Standard Practice to Remove the Capsule for Capsular Contracture During Revision Surgery?

I've had a 2nd opinion that at least 1 of my implants is CC'ing. I'm due for rev. sx for a lift & was told the capsules need to come out if they are. I'm on Singulair, take Vit. E & massage. My surgeon says he never removes the capsule even if it's CC'd. He just opens it by splitting it in 1/2 before inserting new implants. He said it's very bloody & unnecessary to remove it. Is it standard procedure to leave the cc'd capsule in or take it out? I have under the muscle, smooth, silicone implants.

Doctor Answers 19

What Surgery Should I Have For A Capsular Contracture?

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Capsular contractures are tight scars around breast implants which are generated by one's immune system in an attempt to protect the breast implant patient from the foreign bodies in one's chest.  The two major intra-operative causes of capsular contracture are: 1) blood around an implant; and 2) non-pathogenic bacteria around an implant.

Each surgeon has his or her own techniques for revision surgery when capsular contracture is involved.  I personally do a total or subtotal capsulectomy, and since Acellular Dermal Matrix (ADM) are so good at preventing recurrent capsules, I do not believe switching from a sub pectoral to a super pectoral pocket is of any value, and also has many unwanted consequences.  Obviously, in a situation where you are increasing the amount of bleeding inter-operatively, one should use Arista or some other hemostatic agent along with a JP drain that is left in for 3 days.  

I also find the prophylactic use of Accolate to decrease the chance of capsular contracture along with the intra-operative regiment listed above can lead to amazingly soft breasts.  As you can see, I use the Accolate prophylactically and not therapeutically as many surgeons do.  I think it is easier to stop a snowball at the top of the hill than midway down the hill.  

Capsular contracture treatments.

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Capsular contracture is present in ~25% of breast augmentation cases and may be attributable to known causes such as infection (overt or subclinical), hematomas, or persistent seromas. Many times, the reason for capsular contracture is unknown. It can present as early as a month postoperatively or several years later. Treatment begins with conservative methods such as massage, ultrasound, anti-inflammatories, etc. However, surgery is the mainstay of treatment for recurrent contracture. The basic issue is a prolonged inflammatory response due to some factor within the capsule itself. The goal of capsular contracture surgery is to minimize the chance that the contracture will recur. Removal of the entire capsule (including the posterior wall) with or without the addition of an acellular dermal matrix (ie Alloderm or Strattice), site change of the implant (if possible), and aggressive postoperative massage give the best chance at capsular contracture resolution. Even with all of these techniques, contracture may still recur. In some women, the only curative procedure is removal of the implants permanently.

Many theories exist for the prolonged inflammatory response causing contracture. In some cases, that inflammatory response may burn itself out, however the capsule remains. In those types of cases a capsulotomy (what your surgeon described) may work. The difficulty is identifying when the inflammatory response or the inciting cause is still present within the capsule or implant space. Because of this uncertainty and the cost of surgery (including patient recovery and downtime), I believe that total capsulectomy is justifiable.

David Bogue, MD
Boca Raton Plastic Surgeon
5.0 out of 5 stars 26 reviews

Standard Practice to Remove the Capsule for Capsular Contracture During Revision Surgery?

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Removing the capsule has a higher complication rate such as bleeding and thinning of the tissues compared to capsulotomy (releasing or scorring the capsule)

A new capsule forms anyway when a new implant is placed

I therefore tend to leave tha capsule unless it is thickened or calcified

I will use an adjustable implant in recurrent cases ,where after capsule release I temporarily overexpand the capsule and then release it to the optimal size later

When to do capsulectomy after breast capsular contracture?

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This is a tough question to globalize: every case is different.  In general, it this is the first time the breast capsule has contracted and the implant is above the muscle, one can do a capsular release only and place the implant below the muscle.  If the implant is below the muscle and the contracture is mild, I may do capsulotomy only.  If this is the second time or more the capsule has contracted, then the capsule should be removed.

Michael A. Jazayeri, MD
Santa Ana Plastic Surgeon

How to treat a capsular contracture?

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I do tend to remove the capsules in my patients with capsular contracture, but if the implants are under the muscle, I do usually leave some of the capsule attached to the ribs.  Sometimes, though, I do leave the capsule, but I put the implant in a new plane of dissection just above the capsule (a "neosubpectoral pocket").  Regardless of the method, I do think it's important to place the implant into a mostly virgin space, not just put a new implant back into the same pocket that was contracted in the first place.

Treatment of Breast Capsular Contracture

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With breast implant revision, it may not be necessary to totally remove the capsule. However, with a significant capsular contracture, removal of the capsule is usually recommended. There are several reasons for this. One of the main reasons is that many surgeons believe that many, if not most, capsular contractures now are caused by a bio-film of non-invasive germs on the implant. These cause the surrounding tissue to react and contract. By replacing the old implant, removing the contaminated capsule and thoroughly irrigating with an antibiotic solution one can reduce the recurrence rate. Other methods of reducing recurrence are changing implant position and changing the type of implant (i.e., using a textured implant instead of a smooth one).

Robert T. Buchanan, MD
Highlands Plastic Surgeon

Treatment of capsular contracture

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Capsular contracture with silicone implants, usually requires removal of all or most of the capsule.  The capsule has typically shrunk down around the implant and requires removal in order to re-insert a new implant.  Also, the capsule may have some biofilm of bacteria, which has on the old implant, and this needs to be removed.

Best wishes,


Remove capsule to treat capsular contracture?

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Great question. Whether or not to remove the capsule depends on why you are having the revision.  If you are having increased firmness of the breast due to the capsular contracture, it makes sense to remove at least some of the tissue that is causing the firmness (the capsule).  If your breast shape is altered due to the capsular contracture, your surgeon can either cut or excise some of the capsule to improve the shape.  Removing the capsule does cause bleeding at the time of surgery and blood left around the implant can set you up for another capsular contracture.  Careful and judicious removal of the capsule in cases of capsular contracture is my preferred approach.

Treatment of capsular contracture (revision breast surgery)

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The answer to your question is multifaceted since it depends on the location of the capsule and its severity. If I am dealing with a significant capsule that has resulted from a leaking old silicone prosthesis (placed in the 70’s), then I would perform a total or subtotal capsulectomy. That capsule is usually calcific and has a egg shell texture. If you leave it when replacing the prosthesis to a new position, generally submuscular, you run the risk of either seeing or feeling the capsule.

When the capsule is soft and in a subglandular position, and I am switching to a submuscular position, I do nothing to the capsule since it will obliterate and become a non issue on its own.

In dealing with a submuscular capsule, I feel that a capsulotomy - with possibly a small capsulectomy at the area of the incision -typically suffices. Attempting to perform a capsulectomy in the submuscular position is not worth the increased morbidity.

It sounds that in your case your prosthesis have not been in for a long time.  If that's true, then simply opening the pocket a bit more (in order to allow the prosthesis to sit in a better position) should suffice.  

Capsular contracture

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The treatment varies for capsular contracture. Some surgeons remove the entire capsule if possible, and place the implant in another pocket plane.

These answers are for educational purposes and should not be relied upon as a substitute for medical advice you may receive from your physician. If you have a medical emergency, please call 911. These answers do not constitute or initiate a patient/doctor relationship.