Physiopathology, Prevention, and Treatment of Capsular Contracture
Capsular contracture is the formation of a fibrous periprosthetic shell as a foreign body response. The capsule has a trilaminar structure. The inner layer consists of a synovial-type metaplasia from fibrocytes and histiocytes, the intermediate layer of s
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48
Alessia M. Lardi and Jian Farhadi
48.1 Introduction
48.2 Diagnosis
Capsular contracture is the formation of a fibrous periprosthetic shell as a foreign body response. The capsule has a trilaminar structure. The inner layer consists of a synovialtype metaplasia from fibrocytes and histiocytes, the intermediate layer of smaller fibrils in a vessel-rich network, and the outer layer of densely packed collagen fibers. Myofibroblasts sit in the outer layer, and the capsule may constrict and cause pain and deformation of the implant. Capsular contracture despite advances in surgical technique and implant devices remains a frequent complication after breast reconstruction (2.8–15.9%) [1, 2]. With the adjunct of radiotherapy, a recognized risk factor, capsular contracture rates of 15–50% have been reported [3–8]. In 20–30%, revision surgery has to be performed because of capsular contracture [9–12]. Capsular contracture, because of the multifactorial and in part still unclear etiology, the impairment of quality of life, and the significant economic impact, is subject of greatest interest in plastic and reconstructive surgery.
Estimation of the presence and severity of capsular contracture is performed by a clinical evaluation. Baker’s classification of capsular contracture is used widely for assessment and classification of capsular contracture. The modification of the Baker’s classification includes classes IA, IB, II, III, and IV and has been developed to describe breast reconstruction more accurately (Table 48.1) [13, 14]. This evaluation is subjective in regard to the individual examiner, and various clinical works outline the importance of imaging techniques in the evaluation of the severity of capsular contracture. A range of imaging modalities was tested for this purpose including mammography, ultrasound, CT scans, and magnetic resonance images (MRIs). Of these, MRI and ultrasound (US) were proven as the modalities of choice [15, 16]. In clinical practice there is no consent of performing imaging to confirm capsular contracture. Many plastic surgeons still rely on clinical evaluation in planning further treatment. MRI and US might be useful to find rupture of the implant and distinguish from other causes of pain/symptoms as tumor or seroma and last but not least for legal reasons. Table 48.1 Baker’s classification
A. M. Lardi Department of Plastic and Reconstructive Surgery, Guy’s and St. Thomas Hospital, London, UK Department of Plastic, Reconstructive, Aesthetic and Hand Surgery, University Hospital Basel, Basel, Switzerland J. Farhadi (*) Department of Plastic and Reconstructive Surgery, Guy’s and St. Thomas Hospital, London, UK Department of Plastic, Reconstructive, Aesthetic and Hand Surgery, University Hospital Basel, Basel, Switzerland Centre for Plastic Surgery, Pyramid Clinic at the Lake, Zürich, Switzerland e-mail: [email protected]
Class IA Absolutely natural; cannot tell breast was reconstructed Class IB Soft, but device is detectable by physical examination or inspection because of the mastec
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