What is a Capsular Contracture?
What is Capsular Contracture?
Capsular contracture is the most common complication of breast augmentation surgery. It results when an individual’s immune system forms a capsule of collagen fibers around an implant. This capsule is the body’s way of ‘walling-off’ a breast implant and isolating it from the rest of the body, in an attempt to protect the body from what it believes is a foreign antigen.
Doctors and scientists do not why certain people are more prone to capsular contracture, although modern surgical techniques (explained below) have helped mitigate the increased incidence of their formation.
How are Capsular Contractures diagnosed?
As a capsule forms and contracts around a breast implant, the breasts become hardened, sometimes resulting in an abnormal appearance. Depending of the degree of the capsular contracture, doctors classify it into one of four categories:
Grade One: The breast remain soft when touched is normal in shape and appearance.
Grade Two: The breasts are slightly firm but stil appear normal in shape and appearance.
Grade Three: The breast is firm when touched and is slightly abnormal in shape and appearance.
Grade Four: The breast is hard when touched and no longer appears normal In shape and appearance.
If you\'re concerned you have a capsular contracture, you should visit a board certified plastic surgeon.
How Common is Capsular Contracture?
Studies have shown that nearly 27% of women that have a breast augmentation experience some degree of capsular contracture. However, most surgeons see much lower incidence rates (10-20%).
Can Imaging Detect a Capsular Contracture?
Imaging is not typically necessary for a patients to be diagnosed with a capsular contracture. Patients are often able to first feel and see changes in their breast size and appearance before imaging is required. A mammogram with either ultrasound or an MRI, should detect a thickened capsule around the breast implant (see picture below).
The photos below show a patient who had silicone implants placed 15 years ago. This bilateral mammography shows the woman on the left has a capsular contracture.
The image below show the capsule formation around the image up-close.
How Can the Risk of Forming a Capsular Contracture Be Reduced?
Breast Implant Placement: Breast implants placed under the muscle (submuscularly or subpectoral) reduces the risk of capsular contracture by approximately 10%. Placing an implant on top of the muscle reduces the risk of capsular contracture by as much as 8%.
Textured Implants: Textured implants (see picture below) contain a rougher, 'textured' surface. Textured implants help reduce capsular contracture by deterring tissue formation around the implant. However, textured implants only help reduce capsular contracture when the implant is placed above the subglandularly or above the muscle. Since most breast augmentations are now performed by placing the implant submusclarly or subpectoral (behind the chest wall), the advantages of textured implants for capsular contracture are greatly reduced. Patients do not usually prefer textured implants, because of their rougher surface, which causes patients to feel them more.
Textured implant on the left and a non-textured implant on the right.
Massaging Your Breasts: Some plastic surgeons believe massaging your breasts will help prevent capsular contractures. While there is no scientific evidence to back this up, massaging your breasts will certainly help soften your breasts after a breast augmentation and may expedite the dropping of your implant into the pocket of your breasts, helping properly position them. Massage also helps with the emotional well-being of patients, because who doesn't like a massage?
Closed Filling System: When saline implants are used during a breast augmentation, implants that are filled through the use of a sterile bag/tubing system (see image below).
Limited Touching Implants During an Augmentation: Some doctors believe in the 'no-touch' technique of breast augmentation. With this technique, surgeons limit directly touching the implants. The implants are expelled from their sterile packaging and are only opened immediately prior to their insertion into the breast pocket. The skin of the patient is thoroughly sterilized with betadine, the surgeon replaces their gloves, removes any excess powder on them, and only then touches the implants. The implants are then carefully placed in the implant pocket without touching any of surgical instruments, skin, or drapes surrounding the patient. By limiting the surfaces the implant touches, the implant picks up fewer contaminants, and therefore reduces the chance of the body's immune system creating a capsule around the implant. If your body thinks the implant belongs, a capsule is not formed.
What Methods are Used to Treat Capsular Contracture?
There are both surgical and non-surgical methods used to treat a capsular contracture. Here are some of them.
- High Dose of Vitamin E: Vitamin E is known for its scar softening properties on the skin. Unfortunately, it does not work well when taken orally for capsular contracture. Most surgeons do not recommend this treatment, as high doses of vitamin E over long periods of time can lead to cardiovascular disease.
- Antibiotics: While bacteria is one of the causes of capsular contracture, taking antibiotics does not eliminate the collagen fibers around the implant and does not help improve the capsular contracture.
- Ultrasound/Infrared/RF Devices: While some providers offer these devices to treat capsular contracture, that have not been proven to be effective.
- Implant Massage: Many patients are told to massage their breasts following a breast augmentation. This has not been proven to be effective in preventing and treating capsular contractures.
- Leukotriene Inhibitors: Singulair and Accolate are FDA approved drugs that can reduce the severity and frequency of asthma attacks. Some doctors believe these same drugs can be used to soften capsular contractures, although they are certainly not the norm and most physicians do not believe that they help with capsular contractures.
- Closed Capsulotomy: This procedure involves forcibly rupturing the capsule around the implant using strong forces applied directly to the implant. This was found to not be effective, as the capsule frequently reformed and was quite an unpleasant experience for the patient.
- Acellular Dermal Matrices: Sheets of collagen/protein that are derived from various biological sources and have been decellularized (a process that removes the extracellular matrix (ECM) from its inhabiting cells). Frequently used in implant breast reconstruction to lower capsular contracture, doctors have tried using ADMs for cosmetic breast augmentation capsular contractures. Unfortunately, ADMs have not been found to be superior to a complete capsulectomy (see below).
- Open Capsulotomy: A simple surgical procedure where the capsule in cut into small pieces using an electrocautery device. In this procedure, the original implant that originally surrounded the capsule is left inside the body. This procedure is not frequently used, as there was a high recurrence rate of capsular contracture with this method.
- Partial Capsulectomy: A more involved surgical procedure than open capsulotomy, this procedure involves the partial removal of the capsule. The amount removes varies, from a small to very large piece of the capsule. A new implant is usually used with this procedure. While this procedure is effective and there are lower recurrence rates than with an open capsulotomy, the rates are still higher than a complete capsulectomy (see below).
- Complete/Total Capsulectomy: This procedure involves the complete removal of the scar capsule and implant (see images below). This procedure is the most time intensive for surgeons to perform, but offers the most effective results. The reoccurrence rate with a total capsulectomy is significantly lower than any other treatment method currently offered.
Complete Capsulectomy: The capsule is shown surrounding an implant
An image showing a capsule that once surrounded a breast implant.
First, the capsule is a normal reaction to the implant. All implants have a capsule. The capsule is a scar.
It is VERY DIFFICULT to form Capsular Contracture in three weeks.
However, if there was some blood accumulation that was not recognized, one could form a hard scar. Capsular contracture occurs in 5-15%.
The other issue one needs to know is where the implant was placed - above or below the muscle?
It is possible if the implant is under the muscle that the muscle is not adequately released; this will cause the implant to ride high and be tight.