DOI: 10.1097/01.PRS.0000156771.36773.F4

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Issn Print: 0032-1052

Publication Date: 2005/04/15


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Discussion

B R. Burkhardt

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In this follow-up to his original article on the longevity of capsular tissue, Dr. Rockwell and his co-authors fail to expand on their original data. This is not a criticism: once you have demonstrated that breast implant capsules can persist a surprising 17 years after simple implant removal, there is just not much more to add!
With regard to capsular management, experienced surgeons recognize that a remaining capsule can accumulate fluid unpredictably, requiring later drainage or even capsulectomy, and that the fibrous tissue and calcification can at least theoretically present a confusing picture on later mammography. Whether these potential problems routinely justify the sometimes-difficult procedure of total capsulectomy (especially through a periareolar incision) is the real question. Although some investigators have examined this issue, the incidence of significant clinical problems from retained capsular material is so small that few practitioners have particular concern.
My own approach to correcting contracture around a subglandular prosthesis has become explantation with placement of a new device behind the muscle. In these instances I have been reluctant to perform a complete capsulectomy, in part because attempting this procedure through a periareolar incision challenges my surgical skills and in part because I do not want to risk fenestrating an already thinned pectoralis major when I am relying on it to cover the new prosthesis. I do not have sufficient data to make a good case one way or the other.
Dr. Rockwell touches briefly on the issue of smooth versus textured implants, suggesting that if a textured implant is to be used as a replacement, a capsulectomy will allow the textured surface to interact with the native tissue. Maybe so, but is this an advantage? Although our own studies attributed a significant advantage to textured surfaces, our follow-up was short.1,2 Fagrell et al.’s recent report from Sweden confirmed an early advantage with texturization and provides an excellent review but in a commendably long follow-up of 7.5 years (!) found no difference.3 I believe Fagrell et al.’s data, and I rarely use textured implants.
Dr. Rockwell’s preferred procedure for primary augmentation is submuscular placement of the implants. Although I heartily agree with him I have no data, just strong impressions.
Dr. Rockwell also believes that the best nonsurgical approach to prevent contracture is early postsurgical external massage.4 I believe that massage represents the triumph of Hope over Reason, unfairly assigns responsibility for the prevention of contracture to the patient, and is not only useless but also potentially harmful. The ductal system of the breast is often contaminated and has been clearly identified as a probable source of positive periprosthetic cultures. Do we really want to keep squeezing the breast after surgery? Dr. Rockwell and I could argue about the theory of massage forever, but without comparative data neither of us could prevail.
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