Preventing Capsular Contracture
Because of a number of techniques I use during breast augmentation surgery, including the use of the Keller Funnel, that are outlined below, I see very few capsular contractures in my breast augmentation patients. However, the reality is that if you are a breast augmentation patient with a capsular contracture, the incidence - at least to you - feels like 100%. A well-established capsular contracture can be corrected, but doing so involves a return to the operating room, removing and discarding the implant, removing or excluding the contracted capsule, creating a completely new implant space, and putting in a new breast implant (that statement may be somewhat controversial, but I believe the procedure just described is what is what provides a patient with the lowest risk of recurrent contracture). So I think that surgeons should feel obliged to do everything possible to limit the likelihood that a patient develops this frustrating postoperative problem.
Studies have shown that a bacterium called Staph epidermidis can be cultured from as many as 70% of capsule specimens obtained during surgical procedures for capsular contracture. So I employ a number of measure that address the possibility that skin bacteria or nipple duct bacteria may adhere to the implant surface during the augmentation procedure. We prep the skin using potent antiseptic solutions prior to draping the surgical site with sterile drapes, however the microscopic surface of the skin is full of peaks and valleys, and `nooks and crannies' - like sweat glands, hair follicles and sebaceous glands - that may harbor bacteria despite thorough application of an antiseptic prep solutions.
After prepping, we apply a new skin sealant product called InteguSeal to the skin surface where the incision is to be made. This effectively seals off all of the `nooks and crannies' that may harbor bacteria, and the sealant lasts for several days postop. We also apply it over the nipple and areola to seal off the nipple ducts which may also harbor bacteria.
Over the course of the surgery, we irrigate the implant space several times with a large volume of a saline solution containing three antibiotics (which can be modified in patients with an allergy to any of the antibiotics in the solution). Prior to implant placement, we irrigate the implant space with full-strength Betadine, a potent topical antiseptic that has been shown in clinical studies to reduce the incidence of capsular contracture.
I think one of the greatest advances in reducing the possibility of implant contamination by skin bacteria during breast augmentation surgery is the development of a soft, sterile, paper funnel for insertion of silicone gel implants into the implant pocket. This simple yet clever device actually looks much like a pastry chef's bag. It allows me to introduce the implant into the subpectoral pocket without ever touching it with my gloves, and without the implant ever contacting the patient's skin surface. The implant package is opened, the implant is irrigated with antibiotic solution then `poured' into the funnel, the small end of the funnel is inserted in to the skin excision which is held open with retractors, and I gently `squirt' the implant into the pocket. Before this was available, there was a great deal of implant contact with the patient's skin, under great pressure, as a pre-filled gel implant is forced into the pocket through a relatively small incision. The implant insertion funnel completely eliminates what I think has been the most concerning aspect of breast augmentation surgery in regards to the potential contamination of the implant with bacteria during the procedure.
There is no breast augmentation practice with a capsular contracture rate of zero. Yet there are obviously a number of measures that can be taken to make the rate of contracture as low as possible. I think it is important for patients to have confidence that their surgeon is focused not only on providing a breast enhancement that is beautiful and natural-appearing, but also on maximizing the likelihood that their aesthetically pleasing result will remain beautiful and natural-appearing over the long term.
Breast implants and capsular contracture
Capsular contracture is the term for excessive or thick scar tissue which can form around breast implants. This occurs in about 10% of breast implants and can result in a very hard feeling breast and occasionally a distorted appearing implant. The location of the implant has been studied and implants placed subpectorally have a tendency to have lower rates of capsular contracture. Also, cohesive gel implants ("gummy bear") have a lower rate than traditional silicone or saline implants.
The exact numbers depend on the surgeon's technique to some extent also, so it's important to know if your surgeon bathes the implants in any antibiotics prior to insertion, if he/she changes gloves, etc.
In general an implant placed under (behind) the muscle has lower rates of capsular contracture than those place in front of the muscle (subglandular).
Silicone implants used to have higher capsular contracture rates, but now with the newer generation cohesive gel implants, the rates are comparable to saline; some studies even suggest they are lower than saline.
Please discuss this with your plastic surgeon prior to selecting your breast implants.
Capsule contracture is a risk for all types of breast augmentation
The risks of a complication after breast augmentation are very small, and the risks can be reduced by a well experienced and qualified surgeon. Capsule contracture is one risk however that has eluded our understanding despite a considerable amount or research dedicated to the cause and treatment. Capsule contracture is a tightening of the natural scar which forms around all breast implants which causes the implant to become firm and round up. The scar can become tender and distort the shape of the breast. So far we have been unable to identify who will get a contracture, or why, and we are unable to improve the contracture after it has occurred in at least half of augmentation patients. Some surgeons will claim that their 'capsule rate' is lower than other surgeons because of their technique. We have no published proof that one surgeon, or surgeons technique, is better as we all are interested in reducing contracture rates.
Risk is relative and statistics can be cruel. Most do not develop a contracture, though some do which seems quite unfair. The irony also is that very often the contracture is only in one breast. There are three things we have learned that will reduce contracture risks. The first is that a submuscular implant is likely to stay softer than a subglandular or subfascial implant. Second, the saline implant has a lower capsule rate than a silicone gel implant. Third, silicone bleed through the implant shell can increase the contracture rate, and silicone leakage will produce a contracture in a worn silicone gel implant. Therefore, the highly cohesive implant such as the 'gummy bear" may reduce ccontractures, though the data is not fully out.
Note the gummy bear or form stable implant is not particularly soft to begin with though if they 'cure' the capsule problem the trade-off may be worth the difference.
Best of luck!
Risks of capsular contracture
You have listed them already from highest to lowest - above the muscle anything, below the muscle gel, below the muscle saline. Gels are more than salines but only by a few percent.
Breast Implants and Capsular Contracture
Capsular contracture is not completely understood as of today, but the rates have decreased significantly over the years. Placing the implants under the muscle - whether saline or silicone or total or partial muscle coverage - has provided the most amount of improvement in the rate of capsular contracture. Textured implants have also been shown to have a lower rate of capsular contracture. Beyond these two points you will have varying opinions depending on the surgeon. Many techniques used in surgery have also helped in reducing capsular contracture. As long as you choose a board certified plastic surgeon experienced in breast augmentation surgery you will have a low rate of capsular contracture.
Breast augmentation, silicone implants, breast capsules
You ask a very good question...the difficult ones are the best. As you can see, there are multiple answers but none well substantiated or absolutely conclusive. The choice of implant and position of the implant is best determined by the result you are looking for and the risks you wish to undertake. The risk of capsular contracture is the hardest to put a fixed number on and should not be the major determining factor.
Rates reported for capsular contracture vary from implant company to implant company and from location of implant as well as texturing. Some studies contradict others. Your best bet is to go in a partial submuscular plane.
CC tends to be lowest under the muscle vs subglandular (I don't know about subfascial).
Silicone tends to have higher cc rate than saline.
Texture tends to reduce cc above muscle.
There you have it.
Capsular contracture rates
Everyone's experience differs but statistically, here is a list from greatest chance of capsular contracture to least:
- Below the fascia + gel
- below the fascia + saline
- Below the muscle + gel
- below the muscle + saline
Different capsular contractures
It almost sounds like you have been given too many opinions. While there is a published body of literature for each of those options, you should realize that each surgeon has their own rate of capsular contracture using their particular technique. I would consult with a couple of surgeons and ask what their reoperation rate is within 6 months, 1 year and 5 years. We all know those numbers, or at least an approximation. There is a lot of dogma out there one way or another, but , frankly, there are many good options and not just one. Finally, whatever rate of contracture is out there, it matters little to your individual genetics and how you heal from the operation. Those factors are out of your control.