Causes of capsular contracture. A patient asks WHY?

Richard H. Tholen, MD, FACS
Article by
Minneapolis Plastic Surgeon

A capsule is the scar every woman's body forms around her breast implants (or any implanted object, like a pacemaker, for example). If the scar capsule is soft, thin, and pliable the breasts are soft and natural; if the scar is thick, tight, and contracted firmly around her implants, this is called capsular contracture and the result is breast firmness (and sometimes pain).

Breast implants do not become hard, ever.

When a breast enlargement patient has abnormally hard breasts, the problem is the scar capsule around the implants — for one reason or another, the capsule has thickened and contracted, squeezing the implant into a smaller space and causing the hard "feel" to develop. The human body creates a scar around any kind of foreign body, whether it is a pacemaker, a breast implant, or an artificial hip. Since every person forms scar tissue around any foreign body, every woman undergoing breast augmentation will have a capsule, but fortunately, only a few will develop capsular contracture to a problematic degree. If the scar capsule is thin, soft, and pliable around a breast implant, the augmented breast will feel soft. Since all scar tissue contracts, an excessively thick, non-pliable, and contracted scar capsule around a breast implant can make an augmented breast feel hard. Capsular contracture can be mild (Baker grade 2), moderate (Baker grade 3), or severe and visibly deforming (Baker grade 4).

Many studies have been conducted over the years regarding capsular contracture, and how to control or minimize the likelihood that it will occur. With a surface skin cut or surgical incision, despite any surgeon's skill, best efforts, and technique, a small percentage of patients will heal with a thick, wide, or ugly (hypertrophic--mild to moderate; keloid--severe) scar. This occurs rarely, appears to be genetically-based, is worsened by irritation and inflammation while healing, and is slightly more common in patients with darker skin. Vitamin E massage, scar pads, steroid tape or injections, or even scar revision plus any or all of the above can be used to reduce visible surface scars. Radiation treatments have even been used for the most severe surface scars, known as keloids. Fortunately, these are uncommon. Similarly, internal scar contracture causing firmness or distortion of appearance is also uncommon, occurring in 5-10 percent of augmentation mammoplasty patients. If this occurs, surgical revision may be necessary, and contracture may in some cases recur despite careful re-operation.

Avoidance of most cases of capsular contracture is possible, in my opinion, by careful initial surgery, maximum avoidance of irritation and inflammation (including bacterial contamination), and patient compliance with postoperative instructions. Bleeding (even a small amount) around your implants can lead to increased scar capsule formation, and is probably the number one cause of capsular contracture! If your surgeon used blunt dissection techniques, if you are wrapped in an Ace elastic bandage or tight surgical bra to "reduce bruising and bleeding," or if a drain is used "to remove the excess blood," you may be at increased risk for capsular contracture, simply because the way the surgeon does his or her operation.

Any foreign body, such as talcum powder from the surgeon's gloves, cotton fibers from surgical sponges, dust or bacteria from the air of the operating room on the surface of the implant, and bacteria from the ducts of the breast, as well as post-operative bleeding or bruising, can cause an increase in scar formation. This is analogous to a grain of sand in an oyster; in humans, a pearl is not formed, just layers of scar tissue, in response to one or several of these irritants. Every effort is taken to reduce all of these to an absolute minimum in order to minimize the likelihood of capsular contracture. I utilize a no-touch technique (facilitated by use of the Keller funnel) to place implants, as well as antiseptic irrigation, pinpoint cautery control of capillary bleeding, and avoidance of sponges in the pocket.

Most investigators now have identified bacterial biofilms on the surface of implants (from skin contamination, intraductal bacteria, or "normal" bacteria present in hair follicles or sweat ducts) as perhaps the second most common instigator of capsular scar contracture. Minimization of this biofilm by use of a no-touch technique, Betadine irrigations, or appropriate antibiotic irrigation, helps keep capsular contractures from bacterial sources to a bare minimum.

I never use drains for breast augmentation. Drains may allow blood or fluid out of the pocket, but of greater concern is that they can allow bacteria in, increasing the risk of contracture or infection severe enough to require implant removal. Careful surgery and control of all bleeding points is preferable to a drain or a tight surgical bra or elastic wrap after surgery! Intravenous antibiotics are used prior to surgery, and oral antibiotics are continued for several days post-operatively.

Recently, a new type of medication (in use since 1999 for the treatment of asthma) known as a leukotriene inhibitor has been shown to be helpful in possible prevention, reduction of severity, or even reversal of capsular contracture. Though preliminary, the use of this medication (zafirlukast, trade name Accolate™, or a similar drug Singulair™) may be an alternative to re-operation for removal of capsular scar tissue, or may lessen the likelihood of capsular contracture recurring after surgery. If you have liver disease, this may not be a choice for you, as this medication can have hepatic side effects in a small number of patients. I usually also prescribe 400iU of Vitamin E twice daily in addition to a leukotriene inhibitor in cases where capsular contracture is being treated or (hopefully) prevented.

I also question the use of textured implants BELOW the muscle. Since textured implants "work" by having tissue "adhere" to the textured surface, this means the implant pocket must be the exact size of the implant, and no movement is advised, or the tissues won't "stick" to the textured implant. In the submuscular position I recommend smooth implants and a pocket slightly larger than the implant's size, with implant movement exercises (often incorrectly called "massage") designed to keep the pocket open and larger than the implants. Even if the scar capsule contracts slightly, the pocket will still be larger than the implant, and the breasts will still feel soft and the breast implants will drop to the side of the chest when reclining, as natural breasts do. (HINT: natural breasts don't point straight up like a couple of hard coconuts!)

So, after all this explanation, you may have an idea or two as to what happened with your surgery. Or perhaps your surgeon did everything "RIGHT." Capsular contracture still occurs in a few of my patients, but it has become quite rare since I follow the "rules" and scientific evidence as to how to best avoid capsular contracture in my practice. And I do well over 150 breast augmentations per year, so this is not random.