Capsular Contracture in Breast Implants

What is Capsular Contracture?

Capsular Contracture is defined as a thick scar around the breast implant that causes hardening of the breasts, breast pain and a visible distortion of the breast shape.

Capsular Contracture is classified according to the following subjective scale (known as the Baker Classification). Fundamentally, the tighter the capsule becomes the firmer the breast feels and the more abnormal it appears.

1. Grade I – the breast is normally soft and appears natural in size and shape
2. Grade II – the breast is a little firm, but appears normal
3. Grade III – the breast is firm and appears abnormal, there is no pain
4. Grade IV – the breast is hard, painful to the touch, and appears abnormal

What Causes Capsular Contracture?

The exact mechanism that leads to capsular contracture is still unknown, however it is hypothesized that inflammation is the trigger that causes the contraction of the normal breast capsule.  The inflammatory process then leads to contraction of smooth muscles cells.

Incidence of Capsular Contraction

Published rates of capsular contracture in Breast Augmentations are usually reported at about 8% at 5 years, while incidence in our patients ranges between 1 – 5%. The exact numbers vary, and some surgeons claim their rates to be 1% or less; although, there are no independently verifiable rates that low. In general, Capsular Contracture is the the most common cause of re-operation after Breast Augmentation, which most often takes places during the first year after surgery.

Prevention of Capsular Contracture

Capsular Contracture is one of the most researched topics in cosmetic breast surgery. Although the exact cause of this condition is not known, it is thought to result from the combination of multiple factors. Evidence suggests that contamination, bleeding, and an implant placement above the chest muscle (sub-glandular or sub-mammary) of smooth breast implants increase the risk, while using a textured implant placed under the muscle (sub-muscular or sub-pectoral) through a breast fold incision is the best way to significantly reduce the risk. There is no difference between the use of silicone and saline implants.

The following have been found to be factors that increase the risk of Capsular Contracture occurring:

1. Above muscle placement (vs. below)
2. Textured implants (vs. smooth)
3. Peri-areolar incision (vs. Breast Fold incision)
4. Peri-areolar incision (vs. Breast Fold incision)
5. Larger implants (greater than 420 ccs)
6. Use of a post-operative bra
7. Development of hematoma/seroma after surgery

Leukotriene receptor antagonists (such as Singulair) prevent the action of various inflammatory mediators and have been shown in various studies to prevent or reverse capsular contracture.

How Dr. Jugenburg Minimizes the risk of Capsular

Contracture Formation

At the Toronto Cosmetic Surgery Institute, we are meticulous in our approach towards minimizing your risk of developing Capsular Contracture and in achieving the perfect, worry-free breast enlargement for you. The following steps are taken during surgery:

• To minimize the risk of contamination, we use absolutely strict sterility measures during Breast Augmentation surgeries. Dr. Jugenburg uses the most effective antiseptic to clean the surgical sites, changes sterile gloves prior to handling the implants, and uses a Keller Funnel to achieve an absolute no touch placement of all silicone implants. All implants are also washed with an antiseptic solution prior to insertion under your breasts. All these measure reinforce our efforts to ensure absolute sterility of each and every procedure.
• To minimize the risk of bleeding, Dr. Jugenburg’s meticulous surgical technique carefully prepares the breast pocket. This is achieved through the use of a special tool during the surgery, virtually creating a Bloodless Breast Augmentation.

Since Capsular Contracture is believed to result from a combination of effects, other factors should be taken into account when making decision in the planning of Breast Augmentation. Above muscle placement may, for example, have higher incidence of Capsular Contracture, but is also associated with less discomfort after surgery and less unwanted movement with chest muscle contraction.

The following considerations will therefore also be taken by Dr. Jugenburg during the planning of your Breast Augmentation surgery:

• Dr. Jugenburg most commonly uses a breast implant placement below the chest muscle (or dual-plane). There are, of course, indications for a placement above the chest muscle in certain patients. If this is the better approach for you, Dr. Jugenburg will discuss this with you at the time of your Breast Augmentation consultation.
• Although textured breast implants are believed to be beneficial in reducing capsular contracture, particularly when an implant is placed above the chest muscle, Dr. Jugenburg does not regularly use them due to various negative features of such implants. If textured implants are the right choice for you, Dr. Jugenburg will discuss this with you during your Breast Augmentation consultation.
• The Breast Fold approach may be beneficial in reducing Capsular Contracture, but it is not recommended when existing breast volume is less than 200 ccs, the shape of the breast is tubular and drooping, or when there is no breast fold (which is dependent on existing breast size and shape).

The No-Touch Technique

Limiting handling and skin contact prior to insertion of a breast implant follows the indication that less handing causes lower bacterial contamination and is likely an important concept in preventing Capsular Contracture. The No-Touch Technique employed by Dr. Jugenburg is designed to avoid even the air from touching an implant during surgery. Implants are packed in a sealed, sterile plastic container. As soon as the package is opened the implant is covered with an antibiotic liquid. After the breast pocket is created, Dr. Jugenburg changes gloves and coats the new gloves and instruments with antibiotic solution. The breast pocket is then also washed with antibiotics solution. Next, Dr. Jugenburg places the implant into the breast pocket, touching it only with gloves and instruments covered with antibiotic solution. Neither air nor skin bacteria are allowed to touch the implant.

Treatment of Capsular Contracture

Only a relatively small percentage of women with implants develop Capsular Contracture that is severe enough to require surgical treatment. The rare patient also develops repeated Capsular Contracture, but in the majority of cases it can be successfully treated.

In the early stages of Capsular Contracture, medical (non-surgical) treatment may be effective in stopping its progression. Such methods include breast implant massage, ultrasound, pulsed electromagnetic field, and leukotriene pathway inhibitors (Accolate, Singulair). When non-surgical methods fail, surgery is used to release the tightened capsule. Under sterile conditions, the breast pocket is opened, the implant is removed, and the capsule is either cut multiple times to release the contraction (Open Capsulotomy), or cut out and removed (Open Capsulectomy) before replacing the implant. An Open Capsulotomyis normally the first line of defense and works in the majority of cases; it can be performed through the underarm and the recovery time is typically 1 – 2 days.