Authors' response: Reply from Messrs M. W. Kissin and A. E. Kark

Correspondence when there is no sort of endotracheal tube in place. Factors which cause it include confusion. debility, the presence of a nasogastric tube and drinking while semi-recumbent. In these circumstances rather than blaming the minitracheotomy. we regard it as positively indicated as a way of dealing with the problem, for the technique is, of course, equally effective in removing liquid material that has arrived from above by aspiration as it is in dealing with secretions that have been generated in the tracheobronchial tree. We note that one of the patients reported (having a subclavian bypass) had a ‘postoperative intrathoracic haematoma’, which required formal tracheostomy for a period of 3 months. We would suggest that in this patient aspiration was caused in some way by this problem, and not by the minitracheotomy. Details of the other two patients are necessarily scant in a letter of this type, but the authors would need to demonstrate that no other factors could have caused aspiration in order to conclude that the minitracheotomy was responsible. This they have not done. We also think that it is not valid to assume that the effects of a full sized tracheostomy tube will be the same as with the much smaller minitracheotomy. We find it difficult to accept that a 4 mm uncuffed tube placed in the subglottic position will interfere significantly with supraglottic function. Dr Pasi rt at. admit the technique was effective in dealing with the respiratory problems in two of their three patients, without the need for further measures, and the third patient had a problem for which the minitracheotomy was clearly not designed. The point they have raised may justify further study, but on the data which they have presented we are unable to agree with the conclusions which they have drawn. 1. zy Cairns TS, De Villiers W. Capsular contracture after breast augmentation-a comparison between gel and saline filled prostheses. S Afr Med J 1980; 57: 951-3. McKinney P, Tresley G . Long term comparison of patients with gel and saline mammary implants. Plastic Reconsrruct Surg 1983; 72: 27-9. Hetter GP. Satisfactions and dissatisfactions of patients with augmentation mammaplasty. Plastic Reconstruct Surg 1979; 64: 151-5. Rudolph R, Abraham J, Vecchione T et al. Myofibroblasts and free silicone around breast implants. Plastic Reconstruct Sury 1978;62: 185-96. Burkhardt BR. Fried M, Schnur PL et al. Capsules. infection and intraluminal antibiotics. Plastic Reconstruct Surg 1981;68: 43-7. Hipps CJ, Raju DR, Straith RE. Influence of some operative and postoperative factors on capsular contracture around breast prostheses. Plastic Reconstruct Surg 1978; 61 : 384-9. Ksander GA, Vistnes LM, Kosek J. Effect of implant location on compressibility and capsule formation around miniprostheses in rats and experimental capsule contracture. Ann PIast Surg 1981 ;6 : 182-93. Wallace AF. Capsular contracture in breast augmentation : a return to the good old days? Br J Plastic Surg 1982; 35: 374-5. zyxw zyxwvutsrqpon zyxwvuts zyxwvuts H. R. Matthew R. B. Hopkinson 2. 3. 4. 5. 6. 7. 8. Authors‘ response: reply from Messrs M. W. Kissin and A. E. Kark Sir Thank you for the opportunity of replying to the comments by M e w s Dickson and Sharpe. We agree that a proper comparison between the gel-filled and saline-filled prosthesis is needed, preferably in a doubleblind controlled trial. The placement deep to the muscle provides a less obtrusive capsule than subcutaneously and we have felt it important to drain the cavity for 24 h to prevent any haematoma formation. The deflation rate is, of course, a significant complication. The fear that this might increase with longer follow-up has not been realized and in our series there havc been no further cases after a mean follow-up period of 38 months. Although the complication is unfortunate and causes a good deal of concern we have made a practice of re-admitting the patient immediately removing the deflated prosthesis through a small incision and replace it with a saline- or gel-filled prosthesis. The hospital stay on this occasion does not usually exceed 2-3 days. Although the saline-filled prosthesis is no longer available, it still provides in our view, a better cosmetic result despite deflation problems, but we agree that the gel-filled implants are a very satisfactory substitute. zyxwvuts Postmastectomy breast reconstruction with an inflatable prosthesis Sir We read with interest the paper by Kissin and Kark (Br J Surg 1984; 71: 8024), and would like to make some comments on their choice of a saline-filled rather than a gel-filled prosthesis. Although there does appear to be a slightly higher incidence of capsular contracture with gel-filled implants than with saline-filled implants, the difference is nowhere near as great as Cairns and De Villiers report’. McKinney and Tresley2 cite a 36 per cent incidence for gel-filled against 24 per cent for saline-filled, and Hetter3 gives 60 per cent for gel-filled against 40 per cent for saline-filled.There has, as yet, been no reported double blind controlled series comparing the two. Various factors have been suggested as being the possible cause of capsular contracture. As Kissin and Kark point out, foreign body reaction, either to the implant envelope or to ‘gel bleeding’,seems a likely cause. although microscope studies of capsules have shown that the presence of silicone particles does not correspond with clinical firmness4. Other factors that have been implicated are infection’ and haematoma6. The incidence of unilateral contracture in cases with bilateral implants (54 per cent in one series‘) suggests that thecause may be multifactorial. Retromuscular placement of the implant does seem to reduce clinical firmness of the breast, but the mechanism of this is obscure. It may be that softness of the submuscular implant is an artefact caused by greater overlying tissue mass. and there are experimental studies that seem to confirm this’. Local steroids, topical and systemic antibiotics have also been used to prevent contracture but no clear benefit has been demonstrated. Indeed steroids may lead to unwanted tissue atrophy and possible implant extrusion. Our practice in this unit is to instruct the patient to use compression exercises on the augmented breast in order to maintain a larger volume of the capsule. Finally, the incidence of late deflation of saline filled implants is high. Kissin and Kark cite a 14 per cent deflation rate, but this figure may become higher as time passes..Patients seem to tolerate sudden deflation of the implant less well than the gradual development of firmness. For this reason, most plastic surgeons in the United Kingdom use gel-filled implants. It is interesting to note that Wallace* has reported a very low incidence of capsular contracture (3 per cent) with gel-filled implants that have thicker capsules, a finding which may support the ‘gel bleed‘ theory of aetiology. M. W.Kissin A. E. Kark Clinical Research Centre Watford Road Harrow Middlesex HA1 3UJ A method of securing suction drains Sir I read with interest the paper by Messrs O’Neil and Harrison (Br J Surg 1984; 71: 932). The method of using a rubber collar to secure drainage tubes is a useful one but the use of short segments of rubber capillary tubing which have to be separately sterilized is unnecessary. A short, sterile, segment of tubing of the correct calibre can be very conveniently obtained by cutting a 3 4 mm piece off the rubber connector which is provided by themanufacturer to connect thedrain itself to the widerbore tubing leading to the bottle. Apart from convenience this method ofdrain fixation is also valuable in situations where the surgeon wishes to shorten the drain before its final removal. The collar can be rolled down the drain as it is withdrawn leaving the shortened drain still firmly attached to the patient. In drains of large calibre such as silastic tubing commonly used to drain the peritoneal and pleural cavities a segment of the drain itself can be conveniently used as a collar. zyxwvutsrqpo M. G. Dickson D. T. Sharpe St James’s University Hospital Leeds LS9 7TF Br. J. Surg., Vol. 72, No. 3, March 1985 R. J. Ham The London Hospital Whitechapel London E l IBB 253