The Phenomenon of Capsular Contracture in Breast Implants
In a remarkable demonstration of biological defense mechanisms, the human body instinctively creates a scar-tissue network around objects it doesn't recognize as part of itself, such as breast implants and other medical devices. This is done to keep out intruders and counter perceived threats. "Typically, that scar tissue remains soft and flexible, and you might not even notice it – it merely serves as a barrier between the body's tissues and the foreign object," remarks Dr. Renee Burke, a board-certified plastic surgeon based in Barrington, Illinois. However, sometimes when these naturally occurring, collagen-rich coverings are activated – usually by bacteria or blood, both of which are inflammatory agents – they "can harden, thicken, calcify, and/or distort the implant within, potentially causing pain," elaborates board-certified plastic surgeon Dr. Melissa Doft from New York City. This occurrence, known as capsular contracture, is regarded as the foremost risk associated with breast implants.
What Triggers Capsular Contracture?
Although the precise cause of capsular contracture isn't entirely clear, "it is believed that capsular contracture is due to a biofilm or a thin layer of bacteria – typically bacteria commonly found on our skin – that forms around the implant during surgery," states Dr. Umbareen Mahmood, a board-certified plastic surgeon in New York City. "The body responds to the bacteria by increasing the formation of scar tissue." Less frequently contributing factors include hematoma and seroma – accumulations of blood or fluid that gather during or after the operation – as well as "implant rupture or a possible genetic predisposition to developing aggressive scar tissue," Dr. Mahmood informs us.
It's important to note, though, that "contracture doesn't always have to be a problem," adds Dr. Carolyn C. Chang, a board-certified plastic surgeon in San Francisco. There are four distinct levels of irregularity – and "often only the more advanced degrees of contracture require treatment."
Who Is More Susceptible to Capsular Contracture?
According to Dr. Chang, historically, plastic surgeons have observed a higher rate of contracture with silicone implants compared to saline ones, and with smooth implants compared to textured ones.
Beyond the type of implant, there's also a connection between the incision location and capsular contracture, with certain entry points proven to be safer than others. "Implants inserted through an inframammary fold incision [in the breast crease] have been shown to have lower rates of capsular contracture, because there is less bacterial seeding of the implant compared to areolar or axillary incisions," explains Dr. Mahmood. In other words, the skin of the breast fold typically harbors fewer native bacteria than that of the armpit (not surprisingly) and the nipple-areolar complex, which actually secretes a considerable amount of natural bacteria, thanks to the milk glands.
The position of the implant can also affect its risk profile. Those placed above the pectoralis muscle (in what is known as the prepectoral or subglandular position) are at a higher risk of contracture than those tucked beneath the muscle. Indeed, "studies show that positioning the implant behind the muscle, rather than on top, can prevent capsular contracture," adds Dr. Burke. The reason being, "every time you flex your pectoralis major muscle, you're massaging that implant, and by moving it within the pocket, you're keeping the capsule nice and open."
While some surgeons suggest regularly massaging augmented breasts to keep the capsules soft, "if the implant is behind the muscle, you're essentially getting the equivalent of a daily massage every time you get out of bed or open the refrigerator – or do any small activity that [requires] you [to] use your pectoralis major muscle," explains Dr. Burke.
Patients who smoke, as noted by Dr. Chang, along with anyone with aging implants, postmastectomy breast reconstruction patients, those who have undergone radiation to the breasts, and individuals with a history of capsular contracture, are also at an increased risk of capsular contracture. "I always tell patients that once you have it, there's always a possibility it could recur," says Dr. Burke – "especially if you form capsules very quickly."
How Do Surgeons Reduce the Risk of Capsular Contracture?
By adhering to techniques designed to minimize bacterial contamination and bleeding during breast augmentation, plastic surgeons have significantly reduced the incidence of capsular contracture. Among the now indispensable aseptic standards of breast surgery are using nipple shields to prevent bacterial contamination, performing a gentle and bloodless dissection, preparing the breast pocket with an antibiotic/antiseptic solution, changing surgical gloves after placing each implant, avoiding a drainage tube, and using the Keller funnel, "whereby the implant is transferred from the sterile box, to the sterile funnel sleeve, directly into the patient, without any other handling," says Dr. Mahmood.
In a 2016 retrospective review, published in the Aesthetic Surgery Journal, surgeons witnessed a 54% decrease in the rate of reoperation due to capsular contracture in primary breast augmentation patients whose implants were placed with a Keller funnel.
Dr. Doft also points out that "more physicians are now placing the implant beneath the pectoralis muscle and [that] the silicone implants are all cohesive gel implants, meaning that the gel is crosslinked to prevent leakage" and inflammation of the capsule – two crucial factors that have helped lower the complication rates of breast implants over the past decade.
While capsular contracture remains one of the most common risks associated with breast implants, our surgeons concur that the likelihood of developing it has decreased significantly, particularly for first-time implant patients. Assigning a reliable percentage here is challenging, as the figures published in scientific literature often "do not distinguish between implant type, pocket placement, or incision location," Dr. Mahmood says, and "the data reflects studies conducted several years ago," before today's gold-standard techniques were widely adopted by the industry.
What Are the Symptoms of Capsular Contracture?
"Most instances of capsular contracture occur within the first two years following augmentation," says Dr. Mahmood. In the early stages, patients might notice tightness in their breasts, but there might not yet be a detectable change in their appearance. As the scar tissue thickens, it can compress and displace the implant, pushing it upwards and distorting the shape of the affected breast. Breasts affected by severe contracture feel hard and appear misshapen, uneven, or asymmetrical. "Ultimately, when it progresses quite far, it can become very painful," says Dr. Burke.
Is There a Method to Stop and Reverse Capsular Contracture?
In the initial stages, yes, there are non-surgical solutions for capsular contracture, including implant massage and various medications.
Since bacteria are often the culprit behind this condition, you might think antibiotics would be effective. But as Dr. Burke explains, "the capsule has very poor blood supply – it's avascular – so antibiotics and substances that need to travel through the bloodstream can't easily reach the capsule." Instead, surgeons tend to rely on asthma drugs like Singulair – leukotriene inhibitors that target the inflammatory process involved in capsular contracture. "These medications can help loosen the scar tissue contracture in breast implant patients," says Dr. Chang. (She adds that preventing and treating capsular contracture is an off-label use for these drugs.)
"There has been some discussion regarding the use of ultrasound to assist in breaking up contracture, although its effectiveness is debated," notes Dr. Chang.
What Is the Treatment for Capsular Contracture?
According to Dr. Mahmood, when massage and medications are provided promptly, "some patients might not progress to more severe capsular contracture." Once the capsules harden and the contracture becomes visible, however, "there's really nothing else you can do but take the patient back to the operating room," Dr. Burke states. Surgeons remove the implants and the surrounding capsules before inserting new implants, sometimes along with an acellular dermal matrix – a supportive surgical mesh, which has been found to help reduce the recurrence of capsular contracture.
On the positive side, adds Dr. Mahmood, "the major breast implant companies understand that capsular contracture can occur, so they all offer free implants for primary augmentation for a specified period – Allergan for 10 years, Sientra for 20 years – as well as a certain amount of money to cover surgical costs within the first two years."
