3 weeks post op. Capsular contracture? (photos)

Question

Hi. I'm 3 weeks post op from a bilateral breast implant exchange and internal stitches put in to keep the breast safe medial (they bottomed out and were lateral before). The left one feels high and looks different than the right. I like the position and location of the right but the left doesn't look or feel right. It doesn't feel hard, but I do feel it sitting really high. And swollen. Does it look like it could be capsular contracture? I'm also a registered nurse and its my first night back:(

Gary Lawton, MD, FACS · Answer

It is too early for capsular contracture, although implant massage might help.Implant massage is a critical part of the postoperative recovery from breast augmentation (like physical therapy is a critical part of the postoperative recovery from knee surgery).  The space for the implant is meticulously crafted at the time of augmentation surgery, especially when the operation is performed using the surgical endoscope through the transaxillary approach.  However, the distance from the nipple to the inframammary fold needs to stretch out to accommodate the implant (dropping) and the skin and muscle need to relax to give the desired shape (fluffing).  Implant massage allows you to manipulate the pocket from the inside to direct the forces in the appropriate directions to mold the breast shape to the desired outcome.  If the scar that is actively forming around the implant is allowed to heal without the influence of breast massage, the fold will not stretch appropriately (implant stays too high), the scar will attempt to contract in a linear way over the curved surface of the implant (breast shape will remain too flat), and the space will attempt to heal smaller and tighter than the implant (capsular contracture).  Implant massage influences the scar formation on the inside at the most critical phase of the healing, allowing the space to be larger than the implant (mobility which creates the natural feel and bounce).

Implant massage starts at one week at 5 times per day for one minute at a time and continues at this pace until one month.  I often see the patients weekly during this time to reinforce the technique and help the patients who need extra effort to soften the breasts. During this time period, the massage also breaks up the spasm, relieving the discomfort, particularly upon awakening from sleep (morning breast).  During the day, every time there is the sensation of tightness, implant massage breaks up the spasm and relieves the discomfort, minimizing the need for narcotics.  At one month, the force that can be exerted is increased but the frequency of massage decreases to 3 times per day.  As the wound matures, the massage can decrease to once per day forever as maintenance.  The patients integrate this into their shower routine.

Although some patients can get away with no massage, it is a common issue for those who stop the massage and make none of their follow up appointment to suddenly show up years after surgery claiming that they woke up one morning with a capsular contracture and implant malposition.  Of course this did not happen overnight, but was a slow process that could have been prevented with daily maintenance massage and regular routine follow appointments on a yearly basis (which we provide for free, forever). With this type of perpetual follow up, it is possible to identify a problem early that might need a modification in the massage technique.

Implant massage involves moving the device up against the wall of the pocket, holding pressure against the surface of the scar. The specifics are determined on an individual basis guided by what the patient needs. In some patients it is simple and of little significance.  In some patients it is a struggle to get the implants into the right position and to gain softness and mobility, but with the right technique and the appropriate dedication it is a huge success.  For the patients that do not participate in the massage in a meaningful way, some will get away with their lack of dedication because they were going to have soft breasts no matter what.  On the other hand, some patients will squander their opportunity to have an excellent result because they don't believe that the massage is necessary, or because they have been told by their friends or other doctors that they didn't need to perform massage.  Regardless, they often require surgery that could have been avoided by following the postoperative instructions of a surgeon that has performed nearly 10,000 breast implant operations and has seen the healing of each of those patients and integrated the successes and failures of each one into a postoperative plan that really works.

I find no use for bands, straps, bras or appliances after breast augmentation surgery.

Emmanuel Mallol Cotes, MD · Answer

Thanks for the question. In my practice, after performing a BA I recommend to my patients to limit the movement of the arms for two weeks. After that, you can move your arms taking care and always with common sense. In this regard, it's not advisable to carry heavy weights to prevent the implant out of position, and allow the formation of the physiological capsule around the implant, also to avoid pain and breast swelling. Kind regards

Nathan Eberle, MD, DDS, FACS · Answer

congratulations on your recent surgery, it appears you are healing appropriately from the photos. The left side does appear to be a little more swollen/larger/higher than the left, but remember you are very early in your post-op period, allow the swelling to go down and for the left side to likely settle a little more. You may have also had a large breast on the left(typical for most woman) to begin with, if the surgeon didn't attempt to correct for this, than the left will continue to be a little bigger. Reach out to your surgeon, discuss with him/her your concerns and hopefully things continue to heal and settle appropriately. The chances of having a contracture 3 weeks out are almost zero.

David Bogue, MD · Answer

It is unlikely that at 3 weeks your capsules are even well formed. Rather, what is more likely is that the breasts are tight from the capsullorhaphies. When you have an issue with malposition of the implants, the issue is often over-corrected to account for the inevitable relaxation that will happen in the coming months. Be patient, follow your postoperative instructions, and try to avoid overanalyzing the early results.

Darryl J. Blinski, MD · Answer

Without seeing your before photos very hard to advise! Mild or minor asymmetries are acceptable but can be corrected after 3 months healing. Best to discus with your chosen surgeon....

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