What's the best method to treat capsular contracture?

Question

I had breast aug 10/15/09. Saline, under the muscle. I have capsular contracture in my right breast & have tried massaging & singlair per my surgeon. I am going to have to go back into the operating room to correct. What is the better method--having the tissue cut and corrected or replacing the implants? I am not happy with the size of my implants (too small) and would like to upgrade. However I do not want to increase my chances of this happening again.

Jed H. Horowitz, MD, FACS · Answer

Capsular Contraction is the #scar tissue that forms around the #implant is a natural response to a foreign object implanted in the body. The capsule can tighten and squeeze the implant making it firm. This is referred to as capsular contracture. This firmness (breast capsule) can range from slight to very hard. The firmest ones can cause varying degrees of discomfort or pain. #CapsularContracture can occur in one breast or both. Those  experiencing this are candidates for Breast Revision Surgery.  An implant revision or exchange intends to replace the damaged implants with new silicone or saline filled implants with newer technology.  econdary breast surgery can be complex and needs to be done by an experienced plastic surgeon. The specific procedure to be performed will depend on the complications experienced and the condition of the implants.

Richard J. Bruneteau, MD · Answer

It’s normal
for patients to form capsules around breast implants following breast
augmentation procedures.These capsules
are necessary to hold breast implants in proper position and, without capsule
formation, implants tend to migrate.Unfortunately, in a small percentage of patients, capsules become
exuberant.Under these circumstances,
they can cause implant distortion, implant hardening, implant migration, and
pain within the breasts.Unfortunately, the mechanism for
capsule formation is poorly understood.In some cases, it may be related to infection, while in other cases,
bleeding may be the cause.Regardless of
the precipitating event, inflammation appears to be a critical component.It’s important to note that the rate of
capsular contracture is significantly lower when breast implants are placed
beneath the pectoralis muscle.When capsule formation is relatively
mild, implant massage may occasionally improve the condition.Unfortunately, in many cases the problem
becomes progressive and the deformity worsens.When severe capsules occur, surgical
intervention may be necessary.In this
case, a procedure known as a capsulotomy can be performed.This procedure simply releases the capsule
and effectively increases the pocket size.In other cases, patients may undergo a procedure called a capsulectomy,
in which the capsule is actually removed.In some cases, removal of the implant and placement in a different
location, either on top of the muscle or below the muscle, may be necessary as
well.When these procedures are
performed, it’s not unusual to replace the current implant with a larger
implant.It’s important to wait for at
least six months before proceeding with surgical intervention to allow the
inflammatory response to diminish.The recurrence rate following these
procedures is relatively high and, for this reason, many surgeons utilize drugs
such as Singulair and steroids to decrease the inflammatory response.The use of these agents is somewhat
controversial and no scientific studies at this time have demonstrated
decreased rates of capsule formation.Once a severe capsule develops, it’s
important that the patient maintain close contact with their surgeon.Their surgeon should be able to formulate a
treatment plan that addresses their anatomic findings and hopefully achieves
their aesthetic goals.

Lewis Albert Andres, MD · Answer

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!

Michael Law, MD · Answer

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.

Otto Joseph Placik, MD · Answer

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.

Raffy Karamanoukian, MD, FACS · Answer

Simply removing and replacing the implants will not solve the problem of capsular contracture. I treat breast capsular contracture using a combination surgical and non-surgical approach including capsulectomy, implant replacement, topical protocols, and oral medications.

Tim Sayed, MD, MBA, FACS · Answer

Capsular contracture can range from very mild and hard-to-detect changes to the position of one or more implant all the way to a painful hardening of the breast (much less common, and often related to secondary issues like radiation treatment, infection, or a leak of an older generation silicone implant). The Baker classification is most commonly used to describe the extent of capsular contracture:
Baker Grade 1 – The breast is normally soft and appears natural in shape and size (not really a contracture)Baker Grade 2 – The breast is slightly firm but normal in appearanceBaker Grade 3 – The breast is firm and abnormal in appearanceBaker Grade 4 – The breast is hard, painful to the touch, and appears abnormalPatients with capsular contracture from prior augmentation have more options for correction than ever before. Some options for treatment of capsular contracture include:
Capsulectomy — removal of the capsule and implant) with replacement of the implant(s) and possible pocket change to the so-called “neosubpectoral pocket”Capsulotomy — scoring or otherwise partially releasing the capsule to allow the implant to settle betterImplant exchangeImplant and capsule removal without replacement of the implantUltrasound therapy and massage (appropriate for mild degrees of early contracture)One approach occasionally prescribed by plastic surgeons — though not FDA approved for this purpose and therefore “off-label” — is the use of medications called leukotriene inhibitors. These are medications usually prescribed for treatment of asthma and other respiratory conditions, which have found to potentially have modest beneficial effects on capsular contracture. I have not found them helpful in the rare cases I have prescribed them to test their value.

John J. Edney, MD · Answer

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.

Tom J. Pousti, MD · Answer

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.

David Whiteman, MD · Answer

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.

What's the best method to treat capsular contracture?

Answers (19)

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