Big Help needed for Capsular contraction

[22PT]

I am wondering what your protocol is for someone who has capsular contracture. A little hx on my case: I had saline implants 8 years ago and ~ 2 years ago one had a slow leak at the valve and I had to undergo surgery. I decided to go with silicone and go up 25 or 50cc Bilaterally. I had capsular contraction on the L after several months and massage techniques did not work therefore, my plastic surgeon did a capsulotomy. After about 3 months the pain was intense, I had a lot of bruising and I believe a hematoma and there wasn't any amount of massage that was going to allow for softening or dropping of the L breast with the CC that I had. I had to recommend a capsulectomy to the plastic surgeon and he completed the surgery. I am 3 months post op and I cont to have a firm L breast and there appears to be CC starting again. I am wondering what can I do to be the most aggressive with this situation. I have undergone way too many surgeries for this situation and I want to be as aggressive as I can. I have heard of using ultrasound, using bands etc..... What would you recommend if I were your patient? I am a PT and I have my own practice with an ultrasound machine so I could use that if need be. With your research and your clinical expertise on this subject what would you recommend??
Thanks so much for your time! 22PT

[DrSorokin]

My protocol:
Postop everyone massages. I do not use textured implants as you can't really massage them. If any hardness I start Vitamin E. If that doesn't work sometimes I will use other medications which have been detailed on this site but have medical risks and thus need to be considered on a case by case basis. If no improvement then capsulectomy. I skip over capsulotomy. I keep implants under the muscle. As you have already had capsulectomy you may consider putting implants under the muscle if not there already. Does your surgeon irrigate with triple antibiotic irrigation in the OR? There is clear data on what antibiotic combinations work (from Dr. Adams' research in Dallas) Does your surgeon give you antibiotics periop? Do you take antibiotic prophylaxis when going to the dentist or having other invasive (like colonoscopy) procedures? What incision did you use? There are so many questions to ask and I hate to say it but sometimes you need to get other opinions. I really am unable to give you specific medical advise on your specific situation other than to say hematomas are a set-up for CC and perhaps this is what led to it. Maybe you need a drain at your next surgery. So many questions.......

[Gabrielle]

Originally Posted by DrSorokin

My protocol:
Postop everyone massages. I do not use textured implants as you can't really massage them. If any hardness I start Vitamin E. If that doesn't work sometimes I will use other medications which have been detailed on this site but have medical risks and thus need to be considered on a case by case basis. If no improvement then capsulectomy. I skip over capsulotomy. I keep implants under the muscle. As you have already had capsulectomy you may consider putting implants under the muscle if not there already. Does your surgeon irrigate with triple antibiotic irrigation in the OR? There is clear data on what antibiotic combinations work (from Dr. Adams' research in Dallas) Does your surgeon give you antibiotics periop? Do you take antibiotic prophylaxis when going to the dentist or having other invasive (like colonoscopy) procedures? What incision did you use? There are so many questions to ask and I hate to say it but sometimes you need to get other opinions. I really am unable to give you specific medical advise on your specific situation other than to say hematomas are a set-up for CC and perhaps this is what led to it. Maybe you need a drain at your next surgery. So many questions.......

Doctor, when do you normally remove the surgical drains? I am post op day 7 capsulectomy, implants under muscle. My grade 4 CC is recurrent and the result o a traumatic hematoma. I am on Accolate and antibiotics. My questions: when do you remove the JP drain, at <25mL overnight or <30 mL/24 hrs? How long do you recommend I continue the Keflex, until the drains are out or for 4-6 weeks? And lastly, should I start massage the day I have the drains out even if the breast is still very sore? Or should I wait a day or two? Thank you so much for your advice. My plastic surgeon is great and it is kind of a learning curve with recurrent CC. We are hopeful this will be the last surgery!

[DrSorokin]

I continue the antibiotics until drain is out. This is probably more than needed. Be very careful with drain care where the drain exits the skin not to let it move in and out as this is a potential entry point for bacteria and must be protected. I do not remove until less than 30cc in a day. I would not start massage until your doctor says it is ok. I do not know what he did in there and how much bleeding he had. The last thing you want to do is restart bleeding or cause more bruising with massage. You need to know the incision will be strong enough for massage. Massage is extremely important but could be started to early so get clearance. Good luck!

[Gabrielle]

Thank you for your advice! I will use betadine at the drain site and keep the tubing taped down to prevent it from moving. The sutures still are holding it securely. The drainage is still bloody 8 days post op.

The capsule was 1/2 inch thck with some loose "floating" scar tissue. This is my fifth surgery so I am a case study for sure! In retrospect I can see why each surgery failed previously. I think the combination of drains, antibiotics, accolate and massage will be a winner!

[22PT]

Gabrielle,
I am so sorry to hear that you are in the same boat that I am in! It is so frustrating to have to go back for surgery for CC and I just want this all to be over!! I would love to be able to move on from here. How are things going for you at this point??

[22PT]

Originally Posted by DrSorokin

My protocol:
Postop everyone massages. I do not use textured implants as you can't really massage them. If any hardness I start Vitamin E. If that doesn't work sometimes I will use other medications which have been detailed on this site but have medical risks and thus need to be considered on a case by case basis. If no improvement then capsulectomy. I skip over capsulotomy. I keep implants under the muscle. As you have already had capsulectomy you may consider putting implants under the muscle if not there already. Does your surgeon irrigate with triple antibiotic irrigation in the OR? There is clear data on what antibiotic combinations work (from Dr. Adams' research in Dallas) Does your surgeon give you antibiotics periop? Do you take antibiotic prophylaxis when going to the dentist or having other invasive (like colonoscopy) procedures? What incision did you use? There are so many questions to ask and I hate to say it but sometimes you need to get other opinions. I really am unable to give you specific medical advise on your specific situation other than to say hematomas are a set-up for CC and perhaps this is what led to it. Maybe you need a drain at your next surgery. So many questions.......

Thank you so much for your response. I have not taken antibiotics prior to surgery and do not usually when going to the dentist or with other medical procedures including my colonoscopies. We have used the periareolar each time and the implant is under the muscle. I did have a drain on the last surgery which was the capsulectomy and I was on Keflex for a few days following the surgery. I have recently taken a muscle relaxer as it felt as though the pectoral muscles just wouldn't let go! It seemed to help some. I have also tried a strap as some of the ladies have stated that they have used and it appears to have helped with assisting in the dropping of the breast but not the firmness so much. I would love to know what step you would give your patient if they were at this stage 4 months post capsulectomy. Would vitamin E still be worth trying at this point? Or is it too late to implement at this point?
Please any advice is greatly appreciated!! 22PT

[DrSorokin]

I honestly think you need to get a second opinion. Several things about your post bother me. First of all, you wrote that you had to suggest the capsulectomy to the surgeon. Why is this? Does he not have much experience with CC? Does he do much breast surgery? Second thing, you wrote that you had a capsule 1/2 inch thick. Capsules do not get that thick. You are a PT and understand anatomy. Was there a pathology report? If I saw a capsule truly 1/2 inch thick it would be biopsied. Finally, floating scar tissue? Scar tissue doesn't just float around. It needs to be connected to something to have a blood supply to even form in the first place. It doesn't just precipitate out of nowhere. Thus, where did it come from? What loose tissue left floating around in a previous surgery? Thus, my opinion. Get a second, independent opinion.

[22PT]

I am so happy to have a response from you! Thank you for your time. I think that there are 2 stories that are getting confused here. I am a PT and have had the capsulectomy (which I did have to suggest to the plastic surgeon) but I did not have a 1/2 inch thick capsule. I also did not have the loose scar tissue. I have had 2 surgeries in the last 7 months for CC. The first one was just a capsulotomy and the 2nd was a capsulectomy with a new implant and a drain that was placed. I was told that since there has been surgery this close together that there will be more scar tissue and therefore it will take longer to soften. It sounds feasible but I am just so anxious that this is just not going to be the end of my dilemma!! I do have an ultrasound machine at my private practice that I could use. Have you found this to work for any of your patients? How about accolate? How about injections of corticosteriods? I just found the injection info on another site and that was the first that I had heard of it. I was also wondering does vit E work and if so how much would you recommend? Is it too late to start any of this 4 months post op? I feel as though I have made some progress over the last month or 2 but I am be optimistic!! I really appreciate your advice!

[DrSorokin]

Sorry I mixed up the stories there. I would say go for it with the Vitamin E because there really is limited downside. As far as the ultrasound goes, you are lucky because you have easy access to it. It is cost prohibitive to have most patients use it so there is little science to saying it would work. I would have difficulty recommending an exact protocol to use as I do not know of real scientific studies showing it works. As you state you are improving I would avoid the accolate if possible because it does have bigger potential side effects. If you were not improving then it would be something to consider. Finally I would never inject steroids into the breast for capsular contracture.

[22PT]

Sorry I mixed up the stories there. I would say go for it with the Vitamin E because there really is limited downside. As far as the ultrasound goes, you are lucky because you have easy access to it. It is cost prohibitive to have most patients use it so there is little science to saying it would work. I would have difficulty recommending an exact protocol to use as I do not know of real scientific studies showing it works. As you state you are improving I would avoid the accolate if possible because it does have bigger potential side effects. If you were not improving then it would be something to consider. Finally I would never inject steroids into the breast for capsular contracture.


Is there a certain mg that I should take and/or a particular kind of Vit E that you usually prescribe? Is a the CC that occurs scar tissue or is it different? How about pressure garments for CC? Is it essentially too late once the CC starts?

[22PT]

I was just wondering if there is a difference between scar tissue and CC. My plastic surgeon keeps telling me that since I have had a couple of surgeries in a short period of time that there is going to be more scar tissue causing a slower healing process. Do you agree that this can be the case? He states that there is more scar tissue that needs to be massaged to allow the implant to drop and settle. It is the beginning of the 5th month. I think that the implant has dropped some in the last month or so and perhaps is getting a little softer but is not completely soft by any means. Do you agree with these statements and is it a potential that things will soften with massaging of the scar tissue?? I can send a photo if that would help you to decide.

[DrSorokin]

More surgery can lead to more scarring of normal tissues which is different from capsular contracture. It often takes many months to completely soften. Keep massaging. Massage and time are your best friends right now.