You may have heard of someone's breast implants 'turning hard'. It is not the implants themselves that turn hard, of course; what has really happened is that the fibrous capsule around the implants has tightened and thickened, making the implants less mobile and causing them to feel firm (and eventually, in some cases, even 'hard'). The medical term for this phenomenon is 'capsular contracture'. It is a problem that is best managed by avoiding it altogether, and fortunately there are a number of things that can be done on the day of surgery to guard against it.
Any time a foreign object is implanted in the body, whether it is a pacemaker or a breast implant or an orthopedic device or anything else, the body responds by forming a thin, wispy, fibrous membrane around it. In most cases this membrane or 'capsule' stays thin and wispy, but in some cases over time the capsule may tighten around the implant and thicken, making the implant feel firm or even hard. In advanced stages the contracted capsule can even distort the shape and position of a breast implant. Capsular contracture can be treated, but it is a surgical treatment, so avoiding capsular contracture is all about avoiding another trip to the operating room.
Capsular contracture can occur on one or both sides, and while it can develop early (weeks) or late (years) after a breast augmentation surgery, in the vast majority of cases it is evident fairly early following the procedure. So the good news is that once you are six to 12 months out from your surgery, if your augmented breasts are soft and supple then they are likely to stay that way for the long term.
It is believed that capsular contracture is primarily a response to the presence of low-virulence or non-virulent bacteria (i.e. not the kind that generally produce an actual infection, with redness/tenderness/fever etc) that adhere to the implant surface on the day of surgery, and which over weeks and months following surgery stimulate the cells that make collagen (called fibroblasts) to make more collagen - thickening the capsule and stimulating it to contract and tighten around the implant. It is not an actual infection; there are no symptoms that this is going on, and taking antibiotics will not prevent the process or reverse it. The source of these non-virulent bacteria is thought to be the patient's skin, or the ductal systems of the breast that lead to the nipple, as both are normally colonized with bacteria.
Because plastic surgeons now have an understanding of some of the reasons why capsular contracture occurs, there are a number of measures that can be taken to significantly reduce the likelihood that it will happen following breast augmentation surgery.
Treatment of Capsular Contracture
The fact is that EVERY single foreign body or implant in our body becomes walled off by scar tissue. The body simply will not tolerate it otherwise. The scar tissue (also called CAPSULE) can be soft, impalpable and pose not symptoms (BAKER I class capsule) OR It can be hard, visible, palpable and associated with discomfort (BAKER IV capsule=CONTRACTURE).
Contractures have been associated with bacteria (placed at the time of surgery or by infections elsewhere in the body months to years later), by blood in the pocket, by cloth or surgical gown micro-fragments, by powder off the gloves - BUT the most common cause is never identified (in Medicalese - it is IDIOPATHIC).
Since we do NOT reliably know what caused a contracture, we cannot always reliably permanently fix it. Treatment with asthma drugs is based on nonscientific studies that it works in some cases. But - use of Accolate has been associated with rare cases of severe liver damage. So Plastic surgeons are justifiably leery of such use. In some cases Vitamin E and other drugs have been used with mixed success.
Partially weakening the scar with serial cuts (IE CAPSULOTOMY) helps immediately but in many cases the scar tissue reforms. Removal of the scar tissue (IE CAPSULECTOMY) can be complete or partial. Many of my colleagues would agree that complete capsulectomy is bloody (thereby increasing subsequent recurrence) and prone to major complications.
I think a partial capsulectomy, total irrigation of the pocket with antibiotic solution (both to remove any particulate matter and bacteria) and replacement with new implants (free of potential bacteria) is a safe way to proceed.
Personally, I would NOT "go larger" unless you have enough breast tissue to cover the new implants. But you and your surgeon need to discuss this. The act of removing the capsule makes the pocket larger which MAY make the implant look smaller.
Dr. P. Aldea
What is the best method to treat capture contracture?
After an implant is placed in the performance of a breast augmentation the body forms a lining around the implant creating a barrier between the foreign object and the rest of the body. Normally this barrier is thin and soft and does not create any change in the appearance or feel of the breast. This lining is called a capsule. If this capsule thickens, becomes harder and shrinks in size the breast will feel firmer and possibly change shape. This shrinkage and or thickening of the capsule is called a capsular contracture. 92% of capsular contractures will occur within the first 12 months following surgery. Although the exact cause for a capsular contracture is not well understood there are a few things that seem to be related to this phenomena. Implants placed under the muscle have a lower incidence of capsular contracture than implants placed above the muscle. If bleeding occurs in the pocket after a breast augmentation, and is not removed the accumulated blood will gradually be broken down. As the blood is broken down inflammation occurs in the pocket which can then lead to the formation of a capsular contracture. Any type of infection in the pocket can cause inflammation leading to a capsular contracture. The infection can be very minor and not cause any other symptoms.
There are several different treatment options for an established capsular contracture. One of the simplest ways is to release a capsule contracture is is by performing a capsulotomy. In the performance of a capsulotomy the previous incision is opened, the implant is removed and the capsule is then cut in several different locations to release the constrictions and establish a softer breast. The implant was then replaced and the wound is closed. Unfortunately this procedure by itself has a relatively high rate of recurrence. Many surgeons feel that it is important to create a site change and replace the implant with a new one. A site change refers to moving the implant to a new pocket location. For instance if the implant had been placed underneath the breast the new pocket is made under the muscle layer. If the implant was originally under the muscle it can either be placed under the breast or in what's called a neo-pectoral pocket. A neo-pectoral pocket is developed by temporarily removing the implant and creating a new pocket behind the back wall of the capsule surrounding the implant. The implant is then placed in this new pocket. Most surgeons agree that it is also important to put a new implant in when treating a capsular contracture. This is due to the possibility that the old implant is covered by "biofilm". Biofilm is a barrier forms around some implants possibly secondary to a subclinical infection. A subclinical infection is one that affects the breast implant pocket but does not cause any other external symptoms.
What's the best method to treat capsular contracture?
Hello! Thank you for your question! Physical examination will determine if you have capsular contracture. The look and feel of hardness surrounding your implant is seen and/or felt. It may also cause distortion of your breast. What has caused it will be in question.
Your surgeon will likely recommend implant massage and may add the medication Singulair. It is a matter of surgeon preference as well as what is seen during your procedure that will determine whether or not a complete capsulectomy is performed. If significant capsule formation is seen intraoperatively, a full capule removal may be warranted with a drain in order to completely remove all of the tissue and allow better adherence of your breast back to its normal anatomic position down on your chest wall. Irrigating with certain medications may also be if benefit. If minimal contracture is seen, it may be possible to leave the capsule, or place cuts within the capsule to allow better adherence. It truly is dependent on what is seen with your capsule and the issues that may be causing you to have such a procedure (e.g., contracture from rutptured implant vs pain vs simple pocket adjustment, etc).
Without knowing your issues and without an examination, it is difficult to tell you what may be the best thing for you. I tend to favor performing capsulectomies in order to create a fresh pocket, reshape the pocket, allow better shape and adherence of the overlying breast. I would discuss your issues with your plastic surgeon who will assist you in determining the right modality for you. Hope that this helps! Best wishes!
What's the Best Method to Treat Capsular Contracture?
Sorry to hear about the complications you have experienced. Capsular contraction can be a very frustrating complication for both patients and surgeons. In my practice, I have found the most success treating these difficult problems utilizing techniques such as sub muscular pocket conversion (if relevant), capsulectomy, use of fresh implants, and the use of acellular dermal matrix. Acellular dermal matrix is a biologic implant that carries the ability to become integrated into native tissue. It is made by taking a full thickness section of skin from a donor source ( human, porcine, or bovine in origin). I hope this, and the attached link ( demonstrating a case utilizing acellular dermal matrix) helps.
Capsular contracture treatment options
When any foreign object is placed in the body, the immune system responds by forming a lining around the object. While the causes for capsular contracture in breast implants are still unclear, the condition is fairly easy to treat surgically. Some surgeons will surgically reopen the breast and cut the scar tissue to release its hold on the breast implant. Most surgeons will surgically reopen the breast, completely remove the scar tissue that is causing the capsular contracture, and insert a new breast implant (or remove them completely based on the patient’s wishes). This option can offer an added benefit, because the scar tissue that may be causing the contracture can be removed and the size of your implant can possibly be increased all in one surgical procedure. As far as which option is the better method would be based on your individual case. It is important for you to discuss your best options with the plastic surgeon that performed your breast surgery as he/she is best suited to address the capsular contracture. If you are not satisfied with their answer then it is certainly your decision to be seen by another plastic surgeon to get another opinion.
It is unclear why capsular contractures develop in one patient and not another. It may be multifactorial. I usually remove the capsule and replace the implants.
Preveneting recurrent capsular contracture with revision breast augmentation
There is no definitive answer to this question other than the best way to prevent capsular contracture is to remove the implants and leave them out. That having been said. I would advise capsulectomy with implant removal and replacement.
Treatment of capsular contracture
You have brought up an important topic.
Unfortunately, since we don't know the exact cause of capsular contracture, we cannot prevent this problem.
The only two methods which have any chance of correcting your situation is capsulotomy (where cuts are made in the capsule to "open up" the tightness) and capsulectomy (where the entire capsule is removed).
I reserve capsulectomy for patients who have had recurrent contracture, as it is a much more involved procedure and the chance of thinning the breast tissue is higher. This may make your implants more visible.
Unfortunately, there are occasional patients who develop recurrent contracture and may be better off with no implants.
Treatment of capsular contractures
Unfortunately, capsular contracture continue to plague plastic surgeons and our patients despite using the best techniques known to prevent them Non-surgiacl methods of treating capsular contractures include multiple sessions of external ultrasound and oral medications suche as Accolate, Singulair, PavaBid, and Vitamin E. I have had only rare success in treating capsular contractures non-surgically.
Most patients will require surgery to remove the entire capsule or create a neopectoral pocket-- a new pocket right on top of the old one. The addition of a material called Strattice, a type of acellular matrix, has been show to prevent the formation of a scar capsule completely around the implant and prevent contractures. Despite its expense, I have found Strattice to be very useful.