Posted by Dr. Hardesty
A “breast capsule” is the normal result of the of the body surrounding the breast implant with a thin layer of tissue. A “capsular contracture” is the term used to describe an abnormal amount of tissue that abnormally forms and contracts around the breast implant, causing the implant to be compressed and resulting in a spectrum of slight firmness to rock-hard feeling breasts.This process may cause the breasts to feel and/or look different as well as create a malposition of the implant(s). In addition the contracting tissue may irritate nerves, resulting in slight discomfort to outright pain from the tightening of the abnormal capsule around the breast implant.
Capsular contracture is believed to be the most common untoward result of a breast augmentation procedure.
Typically during breast implant contracture, the breast becomes firmer to rock hard, less mobile, often elevated resulting in asymmetry, distorted in shape, or even painful. The implant usually moves upward and outward with a flattening under the breast. The breast implants can appear “fake” (like “bolt-ons”) and “stuck on” or less natural in appearance. The worst symptom is constant pain from the compression of the implant and irritation of sensory nerves.
The body reacts to all implantable foreign bodies (breast implants) by enclosing them in a normal thin layer of scar tissue around them called an “implant capsule” which is normal. In some cases the scar tissue becomes thicker and tighter, resulting in compression of the implant from an elliptical shape into a more rounded shape termed capsular contracture which is abnormal. In rare cases the capsule can become calcified and have the feeling of an egg shell.
The ratio of implant surface area (SA) to volume (V) best explains what transpires.
Example: Using a piece of paper
Highest SA to V is a flat piece of paper.
Lower SA to V, take the same piece of paper and compress into to a sphere.
The breast may feel firmer, may become rigid, or can be distorted and even painful at times. This process is a continuum and has been classified using the Baker classification:
Grade I: The breast is normally soft and looks natural.
Grade II: The breast is a little firm but looks normal.
Grade III: The breast is firm and looks abnormal (visible distortion).
Grade IV: The breast is hard, painful and looks abnormal (greater distortion).
The cause of capsular contracture is still not well understood despite multiple investigative studies. It has been associated with:
- A low-grade infection.
- Blood around the implant after surgery.
- A patient who simply is genetically predisposed and makes firm capsule (scar tissue).
- Biofilm – highly adherent bacteria that attaches to the implant and induces a capsular contracture; it can occur at any time, but generally most cases will be seen within the first several years after surgery.
Based on my personal experience, capsular contracture is more common in a patient with:
- Subglandular implants (implants placed under the breast tissue and above the muscle).
- When active breast displacement massage is not performed, which keeps the breast pocket larger than breast implant dimensions (maintaining SA to V) and thus keeps breasts feeling soft.
3. Breast infection after surgery.
4. An untreated hematoma around a breast implant (not removing the blood).
5. Leaking older liquid-silicone implants.
Treatment of a breast contracture usually involves progressive steps or a domination of the following:
- Implant removal (containing the biofilm), replaced with a new implant.
- Removal of the offending capsule (capsulectomy), the potential source of bacteria and abnormal scar-producing tissue.
- Relocation from a sub-glandular to a sub-pectoral pocket change.
- The use of a textured implant by increasing the SA to V ratio of the implant.
- However the textured surface may result in a less natural movement of the implant in the implant pocket.
- The use of acellular dermal matrix, or ADM, as a spacer graft to prevent secondary capsule formation.
- A combination of the above.
Unfortunately there is no guarantee you will be contracture-free after surgery, but my personal experience demonstrates the success rate is reasonable and consistent with others (well over 80 percent).
Medical or non-surgical treatment for breast contracture
Some therapy options include medications, injections, lasers and ultrasound treatments that have been helpful but none have proven to be totally effective.
The following is based on both scientific evidence and my personal experience:
1. Sub-muscular placement of breast implants
2. Gentle and traumatic technique
3. Meticulous hemostasis (no bleeding)
4. Perioperative use of antibiotics
5. Intraoperative irrigation of the breast pocket with broad spectrum antibiotics
6. “No touch” of breast implants (barriers to prevent skin contamination)
7. Preoperative decolonization of skin bacteria
Is the use of oral antibiotics before major dental work or other surgeries recommended?
The evidence here is not entirely clear. Most surgeons will use antibiotics after a breast enhancement as a prophylactic measure even though the evidence may not support its use.
Does a capsular contracture become softer over time?
It is possible the firmness of the breast implant may soften to some degree with time, but an established contracture is not likely to change.
Is there anything new that helps with secondary treatment of capsular contracture?
The use of textured implants and acellular dermal matrix (ADM) has shown promising results in reducing capsular contracture in those who undergo breast revision surgery. My personal experience with the material has been favorable.
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