Posted October 07, 2010 in Breast Augmentation, Breast Implants, Home, Plastic Surgery

Capsular contracture refers to formation of a tight scar surrounding a breast implant following breast augmentation, causing the implant to look or feel hard.  The implant itself does not actually become hard; it just feels like it because it is being squeezed by the scar tissue.

Mechanism of capsular contracture formation

When a breast implant is placed, your body recognizes it as foreign and builds a wall of scar tissue (capsule) around the implant to seal it off from the rest of your body.  This is normal, and it’s a good thing.  On a long-term basis, this capsule provides support to your implants, so they don’t drop down to your belly button later in life.

The problem is that sometimes the scar tissue contracts or tightens around the implants.  This may be due to a postoperative infection or bleeding problem, either of which can increase internal scarring.  Most of the time there is no obvious cause—it just happens.

Risk factors for capsular contracture

1.       Capsular contractures are more common in implants placed above the pectoralis muscle (subglandular implants) than those placed below the muscle (submuscular implants).   It is theorized that the constant motion of the pectoralis muscle over the subpectoral  implants keeps the capsule from tightening excessively.

2.       Capsular contractures are more common with silicone gel breast implants than with saline breast implants.  This is likely related to the foreign—and therefore more reactive–nature of silicone gel compared to salt water.

3.       Among women with subglandular implants (above muscle), capsular contractures are more common with smooth breast implants (smooth implant surface) than with textured breast implants.   Surface texturing (smooth vs. textured) does not appear to make a significant difference if implants are placed in subpectoral position.

4.       Significant trauma to the breast can cause a small amount of bleeding around the implant, precipitating the formation of a capsular contracture.

5.       Immediate postoperative infection, bleeding, or implant exposure significantly increases the risk of capsular contracture formation.

6.       Silicone gel breast implant rupture can cause an inflammatory reaction with silicone granuloma (small nodules adjacent to the implant) formation and/or capsular contracture.

7.       Saline breast implant deflation will not cause an inflammatory reaction.  However, if the implant is not replaced quickly (within a few weeks), the capsule contracts in an attempt to eliminate the empty space left behind by the deflated implant.

Capsular Contractures of Breast Implants: Grading, Treatment, Definition, Mechanism, and Risk Factors

Capsular contracture refers to tightening of scar tissue around a breast implant, causing the implant to look or feel hard.  The previous blog discussed the definition, mechanism, and risk factors for capsular contracture.  Now we’ll examine the grading system and treatment.

Grading of implant capsules

Grade 1:  There is no capsular contracture.  Remember that formation of a capsule around a breast implant is expected and normal—there is a capsule surrounding every breast implant.

Grade 2: The implant looks normal but feels firm.  Most women find grade 2 capsules to be reasonably acceptable.  Many don’t even realize that the implant is firmer than normal.

Grade 3: The implant feels hard and looks abnormal.  The capsule tries to force the implant into a spherical shape, causing the implant to stick out too much and look too narrow.  The implant may look artificial or “stuck on.”

Grade 4:  Same as grade 3, but the contracture is so tight that it causes breast pain.

Treatment of capsular contracture

Grade 1: Normal capsule.  No treatment required.

Grade 2 : I generally recommend aggressive massage of the implants with implant displacement exercises.  These involve forcefully pushing the implant up, down, and toward the midline, trying to stretch and loosen the capsule.  These exercises are generally much more effective in the first 6 months to a year after surgery (while the implant capsule is still pliable) than after the capsule has matured.  Certain medications (discussed below) may also be considered, particularly if the capsule appears to be worsening.  There is no good reason to do surgery for a grade 2 capsule.

Grade 3-4:  If sufficiently bothersome, these contractures may benefit from surgical management.  The most common methods of surgery include capsulotomy (cutting the capsule to enable it to expand) or capsulectomy (removal of part or all of the capsule) with placement of a new implant.  For those women who would like to try nonsurgical management, there is anecdotal evidence that certain medications, including certain asthma medications, such as Singulair or Accolate, or high dose Vitamin E may lessen capsular contractures.  Like breast massage, these medications tend to be most effective for relatively early contractures.

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Ronald M. Friedman, M.D.

Director, West Plano Plastic Surgery Center

Former Chief of Plastic Surgery, Parkland Memorial Hospital, Dallas