Secondary Breast Reconstruction with Deepithelialized Free Flaps from the Lower Abdomen for Intractable Capsular Contracture and Maintenance of Breast Volume

ABSTRACT

Although surgical techniques and the quality of mammary prostheses have been improved significantly in recent years, capsular contracture attendant on prosthetic mammary reconstruction remains a major flaw. Although rarely, some patients are confronted with recurrent and intractable capsular contractures with resultant breast deformity, even after multiple attempts at capsulectomies and implant exchange. Patients with recurrent capsular contracture often do not want replacement with a new prosthesis, but desire the maintenance of their breast volume with a safe alternative. In an attempt to maintain breast volume and to improve the aesthetic appearance, secondary breast reconstruction using bilateral deepithelialized free flaps from the lower abdomen was performed in a series of seven patients. Three bilateral muscle-sparing TRAM flaps, two bilateral DIEP flaps, one bilateral SIEA flap, one unilateral SIEA flap, and one unilateral DIEP flap (a total number of 14 flaps) were used following implant removal, total capsulectomy, and prophylactic subcutaneous mastectomy. The early postoperative course was uneventful, and all flaps survived completely with no complications. There were no donor-site problems, except in one patient (case 5), who had partial skin necrosis of the abdominal flap. The long-term results (mean follow-up: 4.8 years) demonstrated an aesthetically satisfactory appearance of the breasts, with no major donor-site problems. Several advantages, as well as drawbacks, are highlighted with this technique.

KEYWORDS

Capsule contracture - breast implant - silicone - breast reconstruction

REFERENCES

• 1 Burkhardt B R. Capsular contracture: hard breasts, soft data.  Clin Plast Surg. 1988;  15 521-532
• 2 Baker Jr. J L. Augmentation mammoplasty. In: Owsley JQ, Petterson RA Symposium of Aesthetic Surgery of the Breast St. Louis; Mosby 1978: 256-263
• 3 Baker J L. Augmentation mammoplasty. In: Grabb WC, Smith JW Plastic Surgery Boston: Little, Brown; 1979: 719
• 4 Shah Z, Lehman Jr. J A, Tan J. Does infection play a role in breast capsular contracture?.  Plast Reconstr Surg. 1981;  68 34-42
• 5 Burkhardt B. Fibrous capsular contracture around breast implants. The role of subclinical infection.  Infect Surg. 1985;  4 469
• 6 Burkhardt B, Dempsey P D, Schnur P L, Tofield J J. Capsule contracture: a prospective study of the effect of local antibacterial agents.  Plast Reconstr Surg. 1986;  77 919-932
• 7 Virden C P, Dobke M K, Stein P, Parsons C L, Frank D H. Subclinical infection of the silicone breast implant surface as a possible cause of capsular contracture.  Aesthet Plast Surg. 1992;  16 173-179
• 8 Netscher D T, Weizer G, Wigoda P, Walker L E, Thornby J, Bowen D. Clinical relevance of positive breast periprosthetic cultures without overt infection.  Plast Reconstr Surg. 1995;  96 1125-1129
• 9 Caffee H H. Textured silicone and capsule contracture.  Ann Plast Surg. 1990;  24 197-199
• 10 Hakelius L, Ohlsen L. A clinical comparison of the tendency to capsular contracture between smooth and textured gel-filled silicone mammary implants.  Plast Reconstr Surg. 1992;  90 247-254
• 11 Burkhardt B R, Demas C P. The effect of Siltex texturing and povidone-iodine irrigation on capsular contracture around saline inflatable breast implants.  Plast Reconstr Surg. 1994;  93 123-128
• 12 Burkhardt B R, Eades E. The effect of Biocell texturing and povidone-iodine irrigation on capsular contraction around saline-inflatable breast implants.  Plast Reconstr Surg. 1995;  96 1317-1325
• 13 Tarpila E, Ghassemifar R, Fagrell D, Berggren A. Capsular contracture with textured versus smooth saline-filled implants for breast augmentation: a prospective clinical study.  Plast Reconstr Surg. 1997;  99 1934-1939
• 14 Fagrell D, Berggren A, Tarpila E. Capsular contracture around saline-filled fine textured and smooth mammary implants: a prospective 7.5-year follow-up.  Plast Reconstr Surg. 2001;  108 2108-2112
• 15 Puckett C L, Croll G H, Reichel C A, Concannon M J. A critical look at capsule contracture in subglandular versus subpectoral mammary augmentation.  Aesthet Plast Surg. 1987;  11 23-28
• 16 Vazquez B, Given K S, Houston G C. Breast augmentation: a review of subglandular and submuscular implantation.  Aesthet Plast Surg. 1987;  11 101-105
• 17 Caffee H H. Intracapsular injection of triamcinolone for intractable capsule contracture.  Plast Reconstr Surg. 1994;  94 824-828
• 18 Ninkovic M, Anderl H, Hefel L, Schwabegger A, Wechselberger G. Internal mammary vessels: a reliable recipient system for free flaps in breast reconstruction.  Br J Plast Surg. 1995;  48 533-539
• 19 Young V L. Guidelines and indications for breast implant capsulectomy.  Plast Reconstr Surg. 1998;  102 884-891
• 20 Rohrich R J, Beran S J, Restifo R J, Copit S E. Aesthetic management of the breast following explantation: evaluation and mastopexy options.  Plast Reconstr Surg. 1998;  101 827-837
• 21 Hollos P. Breast augmentation with autologous tissue: an alternative to implants.  Plast Reconstr Surg. 1995;  96 381-384
• 22 Beraka G J. Autologous secondary breast augmentation with pedicled transverse rectus abdominis musculocutaneous flaps.  Ann Plast Surg. 1995;  34 242-247
• 23 Spiro S A, Marshall D. Bilateral TRAM. flaps for the reconstruction of the post implantectomy/capsulectomy breast deformity.  Aesthet Plast Surg. 1996;  20 315-318
• 24 Feller A M. Free TRAM. Results and abdominal wall function.  Clin Plast Surg. 1994;  21 223-232
• 25 Allen R J, Treece P. Deep inferior epigastric perforator flap for breast reconstruction.  Ann Plast Surg. 1994;  32 32-38
• 26 Blondeel P N, Boeckx W D. Refinements in free flap breast reconstruction: the free bilateral deep inferior epigastric perforator flap anastomosed to the internal mammary artery.  Br J Plast Surg. 1994;  47 495-501
• 27 Blondeel N, Vanderstraeten G G, Monstrey S J et al.. The donor site morbidity of free DIEP flaps and free TRAM flaps for breast reconstruction.  Br J Plast Surg. 1997;  50 322-330
• 28 Arnez Z M, Khan U, Pogorelec D, Planinsek F. Breast reconstruction using the free superficial inferior epigastric artery (SIEA) flap.  Br J Plast Surg. 1999;  52 276-279
• 29 Kroll S S, Gherardini G, Martin J E et al.. Fat necrosis in free and pedicled TRAM flaps.  Plast Reconstr Surg. 1998;  102 1502-1507
• 30 Kroll S S. Fat necrosis in free transverse rectus abdominis myocutaneous and deep inferior epigastric perforator flaps.  Plast Reconstr Surg. 2000;  106 576-583
• 31 Stewart N R, Monsees B S, Destouet J M, Rudloff M A. Mammographic appearance following implant removal.  Radiology. 1992;  185 83-85
• 32 Hayes M K, Gold R H, Bassett L W. Mammographic findings after the removal of breast implants.  AJR Am J Roentgenol. 1993;  160 487-490
• 33 Hardt N S, Yu L, LaTorre G, Steinbach B. Complications related to retained breast implant capsules.  Plast Reconstr Surg. 1995;  95 364-371