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André Camirand, M.D., Jocelyne Doucet,R.N., and June Harris, M.D.
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Montréal, Québec, Canada
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The incidence of capsular contracture is reduced when smooth-surfaced, saline-filled implants are placed subpectorally,avoiding contamination and the presence of blood. In addition, since the autors began using compression,they have not had one single capsular contracture requiring surgery.The authors'technique, their preoperative and postoperative regimens,an explanation of how they use compression, and the scientific and mathematical explanation of why compression could be the most important factor in preventing capsular compression are described.
Of more than 1700 augmentations perfomed in our private clinic, only 830 could be included in the study.The patients were followed clinically for 1 year, after which time they completed a questionnaire, the results of which showed the authors that capsular contracture had not developed.
(Plast.ReconstrSurg. 104:529,1999)
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After a breast augmentation, a scar forms around an implant and contracts in a centripetal direction in an effort to conform to a spherical shape, which as the smallest surface area for the given volume of the implant.If the implant itself is spherical,the contracture will not change the shape of the implant but will exert the same pressure, resulting in hardness. A spherical implant will become oval-shaped when it is placed behind the pectoral muscle. Under certain circumstances such as the presence of blood, bacterial contamination, necrotic tissue, silicone,talcum powder or any other irritant, this scar formation can be exagerated to the point that the periprosthetic scars thicken and contract very strongly.This will result in a hard, spherical, distorted,fixed, and painful breast: a capsular contracture.
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Capsular contracture
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Capsular contracture results from myofibroblast, and as the scar matures,collagen forms, resulting in a spherical capsular contracture. Capsular contractures can appear anytime after surgery.However, in our experience, most of them manifest within 2 to 3 months and rarely more than 1 year after surgery.We stressed to our patients the importance of compressing the implant to increase its surface area, thereby stretching the periprosthetic contracting scar to prevent its contracture, and we instructed them to compress their implants for at least 3 months.At follow-up, we found that none of them had developed capsular contracture.There was no scientific reasoningbehind chosing 3 months for compression, but it seemed a reasonable lenght of time to expect patients to cary out our instructions, which they did,and the results were conclusive.It may be interesting to determine if less compression time would yield the same results. |
| Fig.1. The breasts are soft and look natural,even when the patient raises her arms. Furthermore, the inframammary scars are invisible. |
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Patients and methods
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We reviewed the charts of each of our breast augmentation patients. All had subpectoral,smooth-sufaced, saline-filled breast implants,and they were all followed closely for 1 year.Pictures were then taken showing the index finger and thumb squeezing the implant, demonstrating is softness, and with two arms raised, showing a natural look of the breast (Fig.1).All patients confirmed complying with compression for a minimum of 3 months. If, after 1 year,they notice any abnormality, such as hardening,patients are encouraged to return to us for further treatment at no additional cost. If the surgery had been done more than1 year before this study, patients were telephoned and asked the following questions:
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- Are your breasts as soft as they were when last seen (1 year after surgery)?
- Are your breasts as mobile (not fixed) as they were when last seen (1year after surgery)?
- Do your breasts look as natural as they were when last seen (1 year after surgery)?
- Are your breasts as pain free as they were when last seen (1 year after surgery)?
- Are you satisfied as you were when last seen (1 year after surgery)?
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Although we have performed more than 1700 breast augmentations, only 830 patients could be included in our study.The patients operated on more recently were easier to contact and therefore more likely to respond to the survey, which explains why we had fewer long-term results in our study. Although the Baker classification is a very useful qualitative clinical tool, we did not use it in our quantitative evaluation
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Results
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In all our patients, the answers were positive.We had folow-up of 6 years for 50 breast augmentations, 5 years for 66 augmentations, 4 years for 106 augmentations,3 years for 134 augmentations, 2years for 160 augmentations, 1 year for 314 augmentations.Mean follow-up was 2.39 years.All patients were satisfied with the softness, mobility, and natural look of their breasts (Figs.2 through 5; Table I) . Capsular contracture was rarely seen after 1 year.Although compression prevents early contracture, eventual contracture is still possible even if unusual.
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| Fig.2. Preoperative and 1 year postoperative views of a subpectoral implantation. |
Fig.3. An average result following a subpectoral implant without contracture. |
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The Role of Compression
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The Encyclopedic Dictionary of Mathematics states the following: Specifically, if an ovaloid and a sphere have the same volume then the surface area of the ovaloid is greater than or equal to the surface area of the sphere with equality only when the ovaloid is a sphere.
Rephrasing, if an ovaloid and sphere have the same volume but the ovaloid is not a sphere then the surface area of the ovaloid must be strictly greater than the surface area of the sphere.
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If the volume of the ellipse is kept fixed, then the surface given as a function of the axes a and b (Fig.6).In three dimensions, ther is a third radius, c which lies enteroposterior (depth), but for sake of simplicity, we will assume that we deal with a uniform compression and the resulting c has the same dimension as a .
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These formulas show that the surface area is, for a fixed volume, inversely proportional to the magnitude of b and directly proportional to the magnitude of the square root of a. To simplify, the more we compress the implant, the more we reduced the radius b and augment the radius a ; therefore, the more we augment the surface area. In other words, it is a mathematical |
and a physical fact that the smallest surface area for a given volume is the sphere. Figure 6 shows that the radius in a sphere is the same in all three dimensions. As we compress the sphere,we augment the radius a and reduce the radius b and we get a flattened ellipse or an oval. There is also a formula that can give us the percentage increase in surface area (Fig.7) we get with compression.If the radius a becomes 8 times as long as the radius b, we double the surface area for the given volume, or increase it by 100 percent. We believe this ratio is eaily attainable as one sleeps in a prone position.
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| Fig.4. An average result following a subpectoral implant without contracture. |
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The Importance of Compression in Preventing Capsular Contracture
We believe that the best way to explain to patients the importance of compression is to explain the physical and mathematical fact that the smallest surface area for a given volume is the sphere.Crushing a spherical balloon will stretch the surrounding rubber (which thins and become transparent), and if too much pressure is applied, the ballon will burst. This happens not because the volume of air is greater but simply because the shape has changed from spherical to oval-shaped,overstretching the rubber to the point of rupture.Patients easily understand that (1)if the implant is crushed, the scar surrounding the implant wil stretch like the rubber balloon, and (2) after 2 or 3 months, the body adapts,the scar ceases to contract around the implant, and the breast remains soft.
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The Difference between Compressing an Air-Filled Sphere and a Liquid-Filled Sphere
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In both cases, the outer surface area will increase, but less so in the air-filled balloon because air is compressible and its volume will reduce. In the case of water-filled sphere or balloon,the surface area will increase much more because the volume remains constant and the pressure applied with the crushing hand distributed equally in all directions and entirely around the periphery. In the air-filled balloon, the compressing hand will not distribute pressure equally on the outside of the balloon.Instead, a large amount of pressure will be applied immediately under and around the crushing hand, overstretching the rubber and tearing it.This explains why it is so much easier to burst an air-filled balloon than a water-filled balloon. Using the crushed air-filled balloon as an example is the simplest way to convince our patients that compressing the implant for a few months is the best way of preventing capsular contracture.
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Subpectoral Implantation
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We much prefer the subpectoral approach (Table II) for the following reasons :
(1) It looks more natural ; the result is a pear-shaped breast because of the axillary projections.It somewhat resembles the tail of Spence.
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In one patient who consulted us,the left implant was placed in front of the muscle and the right one behind (Fig.8);this probably resulted from a surgical mistake.Because the patient preferred the implant behind the muscle, she asked us to relocate the left implant.
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| Fig.5. An average result following a subpectoral implant without contracture. |
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Table 1 : Follow-up*
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6 |
50 |
5 |
66 |
4 |
106 |
3 |
134 |
2 |
160 |
1 |
314 |
Total |
830 |
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Sphere ? Flattened Ellipse or Oval
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| Fig.6. Volume remains constant because saline cannot be compressed .Surface area increases as the sphere becomes an oval a , major axis or horizontal radius ; b , minor axis or vertical radius.For simplicity ,we will assume all horizontal radii are equal to a, as when pressure is applied uniformily. As the spherical implant is compress to an oval, a is increased and b is reduced, resulting in greate surface area with the same volume and thereby stretching the contrated capsule. |
(3)The muscle will also reduce the sound of air (if there is any ) in the prothesis or liquid within the cavity in the early postoperative period .In other words,it behaves as an isolant.
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| (4) Technically, the dissection is much easier, faster,and safer because most large blood vessels and nerves are located between the muscle and the gland. |
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| Fig.7. The formula of the percentage of augmentation of the surface area. |
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| Table II : Advantages of Subpectoral Implantation |
Continuous compressing (tonus) and repeated milking action of the muscle.
Less bleeding because the vessels are located between the muscle and the breast .
No anesthesia of the arcola (nerve between muscle and the gland).
More vascular medium increases against presence of bacteria: |
... (1) gammaglobulin
... (2) leuckocytes
... (3) antibiotics |
Axillary projection---pear-shaped natural looking breast.
Muscle prevents palparion of the implant in thin patients,especially if there
Is wrinkling of the prothesis.
No noise from air in the prothesis or fro liquid in the megacavity at first.
If there is capsular comperssion, palpate the muscle instead of the capsular contracture.
Dissection is easier and faster and draws less blood. |
- compresses the prothesis (reducing the suprareolar projection)
- produces a better axilliary projection |
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The dissection draws less blood, reduicing the risk of postoperative hematoma.In addition, the areolac will not lose their sensitivity.The pectoral fascia and the posterior wall of the mammary gland are less well vascularized than the pectoral muscle anteriorly and the intercostal muscle and rib periosteum that lie behind the implant when the subpectoral location is chosen.The subpectoral tissues are better perfused so they will give a better defense against contamination, a major cause of capsular contracture.The tissues carry more leukocytes, gammaglobulins,and antibiotics than the less-vascular prepectoral space, and we are well aware of the importance of eliminating contamination.The most important advantage in locating the implant behind the pectoral muscle is its efficient continuous compression.(5) The continuous milking effect and persistent tonus wil compress the implan (so that it becomes more oval-shaped ) and also reduce the undesirable spherical shape of the prepectoral implant. In mild to moderate ptosis (i.c.,the nipple is pointing forward and is not below the inframmmary crease ), this approach is advantageous beacuse the muscle compressing the implant will reduce the supra-areolar projection of anaugmentation when there is ptosis.
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Our atheletes and weight-lifters never suffered any pectoral or shoulder weakness (as shown in Fig.9 ) following subpectoral breast augmentation.
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Preoperative Protocol
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During consultation, after a complete medical questionnaire, physical examination, psychological evaluation,and laboratory investigation,we advise our patients verbally and on paper to avoid aspirine,oral vitamin E, garlic,black Chinese mushrooms,alcohol (especially red wine ), and exposure to smoke (postoperative cougching can cause bleeding ) for 2 weeks before and after surgery. We give patients a thorough written documentation on intervention, convalescence,pain,scarring, and possible complications such as hematoma, infection, extrusion, rupture, asymmetry, rippling, palpability,and hypertropics scars.We advise them to come back for another consultation before they make a decision. Pictures of results and of scars are shown to the patients preoperatively.
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On the night before and morning of surgery, patients must shower and clean their upper chest and axilla with an antiseptic soap.They must avoid shaving their axilla for 1 week before surgery to avoid folliculitis. We prescribe antibiotics :cephalosporin 500 given every 6 hours beginning 24 hours preoperatively, continuing on the day of surgery until 24 hours postoperatively. If the patient is allergic to penicillin, we recommend the same dosage of Lincocin.
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Technique
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We spray OpSite (Smith& Nephew, Lachine,Québec) on the areolae to prevent contamination from mammary ducts. We then infiltrate an anesthetic solution around the gland,horizontally at the level of the inframammary crease, along the parasternal and anterior axillary lines, and then above, at the level of the second rib into the pectoral muscle.We also infiltrate from the inframammary crease horizontally and parallel to the ribs in a cephalic direction.This infiltration is always done, even if general anesthesia is used.The solution used is 50 ml of Xylocaine 1% with adrenaline and 25 ml of bupivacaine 0.25% mixed in 250 ml of saline.Anasthetic infiltration is carried out before scrubbing, allowing 20 minutes for vasoconstriction. We rinse our gloves with water to remove talcum powder (talcum is a cause of granuloma, and any irritant could enhance capsular contracture).We then make a 3 cm incision at the level of the inframammary crease or at a distance at least half the diameter of the implant from the middle of the nipple.We believe that an incision at the inframammary crease gives us a better exposure for hemostasis when necessary, there is less contamination,i.e.,axillary sweating or mammary duct contamination (Table III), and symmetry is achieved more easily.
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Fig.8. This culturist and weightlifter, a national champion in both disciplines was able to bench press 75 kg more than before surgery, less than 9 months after receiving her subpectoral implant. |
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Table III : Factors to Prevent Capsular Contracture
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| Subpectoral location creates compression |
| Compress the implant |
| Lie on stomach |
| Compress for 1 second each hour |
| Wear a compressive brassiere |
| Less bleeding |
| Subpectoral(blood vessels between the gland and the muscle) |
| Meticulous hemostasis |
| If the patient is under general anesthesia we used propofol because it is antemetic |
| Stop smoking;coughing leads to bleeding |
Avoidance :
ASA
Garlic
VitamineE
Red wine |
| Inframammary incision : bettrer exposure for coagulation |
| Absence of bacteria |
| Asepsis and shampoo,spay OpSite on areola |
| Antibiotics |
| 10 cc of Betadine in the cavity |
| Inframammary incision :less contamination from axillary swearing or areolar duct manipulation |
| Megacavity or cavity larger than the implant eliminates tension |
| Clean talcum powder from gloves |
| Eliminate silicone bleed (quality implant or saline-inflated implant) |
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Although the majority of patients do not require cauterization, we use a bipolar electrocautery if necessary; a bloodless field is essential. After dissecting a cavity, we explore to make sure there is no bleeding.We then inject 20 ml of Xylocaine, adrenaline, and bupivacaine solution (the same as for the infiltration ) and 10 ml of proviodine into each cavity.we insert the prothesis,inflate it using a closed system for sterile saline inflation to minimize the risk of contamination, and suture the deep dermal layer, including the subcutaneous fat to obtain a good eversion of the closure, and the intradermal layer with Vicryl 4-0. We apply Steri-Strips, compresses, and Elastoplasts or a compressive brassiere.
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Postoperative Protocol
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After 1 week, we encourage patients to gradually lie on their stomach at night. If they cannot, we ask them to watch television in the evening in the prone position for a few hours, on a hard surface, such as carpeted floor, and we advise them to compress their implants for 1 second each hour.This is accomplished by simultaneously touching each ear with the opposite hand, forcing compression by the elbows. These compressive maneuvers are recommended for 3 months,after which time the stretched capsule would rarely if ever contract in our “series” and did not contract in any of our 830 smooth-surfaced, saline implants.
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Table IV : Complications with the Smooth-Surfaced, Saline-Inflatable Prothesis
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| Complications |
n* |
| Capsular contracture |
0 |
| Hypertropic scar |
15 |
| Infection |
8 |
| Hematoma |
5 |
| Thrombophlebitis (Mondor's disease) |
4 |
| Implant deflation |
9 |
| Areolar necrosis |
0 |
| Loss of sensation of the areolae |
0 |
| Pneumothorax |
1 |
| Migration of implants |
1 |
| *A total of 830 bresat augmentations were included in the study. |
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Complications Encountered in This Study
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Roughly two-thirds of our 830 smooth-surfaced, inflatable implants were supplied by Mentor (Santa Barbara, Calif.) and one third were supplied by McGhan (Santa-Barbara, Calif.) .
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As mentioned previously,our patients are seen regularly for a minimum of 1 year .They are encouraged to return to us anytime within 5 years of their surgery for additional treatment without incurring additional expense.We maintain an excellent rapport and make sure the patient gets the best possible result.We always look for capsular contracture. We had no capsular contracture necessitating further surgery with our smooth-surfaced,saline-inflatable implants.However,we did encounter some other complications (Table IV). Sixteen of our inflatable implants where slow to soften (Baker II) and possibly improved with large doses of vitamin E, 1000units four times a day.(Vitamine E could interfere with fibromyoblast and collagen contraction). One of these patients had undesirable effects from the vitamine E:dermatitis.Of the16 patients, seven had implants from another surgeon and came to us beacause of capsular contracture;six of the seven had silicon gel implants.
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All of these patients improved sufficiently after months of viatmine E therapy and did not require further treatment, as the result was satisfactory. Whether the improvement was a result of vitamine E or just a coincidence, we cannot tell.We know that the breast continues to soften for 3 to 8 months with our inflatable implants, even without treatment.
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None of the 830 smooth-surfaced,saline inflatable implants required surgery for correction of a capsular contracture.We used all precautions described in the literature : subpectoral position, Betadine in the cavity, antibiotics, and hemostasis, but we are convinced that the compression of the implants makes the difference.We do not believe a textured implant would be superior to a smooth-surfaced implant; we agree with the findings of Tarpila et al. and others. There were eight patients with found infection. In one of our patients was the implant exposed, and all infections cleared with a 10 day course of Keflex 500 every 6 hours.In the cases of infection, one Mc Ghan implant and seven Mentor implants were used. Of nine deflated protheses, one (Mc Ghan) deflated within 24 hours. Eight (five Mc Ghan and three Mentor ) deflated many months later.All were replaced under local anesthesia. Five patients developed a hematoma.These hematomas were evacuated within 24 hours, and the postoperative evolution was uneventful.On exploration, bleeding has ceased and an artery was not identified. Four patients had a superficial thrombophlebitis (Mondor's disease) , which is caused by coagulating subcutaneous veins and manifests as a string-like hard structure.At the onset, there might be transient hyperemia of the skin and sensory changes that will completely resolve in 3 to 4 months. Heat can be used as early treatment. Now we avoid coagulating these superficial veins, to reduce its incidence.These veins will stop bleeding with the suturing as we close the incision and they cannot be a cause for hematoma inside the subpectoral cavity.
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Fifteen patients had hypertropic scars that improved with steroid injection, massage,and the application of silicone sheets and silicone ointment (Kelecote/Scarfade,ORCA Surgical, Kingston, Wash.). There was no areolar necrosis in this series and no anesthesia of the areolae. In one patient ( a smoker) undergoing a breast augmentation, we simultaneously treated tuberous breast and had bilateral areolar necrosis. One heavy smoker suffered from a pneumothorax on one side during the surgery. The anesthetist gave us positive pressure and we closed the intercostal space, inserted the implant,and close the wound. Postoperatively, the patient did not have any symptoms,but on auscultation the ventilation was reduced on that side, and an x-ray showed some collapse.A chest tube was inserted for 48 hours, and the postoperative evaluation was uneventful. In one patient the two implants migrated laterally and inferiorly.No steroids were used, and the history and physical (including endocrine) examination were negative.A plication was performed and migration recurred, but to a lesser extent. We are considering a prepectoral implant for this patient to eliminate the downward and lateral push of the pectoral muscle if a second plication is unsuccessful. If we exclude our complications, we had a 100 percent satisfaction rate, with no capsular contracture.Because of complications, our overall rate of satisfaction is 96 percent. We eliminated the consequences of all our complications except for a few hypertropic scars and a case of migrating implants.
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Conclusions
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By keeping bacterial contamination and the presence of blood to a minimum, and by placing the implant behind the muscle, we ha few capsular contractures.However, since we began recommending compression for 3 months, none of our 830 most recent smootht-sufaced, saline-inflatable implants required surgical treatment for a capsular contracture. We never considered using textured saline implants.
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| Obviously the pathophysiology of a capsular contracture manifests itself by a centripetal contracture of the peri-prosthetic scar to reduce the surface area of the foreign body---the breast implant .We end up with a hard, spherical implant. In our opinion, the only logical way to counteract this condition is compression,which will give the implant an oval shape with a resulting larger surface area and will cause the inevitable stretching of the capsule, eliminating contracture. Understanding the scientific and mathematical explanation of this evidence and conserving the findings of our study, we are convinced that compression is the most important factor in preventing capsular contracture. |
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