Prophylactic Use of External Ultrasound for Breast Implant Capsular Contracture

Prophylactic Use of External Ultrasound for Breast Implant Capsular Contracture

After successfully treating breast implant capsular contracture with ultrasound, the author asks, "If it is demonstrated that ultrasound is effective for treating already existing contractures, could it be also effective in preventing them?" Here he presents his protocol and preliminary results of prophylactic application of ultrasound for the avoidance of capsular contractures. (Aesthetic SurgJ 2002;22:205-207.) 

The causes of breast implant capsular contracture are unclear and most likely multlfactonal.l-3

Although implantation of textured surface implants4-7 and several drug administration regimens8-13 have diminished the percentage of contractures, they still occur. Six years ago, 1 started applying external ultrasound to treat breast implant capsular contractures. Preliminary results were so positive that 1 was encouraged to continue.14,15

The ultrasonic device that I use is similar to the one used for superficial soft tissue treatment. In an early study, 1 analyzed 52 patients, 25 of whom had bilateral contractures. Nineteen percent of the implanted breasts had a grade IV Baker scale contracture, whereas the remaining 81 % were distributed between Baker scale grades II and III. The number of treatment sessions was determined by evaluating improvement. Patients were treated with repeat ultrasonic applications, ranging from 2 to 16 sessions, with an average of 6.4 sessions,15

To measure the effect of external ultrasound, contracture grade was analyzed before and after treatment. Changes were measured by subtracting the Baker scale value of the final state from the initial one. In all cases, a positive difference indicated an improvement in the patient's condition. In this study, 1 obtained an overall improvement rate of 82.6% at 1-year follow-up, with almost half of the contractures reaching total softness (Table 1).

In a preceding study of 24 Patients, 14 treated similarly, I found that in 97% of cases the degree of contracture improved at least 1 Baker degree. Joining both studies, an evaluation of 83.8% improvement at 1-year follow-up confirms observations of capsular softening and easier closed capsulotomy after external ultrasonic treatment. In most cases, a limited number of sessions, fewer than 8, was enough 10 obtain a long-term result. A satisfactory result was obtained in 75% of the cases. I also confirmed that the percentage of improvement was higher in patients with prepectoral-placed implants.15

The external ultrasonic treatment has proved to be easy to apply, well accepted by patients, and free of significant complications.14,15

After analyzing the data and considering the positive results, 1 posed the following question: if it is demonstrated that ultrasound is effective for treatment of already existing contractures, could it be also effective in preventing them? Theoretical justification for prophylactic use is based on demonstrated properties and effects (Table 2).16-18

We theorized that early application of ultrasound facilitates healing, diminishes edema, and regulates inflammation, thereby diminishing the possibility of a future capsular contracture. The following protocol for prophylactic application was suggested initially: session 1, 24 hours after surgery; session 2, 3 days after surgery; session 3, 7 days after surgery; and session 4, 1 month after surgery.

Ultrasound was administered under the following parameters: level, prophylactic; energy, 60 J; power, 12 W; type, pulsed; time, 10 minutes. Early application of external

Table 1. Measurement of capsular contractures around breast implants

 

Table 2. Effects of ultrasound

Mechanical

Produces micromassages that improve Iymphatic
drainage and help to resolve the edema

Thermal

Increases speed of cellular metabolism
Activates fibroblast production
Helps the healing process, arranging the scar
architecture

Biochemical

Helps vascular proliferation
Increases tissue oxygenation
Increases release of cellular mediators of inflammation Increases fibrolytic processes

Ultrasound was associated with the highest postsurgical inflammatory peak. The later applications were administered according to a "modulation" scheme of inflammation for up to 3 months when healing and remodeling of collagen were already established.19-22

Generally, in the first session patients did not report any discomfort; however, in the second session (third postoperative day), some patients reported hypersensitivity, mainly in the submammary fold. In the following sessions, patients did not complain of discomfort.

Currently, I have modified the number of sessions and the schedule of application as follows: session 1, 7 days after surgery when removing the stitches; session 2, 15 days after surgery; session 3, 21 days after surgery.

This new protocol avoids the hypersensitivity that some patients had in early sessions by starting treatment when the capsule around the prostheses is already constituted.19-21

It has been almost a year and a half since I began using this prophylactic protocol, and the preliminary resuIts demonstrate faster reduction of edema and inflammation, faster absorption of small bruises and ecchymoses, and a decrease of postsurgical discomfort. Most important is that from the first patients receiving this treatment to the current patients, none has experienced the formation of capsular contracture thus far.

In view of these good results, I have followed this protocol and improved its design, and I look forward to statistically validating the different variables. At the moment, I am carrying out both protocols in parallel: therapeutic and prophylactic. Therapeutic results are quite encouraging and prophylactic results fulfill our expectations so faro

References

  1. Burkhardt BR. Capsular contracture: hard breasts, soft data. G/in P/ast Surg 1988;15:521-532.
  2. Georgiade NO. Aesthetic Surgery of the Breast. Philadelphia: WB Saunders Co; 1990.
  3. McCarthy JG. P/astic Surgery, Vol. VI. Philadelphia: WB Saunders Co; 1990.
  4. Burkhardt BR, Eades E. The effect of Biocell texturing and povidoneiodine irrigation on capsular contracture around saline-inflatable breast implants. P/ast Reconstr Surg 1995;96:1317-1325.
  5. Handel N, Jensen A, Black Q. The fate of breast implants: a critical analysis of complications and outcomes. Plast Reconstr Surg 1995;96:1521-1533.
  6. Lesesne CB. Textured-surface silicone breast implants: histology in the humano Aesth P/ast Surg 1997;21:93-96.
  7. Rioja Torrejón L, Redondo A, De No L, Benitez J. Estudio comparativo de las complicaciones de los implantes texturados rellenos de gel de silicona en oposición a los de relleno de suero. Gir P/ast Ibero-/ati noameric 1998;4:395-401.
  8. Berman B, Duncan MR. Pentoxifyline inhibits normal human dermal fibroblast in vitro proliferation, collagen, glycosaminglycans, and fibronectin production, and increases collagenase activity. J /nvest Dermato/1989;92:605-610.
  9. Berman B, Duncan MR. Pentoxifyline inhibits the proliferation of human fibroblasts derived from keloid, scleroderma, and morphea skin, and their production of collagen, glycosaminglycans and fibronectin. Brit J Dermato/1990;123:339.
  10. Caffee HH, Rotatori DS. Intracapsular injection of triamcinolone for prevention of the contracture. Plast Reconstr Surg 1994;94:824-828.
  11. Ellenberg AH. Marked thinning of breast skin flaps after the insertion of implants containing triamcinolone. Plast Reconstr Surg 1977;60:755-758.
  12. Marin Bertolin S. Profilaxis de la contractura capsular mediante pentoxifilina intraprotesica: estudio experimental en ratas. Gir P/ast /bero-/atinoamer 1997;4:373-381.
  13. Spear SL, Matsuba H, Romm S, LiUle JW. Methyl prednisolone in double-Iumen gel-saline submuscular mammary prostheses: a double blind prospective, controlled clinical trial. Plast Reconstr Surg 1991;87:483-487.
  14. Planas J, Migliano E, Wagenfuhr J Jr, Castillo S. External ultrasonic treatment of capsular contractures in breast implants. Aesth Plast Surg 1997;21:395-397.
  15. Planas J, Cervelli V, Planas G. Five years experience on ultrasonic treatment of breast contractures. Aesth Plast Surg 2001;25:89-93.
  16. Carpaneda CA. Infiammatory reaction and capsular contracture around smooth silicone implants. Aesth Plast Surg 1997;21:110-114.
  17. Lehmann JF, De Lauter BJ. Diatermia y Terapeutica superficial con calor, laser y frio. in Krusen J, 4th ed. Medicina fisica y rehabilitacion. Madrid: Editorial Medica Panamericana; 1994.
  18. Scott WW, Scardino PL. A new concept in the treatment of Peroynie's disease. South Med J 1984;41:173.
  19. Batra M, Bernard S, Picha G. Histologic comparison of breast implant shells with smooth, foam, and pillar microstructuring in a rat model from 1 day to 6 months. Piast Reconstr Surg 1995;95:354-363.
  20. Lilla JA, Vistnes LM. Long-term study of reactions to various silicone breast implants in rabbits. Piast Reconstr Surg 1976;57:637-649.
  21. Vistnes LM, Kasander GA, Kosek J. Study of encapsulation of silicone rubber implants in animals. Plast Reconstr Surg 1978;62:580-588.
  22. Wyatt LE, Sinow JD, Wollmann JS, Sami DA, Miller T. The influence of time on human breast capsule histology: smooth and textured silicone-surfaced Implants. Piast Reconstr Surg 1998;102:1922-1931.

2 Comentarios

  1. Rebeca López
    22 marzo, 2010 at 22:55
    Responder

    Buenas noches Dr. Planas, lo primero felicitarle por su blog que es muy interesante.
    Soy médico residente de Rehabilitación en el Complejo Hospitalario de Badajoz.
    En nuestro servicio no tenemos mucha experiencia con implantes mamarios pues los cirujanos de mama no suelen enviarnos a penas pacientes salvo las mujeres mastectomizadas por Ca de mama que presentan linfedema y es para tratamiento de éste último.
    Hace unos días nos enviaron dos casos de dos mujeres jóvenes con implantes mamarios, que habían hecho una contractura capsular, como no habíamos visto nada parecido, decidimos investigar y encontramos sus magníficos estudios sobre el uso de ultrasonido pulsátil, que nos han parecido muy interesantes, pero tenemos algunas dudas a la hora de aplicar el tratamiento, la primera duda es sobre el aparato de ultrasonido, nosotros no contamos con el “sujetador” sino que tenemos el aparato convencional para tratar partes blandas, nos gustaría saber si se puede usar con el cabezal grande o pequeño, sin necesidad de tener el sujetador, y sobre qué zona exacta de la mama hay que aplicarlo, la dosis (si es como en partes blandas de 1-1,5W/cm2) y duración aproximada del tratamiento (10 min por sesión todo los días, en días alternos, durante 15-20 días…)
    Otra duda que nos surje es sobre el material del implante, pues una de las pacientes lo tiene de gel de silicona pero la otra es de suero, y no estamos seguros si en suero es posible aplicarlo con seguridad.
    También hemos encontrado otro estudio sobre el uso de electroestimulación en ratas que parece que estaba dando buenos resultados, no sé si usted en su clínica aplica alguna corriente más a parte del ultrasonido y si es así si da buenos resultados.
    Agradeciendo su atención.
    Un saludo

    • 30 marzo, 2010 at 17:59
      Responder

      Hola Rebeca:
      Entiendo que ha sido el servicio de Cirugía Plástica quien le ha remitido a las pacientes, y que el cirujano plástico ha dado el consentimiento para el manejo del paciente por su servicio. En nuestra experiencia tanto los masajes como los ultrasonidos son de gran ayuda.
      El aparato convencional sirve igualmente. Sólo tiene el inconveniente que durante los 10 minutos que dura el tratamiento hay que estar moviendo el cabezal alrededor de toda la mama lentamente.
      No hay diferencia si la prótesis es de gel de silicona o de suero, se puede practicar el tratamiento igualmente.
      Se recomienda que las sesiones sean diarias pudiendo parar los fines de semana. Se recomienda dos o tres semanas de tratamiento.
      Una vez finalizado este periodo de tratamiento, el cirujano plástico debe volver a evaluar a la paciente para ver el grado de mejora de la contractura y decidir si realiza capsulotomía cerrada en ese momento.
      Espero haber resuelto sus dudas y estaré encantando en ayudarle en nuevas consultas.

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