Kapsulyarny contracture – the complication of an augmentatsionny mammoplastika caused by an implant sdavleniye the fibrous capsule and which is followed by deformation of a breast. The Kapsulyarny contracture is shown by feeling of discomfort and hardness in a mammary gland, an implant konturirovaniye, change of a form and an unnatural type of a breast. Degree of a kapsulyarny contracture decides on the help of visual survey and a palpation of mammary glands, carrying out MRT. Depending on expressiveness of a kapsulyarny contracture for correction of defect the kapsulektomiya, removal of implants or a reendoprotezirovaniye can be executed.
Kapsulyarny contracture – pathological process at which there is a thickening of fibrous fabric of the capsule around an endoprosthesis and its sdavleniye leading to consolidation, deformation and asymmetry of mammary glands. The Kapsulyarny contracture can arise not only after increase in a breast by means of silicone implants, but also after endoprosthesis replacement of buttocks, shins etc. However most often the esthetic augmentatsionny mammoplastika or reconstruction of a breast is complicated by a kapsulyarny contracture. According to various authors, the frequency of a similar complication in plastic surgery fluctuates from 0,2-2% to 10% of cases. Development of a kapsulyarny contracture results in the unsatisfactory esthetic result of operation which is quite often demanding repeated surgical intervention.
Reasons of formation of a kapsulyarny contracture
The Kapsulyarny contracture represents the cover from fibrous fabric which is densely surrounding an implant. Formation of the soyedinitelnotkanny capsule around an endoprosthesis is quite natural, biologically determined and predicted process which the organism reacts to introduction of a foreign matter. However under certain circumstances this process gains pathological character: the fibrous cover is excessively thickened, causing a sdavleniye of an implant and deformation of a mammary gland.
Can lead various reasons connected as with the operation and the used implants, and with external factors, and also individual reaction of an organism to development of a kapsulyarny contracture. The risk factors caused by technical aspect of an augmentatsionny mammoplastika can turn on the rough operational equipment; the incomplete hemostasis leading to formation of a post-operational hematoma; damage of channels of a mammary gland (is more often at endoprosthesis replacement by perioreolyarny access), an epidermalny staphylococcal infection. The risk of formation of a kapsulyarny contracture increases at a hypodermic arrangement of an implant and decreases at installation of an implant under a pectoral muscle inframammarny access. Also discrepancy of the size of an implant to a pocket, i.e. a situation when the size of an endoprosthesis is more than the size of a cavity in which it is established can provoke formation of the rough fibrous capsule.
It is noticed that the kapsulyarny contracture is more often formed when using silicone implants and endoprostheses with a smooth surface; more rare - in case of application of salt implants, and also endoprostheses with the textured surface. Besides, the risk of development of a kapsulyarny contracture significantly increases at a rupture of an implant and leakage of a filler.
Individual reactions of an organism to endoprosthesis replacement are usually shown by the increased tendency to rough cicatricial processes. As a background for hyper reaction the hormonal imbalance caused by recent pregnancy, childbirth and a lactation can serve. The exogenous factors increasing risk of formation of a kapsulyarny contracture include chronic nicotinic intoxication, reception of certain medicamentous medicines, a bruise of a mammary gland, excessive physical activities. In most cases not one is the cornerstone of formation of a kapsulyarny contracture, and several reasons.
Concerning pathogenesis of a kapsulyarny contracture the fibroplastichesky theory within which this complication is explained by reduction of quantity of muscle cells (miofibroblast) and the increased formation of the soyedinitelnotkanny fibers having the identical direction is put forward. Partly more frequent development of a kapsulyarny contracture when using chest implants has a talk with a smooth surface it. In case of application of the textured fiber endoprostheses, surrounding a relief surface of an implant, have multidirectional growth that is connected with considerable reduction of cases of a contracture.
Symptoms of a kapsulyarny contracture
As a rule, signs of a kapsulyarny contracture become noticeable within the first year after implantation and amplify eventually, in process of "aging" of an implant. Depending on terms of emergence distinguish early (till 1 year) and late (in several years after endoprosthesis replacement) a kapsulyarny contracture. Usually this complication has unilateral character, however can mention also both glands. In process of development of pathological changes the mammary gland becomes dense to the touch, gets triangular and conic, ovoid, and subsequently - spherical, unnaturally round form. Except esthetic defect, formation of a kapsulyarny contracture often is followed by discomfort and morbidity in a mammary gland.
For assessment of weight of symptomatology classification of degrees of expressiveness of a kapsulyarny contracture by Baker is accepted:
- The I degree – density of tissues of mammary gland is not changed; the breast looks naturally. The capsule created around an implant, thin and elastic. Such state meets postoperative standard.
- The II degree – density of tissues of mammary gland is higher, than before operation, however the shape of a breast is not changed. At a palpation edges of an endoprosthesis are felt.
- The III degree – tissues of a mammary gland are considerably condensed, contours of an endoprosthesis not only are felt at a palpation, but also are noticeable visually. At this stage deformation of a breast is noticeable.
- The IV degree – a mammary gland inelastic, firm, painful at a palpation. Deformation, affectation of a form and asymmetry of a breast are obvious.
Degree of expressiveness of changes is estimated by means of visual survey and a palpation, and also carrying out MRT of mammary glands.
Treatment of a kapsulyarny contracture
Approach treatment of a kapsulyarny contracture differentially. So, at the I degree of a kapsuloobrazovaniye of need for any actions is not present. At changes of the II degree waiting tactics practices, special massage of chest glands, ultrasonic therapy, vitamin E reception, a course of anti-inflammatory injections is appointed. At the expressed degrees of a kapsulyarny contracture the technique of the closed (conservative) kapsulotomiya which essence consisted in the strong mechanical sdavleniye of a breast pursuing the purpose a rupture of cicatricial fabric was applied earlier. However performance of this manipulation quite often involved a rupture of an implant, its shift, hemorrhage in gland fabrics, repeated formation of hems. In half of cases the closed kapsulotomiya was followed by repeated development of a kapsulyarny contracture that as a result forced to refuse its carrying out.
Now treatment of a kapsulyarny contracture of the III-IV degree is performed only in the surgical way. Complexity of a situation is that faces the surgeon a complex of tasks: removal of pathologically changed cicatricial fabrics, restoration of an esthetics of a breast, the prevention of repeated development of a kapsulyarny contracture. The choice of a surgical technique always has individual character and depends on the reasons, extent of deformation and solvable tasks.
For the purpose of secondary correction of a mammary gland the open kapsulotomiya - a section of the fibrous capsule can be carried out. This operation allows to estimate thickness of cicatricial fabric, to change cavity size, to make correction of situation or replacement of an implant by new. At the request of the patient or on medical indications repeated operation can consist chest implants only at a distance. Except open operation, carrying out an endoscopic kapsulotomiya is possible.
At a considerable thickness or a kaltsifikation of the fibrous capsule its removal - a partial or full kapsulektomiya with removal of an endoprosthesis and its reimplantation in other pocket or a reendoprotezirovaniye of a mammary gland is made. However this technique is quite traumatic and accompanied by risk of a recurrence of a kapsulyarny contracture approximately in a third of cases. For achievement of the best esthetic result operation for a kapsulyarny contracture is quite often combined with different types of a mastopeksiya.
Thorough training to operation of a mammoplastika, the correct assessment of contraindications at an operation planning stage, observance of the technology of surgical intervention, use of the modern, well proved implants allows to reduce risk of formation of a kapsulyarny contracture. Whenever possible it is necessary to give preference to the textured endoprostheses and a subfastsialny or submuskulyarny arrangement of an implant. In the postoperative period it is important to observe the recommended mode: to wear compression linen, to carry out special gymnastics and massage, to exclude excessive load of pectoral muscles, to be in due time on control surveys etc.