The most recent IBSA best practice session
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The problems and topics approached here are not only limited to reconstructive or cosmetic surgery but, most widely, to the world of breast surgery in general, considered from several different points of view. The focus is not only on surgical techniques, but moves also in the direction of less common subjects and controversies, such as the definition of new classification for breast, both from a clinical and a surgical angle, and the update of diagnostics for patient assessment.
Stepping out from the mere surgical perspective, the IBSA wants to outline a new way of approaching plastic surgery, more open, simple and objective, flexible to changes and more open to innovations |
Document 1: Diagnosis of Capsular Contracture
The first IBSA session has taken place during the last London Breast Meeting, with a live interactive discussion between the IBSA members and the audience, a composite group made of more than 300 breast and plastic surgeons.
The whole session was dedicated to the diagnosis of capsular contracture, with the purpose of defining the most precise and correct approach to this common complication of both implant- based reconstruction and cosmetic breast augmentation.
The incidence of capsular contracture ranges between the 8% and 15% 1, but published data are controversial and data collection still represents an obstacle to a more precise evaluation, as no objective measurement and diagnostic tools are available.
The need of a uniform and coded definition of capsular contracture represented the kick-off of the discussion, with both the panel and the audience finding a common agreement in the use of the Baker- Spear score as the only current clinical scale to define the severity of the pathology. Although this classification is still routinely used for the assessment of the patients with capsular contracture, the fact of being solely based on the clinical examination makes the comparison between individual cases difficult and prone to bias 2. No alternative scoring systems were suggested during the session.
The second topic examined was the reliability of Ultrasound (USS) imaging when it comes to the diagnosis of capsular contracture and to the discrimination of the degree of contracture. Except for a small percentage of the audience, USS has been defined too unreliable by the rest of the experts and attendees. For the panel, the results achievable with this type of imaging are far too dependent on the skills of the radiologist, which performs the USS, and for this reason cannot be considered the gold standard for the diagnosis of the contracture.
This statement is also supported by the literature that reports that US evaluation of contracted implant is more difficult because of the increased antero-posterior thickness of the implant and decreased penetration of the signal in that direction 3.
It is easily understandable how the discussion was than brought on the definition of the value of MRI to provide a correct framework in the diagnosis of the capsular contracture. Since the beginning was clear that this type of imaging was generally more accepted by everyone. The main reasons in support of MRI were listed as follows:
Eventually, the session ended on the definition of MRI as, if not the ideal tool (higher costs, waiting lists), the preferable one for the diagnosis of capsular contracture, although no agreement was achieved about the timings for the request of the imaging. In fact only the 50% among the audience and the experts would use MRI starting from a Baker grade 2, while the remaining 50% would wait for clearer symphtoms.
The whole session was dedicated to the diagnosis of capsular contracture, with the purpose of defining the most precise and correct approach to this common complication of both implant- based reconstruction and cosmetic breast augmentation.
The incidence of capsular contracture ranges between the 8% and 15% 1, but published data are controversial and data collection still represents an obstacle to a more precise evaluation, as no objective measurement and diagnostic tools are available.
The need of a uniform and coded definition of capsular contracture represented the kick-off of the discussion, with both the panel and the audience finding a common agreement in the use of the Baker- Spear score as the only current clinical scale to define the severity of the pathology. Although this classification is still routinely used for the assessment of the patients with capsular contracture, the fact of being solely based on the clinical examination makes the comparison between individual cases difficult and prone to bias 2. No alternative scoring systems were suggested during the session.
The second topic examined was the reliability of Ultrasound (USS) imaging when it comes to the diagnosis of capsular contracture and to the discrimination of the degree of contracture. Except for a small percentage of the audience, USS has been defined too unreliable by the rest of the experts and attendees. For the panel, the results achievable with this type of imaging are far too dependent on the skills of the radiologist, which performs the USS, and for this reason cannot be considered the gold standard for the diagnosis of the contracture.
This statement is also supported by the literature that reports that US evaluation of contracted implant is more difficult because of the increased antero-posterior thickness of the implant and decreased penetration of the signal in that direction 3.
It is easily understandable how the discussion was than brought on the definition of the value of MRI to provide a correct framework in the diagnosis of the capsular contracture. Since the beginning was clear that this type of imaging was generally more accepted by everyone. The main reasons in support of MRI were listed as follows:
- more objective and less operator dependent than USS
- more informative not only about the contracture but also about the state of the implant (rupture)
- able to provide information in reconstructive surgery not only regarding the condition of the implant but also from an oncological point of view (detection of recurrence). As a matter of fact, not only MRI shows the obvious rounding of the implants in patients with contractures but also provides an excellent overview of breast, axilla and chest wall 3.
Eventually, the session ended on the definition of MRI as, if not the ideal tool (higher costs, waiting lists), the preferable one for the diagnosis of capsular contracture, although no agreement was achieved about the timings for the request of the imaging. In fact only the 50% among the audience and the experts would use MRI starting from a Baker grade 2, while the remaining 50% would wait for clearer symphtoms.
References
- Malahias M, Jordan D.J, Hughes L.C, Hindocha S, Juma A. A literature review and summary of capsular contracture: An ongoing challenge to breast surgeons and their patients. Int Journ of Surg Open 2006; 3, 1-7
- Zahavi A, Sklair MJ, Ad-El DD. Capsular Contracture of the Breast Working Towards a Better Classification Using Clinical and Radiologic Assessment. Ann Plast Surg. 2006; 57, 248
- O’Toole M, Caskey C.I. Imaging spectrum of breast implant complications. Seminars in Ultrasound, CT, and MRI; 2000, (21)5, 351-361