A capsulectomy involves much more dissection than a capsulotomy [67]. There is less remaining tissue to provide implant cover and a greater potential for nerve injury [68]. A drain may be needed [15]. It can be technically difficult, and dangerous, to remove capsular tissue from the axilla and the chest wall [17, 67, 69]. Accordingly, an anterior capsulectomy may be recommended [67], although this recommendation begs the question, is a capsulectomy really necessary if part of the capsule is left in the patient? [23]

A unilateral open capsulotomy typically requires 20–30 min versus 1 h or more for a capsulectomy [67]. Recovery room stays are usually 30 min. Because there is minimal submuscular dissection (unless a new subpectoral pocket is created), there is little discomfort. Patients return to their usual activities within a few days. Even in the event of a recurrence, the patient has experienced minimal cost (depending on the surgeon’s policy) and morbidity. The recurrence rate of 23% overall after open capsulotomy (and 14% for patients with intact implants) compares favorably with recurrence rates reported after capsulectomy, which can range from 25% to 53.4% [14, 34].

In the case of thin, noncalcified capsules, there seems to be no harm in leaving the capsule in the patient [70]. The capsule around saline implants is usually absorbed [71]. The low seroma rate (1.3%) indicates that leaving the capsule in situ rarely leads to fluid accumulation [23]. A capsulectomy, either partial or full, may be reserved for thick, calcified capsules (Figs. 4.3, 4.4, 4.6, and 4.7) [16].

Removal of all calcification is unnecessary [70]. Capsular calcifications are not usually a source of confusion for radiologists [67]. Acellular dermal matrix is thought to reduce capsular contracture by serving as a barrier and reducing inflammation and scarring [72]. This objective is also accomplished with a capsulotomy. If lining tissue is preserved, there is no need to replace it.

Unfortunately, aggressive treatment and re-treatment of capsular contracture can leave a patient with a scarred, misshapen breast. A cosmetic patient becomes a reconstructive patient [59]. Occasionally, such patients require large flaps of tissue to reconstruct the breast, much like a post-mastectomy patient after breast cancer, or the patient may require fat injection in an effort to regain volume (also called domain) [59]. The reconstructive ladder (Fig. 4.8) is well known to plastic surgery residents. In general, lesser options that have a reasonable chance of success are chosen before resorting to more aggressive treatments. Treatment of capsular contracture is a case in point. An open capsulotomy is on the lowest rung of this ladder [59].

A neopocket refers to the development of a new plane adjacent to the existing capsule [69, 73, 74]. Typically the new pocket is made anterior to the existing one, but still subpectorally. The logical basis is that the old capsule is not re-used, but the subpectoral location is preserved. However, this approach opens a sizable new wound.

An open capsulotomy limits the wound area and theoretically minimizes inflammation and fibroblast activity by preserving the existing capsule [23]. The subpectoral location is at lower risk for capsular contracture [13, 15, 17, 35, 62], a finding often attributed to more separation from nonsterile breast tissue [17, 35, 37, 38], although there is still plenty of contact. Regardless of capsular contracture risk, replacing a subglandular implant in the submuscular plane provides additional tissue cover and optimizes upper pole aesthetics [15, 16].

At the 2016 meeting of the American Society of Plastic Surgeons [59], plastic surgeons in the audience were informally polled regarding their treatment of capsular contracture. Eighty-four percent responded that they would use ADM either for a first or second capsular contracture. Only 16% of respondents said they never use acellular dermal matrix (including the author).

Acellular dermal matrix is a popular tool in reconstructive breast surgery [75]. ADM is now used by many plastic surgeons treating or attempting to prevent complications of cosmetic breast surgery, including bottoming out, implant malposition, rippling, skin flap deficiency, and capsular contracture [34, 76, 77]. Its use has not been limited to secondary surgery. Hester et al. [34] incorporated Strattice (Lifecell Corp., Branchburg, N.J.), a porcine ADM, in some primary breast augmentation and augmentation mastopexy patients. ADM is viewed as a barrier to reduce inflammation and scarring [72] that would otherwise take place in a raw tissue bed. Early studies report low capsular contracture recurrence rates [76, 77]. Salzberg et al. [75] report a 0.8% rate of capsular contracture in breast reconstruction cases using ADM, and a 1.9% contracture rate in irradiated breasts. These results do seem extraordinary.

However, there are serious drawbacks. Acellular dermal matrix (e.g., AlloDerm, Lifecell Corp.) is usually a human biological tissue, obtained from cadavers [78]. Although ADM has received FDA approval, this approval is not specifically for use in the breast. In 2015, the FDA issued a warning letter to Lifecell Corp. regarding marketing of their Strattice product for breast reconstruction rather than its approved use as a soft tissue patch, such as in hernia repairs [79]. Recovery techniques and locations may be limited by the donor families’ wishes or funeral arrangements [78]. Suppliers must obtain proper consent, and if this is not done the product is subject to recall [80]. There are risks – skin necrosis , infection, hematoma, seroma, and recurrent deformity [76, 81–84]. When used adjacent to a breast implant, non-vascularized ADM contributes to a hypovascular environment [82]. The product is expensive, costing $3500 or more for sufficient material to treat one breast [85]. Donors are screened for communicable diseases [78, 85]. Nevertheless, Hartzell et al. [85] inform their patients of the risk of transmission of viral hepatitis and the human immunodeficiency virus, although there have been no reported cases. Some products, including aseptic freeze-dried AlloDerm (Lifecell Corp.), FlexHD (Ethicon, Somerville, N.J.), and BellaDerm (Musculoskeletal Foundation, Edison N.J.), are not sterilized, but aseptically processed to retain favorable properties of the dermis, such as its scaffold structure, collagen and elastin composition, host fibroblast cell attachment, and mechanical strength [78]. These properties may be compromised by terminal sterilization with e-beam radiation, used for the pre-hydrated AlloDerm Ready-To-Use (RTU) product [78].

In their systematic review and meta-analysis, Ho et al. [81] report a higher rate of seromas (6.9%), infection (5.7%), and reconstructive failure (5.1%) in ADM-assisted breast reconstruction compared with non-ADM-assisted cases. ADM-assisted breast reconstructions are almost four times as likely to be complicated by seroma, nearly three times as likely to become infected, and three times as likely to have a reconstructive failure [81]. The meta-analysis by Kim et al. [82] produced similar findings for ADM-assisted submuscular tissue expander or implant breast reconstructions. These investigators [82] documented a greater risk of overall complications (15.4%), seromas (4.8%), infection (5.3%), and flap necrosis (6.9%). Relative risks were 2.05 for complications, 2.73 for seroma, 2.47 for infection, and 2.80 for reconstructive failure [82]. ADM may incite an inflammatory response known as red breast syndrome [82]. Weichman et al. [83] report significantly more infections (20%) using aseptic AlloDerm (20%) for consecutive breast reconstruction compared with subsequent patients who received sterile ready-to-use AlloDerm (8.5%). Mendenhall et al. [86], in their microbiological study, cultured bacteria from both sterile and aseptically processed acellular dermal matrices.

There is also the matter of financial conflicts. Many investigators using ADM receive financial support from the manufacturer [75–77, 84, 87]. This remuneration can exceed $100,000 [88]. Writing support and statistical analyses may be provided by the manufacturer [84]. Financial entanglement is known to influence how results are reported [89–92]. Lopez et al. [89] found that reported surgical complications were significantly lower in studies with conflicts of interest when acellular dermal matrix was used for implant-based reconstruction. However, when this product was not used, complication rates were similarly reported by authors with and without conflicts of interest. In general (not just acellular dermal matrix), plastic surgery studies that disclose a financial conflict of interest are seven times more likely to report a positive outcome over a negative outcome compared with studies with no financial conflict of interest [92]. Indeed, plastic surgeons can function as impartial investigators or highly paid consultants, but not both [89–92].

When considering the possible role of ADM in treating or preventing capsular contracture, its possible benefit must be weighed against any ADM-related complications. The bottom-line question is whether the surgeon would be willing to have it implanted, or use it in a family member undergoing cosmetic breast surgery. Regardless of the possible role of ADM, open capsulotomy should remain a treatment option [23]. An open capsulotomy leaves all other options available, and avoids creating a deformity that will require reconstructive options later on.

The risk of capsular contracture is listed on consent forms and mentioned in any discussion of complications. However, the patient who develops a capsular contracture will often be unhappy regardless and wonder why her girlfriend, who went to another plastic surgeon, did not have the same unfortunate outcome. Many patients are young women who have made a substantial financial sacrifice to have the surgery. They may now be confronted by paying a similar amount again for the surgeon, anesthesia, and surgery center, and possibly more for ADM.

Most plastic surgeons charge for their services to treat capsular contracture, reasoning that they are not responsible for this known complication. This approach does little to assuage an unhappy patient. My own practice is to keep management as simple as possible [59]. The patient only pays for the surgery center and anesthesia. There is no surgical fee and nothing is billed to insurance. The financial cost is therefore tolerable. This approach helps to keep patients happy [59]. I perform about four open capsulotomies per year. The lost income is likely to be recouped by one or two referrals from these patients.

Some plastic surgeons do not discuss their financial policy for managing complications at the time of the consultation. The policy may be buried in paperwork . Such discussions are well received by patients and may place the surgeon at a competitive advantage when the patient selects her surgeon. Sforza et al. [93] go a step further, offering 3 years of free revisions in case of capsular contracture, implant rupture, or even an unsatisfactory aesthetic result.

Recommendations to avoid recurrence include capsulectomy, site change, new implants, bloodless dissection, antibiotic irrigation, glove change, covering the incision site with an adhesive barrier, form-stable implants, a sleeve or funnel, nipple shields, and acellular dermal matrix [15, 32, 33, 35, 44]. In 1981, Brody and Latts [25] lamented the lack of controlled studies leading to a “shotgun approach using every means ever reported,” commenting that “the enthusiastic espousal of circumstantial evidence becomes dogma.” In the years since, investigators have frequently noted the lack of scientific data [16, 98, 99] and the shortcomings of treatment dictated by clinical impressions alone [22, 98].

In 2012, Hester et al. [34] observed that breast-pocket irrigation, site changes, and submuscular or dual plane implant placement had minimal identifiable effect on the rate of capsular contracture. Despite capsulectomy, site change when appropriate, and implant replacement, these experienced surgeons reported a recurrence rate of 53.4%, prompting them to start incorporating ADM.

A recent survey [36] and review articles [15, 32, 36] do not include open capsulotomy as a treatment option. Twenty percent of plastic surgeons use silicone gel implants exclusively [36]. Although silicone gel implants are thought to have a more ideal feel characteristic [15], this difference may be negligible when the implant is placed submuscularly. The appearance of saline-filled implants is the same [15]. Implant deflation is easier to detect, and treatment of a capsular contracture is likely to be uncomplicated and successful [23]. Saline implants are less expensive than silicone gel implants and patient satisfaction is very high (87.5–98.1%) with both devices [1, 13, 62, 100, 101].

When considering the pros and cons of silicone gel versus saline implants, management of capsular contracture is not typically considered. The capsule around a saline implant is never exposed to silicone gel and rarely becomes densely calcified. The risk of a capsular contracture is 6%, and the risk of a recurrent capsular contracture is a tolerable 23% [23]. Perhaps plastic surgeons should reconsider saline implants based on the full profile of pluses and minuses. Patients should be given all of this information and not simply directed to silicone implants “because they are more natural.” In my practice, most patients still choose saline despite the full availability now of silicone gel implants. A silver lining to the silicone gel implant moratorium is that many American plastic surgeons have learned that the alternative (saline implants) is not such an inferior option after all [1, 36, 100].

Low hematoma rates are reported in breast implant core studies, in the range of 1.2–2.9% [11, 12, 102]. In my experience, hematomas develop within 24 h in almost all cases and most occur within the first 12 h (Fig. 4.9). A telltale sign is the inability of the patient to abduct her arm without pain on the affected side. Today patients often send selfies on their cellphones if they develop excessive swelling. This practice prevents some needless visits to the clinic.

Diagnostic ultrasound can be helpful in making the diagnosis if this device is available (Fig. 4.10). Occasionally (perhaps once a year) I use ultrasound in the recovery room in cases of unilateral swelling. All breast augmentation patients return to the office the day after surgery. Out-of-town patents remain in the area (< 1 h) for at least 24 h so that they do not have to travel far for treatment. If a hematoma is detected early and treated promptly, the outcome is usually not compromised, although there is more bruising and a higher risk of capsular contracture [15, 27]. This problem is largely mitigated by thorough evacuation of the clot and wound irrigation.

Strict sterility is particularly important for cosmetic breast surgery because an infection can require implant removal and delayed replacement (most surgeons allow at least 3 months), which is onerous for patients. Accordingly, the surgery should be performed only at a properly credentialed facility that adheres to infection prevention guidelines. When combining surgical procedures, it makes sense to start with the breast surgery to optimize sterility, which may be compromised later in the case during liposuction or other body contouring procedures.

It is important to differentiate between cellulitis or a yeast infection, which usually responds to local wound care and oral antibiotics, from a deep infection around the implant. Implant-related infection is signaled by increased discomfort, redness, and swelling of the affected breast, and a fever (Fig. 4.11). Exquisite tenderness is elicited by gentle compression anywhere on the breast, as opposed to just in the area of the wound in the case of a surface skin infection. An allergy to adhesive strips or neomycin can sometimes be confused with cellulitis.

Breast implant core studies report infection rates of 0.9–1.7% [10–12, 14, 102]. The responsible organisms are usually gram positive bacteria, likely skin flora, although gram negative infections rarely occur. Sforza et al. [93] cultured methicillin-sensitive Staphylococcus aureus from nine patients, methicillin-resistant S. aureus from two patients, S. epidermidis from two patients, mixed flora from three patients, and Pseudomonas aeruginosa from one patient. All the bacteria were sensitive to ciprofloxacin.

Nontuberculosis mycobacteria can also be responsible for breast implant infections. Scheflan and Wixtrom [103] reported an outbreak of a new species of mycobacterium in breast augmentation patients. Patients presented 3–6 weeks after surgery with a serous drainage, minimal redness, no fever, and negative standard bacterial cultures. The identification of the responsible organism was extremely difficult. It was eventually identified as a new mycobacterium (named Mycobacterium jacuzzii), cultured from the water in a garden hot tub used by the surgeon at this home in Israel. The investigators concluded that dandruff shedding from the surgeon’s skin and eyebrows during surgery was the likely source of infection. Patients were effectively treated with ciprofloxacin, implant removal and pocket irrigation, followed by delayed reimplantation. One-stage salvage was unsuccessful. The authors [103] recommend mycobacterial cultures when infection is suspected, particularly in cases of late-onset serous drainage and minimal symptoms (and operating personnel should avoid using hot tubs). This cautionary tale will make any reader less complacent about sterility.

Some investigators have recommended additional methods to reduce infection risk. Deva et al. [44] insist on a 14-point plan that includes nipple shields and triple-antibiotic irrigation. However, these extra measures have little scientific foundation [23]. Triple-antibiotic solution may actually predispose to infection with resistant organisms, such as Ralstonia (Clemens MW, 20 May 2016, personal communication). Despite using saline alone for irrigation and no nipple shields, my infection rate after breast augmentation is 0.4% [6], very similar to the rate reported by Sforza et al. (0.28%) [93]. My practice is to routinely administer cefazolin 1 g I.V. immediately before surgery and three doses of cephalexin, 500 mg p.o. bid after surgery [23]. Longer courses of antibiotics are not known to be more effective in preventing infection, but do raise the risk of unwanted side effects such as vaginal yeast infections.