Good morning everybody. Again, thank you for the invitation and I'm
gonna talk about uh a little bit of the pathogenesis of capsular contracture and how I
manage the, uh, the capsular tissue.
So, um.
Uh, I'm not sure it's not working.
No, this one, yeah, that's why it's not working.
So we don't need to go too much in details about the pathogenesis of capsular contraction.
We're all familiar with that. We know it's a multifactual,
uh, situation, and we know about the important role of bacteria with biofilm and all the rest,
what we call subclinical infections that can be actually secondary to implant contamination
even during surgery. So it's very important to.
Prevent or to mitigate contamination during surgery, and we are all very familiar with the
14 points that have been published a few years ago by Bill Adams.
I did also some of my research and published this study in which I was making the point of
different situations that could be linked to capsular contracture,
and I followed 1500 patients almost with 3 years follow up medium.
And it was really interesting to see that uh um I could have,
I, I, I had with my patients a higher rate of capsular contracture in those patients were
bigger, so bigger BMI or or larger uh breast to start with.
And if you think of it, it makes a lot of sense because bigger patients and bigger breasts,
they probably have more vessels, so it's more vessels you counter when you do um your um
dissection. Probably small, small, small drops of blood are
in the pocket regardless if you use the drain or not,
and the blood is basically food for bacteria so that can initiate a process that eventually can
turn out into a capsular contracture. So what are we going to do about this
information? Nothing. We cannot avoid to operate those who are bigger,
but you know it's always very good to keep that in mind and also very interesting.
That I had this um publication a few years ago in which I came across a girl who came to me
for bilateral, uh, capsular contracture 7 years after her breast augmentation.
When I spoke to her, I found out that her mother had had bilateral capsular contracture
after 7 years, and her grandmother, who was alive at that time had had bilateral capsular
contracture after 7 years, mind blowing.
So you know, like nowadays when we do a consultation just like each doctor asks for
familiarity for cancer, maybe we should also be asking for familiarity for capsular contraction
because we see a lot of second generation breast augmentation patients so I think it
makes sense to ask them whether or not they have in their family somebody who has had
already capsular contraction again we're not gonna do anything about that,
but it's always very good to know.
And also I wanted to show you my findings about the link between capsular contraction and uh
insertion funnel, which is I think uh very, very interesting,
very simply said, you know, my rate of capsular contracture uh went from 2.73% to
2% so like quite a big change since when I started using.
The insert the insertion funnel and this alone it's a very,
is a very interesting data.
But what's even more interesting that I wanted to show you is that uh uh my rate of capsular
contracture is statistically significant, almost twice as big.
As much bigger in the second implant side, meaning that when I do breast augmentation I
usually implant the right, I always implant the right side first and then I go on the left side
always. I, I think I've performed over 2200 breast
augmentation and all of them have been this way.
And my rate of capsular contraction is higher, uh, almost twice as higher in the second site.
And what I found out was that if I cut, uh, or I did cut a piece of,
um, colour funnel in the, uh, just out of the box before the beginning of the
implantation, I sent it to a laboratory and that came out sterile,
obviously. Then I did the first implantation.
I cut a little piece of colour funnel. I sent it to the laboratory and that came
contaminated with all patients that I studied, meaning that when you use the colour funnel,
the same colour funnel for implantation of the second side,
you're using something that is no longer sterile.
So probably that could be one of the reasons why the rate of caps.
Construction. I'm saying it's only that.
One of the reasons why capsular contraction could be higher,
and this was published a few months ago and my idea would be that each implant comes
with a single kind of funnel just so the surgeon shouldn't have to think,
you know, should I use a colour funnel, how much does it cost?
should I use two colour funnels?
And there is a follow up study to this which is uh has been just uh accepted for publication
just last week in which I actually showed how if we um merge the um.
Califan that we have just used for first implantation in chloroxetine for 2 minutes,
then it's sterile again. So I cut a piece of of of of caliphan I said to
the laboratory after merging it in chloroxetine and it came up sterile.
So maybe if we don't want to use two different caliphans for two different sides,
we can use the same caliphan after we have merged it into chloroxetine.
Uh, yeah, so I really do believe that it's capsular contraction is not only about the
implant. We very often focus about implants,
the surface, what we do, what we don't do, but I think it's a lot about what the surgeon does,
and we as surgeons, we can and will make a difference, you know,
uh, about what we're doing.
What about the capsule?
Uh, what do I do with the capsule? Well, first of all,
there are some guidelines in literature that is widely accepted as to how should we manage a
capsular contracture patient. First of all,
sight change basically always, uh, so if we have a,
uh a subglandular uh patient we go submuscular. If we have a patient who has already a
submuscular, uh, implantation, then we have to do what we call a neo uh submuscular pocket by
removing, uh, the entire capsule.
Uh, implant exchange obviously do not put the same implants,
uh, back into the pocket. I know this might sound funny,
but I've seen, for example, some groups on Facebook where there was somebody saying,
oh, look at that capsule. It's so thick, you know,
be careful when you peel it out because otherwise when you put the implant back in,
you know, it can be injured. I mean, what you always have to use a new
implant obviously because the old implant is contaminated.
And when it comes to the difference between capsulectomy and capsulotomy,
how much capsule are we gonna remove? Are we going to remove any capsule at all?
Well, you need to know that in in literature there are similar capsular contracture
recurrence rates regardless of what we what you do with the capsule.
So my approach is I remove as much capsule as I can.
Until it gets too difficult, until, I don't know, I'm everything starts bleeding and then
I'm, I'm damaging the muscle or or or or or or whatever it is.
At that point I stop and I leave the capsule in.
Um, and actually, you know, this publication was done on PRS a couple of years ago by myself
and some friends, and I asked a bunch of breast experts, what do you do?
Is there a consensus about what you do with the capsule?
And it was any kind of answer. There was absolutely no consensus like each
surgeon would. Probably do different things,
meaning that there is not such thing as a consensus on what we should do with the
capsular tissue and again if I have a patient like this one with a very thick capsule,
let's say Baker 4 capsular contracture, I try and remove the entire capsule and you know it's
very interesting and almost funny to say that that's almost easier.
To remove such a capsule compared to a thin capsule, I usually start going underneath the
implant, uh, because that's usually a very simple plane to find.
Then I remove then I just dissect a little bit on top of the implant.
Then I open the capsule and remove the implant. There is no evidence whatsoever.
That removing the implant and the capsule get what is wrongly addressed as unblocked
capsulectomy, that's the right name should be actually total intact capsulectomy because
unblock is something else. It's also when you remove some of the um
healthy tissue around the implant, uh, you can actually do it,
um, yeah, that's the muscle there and it's, if you find the right plane,
it's very, very, um, uh, in a vascular plane, I actually don't use drains,
not even in secondary surgery. I never use drains.
You can see. The new plane, that's the muscles,
that's what we call a new sub-muscular pocket. There's not a single drop of blood inside the
pocket, so why would I use a drain there?
Um, in these patients with a medium to thin capsule, I do what I call a partial
capsulectomy, just like I said before. I remove as much as I can without damaging,
uh, the, the surrounding tissues and usually, uh, considering a patient like this one who has
an implant in the submuscular space.
Uh, what I do is I remove the implant and then I start going on top,
uh, on, on the anterior leaf of the capsule there until I reach the muscle.
And then when it starts to get difficult to separate the capsule from the muscle because
the capsule is pretty thin, I stop at the at the at the level of the muscle.
You can see there. That's the muscle.
I stop there. I remove the capsule on, on both sides,
and I leave all the rest alone.
The only thing is that if you uh use an implant that is bigger,
then you need to um make also the pocket bigger and that's probably the most difficult part of
the operation because you need to do to cut the capsular tissue between the uh minor down.
The fake major up and that's something can can be sometimes a little bit tricky if you get,
um, like big vessels, uh, down there. But, you know,
again, once you do it, you find yourself in a very a vascular plane.
And even in this case, I don't use drains.
Last case, when I have a very, very thin capsular tissue,
like, for example, when you have a patient who has been operated with,
uh, uh, smooth implants, I do not remove any capsular tissue.
And I actually used the capsule as an 02 ADM, what I call a capsular flap.
It was published by myself a few years ago on ASJ, and you can see here this patient had a
smooth implant in.
And you can see the muscle there. The, the capsular tissue is extremely thin to
me, there is no reason why I would start and try and remove this,
this, this capsular tissue that will be very difficult.
It would probably damage the muscle, but it's very resistant,
so I can actually use it, uh, as an auto, uh, ADM.
So I. The implant around that you can see there and I
suture this capsular tissue down to the IMF just so it really holds the implant
in place, giving me a very, very big stability like you see here.
So it's basically for free. You don't need to use an ADM which is expensive,
but you use the capsular tissue.
Um, that's just a little piece of advice.
Do not place texture anatomical implants back into old implant pockets,
meaning that if you have a patient who wants, who wishes for a for anatomical texture implant,
you have either to change the pocket, meaning that if the patient has a subglandular position,
then you can go submuscularline. There's no problem,
you know, you don't have a higher risk for rotation.
But if you're not able, if you're not willing to redo the pocket,
a new pocket, then my suggestion is to either use a round implant because you don't have risk
for rotation or use a polyurethan implant because in that case the risk for rotation is
basically zero. And the last slide of today I wanted to to show
you this publication of mine that I did a year ago.
This was a patient of mine, uh, operated 15 years back,
and she came to me with Baker for Capsula Construction and.
Uh, a palsy, uh, on the, I think it was the right, the,
the, the right, uh, eye, uh, so this patient had undergone like all possible,
uh, you know, like examinations of, of course, you know,
the first question was, did you ever do any, uh, aesthetics, um,
uh, treatments in the face? She was absolutely.
Uh, negative to that. She didn't do anything at all.
So eventually what they did, they did a biopsy in the,
in the, in the muscle, and they found silicon.
So that's also mind blowing. I mean, I, I think,
you know, I went back to literature and that's the third case ever described in literature,
but as a matter of fact, it seems like that's also a possibility.
Again, thank you. I hope to see many of you in in Milan for the
Milan breast meeting uh 12th to 14th of December.
Thank you so much. Carlo,
please have a seat. We're gonna get also some others.
On the stage, Mo, would you also mind to come, please?
So before going for the next part of the um uh this discussion about capsular
contraction um I did like the fact that you pointed out that um
it's easier to blame an implant for the cause of capsular contraction than to blame the
surgeon or to blame yourself.
I think that's a very, very important point.
And taking that point and then looking about the data which we always see.
In um in presentations in publications, and when you stratify this from which country
the publication comes from and uh having the knowledge what type of implants they usually
use, there seems to be a big difference in rate of capture contractions presented.
So, hence this bit of a round table discussion here
um from different parts of the world.
Why is it that we get different rates, you know, if I look at in the US,
you used to use for a long time.
Um, uh, smooth implants and then we used to do dual planes and but we,
we see very different rates and we see today still very different rates.
Why is that? How can you explain that?
Can I make a comment?
First of all, I think you need to determine what publications and studies you're looking at.
When you're getting that data, because if you look at SARO's data,
21 years of anatomical implants with such a low capsular contracture rate.
Um, is that comparable to some of the, uh, data that came out from the core studies,
which is I, I view as almost historical now, cos the techniques being used back then and not
the techniques contemporary breast augmentations are being performed with.
So are we comparing apples and oranges or are we truly comparing like for like data?
You know, I think part of the issue is really how individual surgeons define capsular
contracture in their own minds. I mean we have our standard definitions,
you know, grade 1 through 4, and it's well defined, but how somebody interprets that is
not, you know, somebody's grade 2 or 1, you know, that may not matter,
but then going from grade 2 to grade 3, there's probably a little bit of wiggle room and uh and
it may be that sometimes capsular contracture rates are underreported.
Um, it was actually a publication on, uh, inter-observer variability on Baker grade
capsular contracture, 50%. Yeah, and, and, and who knows,
maybe it's just an inherent bias that they don't want to admit that it's a capsular
contracture, making their own data look good.
I don't know, but I think that um.
I think they're underreported personally. I, I have seen capsular contracture in my
cosmetic patients. I've seen it in my reconstruction patients,
you know, and it's, it's small, it's not exorbitantly high,
but, um, it's sometimes higher than what you know I.
Seeing the publications.
I also think in some of the uh um trials, the device trials reporting,
you tend to over report it because you don't want in the US we don't want the FDA to think
anything's been fudged or been and also in the US um.
Insurance won't pay for implant related um complications except for rupture or
capture contracture.
I think sometimes surgeons in the US may use capsular contracture as a reason to get
insurance to pay for it so I think we have no idea what the real numbers are,
uh, because it's mostly there's not a good.
Um, measure and is it Steve Tautelbaum always says the ideal capture is a baker 1.3.
We have enough of a capsule that holds the implant in place,
but not enough that that the implant is firm.
So there's so much variability that capsule can be good,
it cannot be good and what becomes capsule contracture.
I mean, I, I agree, uh, absolutely with all of this and you know,
like John, you, you mentioned before, do you think it can be related to.
The use of smooth implants in the states more than in Europe.
I'm not sure. I mean once we used to say that the smooth
implants could have a higher rate of capsular contracture, but apparently in the latest
studies it seems to be kind of evened out now, so probably that's not the reason probably the
reason is the studies that are not really conducted.
Uh, the same way and also, like, if I may, I, the comment that I have is that some people,
some surgeons, uh, maybe not really those who published a lot,
but I have, you know, when you talk to friends also, you know,
and you ask, so how about your complications? No, no,
I have no complications.
Now you hear it all the time.
And then I ask them, but, OK, sure, interesting. So, um,
how do you know? I mean, do you follow your patients?
Have you published? No, no, no, no, if a patient had a complication,
she would come to me. And then I'm like, no,
maybe it's just because she has a complication, she's not coming back to you.
So I mean I think that we surgeons have a tendency not to follow our patients.
I am. Like a little maniac in following my patients,
but I, I think so I think you know the message out here is especially for the young people see
your patients please because you know you will get better actually you know you're not,
you don't need to be afraid to see a complication because you're gonna get better in
avoiding that complication and treating that complication.
I also think that the um form stable devices are firmer so if you're using a
um a thicker anatomic implant it's firmer just to start with a smooth
implant um since I've changed the smooth implants, the capsules with these newer
implants are almost too thin.
We've had more trouble with um.
Capsules are too thin and too thick, and when I remove implants,
if I'm removing a textured device, that capsule is thicker than it is on a lot of the smooth
devices. So I think what the capsule contractor could
just be the implant, you know, I think sometimes the firmer implants,
you start off with a grade 2 capsule in the firmness.
So I think a lot of it is apples and oranges.
What about, what about the anatomical plane?
You still think there's a difference between the dual plane versus prepectoral?
It seems like, like I was saying before, you know, they used to say that probably there is a
higher rate of capsular contraction for smooth implants, at least in the subglandular plane.
But then again, you know, it's oranges and and bananas, so it's,
it's a bit weird, you know, personally I, I can't really notice,
but I don't have the data yet. I'm, I'm collecting because,
you know, like in the coup in the last few years I've actually started to do way more,
uh, some glandular breast augmentation. I'm really waiting to see my data.
That's the only thing that I can do.
You know, I think you know we've made a lot of had discussion points about the plane of
insertion, but I, I think it's more related to, you know,
hematogenous products that there's a little bit of blood in the pocket or if there's
subclinical infection that you never really see it never really manifest,
I think those factors are more likely to cause early inflammation,
early scar form. Which is, which is actually,
uh, you know, very, um, into the, the, the data that I showed in which I found that the bigger
patients to start with might have a higher risk for capsular contraction because you're
actually encountering more vessels during dissection so you might have a little bit more
blood in the pocket so in big patients you might have a higher risk for capsular
contracture, but so I think that that message that you alluded to in your talk and you've
just alluded to is absolutely right that.
We at the time of surgery are more responsible for that rolling the dice for that patient
effectively than anything else, so that's, I think the first message,
how we perform the surgery and how carefully we perform, it's crucial.
But just as a an anecdotal observation, uh, the majority of my breast practise now is secondary
breast surgery, revision surgery.
And it seems, and this is anecdotal, that there is an overrepresentation from macro textured
implants in implant related problems. So if it's for aesthetic reasons,
for waterfall effect or something like that, it doesn't matter what the implant is,
but if I'm seeing patients where I'm doing uh bad capsular contractures,
the eggshell type grade baker grade 4s or badly rupture.
There does seem to be an overrepresentation. You don't think that that might be partially
linked to the fact that maybe micro textural implant has been in place for a longer time?
Yeah, absolutely, so the, the denominator is going to be crucial,
but then it wasn't, there was a sort of certainly in the UK a pretty equal market share
at one point historically between Allergan and Mentor back then.
But uh it does seem to be the um.
When we look at these cases that were implanted 10 years ago,
15 years ago, we've got the big problems now that it does seem to be represented a lot by
those implants. Are there any questions or comments from the
audience? Lots Good
Thank you for the excellent panel. I have a question for patients who come to you
and develop capsua contracts or grade 3 or 4, and you go ahead and you treat that patient,
you do a capsulectomy, a capsulotomy, and they recur.
I'd love to hear the management from all of you. So what you do in a recurrent.
Capsular contractor on a patient with implants because that that gets a little bit more
difficult to treat.
Usually my my idea is if I, if I think I've done really like the whole thing
correctly and you know removed enough capsular tissue and not like all the things that I
showed and I have a patient with recurrency, the only thing that I might think of changing
is the surface of the implant.
There there is one other um uh I guess new product on the market that's widely available
in the US unfortunately not in Europe yet, which is using hypochlorous acid,
and the evidence of hypochlorous acids increasing, and I think that's gonna be
something that we're all gonna be doing routinely quite soon.
Is it if it's your patient or another patient, you always have to make sure Plan B is
different than Plan A.
So yeah, what has been done before and you wanna get that if you didn't do the surgery,
what's the op note? Did they actually change the plane?
Did they use a funnel? Did they use, you know,
irrigate the pocket? It that's all, um, depends.
If I've done it, the patient's recurred. You can use there are studies now that show.
ADM and um I tend to use Galaflex on those patients.
There's an FDA trial that's gonna be starting using uh Galiflex for um capsule contractor so
it's kind of like puts a foot in the door keeps the capsule from reforming.
So that's something I will offer patients. It is off label in the US to use in the breast,
but um if patient is that and they really the other thing.
I tell the patients maybe you shouldn't have an implant, you know,
that's always uh an option that we don't think to offer the patients but you know,
number one, maybe we're not gonna put an implant back in 2,
you know we gotta do something different. It may involve paying a lot of money for this
additional um material to lower your risk. I think you know that this is a very
interesting comment and I generally speaking that doesn't apply only for capsula contractor.
I think don't do the same thing.
If that failed, expecting a different outcome.
Because there yeah.
Um, hi, just, uh, Chris Hu from Belfast.
Uh, just a comment, really.
Um, having spoken to a statistician, uh, when I come back from big meetings like this,
and when I talk about capsular contractor and so forth,
the statistician immediately points out, you're doing a s like Mark very correctly said,
Casuar contractor based on Baker classification is incredibly um observation dependent and you
have a 50%. Observation deviation, that test is usually
kicked out. You'll never get that published in any of the
major science uh publications.
Number 2, I must admit I can, I've lost my second point.
So apologies, but yes, uh, I think the flawed data, uh,
leads to flawed conclusions and we have to be very careful.
Oh, the other thing, patient selection.
We think we select patients, patients select themselves, especially for secondary cases,
um, I'm privileged enough to do public sector work in the NHS.
I see a lot of patients with really bad capital contractors, and then I'm like,
oh, would you like this fixed and so forth. They go,
I don't have enough money.
So we have to realise that not only patients don't come back to us.
That they might not even go back to another surgeon because they just don't have money,
don't have time. We're missing out on all those people and we,
I think any of the publications related to secondary breast surgery needs to be framed in
those two dimensions. Thank you.
I think it makes you make a very, very good point, but,
and I know I keep going on about this, but Sara's data.
The extent of work she did on the phone, phoning up patients to get that long term,
is it over 20 year follow up on some of them you've got,
I mean, I don't know if that's been done before, so this publication when it's out imminently is
a must read because it's probably going to be the most robust data that there is on uh on a
long large series of patients with a single type of implant.
This is from Belgium. What do you think about lipofu or
stem cells in capsule contracture treatment because in my
specially implant-based patients with capsule contracture and sometimes with very thin skin,
especially heavy weight loss patients, when I do one or two sessions
of Lipofilling, which is easy with the capsule, uh, I have the impression that
there is less capsule contraction, what do you think about it?
I don't have any I personally don't have much experience with lipofilling as a as a treatment
for capsular contracture, but it's kind of difficult for me to wrap my head around that
and to as to how it actually.
Works, but I know there are reports and there are people who claim that it's beneficial,
but I, I personally don't treat capsular contracture with stem cells or fat grafting.
Excuse me, it's not only by, uh, fat grafting. It's before doing the uh the operation
to change uh implants and take out the capsule. It's before it.
So to be a bit still on this topic a bit on the controversial side,
would you. Agree or disagree that the cause of capsular
contraction is surgeons related and secondary is patient
related sized BMI unless implant and less pocket related.
You've also got the other group of patients who have the association with a bacterial shower.
I mean, without doubt, whether I saw a patient the other day who had a an episode that
spontaneously settled down of what sounded like capsular contracture and on close questioning
she'd had er she'd required antibiotics for respiratory tract infection was pretty unwell
with it, and we all have these patients that have had dental work,
have had other work, so they're.
That there's more at play than just those two aspects.
I also think it's a combination of all of the above, you know,
for sure it's a lot about what the surgeon does in surgery.
Uh, I believe there is a genetic predisposition like I showed,
and you know, just like somebody who smokes 20 cigarettes a day,
not necessarily she or he will develop cancer. There's like some genetic predisposition.
And compliance of patients, let's say that the patient the next day after surgery goes to,
you know, to the gym, which happens, and you're gonna have blood in the pocket,
maybe not, you know, to, to take her back to the OR but that blood could initiate.
So it's, it's really a lot of factors. So I think it's a lot of what we do,
a lot of what the patient does genetic luck.
I would like to ask the audience and the faculty, do you for patients getting dental
work? Part of, uh, Belle Adams and Anan Diva's 14
point plan says that you should, uh, patients having dental work should have prophylactic
antibiotics if they have implants. I don't do that if you look at the American
Dental Association, they said you get as much bacteremia when you floss your teeth as you're
getting. Your teeth cleaned an antibiotics every time,
yes, right, so that would be taking antibiotics every morning.
So Phil Adams and I have argued this, and um there are a lot of surgeons in the US that will
have their patients that call them if they're getting dental work done.
Now if they have an abscess too, that's different.
The routine dental cleaning. I don't know if that's in uh outside of the US.
Do any of you have your patients get antibiotics before dental?
Good, because I don't. I'm glad you all agree with me.
I, I do.
I do, and it's because I've had a couple of patients who have seated secondarily to a teeth
cleaning, yeah, so this was back to my general surgery days where I've seen dental procedures
done and valcular infections from cardiac procedures related exactly to when they had
their teeth cleaned. So since then I've always in the back of my
mind thought, well maybe there's some benefit and you know sometimes.
Going to the dentist and having your teeth cleaned can be a little more traumatic than
just flossing. I mean, because they do sometimes generate
bleeding, um, so I think in those situations, I don't know,
I tend to err on the side of giving them just, uh, twice a year you'll give them antibiotics.
Yeah, I'll tell him to just take a Kef antibiotics before.
So so you're the cause of the resistance.
No, antibiotic stewardship is not my forte.
But you know, kind of along the lines of antibiotics, I'm kind of curious just what the
panellists do for intraoperative irrigation solutions because we've got so many,
um, you know, I, I tend to use, um, chlorhexidine irrigation.
I'm just kind of wondering what everybody likes to use now for their intraoperative irrigation.
I also do 50% petadine. Perfect.
The question is what, what irrigation solution do you use?
I use. Better than an antibiotics.
Great, well thank you very much for the faculty for this morning.
I think it was great and thank you very much for mentor supporting this morning,
so coffee break.