A Blemish on Your Surgeon's Reputation???
 |
The
Real Story and How to Improve Your Odds!
By
JOEL R STUDIN MD, FACS
New
York, N.Y.
After surgery or injury, our body turns on its emergency repair system! Whether the area that needs repairing is on the surface of the skin or deep inside, the process is similar. The treatment, is however very different.
In this article, I will explain what happens with skin scarring as well as that dreaded internal scar known as "capsular contracture". I will give you an outline explaining how to help prevent scarring and how to treat it if it has already occurred.
Capsular
Contracture
Or
"How Come My Breast Is Hard, Rippled, or Too High?"
Anytime something is implanted, whether it is a knee joint, heart valve or breast implant, our body forms a wall of scar tissue around it. This wall is usually soft, thin and unable to be felt. But just like one child falls on the playground and cuts their chin and has a bad scar, and the next child with the same injury and same plastic surgeon has almost no scar to speak of, the scarring inside around an implant is unpredictable.
It would seem logical that scarring inside could be predicted by past scarring from injuries or by their family history. Unfortunately, none of these help us predict who will form extra scar tissue inside. It is truly a random occurrence.
L
What
happens when a little extra scar tissue forms?
If someone forms a small amount of
scar tissue, they feel rippling through the skin of the breast.
Is this rippling because the implant has not been filled enough?
I don't think this is true.
After removing implants for rippling, I
found small bands of scar tissue in the wall of scar tissue around the implant.
Which came first, the chicken or the egg? Did
rippling of the implant cause the bands of scar tissue or did the bands of scar
tissue cause rippling of the implant?
Because there was no visible rippling of the
implant itself upon opening the pocket, I believe that this rippling is actually
the smallest form of capsular contracture, or over formation of scar tissue
around the pocket.
In cases where a small amount of rippling
occurs (you can feel it but not see it), I recommend only that the patient
continue massage and take vitamin E. (I will explain vitamin E a little bit
later.) Sometimes it goes away over
time and sometimes it does not, but these breasts look perfect. While it is
possible to feel a small amount of rippling if you try, there is nothing that
looks abnormal.
What
happens when a lot of extra scar tissue forms?
If someone really forms a lot of scar tissue, one of two things can happen. They get either visible rippling or hard breasts.
Solving
Visible Rippling
If visible rippling occurs, it is
usually seen on the outer part of the breast upon bending over. These patients
should consider entering the silicone gel study called the "Adjunct
Study" and change their saline implants to silicone gel implants.
This can only be done by a plastic surgeon authorized as an investigator
in this study.
Changing from saline implants to silicone
implants usually solves this problem. Capsular
contracture with visible rippling is one of the indications that qualify someone
for the silicone gel study. Only
authorized investigators are allowed to place silicone gel breast implants
presently.
Many patients think that because placing silicone gel implants involves an FDA approved study, that the surgery is free. Unfortunately, there is no subsidy from either the FDA or the implant manufacturers.
If you have this problem, you should have a
long consultation and discuss the pros and cons of changing to silicone gels.
I find that when I replace rippled saline
implants with silicone for a patient, it almost always solves the problem and
that results in softer natural feeling breasts.
Solving
Hard, Round, High-Riding Breasts
If
firm high riding breasts occur, a lot of extra scar tissue has formed and needs
to be removed. Formation of dense
scar tissue will result in a pocket that is too small and squeezes the implant.
The breast can appear round, feel firm and may ride too high or hurt.
Fortunately, this is uncommon.
To correct this problem the implant is removed, the scar tissue taken out, and the implant replaced. Years ago, it was common to try and squeeze the breast very hard to break this scar capsule. Most surgeons today, believe it is better to remove the scar tissue than to try and rupture it.
Can
I stop scar tissue from forming in the first place?
As we discussed above, capsular contracture
is a random occurrence. While it is
not uncommon to feel a little rippling, especially in thin skinned to patients,
it is not common for someone to have enough scar formation that they need to
have it fixed.
There is no way to test for a tendency to form extra scar tissue but there are two things that I believe may help to prevent it. Notice that I use the word "may". There is no good study to prove that the two suggestions I am about to make really work! It is my belief however, that they do.
Vitamin
E
We have all heard
that vitamin E helps scars. Actually,
vitamin E does not melt scars it makes them softer. It works by reducing the
strength of the three strands that form collagen, making them softer and more
pliable. Technically, it reduces the strength of cross-linking of these strands.
If you take
vitamin E after having implants, does it make the capsule around the implant
softer and more pliable?
While there is no good study showing that this works, I have my patients take relatively high doses of vitamin E for at least one year after having breast implants. (For exact dosages you must ask your own doctor). I believe that this has made a significant difference in decreasing the number of capsular contractures in my practice.
The
Mladick No Touch Technique*
There are many
surgeons that believe that one cause of capsular contracture might be a
low-grade infection and that a super sterile technique in putting in these
implants might lead to a lower incidence of capsule formation.
When you look at a
beam of sunlight entering your bedroom window in the morning, you can see dust
particles floating in the air. The
air in an operating room has dust particles in it as well. Theoretically, these
dust particles could settle on the implant and contaminate it slightly.
After all, there are bacteria in dust particles.
It was theorized
that these dust particles might lead to very low-grade infections later on and
cause capsular contracture.
The No Touch
Technique is designed to avoid even the air from touching the implant.
Implants are packed in a sealed plastic container.
As soon as the package is opened the implant is covered with an
antibiotic liquid. After the pocket
is made for both implants, the surgeon changes gloves and coats the new gloves
and instruments with antibiotic solution. The
pocket is washed out with antibiotics solution.
The surgeon then picks up the implant and puts it into the pocket
touching it only with gloves and instruments covered with antibiotic solution.
Neither air nor skin bacteria are allowed to touch the implants
Does this
technique work?
Nobody has been
able to prove statistically that the No Touch Technique actually works.
My feeling is, though, that my rate of capsules dropped significantly
since adding this technique to my practice.
All of my implant surgery is done following these recommendations.
Scarring of the
skin
-Or-
“Did
the doctor do a bad job stitching me up?”
What
is a Scar?
After a surgical
incision, we make collagen to repair the gap. Collagen is just like cement
filling the space between two bricks.
Too much collagen
is always made, but then we also make an enzyme called collagenase that melts
the extra collagen.
This molding
process goes on for months. Collagen is made and the extra removed in a process
designed to mold the original shape of the skin.
If extra collagen is left, a thick scar is formed.
A perfect balance
between collagen and collagenase will leave the least noticeable scar.
Often, our healing
process works too well! After the skin has re-formed, we keep on healing. If we
could “turn up” the collagenase in our cells, we could melt the extra scar
tissue.
Plastic Surgeons
and Dermatologists have known for decades that there are ways to reduce scars.
Until now though, none have been very convenient.
Pressure
bandages were found to help increase production of
collagenase, our natural scar-melting enzyme, and have been used on burn scars
for over a century.
Cortisone
Creams not only soothe irritated skin but also
stimulate natural collagenase production. In extreme cases, doctors may use
cortisone injections.
Doctors have
prescribed Silicone Sheets for decades. Silicone sheeting taped over a
scar will help reduce it. This was discovered in the early 80’s, when a doctor
tried to apply pressure to a scar more evenly with a silicone gel sheet. The
scars treated with silicone seemed to decrease much more rapidly.
Vitamin E
helps by working on the collagen fibers and makes a scar softer and more
pliable.
Closing
the Skin
The first step in
getting the best scar we can is the skin closure. Fortunately, most patients go
to Board-Certified Plastic Surgeons for their surgery. For a Plastic Surgeon,
closing the skin is like breathing. You have so much practice and training, it
is second nature and there is truly very little difference from one experienced
Plastic Surgeon to another.
I have had many patients come to me over the years to fix scars left by other surgeons. They are sometimes surprised when I explain to them that it looks like the incision was closed properly, but formed a bad scar anyway. This can happen.
After
the skin is closed properly, what else can I do to lessen my scar?
For years, after
the bandage or sterile strips were removed all you could do was cross your
fingers.
In 1938, Vitamin E
was discovered. Over the past 20 years painting it on scars has been popular,
but as I explain above, it softens them and doesn’t shrink them.
There have been cortisones tapes and silicone gels and creams,
all of which were helpful, but difficult to use because they were either messy
or fell off.
I recommend a
product called ScarGuard. This product combines all of the treatments that I
described above into one liquid. It
is a clear liquid that forms a fine flexible film within a few seconds after
painting it onto the scar. This
film helps to protect the scar from irritation while delivering silicone
cortisone and vitamin E throughout the day.
I have my patients start using ScarGuard right after the steri-strips or
bandages come off. Treatment is continued twice a day for three to six months or
until the scar has almost disappeared.
Nothing will completely remove a scar, and a few will heal badly no matter what we do, but I believe that using a product such as ScarGuard makes a very big difference in the end result.
What
if I already have a bad scar?
The first step is
to see your doctor for an evaluation. Sometimes,
a second minor surgery to revise the scar is advisable. If scar revision is not indicated then try using ScarGuard.
ScarGuard works on old scars as well as new ones.
If you undergo a
scar revision, talk to your doctor about starting ScarGuard as soon as the
bandages are removed.
In
ClosingJ
I hope this has
helped to clear up the myths about
scarring. While this will sometimes
happen no matter how careful we are, fortunately there are some very positive
things that we can do to improve our chances.
Dr.
Joel Studin
JOEL R STUDIN MD, FACS
