Total Capsulectomy Without Drains is a Safe Technique Facilitated by Pectoralis Major Muscle Repair.

BACKGROUND: The number of breast implant removal and capsulectomy procedures continues to increase rapidly. The aim of explant surgery should be to optimise patient outcomes from both an aesthetic and functional perspective. OBJECTIVES: To confirm the safety of drainless total capsulectomy and to determine the role of muscle repair in explant outcomes following the removal of sub-pectoral or dual-plane cosmetic breast implants. METHODS: We conducted a retrospective evaluation of our technique between January 2021 and November 2023. We report a single surgeon series of 140 consecutive cases of cosmetic breast implant removal from dual-plane or sub-pectoral pockets, all performed with total capsulectomy. In each case, meticulous repair of the Pectoralis major muscle was performed following capsulectomy. Drains were not used in any case. All patients were followed up for a minimum of 3 months. Patient satisfaction was assessed a minimum of 6 months post-operatively. RESULTS: By performing the described drainless technique, there were no cases of seroma, haematoma, pneumothorax or cosmetic breast distortion in this series. 83% of patients were treated as day cases and patient satisfaction with outcomes was high. CONCLUSIONS: Total capsulectomy without the use of drains is a novel and safe approach, aided by careful repair of the Pectoralis major muscle. There is no increased risk of seroma. The muscle repair may help to prevent post-explant cosmetic deformity of the breast. LEVEL OF EVIDENCE IV: This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Oncological Outcomes After Multidisciplinary Management of Breast Implant-Associated Anaplastic Large Cell Lymphoma (BIA-ALCL).

INTRODUCTION: Breast implant-associated anaplastic large cell lymphoma (BIA-ALCL) is an uncommon type of non-Hodgkin lymphoma, associated with breast implant capsules. Despite improvements in our understanding of BIA-ALCL, communicating the prognosis to patients remains challenging due to limited long-term follow-up data. This has important implications for decision-making, including recommendations for subsequent reconstructive procedures. The aim of this study was to assess the longer-term oncological outcomes of patients receiving multidisciplinary treatment for BIA-ALCL. METHODS: This was a retrospective cohort study of BIA-ALCL patients treated at a tertiary referral unit. The data are presented using simple descriptive statistics. RESULTS: Between 2015 and 2022, 18 BIA-ALCL patients were treated at our institution. The median age at diagnosis was 48.5 (IQR 41-55) years. Ten patients developed BIA-ALCL after cosmetic breast augmentation, and 8 after breast reconstruction following mastectomy for cancer. All patients had a history of textured implant insertion. The median time from first implant surgery to diagnosis was 8.5 (IQR 7-12) years. All patients underwent en-bloc total capsulectomy with implant removal, and 2 received systemic therapy. Fifteen patients had Stage I (IA-IC) disease, 2 had Stage IIA and 1 Stage III BIA-ALCL, based on the TNM classification system. At a median follow-up of 45 (IQR 15-71) months, there were no episodes of local or systemic relapse or death. CONCLUSIONS: Surgical management for BIA-ALCL is sufficient in early-stage disease, and associated with excellent oncological outcomes. This information is reassuring for patients when discussing recurrence risk.

Outcomes of chlorhexidine lavage without capsulectomy versus complete capsulectomy after lead extraction for the treatment of cardiac implantable electronic device infection.

INTRODUCTION: Capsulectomy is recommended in patients with cardiac implantable electronic device (CIED) infection after transvenous lead extraction (TLE) but is time-consuming and requires extensive tissue debridement. In this study, we describe the outcomes of chlorhexidine gluconate (CHG) lavage in lieu of capsulectomy for the treatment of CIED infections. METHODS: This retrospective study included patients who underwent TLE for CIED-related infections in two institutions in Colombia. In the capsulectomy group, complete capsulectomy was performed after hardware removal. In the CHG group, exhaustive lavage of the generator pocket with 20 cc of CHG at 2% followed by irrigation with approximately 500 cc of normal saline (0.9% sodium chloride) was performed. The primary outcomes included reinfection and hematoma formation in the generator pocket. Secondary outcomes included the occurrence of any adverse reaction to chlorhexidine, the need for reintervention, infection-related mortality, and total procedural time. RESULTS: A total of 102 patients (mean age 67.2 ± 13 years, 32.4% female) underwent CIED extraction with either total capsulectomy (n = 54) or CHG (n = 48) lavage. Hematoma formation was significantly higher in the capsulectomy group versus the CHG group (13% vs. 0%, p = .014), with no significant differences in the reinfection rate. Capsulectomy was associated with longer procedural time (133.7 ± 78.5 vs. 89.9 ± 51.8 min, p = .002). No adverse reactions to CHG were found. Four patients (4.3%) died from worsening sepsis: three in the capsulectomy group and one in the CHG group (p = .346). CONCLUSIONS: In patients with CIED infections, the use of CHG without capsulectomy resulted in a lower risk of hematoma formation and shorter procedural times without an increased risk of reinfection or adverse events associated with CHG use.

Anterior capsulectomy versus repair in direct anterior total hip arthroplasty.

BACKGROUND: Utilization of the direct anterior approach for total hip arthroplasty (DAA THA) has increased over the last ten years. The preservation and repair of the anterior hip capsule has been recommended, while anterior capsulectomy has been described by others. In contrast, the higher risk of posterior dislocation using the posterior approach improved significantly after capsular repair. No studies to date have investigated outcome scores based on capsular repair versus capsulectomy for the DAA. METHODS: Patients randomized to anterior capsulectomy or anterior capsule repair. Patients were blinded to their randomization. Maximum hip flexion was measured both radiographically and clinically with a goniometer. Using a one-sided t test assuming equal variance with an effect size, Cohen's d, of 0.6 and an alpha of 0.05, 36 patients in each group (total 72 patients) needed for a minimum 80% power. RESULTS: Median goniometer measurements preoperatively were 95° for repair (IQR 85-100) and 91° for capsulectomy (IQR 82-97.5) (p = 0.52). Four-month and one-year goniometer measurements also had no significant difference, 110° (IQR 105-120) and 110° (IQR 105-120) for repair and 105° (IQR 96-116) and 109° (IQR 102-120) for capsulectomy (p = 0.38 and p = 0.26). Median change in flexion as measured by goniometer at 4 months and one year was 12 and 9 degrees for repair and 9.5 and 3 degrees for capsulectomy (p = 0.53 and p = 0.46). X-ray analysis showed no differences in pre-op, 4-month, and one-year flexion with median one-year flexion of 105.5° (IQR 96-109.5) for repair and 100° (IQR 93.5-112) for capsulectomy (p = 0.35). VAS scores were the same for both groups at all three time points. HOOS scores improved equally for both groups. There are no differences in surgeon randomization, age, or gender. CONCLUSIONS: Both capsular repair and capsulectomy used in direct anterior approach THA result in equal maximum clinical as well as radiographic hip flexion with no change in postoperative pain or HOOS scores.

Capsular repair vs capsulectomy in total hip arthroplasty.

BACKGROUND: A major complication of total hip arthroplasty is dislocation. The hip joint capsule can be incised and repaired, or can be excised. SOURCES OF DATA: We performed a systematic review of the literature following the Preferred Reporting Items for Systematic Reviews and Meta-Analysis guidelines focusing on capsular repair and capsulectomy. AREAS OF AGREEMENT: We identified 31 articles (17 272 patients). Capsular repair produced a lower blood loss (465.2 vs 709.2 ml), and the procedure lasted 102.5 vs 96.08 min in patients who underwent capsulectomy. The patients undergoing capsulectomy experienced a dislocation rate of 3.06%, whereas in the patients undergoing capsular repair, the dislocation rate was 0.65%. AREAS OF CONTROVERSY: Most studies are retrospective observational studies, with no prospective randomized trials. GROWING POINTS: Capsular preservation is association with a lower dislocation rate and a lower blood loss. Capsular excision does take statistically less time, but it is uncertain how a 6 min difference is clinically relevant. AREAS TIMELY FOR DEVELOPING RESEARCH: Appropriately powered randomized clinical trials should be conducted to better define the association between the chosen implants, approach and outcome.

Capsular Management in Direct Anterior Total Hip Arthroplasty: A Randomized, Single-Blind, Controlled Trial.

BACKGROUND: The direct anterior approach (DAA) is a popular approach to total hip arthroplasty (THA). Unlike the posterior approach, the importance of anterior capsular management is unknown. This randomized controlled trial compares capsular repair versus capsulectomy. METHODS: This single-surgeon, single-blinded, parallel-group randomized controlled trial occurred between 2013 and 2016. Patients undergoing unilateral, primary THA for osteoarthritis consented to undergo blinded, simple randomization to anterior capsulotomy with repair or anterior capsulectomy. Primary outcome measures included hip range of motion, hip flexion strength, and pain with seated hip flexion. Secondary outcome measures included surgical time, estimated blood loss, postoperative complications, and hip disability and osteoarthritis outcome score. Data were prospectively collected intraoperatively, six weeks, six months, an average of over 5 years postoperatively. RESULTS: Ninety-eight patients were ultimately enrolled in the trial; 50 received capsulectomy and 48 received capsulotomy. No significant differences were seen in preoperative demographics or in primary or secondary outcomes during this study. No difference was seen in pain at final follow-up at average > 5 years postoperatively. CONCLUSION: This study demonstrates that capsular management in DAA THA does not affect postoperative pain or range of motion. The anterior capsule's role in prosthetic stability after DAA THA remains uncertain, but it does not currently appear that repair provides benefit and may lead to increased surgical time and blood loss. As such, capsular management in DAA THA is at surgeon discretion.

Correcting severe flexion contracture with fusiform capsulectomy of posterior capsule during total knee arthroplasty.

PURPOSE: This study aimed to evaluate the safety and efficacy of fusiform capsulectomy of posterior capsule in correcting severe flexion contracture during total knee arthroplasty (TKA). METHODS: A retrospective analysis was performed in the patients who had preoperative severe flexion contracture (> 30 degrees) prior to TKA and received fusiform capsulectomy of posterior capsule during TKA between December 2013 and November 2018. Range of motion (ROM), knee functional score, forgotten joint score (FJS), post-operative complications, and radiographic results were collected and evaluated. RESULT: Twenty patients (32 knees) were enrolled in this study. The mean duration of follow-up was 27.19 ± 15.92 months. The flexion contracture improved from pre-operative 37.69 ± 11.79° to post-operative 5.78 ± 4.44° (p < 0.001), and ROM increased from pre-operative 63.50 ± 21.74° to post-operative 97.88 ± 13.20° (p < 0.001). KSS clinical score increased from pre-operative 32.94 ± 11.03 to post-operative 82.34 ± 10.73 (p < 0.001), and KSS function score increased from pre-operative 28.97 ± 18.43 to post-operative 68.75 ± 15.96 (p < 0.001). The post-operative FJS was 76.08 ± 2.14. There was no implant loosening, infection, obvious haematoma formation, resultant instability, neurovascular complications, or revision for any reasons in the cohort until the last follow-up. CONCLUSIONS: The technique of fusiform capsulectomy of posterior capsule to correct the severe flexion contracture during primary TKA is safe and effective and could provide good short-term results.

Chronic Persisting Hematoma: Report of a Case and Literature Review.

The authors present a unique case of chronic persisting hematoma formation at the site of a remote congenital melanocytic nevus excision with tissue expander reconstruction. Similarities between chronic persisting hematoma and chronic encapsulated seroma are addressed to provide guidance on the appropriate workup and management for the plastic surgeon. LEVEL OF EVIDENCE V: This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Prospective Evaluation of the Posterior Tissue Envelope and Anterior Capsule After Anterior Total Hip Arthroplasty.

BACKGROUND: Femoral exposure for direct anterior approach (DAA) total hip arthroplasty (THA) invariably requires posterior soft tissue releases. Released posterior structures cannot be repaired. The purpose of this study is to describe the frequency and anatomic consequences of DAA THA posterior soft tissue releases and to compare the appearance of the anterior capsule between a group of patients who had capsulotomy and repair versus capsulectomy. METHODS: Thirty-two DAA THA patients underwent metal artifact reduction sequence magnetic resonance imaging at discharge and 1-year follow-up. Seventeen had underwent capsulotomy and repair and 15 capsulectomy. A radiologist blinded to intraoperative data scored each metal artifact reduction sequence magnetic resonance imaging. Anterior capsular integrity, status of the piriformis and conjoint tendons, and muscle atrophy were graded. Descriptive statistics were performed to analyze results. RESULTS: Immediately postoperatively, 75% of piriformis tendons were intact and 38% of conjoined tendons were intact. At 1 year, 97% had an intact piriformis and conjoined tendon, although many were in continuity through scar with the capsule. The posterior capsule directly contacted bone in all patients. At 1 year, none of the patients who underwent capsulotomy with repair had persistent anterior capsule defects, while 27% in the capsulectomy group had persistent defects. CONCLUSION: Posterior capsule and conjoined tendon releases were commonly performed during DAA THA, yet continuity with bone was frequently achieved at 1 year. In this study, capsulotomy with repair resulted in no anterior capsular defects when compared with capsulectomy. These results may support improved THA stability observed after DAA with capsular repair despite posterior soft tissue releases. LEVEL OF EVIDENCE: Level III, prospective cohort study.

Management of chronic seromas: A novel surgical approach with the use of vacuum assisted closure therapy.

Postoperative seroma is a common complication of many surgical procedures in which anatomical dead space has been created. A particular case of lesion in which seroma occurs is the Morel-Lavallée lesion (MLL), which is an uncommon closed soft-tissue degloving injury that develops after high-energy trauma or crush injury where shearing forces separate the subcutaneous tissue from the underlying fascia. The diagnostic evaluation begins with an adequate history and physical examination, followed by instrumental research with ultrasonography, computed tomography, and magnetic resonance imaging. Postoperative seromas and MLLs share a similar pathology and natural evolution as both injuries, once chronic, develop a pseudobursa; thus, the authors think that the same treatment algorithm may be suitable for both the lesions. Several strategies for the treatment of post-surgical and post-traumatic seromas have been described in the literature, ranging from conservative measures for acute and small injuries to surgical management and sclerotherapy for chronic and large ones. Despite some seromas resolving with conventional management, lesion recurrence is a matter of concern. The authors present their experience in the treatment of both post-surgical and post-traumatic chronic seromas not responsive to conservative treatments by surgical drainage of the seroma, capsulectomy, and application of vacuum-assisted closure therapy to allow granulation tissue formation, dead spaces obliteration, and wound healing. Primary wound closure with closed suction drain placement and an elastic compression bandaging are finally performed. From 2014 to 2019, a total of 15 patients (9 females and 6 males) were treated for recurrent chronic seromas with the proposed surgical approach. Five cases were MLLs, while 10 cases were postoperative seromas. The patients were between 33 and 79 years old, and they were followed up at 4 weeks and 3 and 6 months after surgery. All 15 patients with chronic seromas not responsive to conservative treatment showed a complete resolution of the lesions with the proposed treatment approach with no evidence of lesion recurrence, proving its effectiveness.

Removal of Polyurethane Implants.

Polyurethane (PU) implants are associated with great difficulties in extraction if secondary surgery is needed. The published data are contradictory, often misleading, making the decision for the secondary surgery complicated, the time period and the procedure itself not optimal, thus negatively influencing the final result. MATERIALS AND METHODS: Typical videos of PU implant removal in different periods after primary surgeries with polyurethane implants were selected for the study. The videos show the strength and extent of the tissue ingrowth and the manipulations needed for implant extraction in different periods from the initial procedure. Classifications of the types of adhesion and adhesion patterns are introduced. CONCLUSIONS: The data provided in this article facilitate the decision-making process if secondary surgery is indicated. Secondary surgery should be performed in the first 30 days after the initial surgery or in the period after 6 months. The optimal layer for removal of the PU implant depends on the time after the primary surgery. The polyurethane implant should be exchanged after 1 month if the properties of the polyurethane foam are expected to be used. LEVEL OF EVIDENCE IV: This journal requires that authors assign a level of evidence to each article. For a full description of these evidence-based medicine ratings, refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

[Performance control after arthroscopic arthrolysis with capsulectomy in fresh-frozen elbow joints]. / Erfolgskontrolle nach arthroskopischer Arthrolyse mit Kapsulektomie am Ellenbogengelenk im Fresh-frozen-Präparat.

BACKGROUND AND OBJECTIVE: Posttraumatic or postoperative movement restrictions in elbow joints can often occur (including capsular contracture) and can generate everyday limitations. In persistent elbow stiffness, arthroscopic arthrolysis with removal of the dorsal and ventral capsule portions can be carried out. The purpose of this study was to assess the efficacy of arthroscopic capsulectomy by means of an in vitro anatomical study. METHODS: A standardized elbow arthroscopy with ventral and dorsal capsulectomy was performed and image-documented in five fresh-frozen elbow specimens. Subsequently, open dissection of the elbow joint was performed to analyze the amount of residual capsule by means of photodocumentation of the specimens. RESULTS: Regardless of the surgeon and surgical experience, anterior and posterior remnants of the capsule remained in all specimens. Dorsal capsule strands around the standard arthroscopy portals were noticed particularly more often in the area of the high dorsolateral camera portal. An incomplete capsulectomy was seen on the ulnar side at the level of the posterior medial ligament (PML) in the immediate vicinity of the ulnar nerve. Ventrally, a capsulectomy was performed from the radial side and also the ulnar side until the brachialis muscle and additionally a complete capsulectomy as far as the anterior medial ligament (AML) and radial collateral ligament (RCL) was achieved. The capsule was completely resected in a proximal direction. Distally, irrelevant capsular remnants were found in the region of the annular ligament and distal of the tip of the coronoid process. CONCLUSION: Arthroscopic arthrolysis can be performed with a high degree of radicality. The radicality must be self-critically taken into account in one's own action. The radicality of the portal change may even be higher ventrally than with an isolated column procedure. On the other hand, it must be critically considered that posteriorly, the PML cannot be adequately addressed by means of arthroscopy due to the risk of ulnar nerve injury. Portal changes might help to enable a more complete visualization of the joint capsule and may avoid leaving possibly relevant remnants of the capsule. If a release of the PML is required, this may have to be carried out in combination with an ulnar nerve release in a mini-open technique.

Breast Implant-Associated Anaplastic Large Cell Lymphoma: Immediate or Delayed Implant Replacement?

INTRODUCTION: Breast implant-associated anaplastic large cell lymphoma (BIA-ALCL) is a rare and recently described type of peripheral T-cell lymphoma. Fewer than 550 cases have been reported worldwide. Although BIA-ALCL is usually indolent, early diagnosis and treatment have been shown to improve outcome. CASE DESCRIPTION: This case report describes the management of a 50-year-old healthy Caucasian woman presenting with rapid painful enlargement of the left breast. Imaging revealed findings consistent with BIA-ALCL. This diagnosis was confirmed by fine needle aspiration cytology and subsequent pathological analysis. Bilateral removal of implants, complete left capsulectomy and immediate bilateral implant exchange were performed. CONCLUSION: No consensus currently exists regarding optimal time of implant exchange and management of the contralateral capsule. The immediate replacement with smooth implants was thoroughly discussed with the patient and endorsed by expert opinion, given complete removal of the disease. There was no sign of recurrence at 6 months. Close clinical and radiological visits are planned for the next years. LEVEL OF EVIDENCE V: This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Total dorsal capsulectomy for the treatment of mucous cysts.

PURPOSE: To describe the technique of total dorsal capsulectomy alone for mucous cysts of the distal interphalangeal (DIP) joint and evaluate its outcomes and complications. METHODS: Nineteen patients (18 women and 1 man) with 19 mucous cysts were treated by a total dorsal capsulectomy without cyst excision or osteophyte removal. The average age at surgery was 63 years. The thumb was involved in 4 patients, index finger in 1, middle finger in 7, ring finger in 4, and little finger in 3. Twelve patients had nail deformities associated with the mucous cyst. The average period of postoperative follow-up was 26 months. The dorsal half of the DIP joint capsule was resected with a punch and curette. The cyst and osteophytes were left intact. RESULTS: The average preoperative range of motion for the DIP joint was from 10° of extension to 45° of flexion. Radiographs showed osteophytes at the DIP joint in all affected digits. After surgery, all cysts disappeared at an average of 3 weeks. There was no recurrence at the time of final follow-up. All nail deformities had resolved at an average of 5 months after surgery. The average motion for the DIP joint at the time of final follow-up was from 8° of extension to 56° of flexion. There were no acquired nail deformities or other complications. CONCLUSIONS: A total dorsal capsulectomy alone was a simple treatment for mucous cysts and did not lead to any recurrence. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic IV.

Pathologic Findings in Primary Capsulectomy Specimens: Analysis of 2531 Patients.

BACKGROUND: After breast augmentation, additional operations are often needed for revision or explantation. Although the surgeon may elect to leave the capsule in situ during these procedures, excised capsule tissue may be examined histopathologically for cancer cells. OBJECTIVES: The authors assessed pathologic findings from breast implant capsules submitted for histopathologic examination and evaluated whether it is oncologically safe to leave capsule tissue in situ. METHODS: The authors searched PALGA, the nationwide histopathology and cytopathology data network and registry in the Netherlands, for primary capsulectomy specimens excised between 2003 and 2012. The authors applied a sensitive search strategy with low specificity that included female and breast as the sex and anatomic location keywords, and wildcards were used to detect different spellings. Cases were excluded if previous examinations showed compatibility with a history of breast cancer, prophylactic mastectomy, or prophylactic oophorectomy. The pathologic reports were manually reviewed for relevance, and each case's diagnosis was registered. A total of 6803 reports were available, representing 4948 patients; 2574 reports from 2531 patients were included in this study. The median age of patients was 51.2 ± 12.0 years (range, 15-88 years). RESULTS: Invasive carcinoma was detected in 4 patients (0.16%). Four patients (0.16%) had ductal carcinoma in situ, and 1 patient (0.04%) had lobular carcinoma in situ. Metaplasia was noted in 51 patients (2.0%), calcifications in 375 (14.6%), and silicone in 701 (27.2%). CONCLUSIONS: The incidence of occult invasive or in situ carcinoma in capsulectomy specimens of patients with no previous breast pathology is low. Therefore, it appears oncologically safe to leave capsule tissue in situ. LEVEL OF EVIDENCE: 3.

Is capsulectomy necessary for symptom improvement in patients undergoing implant removal for systemic symptoms?

A case of symptom improvement after implant removal without capsulectomy is presented with a review of the literature.

Blind Curettage Technique for Treatment of Mucous Cysts Associated with Heberden Nodes: Description of Operative Technique.

The standard treatment for mucous cysts with Heberden nodes is excision of the dorsolateral osteophytes and capsule of the distal interphalangeal joint or thumb interphalangeal joint, including the stalk of the cyst. The skin incision varies for cases depending upon the geometry. We propose a surgical method utilizing blind lateral approaches for treating such mucous cysts.

Breast implant illness: A United Kingdom patient-centred approach.

INTRODUCTION: Silicone breast implants are widely prevalent. An increasing group of patients detail self-reported somatic and psychological symptoms that have been ascribed as breast implant illness (BII) and seek capsulectomy and implant removal. To guide consultations and shared decision making, more outcome data relating to this intervention are required. AIM: To present a multicentre study of patient-centred (n = 100) outcome data, following total capsulectomy with implant removal for BII. METHOD: A questionnaire survey was cross-referenced with medical records. Collected data included demographics, operation details, pre- and postoperative symptom scores, overall self-perceived percentage improvement in BII symptoms and breast shape satisfaction ratings after explantation. RESULTS: The 10 most frequently self-reported symptoms were fatigue (81%), pains/aches (72%), brain/memory fog (56%), mood disturbances (36%), neuropathic pain (28%), hair loss (28%), headaches (25%), gastric symptoms/intolerances (24%), eczema/rash (18%) and vision disturbance (17%). A high proportion of patients (98%) experienced a 62 ±â€¯4% average symptom improvement; most self-reported symptoms (21/28) improved significantly after explantation with total capsulectomy (p < 0.05). Furthermore, patients had high overall self-perceived BII percentage improvement (76 ±â€¯3%) and satisfaction with breast shape numerical rating score (8 ±â€¯0.30) postoperatively. CONCLUSION: Despite BII not being a defined disease entity, symptom association with silicone breast implants continues for a growing number of patients. It is important to recognise that in this patient group, capsulectomy and implant removal may not be curative, however we have demonstrated that symptom improvement can occur. It is very difficult to prove a causal link between breast implants and BII; to do so will require extensive prospective data collection.

[Breast implant removal and simultaneous aesthetic optimization : Possibilities, technical considerations and outcome analysis]. / Brustimplantatentfernung und simultane ästhetische Optimierung : Möglichkeiten, technische Überlegungen und Ergebnisanalyse.

BACKGROUND: Breast augmentation is currently the leading aesthetic surgical procedure worldwide. Thus, there is a high prevalence of women with breast implants demanding serious know-how and expertise concerning long-term complication management. Breast implant carriers can suffer from problems and pathologies making implant removal the best solution. The authors of this article have also been confronted more and more with the unspecified complex of symptoms named breast implant disease (BID), also called breast implant illness (BII). The treatment of choice for BID is implant removal. OBJECTIVE: Analysis of problems and solutions regarding implant removal. Specific patient analysis according to patients' breast and body configuration. Technical considerations for surgery and preoperative planning. Evaluation of the authors' techniques. PATIENTS AND METHODS: Evaluation of all patients over a period of 3 years requesting implant removal after esthetic augmentation mammoplasty at the authors' department. All patients were treated according to their specific demands regarding breast shape after implant removal. They either received additional mastopexy, lipofilling or both or simple implant removal without further intervention. Demographic, implant-specific, perioperative and postoperative data have been evaluated for all patients. Additionally, all patients were asked to complete a questionnaire regarding satisfaction and outcome. RESULTS: We observed a trend for more satisfied patients with less invasive procedures (simple implant removal or simultaneous lipofilling vs. explantation and mastopexy ± lipofilling, 1.8 vs. 2.0 or 2.6, p = 0.198). Patients' average scoring was better if they suffered from an implant rupture (1.55 vs. 2.17, p = 0.053). Overall, a high patient satisfaction has been observed for all procedures. CONCLUSION: Breast implant carriers can suffer from problems and pathologies making implant removal the best solution. Exactly these patients, consulting their doctor for those problems and questions seem to profit from implant removal. Simultaneous lipofilling and mastopexy of the breast are good options to nevertheless generate an esthetically pleasing result.

Clinical impact of capsulectomy during cardiac implantable electronic device generator replacement: a prospective randomized trial.

BACKGROUND: The avascular capsule around the generator of the cardiac implantable electronic device (CIED) could be susceptible to bacterial colonization and source of infection. Capsulectomy during CIED generator replacement may be beneficial in preventing device infection, but there is a lack of evidence. METHODS: This prospective randomized trial, conducted from December 2013 to December 2019, included 195 patients divided equally into two groups. In the intervention group (n = 97), capsule removal was performed on the floor of the pocket, while it was not performed in the control group (n = 98). In both groups, swab culture was performed in the pocket. The primary outcome was the occurrence of device infection requiring pocket revision. RESULTS: A total of 195 patients were included (mean age 70.2 ± 13.6 years, 55.4% women), with an average follow-up period of 54.3 ± 28.9 months. Among 182 patients undergoing microbiological cultures of pockets, 19 (10.4%) were confirmed positive, and Staphylococcus species were identified most frequently. The primary outcome occurred in 4 (2.1%), and there was no significant difference between the two groups (3.1% vs. 1.0%, p = 0.606). Hematoma has occurred in 10 patients (3.1% vs. 7.1%, p = 0.338), one of them required wound revision. In multivariable analysis, the occurrence of hematoma was the only independent risk factor associated with device infection (HR 13.6, 95% CI 1.02-181.15, p = 0.048). CONCLUSIONS: In this long-term prospective study, capsulectomy during the replacement of the generator did not reduce the incidence of device infection. There was no association between bacterial colonization in the capsule around the generator and CIED infection.