1.      “I quit this 3 years ago because all contractures treated by closed capsulotomy recurred.”
2.      “The whole procedure is irrational, unhelpful, and usually productive of further and more severe spherical contracture.”
3.      Response from a female plastic surgeon:  “I can't even open a pickle jar, much less crack a capsule, but I have heard the guys complain.”

In the 653 replies from surgeons who do capsulotomies and had never had an injury, there were a number of interesting and pithy comments:

1.      “I have a personal rule that I never use enough force to hurt myself, and consequently, most of my capsulotomy attempts are unsuccessful.”
2.      “I do not feel that publishing the results of this survey will do anything to enhance the current status of augmentation surgery in the eyes of the public, the media, and the FDA.”
3.      “When the results of your survey are published, the headline in the newspaper will read:  Surgeons Injury Hands Squeezing Breasts.”
4.      “Around here we call this breast buster’s thumb.”
5.      “If you will life weights and get in shape, then you will be able to break those capsules without any pain.”
6.      “I had never had an injury following a closed capsulotomy, but I have now developed ‘fatsucker’s arm,’ so that now when I do an external capsulotomy, I have pain in my brachioradialis.”

The 253 surgeons who reported hand or arm injuries represented 29 percent of the surgeons at risk.  This is a much higher percentage than reported in a previous study. ¹

These responses were studied for preexisting disease or injury, method of external capsulotomy employed, area or areas of involvement, treatment, degree of recovery, restriction of activities, duration of symptoms, and any observation or insights on the part of the surgeon.

Preexisting diseases or injuries were mentioned by numerically very few of the respondents; these included gamekeeper’s thumb, previous joint dislocation, old ski pole injury, tennis elbow, and several instances of posttraumatic arthritis.  The methods of external capsulotomy listed included open hands using the thumbs to help encircle the breasts, the closed-fist technique with most of the power coming from the pectoralis muscles, the heel of the palm technique (that is, not  using the thumbs) with the fingers either extended as in praying or interlocked, the use of an assistant (nurse or resident) to supply power over the surgeon’s hands, and some type of mechanical device. ^2-4 Surgeons who sustained thumb injuries usually switched to a method not employing the thumb.

The area or areas of involvement were as follows:

1.      Thumb, 180
2.      Elbow, 17
3.      Wrist, 14
4.      Hand, 10
5.      Shoulder, 9
6.      Forearm, 8
7.      Thumb and wrist, 4
8.      Thumb and index, 3
9.      Thumb and elbow, 2
10.     Not specified, 2
11.     Pectoralis muscle, 1
12.     Neck, 1
13.     Nerve, arm, 1
14.     Muscle, arm1

The thumb, either or both, was involved in over 75 percent of the reported injuries.  We could find no relationship between the area of involvement, the degree of recovery, and the age of the surgeon.

Recovery was divided into complete, partial (still bothered), or recurrent when doing any further external capsulotomies.  Most of the surgeons did have a complete or nearly to so recovery.  Some were still having trouble months or even years afterwards or whenever they attempted a difficult external capsulotomy.  All the groups had some restriction of their activities.  The least restriction noted was pain and/or inability to do any more external capsulotomies on the same day.  Other complaints mentioned were no golf or tennis.  There were restrictions noted secondary to the splinting of the injured area, there were a few surgeons who were unable to operate for a few days up to a few weeks, and several more who had to close down their practice for a few months.

The most common treatment was rest and immobilization with either a plastic or metal thumb or wrist splint or an orthoplast splint. One plastic surgeon developed a special splint for treating these injuries in his colleagues. ⁵ Aspirin, other salicylates, indomethacin, methocarbamol, and a few other drugs were mentioned.  Several surgeons required one or more cortisone injections.  There were two instances of surgery for late sequale of these injuries.

A perhaps not surprising number of surgeons have become disenchanted and either no longer do any external capsulotomies or have cut back considerably on the number being done.  Only a few continue to do the very difficult capsulotomies; several of these recommended bicycling to increase the grip or Nautilus to increase the strength in the upper arms.  A significant number of surgeons mentioned that they had either switched to subpectoral implants or had quit using smooth implants in an attempt to cut down on the incidence of firmness.

In summary, there is a significant risk of disability to the surgeon doing external capsulotomies.  However, the incidence may be expected to decrease as the number of external capsulotomies decreases.

Harry Hayes, Jr. MD
Suite 310
No. 1 St Vincent Circle
Little Rock, Arkansas 72205

References:

1.      Nelson, G.D.  Complications of closed compression after augmentation  mammaplasty. Plast. Reconstr. Surg. 66: 71, 1980 2.      Muldrow, L.   Personal communication, 1984
3.      Frank, D.H. and Robson, M.C.  A pneumatic tourniquet as an aid to release of capsular contracture around a breast implant.  Plast Reconstr. Surg. 61: 612, 1978
4.      Snyder, G.B., and Nestor, J.  An instrument for closed compression of capsular contracture of the breast.  Ann. Plast. Surg. 4: 245, 1980
5.      LeWinn, L.R.  Personal communication, 1984

MEF000024658/1118
(transcribed from handwritten notes by Pam Dowd, 010205)

Article Review, 1989, identified only with initials SAE

There is a significant risk of disability to the surgeon doing external capsulotomies.  The incidence may be expected to decrease as the number of external capsulotomies decreases.  This letter presents the results of a mail survey of the active members of the American Society of Plastic and Reconstructive Surgeons.  Fifty-Four percent of the total membership responded.  Three categories were group 1surgeons who did not perform external capsulotomies (211), group 2did external capsulotomies but never had an injury from doing the procedure (633), and group 3(253) surgeons who perform capsulotomies and had sustained injuries.  The 253 surgeons who reported hand or arm injuries represented 29% of the surgeons at risk.  The thumb, either one or both, was involved in over 75 % of the reported injuries.  All the group had some restriction of activities.  One plastic surgeon developed a special splint for treating these injuries in his colleagues.  Several surgeon required one or more cortisone injections and two instances of surgery for late sequale on these injuries.  A number of surgeons have become disenchanted and either no longer do external capsulotomies or have cut back on the number done.  A significant number of surgeons mentioned the had switched to subpectoral implants or had quit using smooth implants in an attempt to cut down on the incidence of firmness.