Francesco Gargano, MD, Frank Ciminello, MD. Correspondence: Objective: Methods:

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1 eplasty: Vol. 9 a Francesco Gargano, MD,, PhD Frank Ciminello, MD a b Miami, FL, 33155; Miami Children's Hospital,, UMDNJ Plastic Surgery cdepartm Correspondence: francescogargano@hotmail.com Objective: Extrusion represents potential Methods: complications associated Capsularwith flaps have use been of Results breast perfoim Breast implant extrusion represents a challenging problem that concerns breast reconstructive surgeon. Implant exposure due to poor tissue coverage frequently obligates surgeon to remove breast implant and begin anew. In authors' review of literature, successful salvage of breast implants has been reported 1 3 and guidelines for treatment have 4 been recently proposed. Recommended treatment strategies include attempts to salvage implant by antibiotic rapy, pulse lavage, capsulectomy, device exchange, primary closure, and/or flap coverage. 1 3 Techniques of implant salvage have proven useful in cases with good tissues viability and in absence of radiorapy. However, in face of implant exposure and poor soft tissue coverage, outcome is often less optimal. 4 Breast surgery with implants requires good tissue coverage, especially in cases in which adjunctive radiation rapy has been used. Wound complication, such as dehiscence, infection, and fistulas, 5, 6 and clinically significant capsular contracture have been well reported 7 in irradiated breast tissue. The irregular surface of implant, location of pocket, and pressure exerted by implant against skin can also lead to implant extrusion. 8 1/9

2 Capsular flaps have been first described by Gargano et al 9, 10 and later by or authors, 11, 12 with original goal to correct postimplant breast wrinkling and contour deformities. To our knowledge, no previous reports have yet described use of capsular flaps to save extruded breast implants. We postulate that capsular flaps could be extremely useful to reinforce damaged breast envelope due to poor tissue coverage in patients who have undergone radiation rapy. The authors outline an innovative technique using capsular flaps to salvage exposed breast implants. METHODS Capsular flap procedures were performed on 6 patients with implant extrusion and 11 patients with breast contour deformities over last 6 years. In all cases, preoperative planning defined extent of fistula and deformity to be corrected. Parameters considered during preoperative planning were skin quality, presence of infection, previous radiorapy, and location of defect. Capsular flaps were n designed to cover areas of wound separation and implant exposure. We operated on 5 patients with extrusion of implant after breast reconstruction. In se cases, several attempts to save device by fistula excision or implant removal with direct soft tissue suture over a new prossis all resulted in reexposure. The use of capsular flaps resulted in successful healing and implant salvage in all se cases. The sixth patient, a transsexual who during sex reassignment surgery had liquid silicone injections and breast implantation, was operated on only for cosmetic purpose. He developed recurrent fistulas resistant to traditional treatment on 1 breast. Capsular flaps were used to reinforce breast envelope. A new implant was inserted and outcome was successful. CASE REPORTS Patient 1 A 45-year-old woman underwent a bilateral nipple-sparing mastectomy and breast reconstruction with expanders and implants. The breasts were not irradiated in this case. After 1 month, patient developed 2 fistulas located 3 cm below right nipple, exposing implant on skin surface. Four previous surgical procedures were attempted to save implant by direct excision, implant exchange, and direct wound closure. All attempts failed and implant extrusion recurred. The use of capsular flaps was proposed as an alternative treatment modality to breast implant removal (Fig 1 ). 2/9

3 AtFigure on time skin 1. of surface surgery, (Fig 2 ). Preoperative 2 fistulas wereview outlined of and right breast planned withcapsular 2 fistulasflaps at were inferior drawn border of The excised Figure previous with 2. surgical surrounding scar Intraoperative was scar chosen tissues asview (Fig skinof3access ). location to of implant 2 fistulas pocket. and The planning fistulas were of 2 capsu Two was evidence ). 5Figure n inferiorly 3. closed of reexposure, based primarily capsular with (Fig Thereasonable flaps fistulas 4 ). Postoperative were areelevated aestic excisedfollow-up and and result n sutured (Fig within folded inside 18 over months out. Skin defect. showed incision The nodefect is performed alon Figure 4. The capsular flaps are harvested from viable and thick tissues and n hinged Figure 5. Eighteen months postoperative results showing good cosmetic appearance an Patient 2 A 54-year-old woman underwent right lumpectomy and radiorapy. After local recurrence, bilateral nipple-sparing mastectomy and breast reconstruction with expanders and implants were performed. The right breast developed postradiation injury with subsequent exposure of implant. Five attempts to save right breast implant were unsuccessful and implant exposure recurred. Surgical options were explained to patient and use of capsular flaps was proposed as an implant salvage technique. Three inferiorly based capsular flaps were designed on skin surface in areas with evidence of less radiation damage (Fig 6 ). Figure 6. Preoperative view of a 57-year-old woman with soft tissue radiation injuries an The fistula track and all surrounding irradiated scar were excised. The capsular flaps were based inferiorly and included tissue outside zone of irradiation (Fig 7 ). 3/9

4 The postoperative appearance Figure 3 flaps 7. were offollow-up layered soft tissues showed over Intraoperative overlying nodefect recurrence view andimplant skin ofof implant was (Fig same closed 8 exposure patient ). primarily. showing and A improved 12-month skinaestic access located on un Figure 8. Patient 3 Twelve months postoperative follow-up showing complete healing and no recu A 57-year-old woman underwent right mastectomy, followed by radiorapy and breast reconstruction with expander. Extensive right breast radiation injuries occurred and a fistula tract developed over infusion port of tissue expander. Preoperative evaluation revealed thin and damaged skin coverage over majority of breast surface. Therefore, a submammary incision was planned to access expander pocket in order to avoid this irradiated tissue. A single superiorly based capsular flap was harvested from posterior capsule (Fig 9 ). Figure 9. Preoperative view of fistula tract formation on extremely damaged soft tissues The expander was n removed and fistula was excised. The capsular flap was inset in a single layer over implant with pullout sutures to avoid traction on irradiated skin. A vertical scar-reduction mammoplasty was performed on left breast to achieve symmetry. Postoperative results revealed complete healing of irradiated soft tissues and salvage of definitive implant (Fig 10 ). 4/9

5 Figure 10. Patient 4 Postoperative results showing improved skin quality and salvage of implan A 64-year-old woman underwent right mastectomy, followed by breast reconstruction with expander and permanent implant. Postoperatively, patient developed a draining fistula over implant (Fig 11 ). Figure 11. Preoperative view of a 64-year-old woman with breast implant exposure after a A 5 15-cm area of thin damaged skin was excised and reconstructed with an abdominal advancement flap (Fig 12 ). Figure 12. A wide skin excision and reconstruction with abdominal advancement flap. After recreating inframammary fold, soft tissues were reinforced with a superiorly based capsular flap harvested from chest wall (Fig 13 ). Figure 13. The abdominal flap is advanced, inframammary fold is reinstated, and 5/9

6 The final result shows abdominal advancement flap, recreation of inframammary fold, and prevention of implant exposure utilizing capsular flap (Fig 14 ). Figure 14. RESULTS Postoperative result showing success of procedure and prevention of b Complete correction of extruded implants was achieved with use of capsular flaps in all patients treated. Temporary skin depressions were seen in acute phase of healing due, in part, to wound contracture and negative pressure of suction drains (Fig 15 ). Figure 15. Skin irregularities are present 8. for few weeks after procedure and will disap Both skin retractions and irregularities disappeared completely at 6 months (Fig 8 ). No complications, such as implant extrusion, hematoma, seroma, or infection, occurred. DISCUSSION The senior author's interest in this subject started with his 2002 publication 9, 10 describing for first time innovative use of capsular flaps to prevent palpable wrinkling of implants. Since n, or authors have successfully used this technique to correct implant rippling 11 or or breast deformities. 12 6/9

7 Surgical strategies of implant salvage have been described with successful results by renowned surgeons in cases of breast implant extrusion and infection. 1 4 Neverless, Spear et al 4 recognized that poor results can be obtained with conventional methods when deficient soft tissue coverage or overwhelming infection is present. In se challenging cases, implant removal and delayed reconstruction with implants or autologous flaps seem to be only available option. Capsular formation around a breast implant is a physiological response to a foreign body, 13 and it increases when radiation rapy is administered. 7 The viability of capsular flaps has been demonstrated to be adequate in experimental animal models, in which flaps have been used as a recipient area for skin grafts, 14 random flaps, 15 or axial flaps. 16, 17 In this study, vascularized capsular flaps were harvested in unirradiated areas and inset when possible in multiple layers. This allows for reinforcement of breast envelopes and prevents recurrence of implant extrusion. The capsular flaps can be harvested eir from anterior breast envelope (cases 1 3) or from chest wall (case 4). The flap can be superiorly, inferiorly, medially, or laterally based, depending on tissue viability and defect location. The authors advocate use of this innovative technique as an alternative tool when or conventional methods have failed to avoid implant removal and need for delayed reconstruction. REFERENCES 1. Weber J Jr, Hentz RV. Salvage Ann Plast of exposed breast 1986;16(2): implant. 2. Planas J, Carbonell A, Planas Aestic J. Salvaging Plast exposed 1995;19(16): mammary prossis. 3. Yii NW, Khoo CT. Salvage Plast ofreconstr infected expander 2003;111(3): prosses in breast recons 7/9

8 4. Spear SL, Howard MA, Plast Boehmler Reconstr JH, Ducic I, Low 2004;113(6): M, Abbruzzese MR. The infe 5. Ariyan S. Radiation injury. Plastic In: Mas Surgery. SJ, ed. 6. Forman DL, Chiu J, Restifo Ann RJ, Plast Ward BA, Haffty1998;40(4): B, Ariyan S. Breast reconstruc 7. Behranwala KA, Dua RS, J Plast RossReconstr GM, Ward Aestic A, A'hern 2006;59(10): R, Gui GP. The influence o 8. Abramo AC, Casas SG,Aestic Dorta AA,Plast Mateus S, Trujillo 1999;23(6): R. Late spontaneous extru 9. Gargano F, Moloney DM, Br Arnstein J Plast PM. Use of a 2002;55(3):269. capsular flap to prevent palpab 10. Hobman J, Sharpe DT. The Strategies Evidence for minimising for Plastic Harley, Surgery. palpable Shrewsbury, implant rippling England: in T 11. Massiha H. Scar tissue Ann flapsplast for correction of postimplant 2002;48(5): breast rippling. 12. Imran D, Javaid M, Lewis Ann D,Plast Attar KH. Capsular 2005;54(6): flaps for correction of contour d Philadelphia, Pa: Saunders Els 8/9

9 13. Rubino C, Mazzarello V,Ann Farace PlastF, et al. Ultra structural 2005;46: anatomy of contracted 14. Heymans M, Lengele B,BrLahlali J Plast N, Vanwijck R. A1993;46(6): peri-implant capsule flap. 15. Bergtson BP, Ringler SL, Plast George Reconstr ER, DeHaan MR, 1993;91(6): Mills KA. Capsular tissue: a 16. Cariou JL, Hilligot P, Arrouvel Ann Chir C, Plast Banzet Est. P. Experimental 1991;36(6): concept of peripros 17. Schuringa MC, HartmanJ EH, PlastRuhe' Reconstr PQ, Jansen Aestic 2007;60: JA, Spauwen PH. Pedicled pre JOURNAL INFORMATION ARTICLE INFORMATION Journal ID: eplasty Volume: 9 ISSN: e41 Publisher: Open Science Company, LLC E-location ID: 9/9