Capsulotomy and release of tight pocket of her left breast implant

PREOPERATIVE DIAGNOSES:

1.  Symptomatic left breast reconstruction secondary to capsular contracture.

2.  Left breast cancer, status post left mastectomy many years ago.

POSTOPERATIVE DIAGNOSES:

1.  Symptomatic left breast reconstruction secondary to capsular contracture.

2.  Left breast cancer, status post left mastectomy many years ago.

OPERATION PERFORMED:

1.  Capsulotomy and release of tight pocket of her left breast implant resulting in symptomatic complaints of tenderness.

2.  Removal of implant per patient’s request.

OPERATING FINDINGS:                           Revealed generally intact implant with gel bleed.  She did have capsular contracture.  There were areas of scarring, likely points of tethering, which were released with capsulotomies.  She tolerated that quite well.  Simpulse irrigation carried out, 3 liters, to remove small amount of gel bleed secondary to implant.

OPERATIVE INDICATIONS:                    The patient is a very pleasant 75-year-old female status post left mastectomy and left breast reconstruction many years ago.  She continues to be followed by her medical oncologist and continues to be free of any recurrent disease.  She, however, has had progressive tightness over her left breast reconstruction consisting with silicone implant.  At this point, she has requested that I perform removal of the implant.  She informs me that she is 75 years of age and really has no interest in having an implant at this point.  In light of the fact that she does have tenderness with a fairly tight pocket, I believe her request is reasonable.  She underwent medical clearance.  She had no further questions.  She understood her options.  I stressed her what the appearance will be after removal of implant and she had no issues regarding this.  At this point, all her questions were answered.  She was comfortable with the decision.  I met the patient as well as her daughter in the preoperative holding area again today where they had no further questions and requested that we proceed with the operation.  The patient received prophylactic antibiotics prior to skin incision and SCD boots placed per my routine.

PROCEDURE IN DETAIL:                                    The patient was taken to the main operating room and placed supine on the operating table.  Both arms were placed on well-padded arm boards and secured in a non-constricting fashion to prevent neuropraxic injuries.  The entire chest was prepped and draped sterilely in the standard fashion.  A 1% lidocaine with epinephrine was used for local anesthesia.  5-cm incision was made through the lateral most portion of her previous mastectomy scar with the 15-blade scalpel.  The scar was excised as she had some hypertrophy.  Incision was carried down through the underlying layers using cautery.  The muscle fibers, pectoralis were identified and was entered along the length of the fibers.  An intact implant with gel bleed was noted.  The implant was removed without difficulty.  Using Simpulse irrigation with 3 liters of antibiotic solution, pressure irrigation carried out through all remnants of gel bleed.  At this point, with the lighted retractor and cautery, release of tethering of her pocket to the overlying tissue was performed with capsulotomies as needed.  Meticulous hemostasis having been assured.  Complete closure of the muscle and capsule layer subsequently performed after assuring perfect hemostasis.  Further irrigation and antibiotic solution carried out prior to closure of the muscle layer.  Closure of the muscle layer performed using interrupted 3-0 Vicryl pop-off suture.  Dermal layer closed using interrupted 4-0 Vicryl suture.  Skin closed using running 4-0 Vicryl subcuticular suture.  Metzenbaum Steri-Strips applied.  The patient tolerated the procedure well without complications.  She was extubated without difficulty.  All sponge, instrument, and needle counts were correct.