Capsular Contracture Resulting from Breast Augmentation
Capsular Contracture is the most common complication associated with breast augmentation. It is hardening of the scar tissue around the breast implant. Normally, a thin soft lining forms around the breast implant. This is the body’s normal reaction to any foreign body. Capsular Contracture is when this lining becomes very thick and hard. It squeezes the implant upward toward the neck making it firm and round and sometimes painful.
Correction of Capsular Contracture with Textured Saline Implants
It can occur at any time after the breast augmentation but the majority of the time it happens in the first year. Typically, only one side is affected. The reasons are not clear but there are many theories. The most common is that there may be a sub-clinical infection within the scar tissue that causes increased scarring. Another possibility is that a blood clot collected around the implant and then turned to scar tissue. It may be that this is just the way some individuals heal.
Capsular contracture is not an all-or-nothing phenomenon. There are different degrees of hardening of the implant. The most common grading system is the Baker classification.
- Baker 1
This is the ideal breast implant. There is no hardening at all. The breast feels and looks soft.
- Baker 2
The capsule has thickened a little but it is not a problem. It looks normal but is slightly more firm than normal tissue.
- Baker 3
This is where patients start to complain. The implant is clearly firm to the touch and usually has become rounder. The upper part of the breast looks higher.
- Baker 4
This is where the implant is not only hard, round, and elevated but it is usually painful.
Progression of Contracture
It is impossible to say whether or not a firm implant will get worse. It is possible for them to soften somewhat with time. Often, surgeons will encourage aggressive massage to help soften the scar tissue.
Correction of Capsular Contracture with Textured Saline Implants
When capsular contracture occurs very soon after surgery it often appears as if the implant didn’t drop. The patient will usually get upset with the surgeon because she thinks he didn’t lower the implant enough. When it occurs later it is easier to recognize because you can see it progress upwards.
Unfortunately, there are no treatment options for capsular contracture that will predictably prevent its recurrence. For Baker 2 contractures where the implant is firm but still in good position aggressive massage is the best choice. This massage should be very aggressive. Rupturing the implant with massage alone is almost impossible. Massage in all directions.
When the implant elevates and becomes firm and round aggressive massage is still advised at least for a few months. If there is no improvement than surgical treatment is usually the best option.
What are the Surgical Options for Capsular Contracture?
There are many considerations that you and your plastic surgeon should consider when correcting capsular contracture. Below are the most common considerations:
Should the thickened capsule be removed or simply opened up? Technically, this is called capsulectomy vs capsulotomy. Simply, put it means should the entire capsule be removed or should it be cut open and spread apart to allow the implant to come down. The answer is dependent on the surgeon.
Removing the entire capsule involves more surgery. To the layman, this may seem to be the obvious choice but a complete capsulectomy is a much bigger procedure and will result in more bleeding and possible complications. A bigger procedure may increase the chances of capsular contracture. If there is very little breast tissue, removing the capsule may lead to rippling especially if saline implants are placed.
A capsulotomy is a less aggressive procedure. It involves making several incisions usually at the bottom of the breast capsule to allow the implants to drop. The capsule is not removed. It is simply cut and allowed to expand. Hopefully, the cuts will heal with a normal soft capsule allowing the implant to stay soft and in good position.
- Partial Capsulectomy
There is an intermediate procedure between capsulectomy and capsulotomy. This is called a partial capsulectomy. This is when only a portion of the capsule is removed. The portion removed is the part of the capsule that is causing the problem. This is usually the lowest portion near the bottom of the breast. Removing this part allows the implant to drop into correct position but does not involve extensive surgery to the rest of the breast. Rippling of the upper part of the breast is much less likely because no tissue was removed here. Rippling along the bottom part of the breast is still possible.
What is the Best Way to Prevent Recurrence?
A capsulectomy or capsulotomy will often correct the deformity caused by capsular contraction. But what can be done to prevent it from recurring? There are many things to consider but below are listed the four most critical decisions you and your plastic surgeon must address.
Silicone vs Saline
Numerous studies have shown that saline has a lower contracture rate than silicone. The exact amount of reduction is not certain. Overall, it appears that saline cuts the risk of capsular contracture in half. With this in mind, saline is usually the best choice as long there is enough breast tissue to prevent rippling. Women who have very little breast tissue and a capsular contracture have a difficult decision. While saline has reduced risks of contracture it has increased risk of rippling and an unnatural look. It is not unreasonable to try silicone one time and if it recurs than switch to saline. As you can see, the answer is not clear.
Finally, a question with a relatively straight forward answer. Below muscle is usually the best choice in most circumstances in patients with capsular contracture. Studies have shown that placing the implant below the pectoralis major muscle dramatically decreases the risk of implant hardening. This is particularly true if your contracture occurred with the implant above the muscle. Switching to a sub-muscular plane will be beneficial.
A more difficult situation is when a contracture occurs below the muscle. Some plastic surgeons have theorized that putting the implant above the muscle in a “virgin” plane may help. Still, most agree that the sub-muscular position is the best position to avoid recurrence.
This has also been extensively researched. These studies have shown rather conclusively that textured implants have about half the risk of contracture compared to smooth implants. This is especially true if the implants are placed above the muscle. The benefits of textured implants below the muscle exist but are not as great.
Does this mean that you should get textured implants? As with everything else in life, the answer is not so easy. The reason is because textured implants ripple more than smooth implants and do not appear as natural. This is not a significant problem in women with adequate breast tissue. In women with very little breast tissue, however, this can be a big problem. Just like with the silicone vs saline dilemma, you have to ask yourself, “What is the bigger concern; recurrence of capsular contracture or implant rippling?” This is something you must discuss with your plastic surgeon.
With implant contracture it is important to stay within a reasonable size. Unnaturally large implants increase the risk of recurrence. In addition, when a capsule is removed there is often a thinning of the breast tissue in women with little breast tissue to begin with. This thinning will be accentuated by large implants. Bottom line; do not go too large.
Putting it all together
There is much to consider when dealing with hardening of breast implants after a breast augmentation. From correcting the capsule deformity to the choices of implant type, there are many variables. The above information has given you a condensed summary of the science behind the different options. What does this mean?
Taking all the information and putting it together there is a scientific answer. The lowest capsular contracture rate occurs with textured saline implants of normal size placed below the muscle. This is particularly true with women who have at least a fair amount of natural breast tissue.
The problem comes with women who have little breast tissue. Textured saline implants may cause unacceptable rippling. In these women it is reasonable to try a smooth implant below the muscle and accept the relatively increased risk of recurrence.
What about Accolate?
Accolate (Zafirlukast) is a medication that has shown promise in preventing the thick scar tissue of contracture from forming. It is a leukotriene blocker used to decrease inflammation in Asthma patients. It is believed that by decreasing inflammation that scar tissue can be decreased as well. In several rat studies the drug has been successful in decreasing scar tissue but it has not be proven in humans. Still, many plastic surgeons prescribe it simply because they have no other medications that work.
Accolate is taken twice a day. It is currently not generic and, therefore, is relatively expensive. Side effects include headache, sore throat, trouble sleeping, malaise, and nausea. The most serious potential side effect is liver failure but this is very rare.
What do I do if it keeps coming back?
This is a very frustrating problem. The answer may mean removal of the implants. There may be hope in the future. Highly cohesive gel implants (Gummy Bear) are being tested and have shown great promise in reducing contracture. The data is very preliminary but encouraging.