A capsule naturally forms around any foreign object placed within the human body. The body’s natural response is to wall off a foreign body, which includes a breast implant, whether silicone or saline. A capsule has been found to be formed from blood vessels, collagen and myofibroblasts. A capsule, optimally, should remain soft and pliable.
Capsular contracture is a potential risk following breast implant surgery. It may be more common following an inflammatory response involving an infection, hematoma, and seroma. The chance of it happening may increase over time. Capsular contracture occurs more commonly in patients undergoing revision surgery than in patients undergoing primary implantation surgery. Capsular contracture is a risk factor for implant rupture if the contracture because so severe that it causes the surrounding capsule to shrink and to cause pressure on the implant. It is one of the most common reasons for reoperation in augmentation and reconstruction patients. Symptoms of capsular contracture range from mild firmness and mild discomfort to severe pain, distorted shape of the implant, and palpability (ability to feel the implant).
Patients should also be advised that additional surgery may be needed in cases where pain and/or firmness are severe. This surgery ranges from removal of the implant capsule tissue to removal and possible replacement of the implant itself. This surgery may result in loss of breast tissue. Capsular contracture may happen again after these additional surgeries.
Capsular contractures can occur as soon as 4-6 weeks after the original surgery.
Capsular contractures can be identified from mild to very severe. The classic scale used by Board Certified Plastic Surgeons is the Baker Classification:
- Baker I capsule is a soft breast without significant scar tissue.
- Baker II capsular contracture is a palpable scar tissue around the bag; however, not visible.
- Baker III capsular contracture is associated with visible and palpable hardening, leading to a deformed shape to the breast.
- Baker IV capsular contracture, most severe, is associated with hardening, palpable, visible and often a cold, hard breast that is very painful to even mild palpation.
When a patient presents to our office with severe scar tissue, it is very important to determine the specifics as to the original surgery.
First of all, capsular contracture is significantly higher above the muscle than below the muscle. When breast implants are placed above the muscle or subglandular (retromammary), the rate is higher and it may be more difficult to fix these patients as the result of removing scar tissue with capsule may thin out the breast and lead to increased palpability and visibility of the bag.
Therefore, a breast augmentation that is performed it its original phase should be done subpectoral (behind the muscle), to allow for more coverage with the expectation that the patient will probably undergo a secondary surgery in the future. In other words, we almost always place our implants behind the muscle or using the dual plane technique (two-thirds under, one-third over laterally) in order to allow for this need for better muscle coverage, a more natural appearance and better results when breast revision surgery will be required. Surgeries to be performed with capsular contracture include capsulotomies and capsulectomies with or without implant exchange.
A capsulotomy is a procedure where the capsule is simply open and released with an electrocautery device. This allows for an expansion, more room and more volume space to the implant to occupy, to allow for a softer breast. “Otomy” in Latin means to release the scar tissue; however, not to remove it. This is often used for patients who have very thin amounts of breast tissue and if you were to remove the capsule they may have tremendous visibility, palpability and a very deformed appearance to the breast.
A capsulectomy should be performed when there is a thick amount of silicone and/or scar tissue around the implant and there is good coverage even after exenteration of the scar tissue to prevent visibility and rippling of the bag. Removing the capsule also may reduce the incidence of recurrent scar tissue, but this has not always been found to be the case. Just because the capsule is removed, does not mean that they will not reoccur.
It is extremely important to judge each patient as an individual and just because one person, for example, your girlfriend has scar tissue removed, does not mean that in your case it will be the best option, depending upon your physical anatomy of your breast and your chest wall, as well as the placement of your implants by your previous surgeon.
Remove Or Replace Breast Implants
Whether to remove or replace the implants depends upon your previous surgery. If the implants are in good shape and the implants are not ruptured, they often may be left in place and a new implant may not be required.
However, some studies have found that capsular contracture may be associated with micro infections and thereby removing the implants, replacing them with new ones after cleaning and irrigating the pocket with antibiotic solution, may help to reduce recurrent infection.
Most of the time, with a longstanding capsular contracture and implants that have been placed for several years, we like to replace the implants at the same time with new implants, silicone and/or saline.
Capsular contracture is one of the most common causes of women to have breast revision surgery. It can occur anytime after the surgery has been performed, from four weeks on.