Breast implant revision - should the capsule be removed? Does leaving it in increase risk of capsular contracture?

Question

I’ve had 800 cc silicone ultra high profile implants under the muscle for 10 years. I’m going to replace them with the same size and profile but put them in a dual plane so that I get more fullness on the bottom as opposed to the top. My dr says he won’t have to remove the capsule. Will my results be final right away or will it still take time? And why not remove the capsule? Does that put me at risk for capsualr contracture ?

Mert Demirel, MD · Answer

The capsule does not always need to be removed during implant exchange. If the capsule is thin, soft, healthy, and there is no rupture, infection, calcification, fluid, mass, or significant capsular contracture, many surgeons may leave part or most of it in place.
Removing the capsule can add bleeding, trauma, pain, longer surgery time, and higher risk, especially with large submuscular implants. So the decision should be based on what the capsule looks and feels like, not on a rule that it must always be removed.
Leaving a healthy capsule does not automatically cause capsular contracture. However, if the capsule is already thick, tight, inflamed, calcified, contaminated, or associated with contracture, then leaving it may increase the chance of persistent firmness or recurrent contracture.
Your result will not be final right away. Even with an implant exchange, swelling, muscle relaxation, pocket adjustment, and implant settling can take weeks to months. With 800cc ultra-high-profile implants, the tissues are under significant stretch, so the final lower-pole shape may take time and may also depend on pocket control and skin quality.
One important point: “dual plane” still means partly under the muscle. If your implants are already under the muscle, ask your surgeon exactly what pocket changes are being made to create more lower fullness. Sometimes the issue is not only the plane, but implant position, fold level, capsule release, lower-pole tightness, or tissue stretch.
My advice would be to ask your surgeon: Is my capsule soft or contracted? Is there any rupture or silicone leakage? Will you do capsulotomy, partial capsulectomy, or capsule scoring? How will you control the lower pole and inframammary fold with 800cc implants? A healthy capsule can often be left safely, but the revision plan should be very clear.

Gerald Minniti, MD, FACS · Answer

Capsules don't have to be removed with every breast implant revision surgery. Sometimes they need to be tightened, sometimes just cut. They should be completely removed when a capsular contracture is the issue. Regarding implant pockets, it is highly likely that your implants are in a dual plane position now; dual plane is the same as subpectoral. It would be impossible for 800cc implants to be a a full submuscular position (under pectoralis major, serratus, and upper rectus muscles).

Luis A. Mejia, MD · Answer

Thank for your question, No. Leaving a healthy, soft capsule intact does not increase your risk of future capsular contracture.
Capsular contracture is driven by chronic inflammation, subclinical bacterial contamination (biofilm), or bleeding around the implant, not by the presence of a healthy, existing capsule. In fact, doing an aggressive, unnecessary capsulectomy increases bleeding, which is a known trigger for new contracture formation. Complete capsule removal is typically reserved for cases where the capsule is already hardened or calcified (Baker Grade III/IV), or in cases of implant rupture.
Dr. Luis Mejia
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Gary M. Horndeski, MD · Answer

Your implants are behind the muscle, which means the implants are overlying the ribcage. The capsule is then overlying the ribcage. If you try to remove the capsule you are right on the ribs and the muscle and may result in a complication such as pneumothorax and possibly have more bleeding. Unless you are having a problem with the capsule I usually recommend leaving the capsules.

Best Wishes,

Gary Horndeski, M.D.

Best Wishes,

Gary Horndeski, M.D.

Breast implant revision - should the capsule be removed? Does leaving it in increase risk of capsular contracture?

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