high-volume breast
augmentation practices, and we have long sought an optimal solution for capsular revision. In our estimation, thermal capsulorrhaphy (TC) meets the desired criteria. It is quick, facile, and cost-effective, with a proven history of sustained correction and minimal
Drs S. W. Harris and Raphael are plastic surgeons in private practice in Plano, Texas. Mr R. Harris is a medical student at University of Texas Southwestern in Dallas. Corresponding Author: Dr Scott W. Harris, 6020 W Plano Pkwy, Plano, TX 75093, USA. E-mail: [email protected]
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Aesthetic Surgery Journal 34(7)
Figure 1. Parasagittal section of the right breast shows the planned thermal capsulorrhaphy of the lateral wall through inframammary fold incision. Once the implant has been removed and excess pocket margin demarcated, ball cautery is applied to contract, thicken, and toughen the capsule (A) in preparation for double-row placement of barbed suture (B). The same technique can be done to correct implant displacement of any direction.
complications. In this article, we elucidate our technique, present the results of a large patient series, and propose a surgical and postoperative management guide for pocket defects.
Methods Patients Medical records of TC patients treated between January 2008 and November 2012 by the senior authors (S.W.H. and P.R.) were analyzed per an institutional review board– approved protocol from the University of Texas Southwestern Medical School. Only cosmetic breast augmentation cases were considered. Eligibility criteria included the availability of postoperative clinical photographs from at least the 1-year follow-up visit. Patients lost to follow-up within the first year were excluded. All patients were given the option of acellular dermal matrix (ADM), neosubpectoral pocket (NSP), or TC revision. Those who chose ADM or NSP were excluded from the study. Implant-based breast reconstruction cases also were excluded. Collected data included demographics, operation date, follow-up dates, and complications. Operative summaries were examined for TC sidedness and direction; incision location; implant size, placement, material, and surface; and concomitant procedures. Outcomes were rated by the surgeon who performed the TC (S.W.H. or P.R.) and were based on photographic analysis. Specifically, success was defined as full correction at the 1-year follow-up, partial success denoted either overcorrection or unidirectional correction in a bidirectional case, and failure represented either undercorrection or complete loss of repair in which the pocket reopened.
Surgical Technique Crescentic markings are made on the upright patient after balloting the breast to preview the result (ie, manually shifting the implant to the degree that results in an ideal appearance). The objective of this preview is to determine the degree of pocket closure (ie, maximum width of crescent), which typically ranges from 1 to 6 cm and includes an extra centimeter for postoperative relaxation. The patient is then anesthetized (general anesthesia preferred), prepared, and draped. The periprosthetic pocket is accessed with blade tip electrocautery (Valleylab Force FX, Boulder, Colorado) through a previous incision. The implant is removed to evaluate its integrity, prevent damage, and facilitate precise ablation of the pocket. Next, the external markings are converted to internal ones by cautery, with the surgeon alternating his gaze from the skin to inside the pocket. After circumferentially demarcating the excess pocket margin, ball tip electrocautery is applied evenly to the entire redundant surface (Figure 1A). To avoid destroying any area or transmitting excessive heat to the skin, power settings are maintained in the medium range (40-80 W), and the electrode is kept in constant motion. Cases of thin breast tissue (≤1 cm) overlying the capsule require extreme caution. The capsulorrhaphy is performed with 2-0 Quill sutures (Angiotech Pharmaceuticals, Inc, Vancouver, Canada) in 2 rows. The narrow middle segment across the length of excess pocket is closed with the first row of sutures. The second row of sutures serves to grip the capsule with wider purchase to approximate the delineated margins (Figure 1B). The ends of the sutures are then drawn and tied, which effectively cinches the excess pocket space.
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Harris et al 1043 Table 1. Patient Demographics Ethnicity Asian 7
Age Range, y
Black
Hispanic
White
20-29
30-39
40-49
50-59
60-69
70-79
3
10
79
9
35
35
14
5
1
Data are expressed as number of patients.
The day after surgery, patients begin wearing specialized bras to keep the implants centered. Patients are instructed to wear the specific bra 24 hours/day for 6 months, except when washing it or showering. Because the level of postoperative discomfort generally is lower than with breast augmentation, it is important to remind patients to avoid excessive arm movement for the first 6 weeks. Breast massaging exercises are prescribed at 4 to 6 weeks postoperatively and are much less aggressive than typical postaugmentation maneuvers. Patients are advised to apply pressure from side-to-side (not up-and-down) for several minutes, regardless of the direction of revision. This is performed twice daily for 6 months.
Six patients (8 breasts that received TC) were lost to follow-up before 1 year, and 5 patients (7 breasts) underwent non-TC methods of revision (3 ADM, 2 NSP). These 11 patients were excluded from the study. Forty-one TC cases were unilateral and 58 were bilateral. Nearly all implant capsules (96%) were approached via inferior incisions; periareolar incisions represented just 4%. A total of 99 MICs were performed. Surgical details appear in Table 2. Analysis of the medical records revealed near-even distribution among patients who chose smaller implants for the revision (38%), the same size implants (28%), or larger implants (34%). The rationales for TC in the latter group included symmastia (ie, to avoid exaggerating the deformity), capsular shift, and existing pockets that were too large, even for the new implant. Implant data are provided in Table 3. All 12 TC failures occurred in patients whose implants were placed submuscularly. However, the preponderance of patients with submuscular placement (89%) hinders any meaningful interpretation of the differences between submuscular and subglandular placement. We reoperated on 11 of our failed cases, 10 of which were successful and 1 a partial success. One declined to undergo additional surgery. Overall, 16 complications occurred (Table 4), representing 12 patients. These arose more often during the learning curve period of our series and included 5 overcorrections, 5 undercorrections, and 1 episode each of hematoma, capsular contracture, slight deformity, nipple sensitivity, exposed suture knot on the inframammary fold (IMF) incisional closure, and suture abscess. The abscess was associated with infection and managed with suture removal, wet-to-dry dressings, and antibiotics. No burns were observed. Typical clinical results are shown in Figures 2 through 4.
Results
Discussion
Mean follow-up time for the 157 TCs was 2 years (range, 1-5 years). The mean patient age was 43 years (range, 21-77 years), and the race distribution was 80% white, 10% Hispanic, 7% Asian, and 3% black (Table 1). The prior breast augmentation had been performed by a senior author (S.W.H. or P.R.) in most cases (81%).
Many techniques to address periprosthetic problems of the breast have been described.4-8 We advocate TC as a firstline technique because of its ease, low cost, and successful track record. Our capsular revision procedures have evolved through several iterations, beginning with a combination of sutures and external compression (tape and
Mirror-image capsulotomy (MIC) is performed as needed to accommodate a larger prosthesis, to help translate the pocket in the desired direction,4 or to hold the implant while the new capsule heals.3 Note that MICs are usually necessary, even if the implant appears perfectly positioned, unless the patient desires smaller implants or an unnatural appearance. The same or a new implant is then inserted. Routine closure of the capsule and skin is performed with 2-0 and 4-0 Vicryl sutures (Ethicon, Somerville, New Jersey), respectively. Next, Mastisol liquid adhesive (Ferndale Laboratories, Ferndale, Michigan) and ¼-inch Steri-Strips (3M, St Paul, Minnesota) are applied directly over the incision sites, after which gauze pads measuring 4 × 4 inches are secured in place with 3M Kind Removal Silicone Tape. The patient’s chest is then wrapped securely in two 6-inch ACE bandages (3M). For lateral TCs, gauze rolls are placed in the axillary region underneath the bandages for extra support and prevention of seroma. Operating time is approximately 1 hour, including 15 to 20 minutes for the TC alone.
Postoperative Care
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Aesthetic Surgery Journal 34(7) Table 3. Implant Data
Table 2. Thermal Capsulorrhaphy Data Characteristic
No. of Cases
Characteristic
% of Series
Preoperative
Postoperative
a
Placement
Breast side Left
19
12
Submuscular
140
140
Right
22
14
Subglandular
17
17
Bilateral
58
74
Volume, cc Range
225-800
150-860
438
439
Smooth
135
157
Textured
22
0
Incision Inferior/IMF
151
96
Mean
Periareolar
6
4
Surfacea
Direction of displacement Inferior
50
32
a
Lateral
47
30
Material
Medial
27
17
Silicone
70
134
Inferolateral
25
16
Saline
87
23
Inferomedial
6
4
Superolateral
2
1
141
90
4
2
12
8
Outcome Success Partial success Failure
99
NA
112
NA
Mastopexy
40
NA
Reduction/liposuction
19
NA
Subtotal capsulectomy
10
NA
2
NA
Implant replacement
Reconstruction
Data are expressed as number of thermal capsulorrhaphy–treated breasts.
Table 4. Complications Among 157 Thermal Capsulorrhaphy Cases
Concomitant procedures Mirror-image capsulotomy
a
Complication
Incidence
% of Series
Overcorrection
5
3.2
Undercorrection
5
3.2
Exposed suture knot
1
0.6
Suture abscess
1
0.6
Hematoma
1
0.6
Nipple sensitivity
1
0.6
Capsular contracture
1
0.6
Slight deformity
1
0.6
Total
16
10
IMF, inframammary fold; NA, not applicable.
bras). Our high failure rate with this technique likely resulted from the inherent contradiction that plicating already weak tissues would enable them to withstand the same forces that led to their breakdown. In 2005, Dr Gerald Johnson reported satisfactory results on breast capsule repairs using ball cautery—the idea being that ball tips could permanently close small areas of pocket excess more effectively than their blade and needle counterparts (S. Harris and G. Johnson, personal communication, March 3, 2005). Our decision to experiment with cautery was further inspired by analogous application in the shoulder.9,10 To our knowledge, periprosthetic capsules
had not been treated with cautery, although Manero et al5 have recommended scrape cannulae for scoring purposes. We had disappointing results with thermal-only capsule shrinkage (ie, no sutures), including 1 skin burn. Whereas our peer’s procedures were performed within days of primary transumbilical augmentation, our patients usually presented years later, either because their problems developed gradually or because other surgeons had placed their implants. Combining ball cautery with 2-0 Vicryl yielded greater success and fewer complications. For example, burning was eliminated because less heat was required. Efforts to obtain
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Harris et al 1045
Figure 2. (A, C) This 38-year-old woman with submuscularly placed 450-cc silicone implants (Mentor Corp, Santa Barbara, California) complained of misshapen breasts and lack of cleavage. (B, D) Two years after medial thermal capsulorrhaphy with lateral and inferolateral capsulotomies on the left and right breasts (respectively), the right breast demonstrated successful restoration of size and shape; however, only partial success was achieved for the left breast due to slight overcorrection inferomedially.
even greater consistency led to the replacement of Vicryl with Quill sutures in 2008. We surmise that barbed absorbable sutures of other brands may be equally effective. Despite many orthopedic surgeons having abandoned TC,11 its utility in breast pocket revision has endured. Compared with its application in arthroscopic glenohumeral stabilization, visibility and maneuverability are enhanced because of larger incisions and the hollow nature of the breast capsule. The surgical technique also can be less conservative given that the breast is not as functional or mobile a body part. Finally, certain complications plaguing shoulder surgery (such as chondrolysis,12 axillary nerve damage,13 and resubluxation or redislocation14) are anatomically irrelevant in the present application. The synergistic effect of heat and sutures coincides with several orthopedic studies.15-18 Cautery promotes marked
capsular contraction (without palpable induration), reducing the surface area that must be obliterated with capsulorrhaphy to a more manageable size. It also tightens and thickens the often lax and atrophic capsule, thereby fortifying suture purchase. Finally, capsulorrhaphy bolsters apposition of the raw cauterized surfaces as they scar together, especially once the suture is tied (purse-string effect). In Table 5, we present a breast pocket management guide in which the 4 cardinal displacements are considered. In our experience, superior displacement (“snoopy dog” or “waterfall” deformity) is the least common. Although inferior capsulotomy generally provides sufficient correction,19 we suggest performing a superior TC on patients with complaints of high-riding implants when supine. For postoperative stabilization, we recommend bandeau and postsurgical bras. Inferior displacement, which can manifest with or
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Aesthetic Surgery Journal 34(7)
Figure 3. (A, C) This 46-year-old woman with submuscularly placed 450-cc silicone implants (Mentor Corp, Santa Barbara, California) complained of bottoming out and asymmetry. (B, D) Two years after successful inferomedial thermal capsulorrhaphy and superolateral capsulotomy of both breasts.
without a double-bubble deformity (arising from the implant descending below the original fold), is addressed with inferior TC and a push-up bra. Lateral displacement may be diagnosed by gauging arm concealment in the upright position, but more often it is discerned from patient complaints of their breasts falling toward the axillae when lying down. The recommended treatment is lateral TC and a push-up bra, and patients should continue wearing the aforementioned spacers (eg, gauze rolls) inside the bra for 6 weeks to reinforce the line of plication. Displacement either toward or beyond the midline can be more complex. A medial TC is typically sufficient, and MIC can be helpful even if the lateral edge of the implant is properly positioned. However, when symmastia (pectoral detachment from the sternal border), rippling, or thin breast/ capsular tissue is present, ADM grafting may be more appropriate. Even though patients are informed of its slightly higher efficacy,20 few opt for this modality because of cost concerns. If capsular revisions were insured as reconstructive procedures, we believe that more patients would choose ADM grafting. The postoperative strategy includes thong
and postsurgical bras, but thong bras are known to cause discomfort. Although the thong bra provides immobilization medially and inferiorly, it neither prevents superior excursion of the implant nor promotes premature superior pole pocket closure. Our strategy for pocket management has been highly successful; failures occurred in less than 10% of cases. Diagnosing a failure is rather simple, but its cause is not always clear-cut. Unsuccessful TCs may result from technical error; patient noncompliance (eg, due to thong bra discomfort); inadequate scar encapsulation; stretched, weakened, or thin tissues; suture defects (eg, breakage, poor purchase); physical trauma; or suture-line tension from a large, heavy implant.4,7 Although we could not be certain of the causes of failure in this study, many predated 2010 (7 breasts), represented undercorrections (5 breasts), and/ or were inferior pocket displacements (7 breasts). If a case is refractory to TC, there are 2 options. The first is implant-site change. Namely, TC may be availed for en bloc ablation of the old pocket followed by implant placement in the submuscular plane if originally submammary or into an
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Harris et al 1047
Figure 4. (A, C) This 32-year-old woman with submuscularly placed 700-cc silicone implants (Mentor Corp, Santa Barbara, California) presented with borderline symmastia. (B, D) Two years after medial thermal capsulorrhaphy with lateral capsulotomy of both breasts, plus bilateral exchange to 400-cc silicone implants (Mentor Corp), successful downsizing was observed along with widening of the cleavage to a more natural appearance. Table 5. Breast Pocket Management Guide Displacement
Surgical Procedure
Postoperative Support
Primary Superior
Superior TC ± MIC
Bandeau bra under postsurgical bra
Inferior
Inferior TC ± MIC
Push-up bra only
Lateral
Lateral TC ± MIC
Gauze roll under push-up bra
Medial
Medial TC ± MICa
Thong bra under postsurgical bra
TC (standard) + ADM OR TC (total ablation) + implant site change to NSP or SMPb
Location dependent (see above)
Secondary (any direction)
ADM, acellular dermal matrix; MIC, mirror-image capsulotomy; NSP, neosubpectoral pocket; SMP, submuscular pocket; TC, thermal capsulorrhaphy. a ADM is an appropriate alternative, especially in the presence of symmastia, rippling, or thin breast tissue/capsular wall. b NSP if originally subpectoral; SMP if originally subglandular.
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NSP21 if originally subpectoral. In both cases, we suggest underdissecting medially, as the implants tend to migrate in that direction over time. The second and more preferable option, in our opinion, combines TC with ADM. These grafts can reinforce weak capsular tissue (especially medially) or overstrained IMFs, as well as hide rippling.22 All but 1 unsuccessful TC in our series was salvaged by ADM. Our technique may be useful in 2 additional clinical scenarios. First, if explantation is indicated in the absence of capsular contracture, we usually close down the original pocket with TC (much like the quilting technique for abdominoplasty). The second scenario involves capsular contracture with implant displacement, in which case we perform subtotal capsulectomy, sparing the undesired pocket area, followed by routine TC. Rather than excising the entire pocket and trying to suture fat or breast tissue to the pectoralis muscle, part of the diseased capsule is left in place, cauterized, and sutured, thereby obliterating the redundant space. This series contained 10 such cases. There are several limitations of this study. Procedures were performed by 2 surgeons and, therefore, subject to minor variations in technique. Moreover, the outcomes were rated by the operating surgeon, thereby introducing additional bias to an inherently subjective assessment. Furthermore, outcomes for the 6 patients lost to follow-up may have altered the complication rate. Given that complications tend to occur early, that most of these patients were seen 6 months postoperatively, and that patients often return if a complication arises, we suspect that our reported rate is slightly inflated. Since postoperative compliance—a crucial component to successful outcomes— is beyond the surgeon’s control, noncompliance could also inflate the failure rate. Finally, we did not study the efficacy of the barbed suture alone, although we believe that it would mirror that of Vicryl. Despite the fact that the proper suture length was not available during our experimentation phase, we feel that a barbed suture–only trial would have been superfluous, especially given the brevity and facility of thermal application and its ability to contract and thicken the capsular defect.
Conclusions These results shed new light on breast pocket revision, a relatively underappreciated subject. The TC technique is a simple, safe solution for implant malposition, implant displacement, symmastia, or surplus pocket space. It obviates expensive dermal allografts. It also serves to ablate old and partially spared breast pockets. The high success rate of TC is likely attributable to the powerful interplay between cautery and sutures.
Acknowledgments We thank Dr Gerald Johnson of Houston, TX, whose surgical techniques inspired our own.
Disclosures The authors declared no potential conflicts of interest with respect to the research, authorship, and publication of this article.
Funding The authors received no financial support for the research, authorship, and publication of this article.
References 1. Cosmetic Surgery National Data Bank: statistics 2012. Aesthetic Surg J. 2013;33(2)(suppl):1S-21S. 2. Chasan PE, Francis CS. Capsulorrhaphy for revisionary breast surgery. Aesthetic Surg J. 2008;28(1):63-69. 3. Chasan PE. Breast capsulorrhaphy revisited: a simple technique for complex problems. Plast Reconstr Surg. 2005;115(1):296-303. 4. Baxter RA. Intracapsular allogenic dermal grafts for breast implant-related problems. Plast Reconstr Surg. 2003;112(6):1692-1698. 5. Manero I, Montull P, Guisantes E. Bottoming out: a simple technique for correcting breast implant displacement. Plast Reconstr Surg. 2009;124(6):452e-453e. 6. Voice SD, Carlsen LN. Using a capsular flap to correct breast implant malposition. Aesthetic Surg J. 2001;21(5): 441-444. 7. Becker H, Shaw KE, Kara M. Correction of symmastia using an adjustable implant. Plast Reconstr Surg. 2005;115(7):2124-2126. 8. Spear SL, Little JW. Breast capsulorrhaphy. Plast Reconstr Surg. 1988;81(2):274-279. 9. Dugas JR, Andrews JR. Thermal capsular shrinkage in the throwing athlete. Clin Sports Med. 2002;21(4):771-776. 10. Reinold MM, Wilk KE, Hooks TR, et al. Thermal-assisted capsular shrinkage of the glenohumeral joint in overhead athletes: a 15- to 47-month follow-up. J Orthop Sports Phys Ther. 2003;33(8):455-467. 11. Toth AP, Warren RF, Petrigliano FA, et al. Thermal shrinkage for shoulder instability. HSS J. 2011;7(2):108114. 12. Coobs BR, LaPrade RF. Severe chondrolysis of the glenohumeral joint after shoulder thermal capsulorrhaphy. Am J Orthop (Belle Mead NJ). 2009;38(2):E34-E37. 13. Greis PE, Burks RT, Schickendantz MS, Sandmeier R. Axillary nerve injury after thermal capsular shrinkage of the shoulder. J Shoulder Elbow Surg. 2001;10(3):231-235. 14. D’Alessandro DF, Bradley JP, Fleischli JE, Connor PM. Prospective evaluation of thermal capsulorrhaphy for shoulder instability: indications and results, two- to fiveyear follow-up. Am J Sports Med. 2004;32(1):21-33. 15. Bohnsack M, Ruhmann O, Hurschler C, et al. Arthroscopic anterior shoulder stabilization: combined multiple suture repair and laser-assisted capsular shrinkage. Injury. 2002;33(9):795-799. 16. Gartsman GM, Roddey TS, Hammerman SM. Arthroscopic treatment of bidirectional glenohumeral instability: two- to five-year follow-up. J Shoulder Elbow Surg. 2001;10(1):2836. 17. Hawkins RJ, Karas SG. Arthroscopic stabilization plus thermal capsulorrhaphy for anterior instability with and
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Harris et al 1049 without Bankart lesions: the role of rehabilitation and immobilization. Instr Course Lect. 2001;50:13-15. 18. Mishra DK, Fanton GS. Two-year outcome of arthroscopic Bankart repair and electrothermal-assisted capsulorrhaphy for recurrent traumatic anterior shoulder instability. Arthroscopy. 2001;17(8):844-849. 19. Tebbetts JB. Transaxillary subpectoral augmentation mammaplasty: long-term follow-up and refinements. Plast Reconstr Surg. 1984;74(5):636-649.
20. Spear SL, Sher SR, Al-Attar A, Pittman T. Applications of acellular dermal matrix in revision breast reconstruction surgery. Plast Reconstr Surg. 2014;133(1):1-10. 21. Spear SL, Dayan JH, Bogue D, et al. The “neosubpectoral” pocket for the correction of symmastia. Plast Reconstr Surg. 2009;124(3):695-703. 22. Slavin SA, Lin SJ. The use of acellular dermal matrices in revisional breast reconstruction. Plast Reconstr Surg. 2012;130(5)(suppl 2):70S-85S.
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Thermal Capsulorrhaphy: A Modified Technique for Breast Pocket Revision Ryan Harris, Peter Raphael and Scott W. Harris Aesthetic Surgery Journal 2014 34: 1041 originally published online 15 July 2014 DOI: 10.1177/1090820X14542650 The online version of this article can be found at: http://aes.sagepub.com/content/34/7/1041
Published by: http://www.sagepublications.com
On behalf of:
American Society for Aesthetic Plastic Surgery
Additional services and information for Aesthetic Surgery Journal can be found at: Email Alerts: http://aes.sagepub.com/cgi/alerts Subscriptions: http://aes.sagepub.com/subscriptions Reprints: http://www.sagepub.com/journalsReprints.nav Permissions: http://www.sagepub.com/journalsPermissions.nav
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542650 research-article2014
AESXXX10.1177/1090820X14542650Aesthetic Surgery JournalHarris et al
Breast Surgery
Thermal Capsulorrhaphy: A Modified Technique for Breast Pocket Revision
Aesthetic Surgery Journal 2014, Vol. 34(7) 1041–1049 © 2014 The American Society for Aesthetic Plastic Surgery, Inc. Reprints and permission: http://www. sagepub.com/ journalsPermissions.nav DOI: 10.1177/1090820X14542650 www.aestheticsurgeryjournal.com
Ryan Harris, BA; Peter Raphael, MD; and Scott W. Harris, MD, FACS
Abstract Background: Scant attention has been paid to breast capsule revision after augmentation mammaplasty. Dissatisfaction with traditional techniques prompted the senior authors to develop a thermal capsulorrhaphy (TC) technique to obliterate excess breast pocket space using ball cautery followed by barbed suture closure. Objectives: The authors propose a new periprosthetic technique for pocket closure, present a corresponding guide for surgical and postoperative management, and provide results of their retrospective review. Methods: Medical records were reviewed for all patients who underwent TC after cosmetic augmentation mammaplasty during a 5-year period, for whom clinical photographs were available from at least 1 year postoperatively. Operating details and complications were documented. Outcomes were rated a success, partial success, or failure, based on analysis of the photographs. Results: Of the 157 TC cases (41 unilateral, 58 bilateral) with a mean follow-up of 2 years, 141 (90%) outcomes were successful, 4 (2%) were partially successful, and 12 (8%) had failed. There were 16 complications: 10 over- or undercorrections and 1 episode each of hematoma, capsular contracture, slight deformity, nipple sensitivity, exposed suture knot, and suture abscess. Conclusions: The efficacy of TC derives from the symbiosis of stitches and heat: capsulorrhaphy reinforces apposition of the damaged walls, and cautery contracts and thickens the capsule, thus reducing dead space and improving suture purchase. Initially popularized in shoulder surgery, TC is even better suited for breast pocket closure due to superior visibility and maneuverability, more aggressive practices, and the lack of similar complications. Postoperative stabilization and guideline compliance are essential to successful revision. Level of Evidence: 4 Keywords breast implant, pocket, capsule, revision, thermal capsulorrhaphy, ball cautery, quill, symmastia, displacement, malposition Accepted for publication January 8, 2014. Breast pocket defects after augmentation mammaplasty may be iatrogenic (eg, symmastia, malposition, overdissection) or result from chronic pressure on the capsular wall by the prosthesis. In some cases, pocket revision is indicated in implant replacement procedures or in patients who simply desire a rejuvenated appearance. Given the popularity of augmentation mammaplasty and the inevitability of associated complications,1 it is surprising that few authors have addressed the management of breast pocket defects.2 Perhaps capsulorrhaphy is underutilized and thus seldom studied because pocket imperfections so often go undiagnosed.3 By contrast, revisional procedures are not unusual in high-volume breast
augmentation practices, and we have long sought an optimal solution for capsular revision. In our estimation, thermal capsulorrhaphy (TC) meets the desired criteria. It is quick, facile, and cost-effective, with a proven history of sustained correction and minimal
Drs S. W. Harris and Raphael are plastic surgeons in private practice in Plano, Texas. Mr R. Harris is a medical student at University of Texas Southwestern in Dallas. Corresponding Author: Dr Scott W. Harris, 6020 W Plano Pkwy, Plano, TX 75093, USA. E-mail: [email protected]
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Figure 1. Parasagittal section of the right breast shows the planned thermal capsulorrhaphy of the lateral wall through inframammary fold incision. Once the implant has been removed and excess pocket margin demarcated, ball cautery is applied to contract, thicken, and toughen the capsule (A) in preparation for double-row placement of barbed suture (B). The same technique can be done to correct implant displacement of any direction.
complications. In this article, we elucidate our technique, present the results of a large patient series, and propose a surgical and postoperative management guide for pocket defects.
Methods Patients Medical records of TC patients treated between January 2008 and November 2012 by the senior authors (S.W.H. and P.R.) were analyzed per an institutional review board– approved protocol from the University of Texas Southwestern Medical School. Only cosmetic breast augmentation cases were considered. Eligibility criteria included the availability of postoperative clinical photographs from at least the 1-year follow-up visit. Patients lost to follow-up within the first year were excluded. All patients were given the option of acellular dermal matrix (ADM), neosubpectoral pocket (NSP), or TC revision. Those who chose ADM or NSP were excluded from the study. Implant-based breast reconstruction cases also were excluded. Collected data included demographics, operation date, follow-up dates, and complications. Operative summaries were examined for TC sidedness and direction; incision location; implant size, placement, material, and surface; and concomitant procedures. Outcomes were rated by the surgeon who performed the TC (S.W.H. or P.R.) and were based on photographic analysis. Specifically, success was defined as full correction at the 1-year follow-up, partial success denoted either overcorrection or unidirectional correction in a bidirectional case, and failure represented either undercorrection or complete loss of repair in which the pocket reopened.
Surgical Technique Crescentic markings are made on the upright patient after balloting the breast to preview the result (ie, manually shifting the implant to the degree that results in an ideal appearance). The objective of this preview is to determine the degree of pocket closure (ie, maximum width of crescent), which typically ranges from 1 to 6 cm and includes an extra centimeter for postoperative relaxation. The patient is then anesthetized (general anesthesia preferred), prepared, and draped. The periprosthetic pocket is accessed with blade tip electrocautery (Valleylab Force FX, Boulder, Colorado) through a previous incision. The implant is removed to evaluate its integrity, prevent damage, and facilitate precise ablation of the pocket. Next, the external markings are converted to internal ones by cautery, with the surgeon alternating his gaze from the skin to inside the pocket. After circumferentially demarcating the excess pocket margin, ball tip electrocautery is applied evenly to the entire redundant surface (Figure 1A). To avoid destroying any area or transmitting excessive heat to the skin, power settings are maintained in the medium range (40-80 W), and the electrode is kept in constant motion. Cases of thin breast tissue (≤1 cm) overlying the capsule require extreme caution. The capsulorrhaphy is performed with 2-0 Quill sutures (Angiotech Pharmaceuticals, Inc, Vancouver, Canada) in 2 rows. The narrow middle segment across the length of excess pocket is closed with the first row of sutures. The second row of sutures serves to grip the capsule with wider purchase to approximate the delineated margins (Figure 1B). The ends of the sutures are then drawn and tied, which effectively cinches the excess pocket space.
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Harris et al 1043 Table 1. Patient Demographics Ethnicity Asian 7
Age Range, y
Black
Hispanic
White
20-29
30-39
40-49
50-59
60-69
70-79
3
10
79
9
35
35
14
5
1
Data are expressed as number of patients.
The day after surgery, patients begin wearing specialized bras to keep the implants centered. Patients are instructed to wear the specific bra 24 hours/day for 6 months, except when washing it or showering. Because the level of postoperative discomfort generally is lower than with breast augmentation, it is important to remind patients to avoid excessive arm movement for the first 6 weeks. Breast massaging exercises are prescribed at 4 to 6 weeks postoperatively and are much less aggressive than typical postaugmentation maneuvers. Patients are advised to apply pressure from side-to-side (not up-and-down) for several minutes, regardless of the direction of revision. This is performed twice daily for 6 months.
Six patients (8 breasts that received TC) were lost to follow-up before 1 year, and 5 patients (7 breasts) underwent non-TC methods of revision (3 ADM, 2 NSP). These 11 patients were excluded from the study. Forty-one TC cases were unilateral and 58 were bilateral. Nearly all implant capsules (96%) were approached via inferior incisions; periareolar incisions represented just 4%. A total of 99 MICs were performed. Surgical details appear in Table 2. Analysis of the medical records revealed near-even distribution among patients who chose smaller implants for the revision (38%), the same size implants (28%), or larger implants (34%). The rationales for TC in the latter group included symmastia (ie, to avoid exaggerating the deformity), capsular shift, and existing pockets that were too large, even for the new implant. Implant data are provided in Table 3. All 12 TC failures occurred in patients whose implants were placed submuscularly. However, the preponderance of patients with submuscular placement (89%) hinders any meaningful interpretation of the differences between submuscular and subglandular placement. We reoperated on 11 of our failed cases, 10 of which were successful and 1 a partial success. One declined to undergo additional surgery. Overall, 16 complications occurred (Table 4), representing 12 patients. These arose more often during the learning curve period of our series and included 5 overcorrections, 5 undercorrections, and 1 episode each of hematoma, capsular contracture, slight deformity, nipple sensitivity, exposed suture knot on the inframammary fold (IMF) incisional closure, and suture abscess. The abscess was associated with infection and managed with suture removal, wet-to-dry dressings, and antibiotics. No burns were observed. Typical clinical results are shown in Figures 2 through 4.
Results
Discussion
Mean follow-up time for the 157 TCs was 2 years (range, 1-5 years). The mean patient age was 43 years (range, 21-77 years), and the race distribution was 80% white, 10% Hispanic, 7% Asian, and 3% black (Table 1). The prior breast augmentation had been performed by a senior author (S.W.H. or P.R.) in most cases (81%).
Many techniques to address periprosthetic problems of the breast have been described.4-8 We advocate TC as a firstline technique because of its ease, low cost, and successful track record. Our capsular revision procedures have evolved through several iterations, beginning with a combination of sutures and external compression (tape and
Mirror-image capsulotomy (MIC) is performed as needed to accommodate a larger prosthesis, to help translate the pocket in the desired direction,4 or to hold the implant while the new capsule heals.3 Note that MICs are usually necessary, even if the implant appears perfectly positioned, unless the patient desires smaller implants or an unnatural appearance. The same or a new implant is then inserted. Routine closure of the capsule and skin is performed with 2-0 and 4-0 Vicryl sutures (Ethicon, Somerville, New Jersey), respectively. Next, Mastisol liquid adhesive (Ferndale Laboratories, Ferndale, Michigan) and ¼-inch Steri-Strips (3M, St Paul, Minnesota) are applied directly over the incision sites, after which gauze pads measuring 4 × 4 inches are secured in place with 3M Kind Removal Silicone Tape. The patient’s chest is then wrapped securely in two 6-inch ACE bandages (3M). For lateral TCs, gauze rolls are placed in the axillary region underneath the bandages for extra support and prevention of seroma. Operating time is approximately 1 hour, including 15 to 20 minutes for the TC alone.
Postoperative Care
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Aesthetic Surgery Journal 34(7) Table 3. Implant Data
Table 2. Thermal Capsulorrhaphy Data Characteristic
No. of Cases
Characteristic
% of Series
Preoperative
Postoperative
a
Placement
Breast side Left
19
12
Submuscular
140
140
Right
22
14
Subglandular
17
17
Bilateral
58
74
Volume, cc Range
225-800
150-860
438
439
Smooth
135
157
Textured
22
0
Incision Inferior/IMF
151
96
Mean
Periareolar
6
4
Surfacea
Direction of displacement Inferior
50
32
a
Lateral
47
30
Material
Medial
27
17
Silicone
70
134
Inferolateral
25
16
Saline
87
23
Inferomedial
6
4
Superolateral
2
1
141
90
4
2
12
8
Outcome Success Partial success Failure
99
NA
112
NA
Mastopexy
40
NA
Reduction/liposuction
19
NA
Subtotal capsulectomy
10
NA
2
NA
Implant replacement
Reconstruction
Data are expressed as number of thermal capsulorrhaphy–treated breasts.
Table 4. Complications Among 157 Thermal Capsulorrhaphy Cases
Concomitant procedures Mirror-image capsulotomy
a
Complication
Incidence
% of Series
Overcorrection
5
3.2
Undercorrection
5
3.2
Exposed suture knot
1
0.6
Suture abscess
1
0.6
Hematoma
1
0.6
Nipple sensitivity
1
0.6
Capsular contracture
1
0.6
Slight deformity
1
0.6
Total
16
10
IMF, inframammary fold; NA, not applicable.
bras). Our high failure rate with this technique likely resulted from the inherent contradiction that plicating already weak tissues would enable them to withstand the same forces that led to their breakdown. In 2005, Dr Gerald Johnson reported satisfactory results on breast capsule repairs using ball cautery—the idea being that ball tips could permanently close small areas of pocket excess more effectively than their blade and needle counterparts (S. Harris and G. Johnson, personal communication, March 3, 2005). Our decision to experiment with cautery was further inspired by analogous application in the shoulder.9,10 To our knowledge, periprosthetic capsules
had not been treated with cautery, although Manero et al5 have recommended scrape cannulae for scoring purposes. We had disappointing results with thermal-only capsule shrinkage (ie, no sutures), including 1 skin burn. Whereas our peer’s procedures were performed within days of primary transumbilical augmentation, our patients usually presented years later, either because their problems developed gradually or because other surgeons had placed their implants. Combining ball cautery with 2-0 Vicryl yielded greater success and fewer complications. For example, burning was eliminated because less heat was required. Efforts to obtain
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Harris et al 1045
Figure 2. (A, C) This 38-year-old woman with submuscularly placed 450-cc silicone implants (Mentor Corp, Santa Barbara, California) complained of misshapen breasts and lack of cleavage. (B, D) Two years after medial thermal capsulorrhaphy with lateral and inferolateral capsulotomies on the left and right breasts (respectively), the right breast demonstrated successful restoration of size and shape; however, only partial success was achieved for the left breast due to slight overcorrection inferomedially.
even greater consistency led to the replacement of Vicryl with Quill sutures in 2008. We surmise that barbed absorbable sutures of other brands may be equally effective. Despite many orthopedic surgeons having abandoned TC,11 its utility in breast pocket revision has endured. Compared with its application in arthroscopic glenohumeral stabilization, visibility and maneuverability are enhanced because of larger incisions and the hollow nature of the breast capsule. The surgical technique also can be less conservative given that the breast is not as functional or mobile a body part. Finally, certain complications plaguing shoulder surgery (such as chondrolysis,12 axillary nerve damage,13 and resubluxation or redislocation14) are anatomically irrelevant in the present application. The synergistic effect of heat and sutures coincides with several orthopedic studies.15-18 Cautery promotes marked
capsular contraction (without palpable induration), reducing the surface area that must be obliterated with capsulorrhaphy to a more manageable size. It also tightens and thickens the often lax and atrophic capsule, thereby fortifying suture purchase. Finally, capsulorrhaphy bolsters apposition of the raw cauterized surfaces as they scar together, especially once the suture is tied (purse-string effect). In Table 5, we present a breast pocket management guide in which the 4 cardinal displacements are considered. In our experience, superior displacement (“snoopy dog” or “waterfall” deformity) is the least common. Although inferior capsulotomy generally provides sufficient correction,19 we suggest performing a superior TC on patients with complaints of high-riding implants when supine. For postoperative stabilization, we recommend bandeau and postsurgical bras. Inferior displacement, which can manifest with or
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Figure 3. (A, C) This 46-year-old woman with submuscularly placed 450-cc silicone implants (Mentor Corp, Santa Barbara, California) complained of bottoming out and asymmetry. (B, D) Two years after successful inferomedial thermal capsulorrhaphy and superolateral capsulotomy of both breasts.
without a double-bubble deformity (arising from the implant descending below the original fold), is addressed with inferior TC and a push-up bra. Lateral displacement may be diagnosed by gauging arm concealment in the upright position, but more often it is discerned from patient complaints of their breasts falling toward the axillae when lying down. The recommended treatment is lateral TC and a push-up bra, and patients should continue wearing the aforementioned spacers (eg, gauze rolls) inside the bra for 6 weeks to reinforce the line of plication. Displacement either toward or beyond the midline can be more complex. A medial TC is typically sufficient, and MIC can be helpful even if the lateral edge of the implant is properly positioned. However, when symmastia (pectoral detachment from the sternal border), rippling, or thin breast/ capsular tissue is present, ADM grafting may be more appropriate. Even though patients are informed of its slightly higher efficacy,20 few opt for this modality because of cost concerns. If capsular revisions were insured as reconstructive procedures, we believe that more patients would choose ADM grafting. The postoperative strategy includes thong
and postsurgical bras, but thong bras are known to cause discomfort. Although the thong bra provides immobilization medially and inferiorly, it neither prevents superior excursion of the implant nor promotes premature superior pole pocket closure. Our strategy for pocket management has been highly successful; failures occurred in less than 10% of cases. Diagnosing a failure is rather simple, but its cause is not always clear-cut. Unsuccessful TCs may result from technical error; patient noncompliance (eg, due to thong bra discomfort); inadequate scar encapsulation; stretched, weakened, or thin tissues; suture defects (eg, breakage, poor purchase); physical trauma; or suture-line tension from a large, heavy implant.4,7 Although we could not be certain of the causes of failure in this study, many predated 2010 (7 breasts), represented undercorrections (5 breasts), and/ or were inferior pocket displacements (7 breasts). If a case is refractory to TC, there are 2 options. The first is implant-site change. Namely, TC may be availed for en bloc ablation of the old pocket followed by implant placement in the submuscular plane if originally submammary or into an
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Harris et al 1047
Figure 4. (A, C) This 32-year-old woman with submuscularly placed 700-cc silicone implants (Mentor Corp, Santa Barbara, California) presented with borderline symmastia. (B, D) Two years after medial thermal capsulorrhaphy with lateral capsulotomy of both breasts, plus bilateral exchange to 400-cc silicone implants (Mentor Corp), successful downsizing was observed along with widening of the cleavage to a more natural appearance. Table 5. Breast Pocket Management Guide Displacement
Surgical Procedure
Postoperative Support
Primary Superior
Superior TC ± MIC
Bandeau bra under postsurgical bra
Inferior
Inferior TC ± MIC
Push-up bra only
Lateral
Lateral TC ± MIC
Gauze roll under push-up bra
Medial
Medial TC ± MICa
Thong bra under postsurgical bra
TC (standard) + ADM OR TC (total ablation) + implant site change to NSP or SMPb
Location dependent (see above)
Secondary (any direction)
ADM, acellular dermal matrix; MIC, mirror-image capsulotomy; NSP, neosubpectoral pocket; SMP, submuscular pocket; TC, thermal capsulorrhaphy. a ADM is an appropriate alternative, especially in the presence of symmastia, rippling, or thin breast tissue/capsular wall. b NSP if originally subpectoral; SMP if originally subglandular.
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NSP21 if originally subpectoral. In both cases, we suggest underdissecting medially, as the implants tend to migrate in that direction over time. The second and more preferable option, in our opinion, combines TC with ADM. These grafts can reinforce weak capsular tissue (especially medially) or overstrained IMFs, as well as hide rippling.22 All but 1 unsuccessful TC in our series was salvaged by ADM. Our technique may be useful in 2 additional clinical scenarios. First, if explantation is indicated in the absence of capsular contracture, we usually close down the original pocket with TC (much like the quilting technique for abdominoplasty). The second scenario involves capsular contracture with implant displacement, in which case we perform subtotal capsulectomy, sparing the undesired pocket area, followed by routine TC. Rather than excising the entire pocket and trying to suture fat or breast tissue to the pectoralis muscle, part of the diseased capsule is left in place, cauterized, and sutured, thereby obliterating the redundant space. This series contained 10 such cases. There are several limitations of this study. Procedures were performed by 2 surgeons and, therefore, subject to minor variations in technique. Moreover, the outcomes were rated by the operating surgeon, thereby introducing additional bias to an inherently subjective assessment. Furthermore, outcomes for the 6 patients lost to follow-up may have altered the complication rate. Given that complications tend to occur early, that most of these patients were seen 6 months postoperatively, and that patients often return if a complication arises, we suspect that our reported rate is slightly inflated. Since postoperative compliance—a crucial component to successful outcomes— is beyond the surgeon’s control, noncompliance could also inflate the failure rate. Finally, we did not study the efficacy of the barbed suture alone, although we believe that it would mirror that of Vicryl. Despite the fact that the proper suture length was not available during our experimentation phase, we feel that a barbed suture–only trial would have been superfluous, especially given the brevity and facility of thermal application and its ability to contract and thicken the capsular defect.
Conclusions These results shed new light on breast pocket revision, a relatively underappreciated subject. The TC technique is a simple, safe solution for implant malposition, implant displacement, symmastia, or surplus pocket space. It obviates expensive dermal allografts. It also serves to ablate old and partially spared breast pockets. The high success rate of TC is likely attributable to the powerful interplay between cautery and sutures.
Acknowledgments We thank Dr Gerald Johnson of Houston, TX, whose surgical techniques inspired our own.
Disclosures The authors declared no potential conflicts of interest with respect to the research, authorship, and publication of this article.
Funding The authors received no financial support for the research, authorship, and publication of this article.
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20. Spear SL, Sher SR, Al-Attar A, Pittman T. Applications of acellular dermal matrix in revision breast reconstruction surgery. Plast Reconstr Surg. 2014;133(1):1-10. 21. Spear SL, Dayan JH, Bogue D, et al. The “neosubpectoral” pocket for the correction of symmastia. Plast Reconstr Surg. 2009;124(3):695-703. 22. Slavin SA, Lin SJ. The use of acellular dermal matrices in revisional breast reconstruction. Plast Reconstr Surg. 2012;130(5)(suppl 2):70S-85S.
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