Which incisions for BA will most likely cause capsular contracture? Is there one incision that will prevent the percentage of capsular more than the other?
Which Incisions for BA Will Most Likely Cause Capsular Contracture?
Doctor Answers 17
Breast Augmentation Approach
Although I do not disagree with any of the answers other surgeons have provided, because of recent evidence suggesting bacterial biofilms may be related to capsular contracture and because staph epidermidis is a commensal organism in lactiferous ducts, I am avoiding transection of ducts during augmentation as much as possible to avoid the potential introduction of staph epi to the implant pocket.
For me, this means fewer periareolar incisions and avoiding breast parenchyma during augmentation masopexy, although there is no scientific evidence at this time linking periareolar (or any) approach to capsular contracture.
Breast Augmentation Incisions and Capsular Contracture
Because no one knows what causes capsular contracture, it is very difficult to answer questions like yours definitely...
On the other hand, many of us do believe that bacteria have something to do with it... If this is the case, there is no question that placing the incision around your nipple elevates your risk of capsular contracture, as doing so requires transecting some of the ducts to the nipple, and these ducts contain many bacteria in all normal women.
If your goal is to minimize your risk of capsular contracture (as well as the risk of losing nipple sensation and the risk of inability to breast feed), you would probably be best off with an incision in your crease.
Breast incisions at most risk for capsular contracture.
The real problem is no one truly knows what causes capsular contracture. The biofilm theory is currently the most popular explanation but it does not account for all cases. Given this, the periareolar incision that transects the duct tissue probably poses the most theoretical risk for bacterial contamination. However, reports citing a lower overall incidence of infection with this incision would contradict this.
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Breast implants, capsular contracture
There is a least one published study that shows the periareolar (nipple) approach has a significantly higher rate of capsular contracture compared to the infra-mammary (crease) approach. While the reason for this is thought to be related to bacterial biofilms, research is still ongoing.
Capsular Contractures and incision placement
No one knows exactly what causes capsular contractures. One current theory is that of a bioflim on the surface of the implant. Biofilms are colonies of bacteria ( either one species or multiple ones) that cover themselves with a film that keeps them below the radar of the body's immune system. It makes them much, much more resistent to antibiotics. An example of a biofim is the plaque on your teeth. Mechanical disruption of the film is effective in reducing the tarter on your teeth and hence the reason for flossing. The breast ducts are filled with bacteria that normally don't cause a problem, but in theory could be the source of a biofilm on the implant. This has not been proven, however. Biofilms cannot be diagnosed with routine cultures making the study of them more challenging and expensive.
Unless there is a compelling reason to use one incision over another (small areolas for instance) I let my patients decide which incision they want, but I have noticed that a higher percentage of the patients I see with capsular contractures have had peri-areolar incisions. The difference is very small.
Incisions and capsule formation
No one specific incision for breast augmentation has been found to increase the risk of a capuslar contracture.
Does location of the incision in augmentation determine capsular contracture rate?
If it would be that simple, none of us would be doing the approach which leads to higher contracture rate. It is not the location of the incision that causes capsular contractures. There are multiple reasons for this including surgery, your ability to form scars, infections, complications from surgery and many unknown factors. As plastic surgeons, we can control the dissection, prevent bleeding, handle the tissues delicately, minimal handle the implant and so on. What we can't control is how your body heals, how active you are and how much trauma your body and breasts are exposed to after the surgery.
It's not the location of the incision for Breast Augmentation that effects the risks of capsular contraction
There are a lot of factors which influence the frequency of capsular contraction (hard breast Implants) but I don't believe there is any evidence that any one of the three usual incisions make any difference. What does make a real difference is the use of gentle tissue technique, washing out the pocket, changing gloves before handling the implant, irrigating the pocket with triple antibiotic solution and using a sleeve when putting in saline implants or a funnel when putting in gel implants.
I feel that the best incision for implants below the muscle is a trans axillary incision and the best incision for a sub mammary gel implant is the peri areolar.
Also there is no evidence that any of the three have any difference in the sensation loss of the nipple areolar complex. This is higher when the implants are placed under the breast than when they are placed under the muscle.
Incision Choice for Breast Augmentation and Capsular Contracture
As my colleagues have said, there is little data directly comparing the rate of capsular contracture with incision placement. Recent data does suggest that peri-areolar incisions may have a higher CC rate. This makes sense because cutting through breast tissue or milk ducts may release a small amount of bacteria - a leading theory of capsular contracture. The turth is that we just don't know what causes contracture exactly and it is probably a combination of bacteria, blood, and maybe even powder from surgical gloves or lint from surigcal towels. Like many people, I use a "no touch" technique, meaning that nothing ever touches the breast implant. This may reduce contracture rate.
No one augmentation incision has a higher capsule rate
Capsular contracture can be caused by many things such as low grade infection within the breast, bleeding in the breast, particle or dust on the implant, silicone bleed from the implant. The exact cause is actually not completely understood. If bacteria were 'the' cause then it would seem the solution would be at hand, but as yet we do not have a full answer. There is no data to implicate one incision, transaxillary, periareolar, or inframammary. All can give excellent results and surgeons have their biases. We have no capsules with the transaxillary approach, luck maybe, but again bacteria are not the only answer.
Best of luck,