What is capsular contracture, and what causes it?
When breast implants (or any foreign object, such as pacemakers or artificial joints.) are placed into the body, the body forms a fibrous tissue lining around it. Many surgeons refer to this lining as the “capsule”, “tissue capsule”, or “scar capsule”, although it is not exactly the same as scar tissue. This is the body’s natural healing response after breast implant surgery and is to be expected.
Capsule contracture, the most common complication of breast augmentation surgery, can happen at any time, but seems to be more common in the first several months after surgery. During the initial operation, a pocket is created for the implant underneath the breast. During the healing process a capsule forms, which is comprised of fibrous tissue. As the healing process continues during the first year after surgery, the scar tissue within the breast and around the implant will remodel and sometimes will shrink somewhat. Under normal conditions the pocket remains open, allowing the implant to look and feel natural. However, some people can have an exaggerated healing response in the breast tissue during which the capsule will tighten, and squeeze the implant. This may cause the breast to feel hard, and to appear distorted. In severe cases, the implant feels very firm, may become painful, and can take on a “ball-like” look. It’s important to remember that it’s not the implant that has hardened. The shrinking of the capsule compresses the implant, and causes it to feel firm/hard, but once the implant is removed, it’s just as soft as it was the day it was inserted.
Currently, the causes for capsule contracture are still very unclear. The following are thought to put you at higher risk:
- Transient Infectious Contamination: Contamination of the implant shell can cause an inflammatory reaction, thus leading to the shrinking of the capsule. This can occur at the time of initial surgery when the implant is placed, but also can occur during an unrelated illness years later.
- Subglandular Placement: Breast implants placed above the muscle (Subglandular) tend to have higher capsular contracture rates, versus breast implants placed in behind the muscle (Submuscular or Subpectoral).
- Seroma: Rarely, fluid can accumulate around a breast implant following surgery. This tends to occur more commonly after revisional surgery. In certain cases, Dr. Brenner may place drainage tubes at the time of surgery to help prevent fluid accummulation. However, even with drainage tube use, seromas may still occur. If you have had seroma, you may be at more risk for capsular contracture.
- Hematoma: Collections of blood in the breast tissue (surrounding the implant) can cause an inflammatory reaction, which may lead to capsule contracture. Hematoma is a rare occurrence after implant surgery, but when it occurs it should removed expeditiously.
- Smoking. Smoking decreases the oxygen levels in the blood, which could result in delayed healing, and possibly an inflammatory reaction.
Baker Grading System – 4 Grades of Capsule Contracture
- Baker Grade I – The breast is normally soft, and looks natural.
- Baker Grade II - The breast feels a little firm, but appears natural.
- Baker Grade III - The breast feels firm, and is beginning to appear distorted in shape.
- Baker Grade IV - The breast is hard, and has become distorted in shape. Pain or discomfort may be associated.
Breast Revision Surgery: Capsulectomy and Capsulotomy
In this procedure, the surgeon forcibly squeezes the implant, in hopes of “popping” the scar tissue (opening it up). Breast implant manufacturers do not recommend this, as it can lead to possible rupture of the implant. Implants that are ruptured due to closed capsulotomy are not covered under the warranty. You are awake for this, and receive no local anesthesia. And yes, it can be painful, but thankfully, it only lasts a few seconds, and then it’s over. This procedure is not recommended, since it has a very low success rate, and again, puts you at risk for breast implant rupture.
In this procedure, the surgeon goes into the pocket and “scores”, or cuts, the scar tissue, in order to release the capsule’s hold on the implant. The scar tissue is not removed.
This is the most successful treatment for capsule contracture. In this procedure, the surgeon goes in and actually removes the scar capsule. This is a lengthier surgery, but is well worth it, especially when it’s successful. Once the capsule is removed, your body will form a new capsule around the breast implant. Occasionally, Dr. Brenner will perform this procedure at the same time as implant pocket relocation to the submuscular position for women who have developed capsular contracture with their implants place above the muscle.
Can capsule contracture be prevented?
Unfortunately, there is no way to completely eradicate the chances of getting capsule contracture. However, there are things that you can try:
- Choose submuscular implant placement, instead of subglandular (over the muscle) implant placement (which has been proven to have a higher incidence of capsule contracture). This is particularly true for saline implants. Implants placed over the muscle come into contact with the breast ducts, which are known to naturally contain bacteria. Having the implants placed below the muscle helps to prevent this. The muscle also “massages” the implant. Some doctors believe that this is another factor that decreases capsule contracture.
- Massaging: Post-operative massaging of the implants tends to keep the pockets more supple.
- Take vitamin E orally. However, you do NOT want to take this, or anything else that interferes with your blood’s clotting capability PRIOR to surgery. Many surgeons recommend that their patients wait 2 weeks, or so, before taking vitamin E, aspirin, etc.
- Sports Bra: Wearing a fully supportive sports bra will minimize the gravitational forces on the breast and allow the implant pockets to heal in the correct position.
- As a precautionary measure, you should talk to Dr. Brenner about taking antibiotics prior to dental cleanings. Although studies have been inconclusive, dental work does frequently cause transient seeding into your blood stream of the bacteria that live in your mouth. There is insufficient data as to whether or not a general dental cleaning will put you at risk for capsule contracture. However, for women who have had problems with capsular contracture in the past, prophylactic antibiotics may be warranted. If you are having gum surgery, or something more involved than a regular dental cleaning, you should, again, definitely talk with your surgeon regarding antibiotics.Fortunately, most women do not have any problems when they DON’T take antibiotics.
Can I take medications or nutritional supplements to treat or prevent capsular contracture?
Scar tissue consists of collagen strands. Taking Vitamin E is thought to soften these strands, thus making the capsule softer and more pliable. Unfortunately, there is no evidence that vitamin E really works in treating or preventing capsular contracture.
Accolate, a drug used in the treatment of Asthma, is the newest treatment for capsule contracture. It is used due to it’s anti-inflammatory properties. It is a leukotriene receptor inhibitor. Leukotrienes are a group of chemical compounds that occur naturally in white blood cells (aka leukocytes). They’re able to produce allergic and inflammatory reactions. This drug inhibits this process. Accolate is said to work best on early contractures, but may reverse existing capsules. If the capsule is well-formed, it can take several months to successfully treat it. Prophylactic treatment may be used in women who are at a higher risk for capsule contracture, such as those who have had it previously.
Clinical studies still need to be done regarding the use of Accolate as a form of treatment for capsule contracture, although it does seem to have helped many women. Use of Accolate for capsule contracture is “off-label” use. The FDA has not approved Accolate for this type of use.