Removal of ruptured silicone implant with gross leak of silicone and disintegrated implant shell.

PREOPERATIVE DIAGNOSES:

1.  Severe capsular contracture right breast reconstruction, status post mastectomy for breast carcinoma performed 28 years ago.

2.  History of right breast carcinoma, status post right breast mastectomy.

3.  MRI findings suggesting right breast implant rupture.

POSTOPERATIVE DIAGNOSES:

1.  Severe capsular contracture right breast reconstruction, status post mastectomy for breast carcinoma performed 28 years ago.

2.  History of right breast carcinoma, status post right breast mastectomy.

3.  MRI findings suggesting right breast implant rupture.

OPERATION PERFORMED:

1.  Removal of ruptured silicone implant with gross leak of silicone and disintegrated implant shell.

2.  Simpulse pressure irrigation 3 liters resulting in complete evacuation of silicone content from the capsule.

3.  Correction of severe capsular contracture resulting in distortion with circumferential and radial capsular release and revision of right breast reconstructive pocket.

4.  Replacement of previous implant using mentor 350-401 BC implant, serial number 5861506-017.

ANESTHESIA:                                             General.

INDICATIONS:                                             The patient is a 65-year-old female referred to me for correction and replacement of right breast reconstruction implant.  The patient has severe capsular contracture with distorted pockets resulting in significant asymmetry between the reconstructed right breast and her left breast.  Additionally, MRI findings preoperatively suggest silicone implant.  The patient would like improved symmetry and would like to have these implants replaced after removal of the ruptured implant.  The findings discussed with the patient preoperatively, I discussed her options.  I do recommend removal of the ruptured silicone implant.  I discussed the potential complications, which include, but not limited bleeding, infection, severe capsular contracture again recurring, rupture of implant, all of which may require further procedures or at times need for possible temporary or permanent removal of implant.  I have answered all her questions to her satisfaction, she was comfortable with that, and she wished that I proceed.  I have met with this patient on more than one occasion in my office where we addressed all her questions.  However, despite this upcoming procedure, I stressed her that perfect symmetry is not achievable.  I wanted her to have realistic expectations.  At this point, she understands fully.  I have answered all her questions and she wishes that I proceed.  The patient was met in the preoperative holding area today where the nursing staff was present.  She was marked in the upright standing position.  She received prophylactic antibiotics prior to skin incisions.  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 placed on well-padded arm boards and secured in a non-constricting fashion to prevent neuropraxic injuries.  The entire chest was then prepped and draped sterilely in the standard fashion after satisfactory general anesthesia achieved.  A 5-cm incision made through the previous mastectomy scar.  Incision carried down through the underlying layers using cautery technique.  Operative findings revealed grossly ruptured implant with silicone gel oozing upon entering the capsule.  A disintegrated shell was identified.  This was removed from the capsule and with the implant being placed on the back table.  Because of the gross contamination of silicone gel, Simpulse pressure irrigation antibiotic solution with a total of 3 liters then carried out.  This pressure lavage resulted in complete evacuation of silicone remnants as noted intraoperatively.

At this point, a lighted retractor was then used to inspect the pocket.  Operative findings revealed severe capsular contracture with a significantly contracted pocket.  Using cautery, circumferential and radial capsular release was carried out and the inframammary fold was lowered by at least 2 cm to the preoperative markings.  The inframammary fold was reconstructed using Vicryl sutures and capsule to periosteum were available.  Meticulous hemostasis was assured throughout under direct visualization with the lighted retractor.  Completing hemostasis, irrigation carried out.  Sizer placed within the pocket created with operative findings revealing 400 mL implant _____ markedly improved appearance without having any tightness with respect to closure of the skin and capsule muscle layers.

At this point, a 10-20 drape placed overlying the skin incision after removal of the sizer.  New gloves placed from my routine.  A Mentor 350-401 BC implant was chosen.  It was bathed in antibiotic solution.  It was inspected and was noted to be completely intact.  One final check of the pocket was performed with the lighted retractor, and once hemostasis assured, the implant was placed within the pocket created.  Operative findings revealed marked improvement compared to preoperative state.  The patient placed in the upright sitting position with operative findings revealing a pleasing shape.  The patient then placed against supine and subsequent closure of the muscle and capsule layers performed using interrupted 3-0 Vicryl pop-off suture.  Dermal layer closed using interrupted 4-0 Vicryl suture.  Skin closed using 4-0 Vicryl subcuticular suture.  Mastisol and Steri-Strips were applied and surgical bra applied.  All sponge, instrument, and needle counts were correct.  The patient tolerated this procedure well without difficulty or complications.  She was extubated easily and was transferred back to the recovery room in good condition.

ESTIMATED BLOOD LOSS:  Minimal.