Best Ways Pre and Post Surgery to Avoid Capsular Contracture?

can a doctor take to prevent capsular contraction with a high risk patient for cc? (I have had several cc.) Are there doctors who have a very low incident rate of cc due to the way they medically treat the patient before, during and after surgery? I am considering one last try at this, but am very unsure. Currently have no implants in to allow my body to heal. I have very little of my own breast tissue and my chest is caved in from 20+ years of implant use.

Doctor Answers 14

Capsular contracture

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I would have to agree with most of the comments made previously.

No matter what is done during surgery, this is a biological process and no once can ever predict the outcome or necessarily prevent capsular contracture. It is a highly controversial topic for which we still have many unanswered questions.

As stated, the two most popular theories relate to either:

  1. blood around the implant
  2. low grade bacterial contamination around the implant, called a biofilm

In the first case doing all you can do to minimize bleeding requires:

  1. meticulous control of bleeding during surgery some surgeons feel it is best performed with a bipolar cautery but this is not proven
  2. limited/controlled postoperative activity
  3. avoidance of aspirin, etc.
  4. ice compresses
  5. some feel compression is useful

In regards to the second, options to potentially minimize biofilm include:

  1. Perioperative antibiotics
  2. Triple antibiotic irrigation during surgery
  3. Multiple glove changes
  4. Use of a nipple shield, tegaderm, and insert sleeve during surgery
  5. The use of silicone vs saline implants is controversial in regards to capsular contracture.
  6. Placement under the muscle seems to be correlated with lower capsular contracture
  7. Placement throught the breast crease is believed to be the source with the least potential of contamination

Postoperatively: options include::

  1. Breast implant displacement excercises
  2. The use of accolate is controversial
  3. The use of Vitamin E is generally felt to be of little benefit

In cases of recurrent capsular contracture at the time of implant exchange it is probably best to perform a complete capsulectomy (not partial or capsulotomy) and use a completely new implant.

Chicago Plastic Surgeon
4.9 out of 5 stars 86 reviews

Extremely difficult problem with no easy answers but some hope

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Capsular contracture is still the number one complication in breast implant related surgery for cosmetic augmentation, revision surgery and reconstruction alike. It also is more likely following a first time contraction.

The main theories for CapCon development are blood and fluid in the pocket around the implant and a low grade bacteria or BioFilm that can surround the implant inside the implant pocket or space. At the time of surgery most plastic surgeons do everything possible to decrease the chance of CapCon. These mainly include meticulous surgery with bloodless pocket preparation and what we call "prospective hemostasis" -- stopping the blood vessels encountered from bleeding before they are cut, and no trauma to the ribs or tissue with blunt instruments, and then antibiotic irrigation to minimize the chance for this low grade bacteria.

Other things we do that may also lower the possiblility of development include: placement of the implant deep to the muscle, and heavy texturing or a Biocell surface on the implant -- a "textured" implant, and creating a pocket that is higher or taller than the implant diameter to allow the patient to displace or push the implant vertically in the pocket (the only thing you can do and it's benefit is ?), and finally a "No Touch" technique to minimize any contamination or contact of the implant with any drapes, towels, sponges.

Recurrent capsular contracture is a very difficult problem. We do all the things above to try and minimize the recurrence again.

The "hope" in the equation is a new material called Strattice or Alloderm among others, but these are the gold standards. This material is called an Acellular Dermal Matrix (ADM) which is in essence human or pocine/pig skin where the epidermis and any infectious or cells that our body may react to are removed. This material has many uses including supporting implants like a hammock or sling internally, providing covergae to help prevent visible wrinkling and rippling and also helps to decrease or eliminate capsular contracture.

In order to have a CapCon, the body has to form scar tissue completely around the implant. For some reason, the capsule does not form beneath this material. It comes to the edge and stops so there is no complete or circumferential capsule that forms.

I have used this material now for this purpose specifically in ~ 20 patients without capsular contraction recurrence. We are starting a research project to document this further but the preliminary findings are very exciting (I presented this early experience at Atlanta Breast Symposium, Feb-2009). You may want to find a surgeon in your area with ADM experience and go in for a consult.

You are wise however to venture into any future surgery with trepidation.

All my best!

Bradley Bengtson, MD, FACS
Grand Rapids Plastic Surgeon
4.9 out of 5 stars 70 reviews

Capsular Contracture always a risk

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Capsular Contracture is always a risk with any breast augmentation, and in your case, given your history, it is likely a higher risk than in the average patient. As the other doctors have written, 2 things we know increase the risk of capsular contracture are blood around the implant or a low grade infection. With this in mind, I think it's important to pick a surgeon who prides him or herself on meticulous techinque, not just fast technique. Given what we know about what increases the risks of contracture, namely blood around the implant or infection around the implant, I think it's crucial to pick a surgeon that will take his time and do everything possible to avoid these problems.

That being said, the risk always exisits, and the surgeon may do everything right and you could still end up with a contracture. I also agree with the idea of not choosing implants that are too big, and perhaps placing the implants under the muscle, in particular if they are not there already. Some surgeons really believe in this, others think there is no great data to support this, but in your case, I would try everything possible to give you the best result.

Good luck,

Dr. Salemy

Shahram Salemy, MD, FACS
Seattle Plastic Surgeon
4.9 out of 5 stars 155 reviews

Preventing Capsular Contracture

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Because of a number of techniques I use during breast augmentation surgery 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.

Michael Law, MD
Raleigh-Durham Plastic Surgeon
4.8 out of 5 stars 123 reviews

Understanding Capsular Contracture

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Capsular contracture is one of the most difficult problems seen following breast augmentation surgery. For this reason every effort should be made to avoid this complication before it occurs. Even when these efforts are made capsular contracture may still occur because of wound healing biology.
Several steps can be taken at the time of surgery to minimize the potential for this complication. These include submuscular implant placement, avoidance of large implants, meticulous hemostasis, and avoidance of infection and biofilm formation.
Following surgery, most surgeons recommend implant displacement exercises. When early signs of capsular contracture are noted, some surgeons start their patients on a course of vitamin E or Singulair. Many surgeons feel that these maneuvers are helpful, but no scientific evidence is available to support their use.
Despite these efforts, capsular contracture may still occur. If capsular contractures occur and don’t respond to conservative management surgical intervention may be necessary.
If you have a history of capsular contracture, it’s important to discuss the management of this problem with your plastic surgeon prior to surgery. Your surgeon should be able to formulate a treatment plant that minimizes the potential for this complication.

Can you prevent capsular contracture?

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There are things that the surgeon can do to reduce the risk of capsular contracture, but in medicine we cannot 100% guarantee that you will not experience capsular contracture. In your case, with a history of capsular contracture, your risk may be higher just due to your body's wound healing biology. To help prevent recurrent capsular contracture, one can use pre and post op singulair for 3 months or use an ADM in the pocket (i.e. alloderm, strattice). While this is not 100% preventive, it may help reduce the chances as much as possible.

You should be sure your surgeon is well-experienced in not only treating patients with capsular contracture, but also using the most advanced techniques available that we know mitigate the risks of capsular contracture. First, the surgeon should make sure everything is very sterile and antibiotics are used to reduce the chances of an infection. Second, you want to go to a surgeon who uses an advanced technique that minimizes the amount of bleeding during surgery. Best of luck!

Jimmy S. Firouz, MD, FACS
Beverly Hills Plastic Surgeon
4.8 out of 5 stars 18 reviews

Best ways pre and post surgery to prevent capsular contracture?

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Hello! Thank you for your question! Recurrent capsular contracture is a very difficult problem. Assuming you tried conservative measures in the past - implant massage and may add the medication Singulair and Vitamin E. If these fail, surgical correction may be necessary. It is a matter of surgeon preference as well as what is seen during your procedure that will determine whether or not a complete capsulectomy is performed. If significant capsule formation is seen intraoperatively, a full capule removal may be warranted with a drain in order to completely remove all of the tissue and allow better adherence of your breast back to its normal anatomic position down on your chest wall. Irrigating with certain medications may also be if benefit. Some other things that may have been tried include changing the position of your implant, addition of a dermal matrix, or consideration for the the shaped, textured, anatomical gel implants.

Without knowing your issues and without an examination, it is difficult to tell you what may be the best thing for you. I tend to favor performing capsulectomies in order to create a fresh pocket, reshape the pocket, allow better shape and adherence of the overlying breast. I would discuss your issues with your plastic surgeon who will assist you in determining the right modality for you. At a 3rd recurrence, it may continue to occur despite all of these modalities and consideration for explantation or living with the contracture are options. Hope that this helps! Best wishes!

Lewis Albert Andres, MD
Scottsdale Plastic Surgeon
5.0 out of 5 stars 28 reviews

The risk of capsular contracture can be minimized with good technique.

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Hi! Of course, there are no guarantees, but here are some important points:

1) Even a few drops of blood increase the risk, so for you, I would recommend using suction drains to remove every little bit of blood around the implants.

2) Even a few bacteria increase the risk (without having obvious infection). So you should be done with a "super sterile" no-touch technique, antibiotic irrigation of the wounds, and high doses of intravenous antibiotics.

3) Gentle technique that avoids bruising the breast tissue is important.

4) Avoiding very large implants is important.

5) I don't think that what you do before and after surgery makes much difference. Massage does not help. (I know this is controversial, but I have a lot of experience.) So never blame yourself. It's what happens DURING surgery that's critical, and the unpredictable biological factor in your tissues.

George J. Beraka, MD (retired)
Manhattan Plastic Surgeon

Nothing can guarantee

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Some people are just prone to form contractures around the implant, despite optimizing all conditions.

Be sure that you do not have any active infections. You may also want to be on preoperative antibiotics that are powerful for skin bacteria, like say augmentin?. You will want to take an antimicrobial shower just before you go to the hospital. Your doctor may hav a few tricks for after surgery, but as I said in the teaser, no guarantees. I feel for you and wish you luck.


Best Ways Pre and Post Surgery to Avoid Capsular Contracture

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Capsular contracture may recur regardless of surgeries being performed at this time and may require additional surgeries. There is as much as a 40% chance that additional surgery will be needed following this operation. 

Nicotine users, such as smokers, have up to a 30 times increased #risk of capsular contracture. The #reason capsular contraction happen is unclear. It's possibly caused by microscopic bacteria on the implant, a   collection of blood after surgery or perhaps it is a tendency for some women to form scar tissue. What we do know is that is cases reported have decreased from 25% to  5-10% or less.

One way to attempt the prevention of it is to follow your surgeon's post op instructions as recommended and ask questions of your surgeon when healing concerns arise.

Jed H. Horowitz, MD, FACS
Orange County Plastic Surgeon
4.9 out of 5 stars 116 reviews

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.