The majority of women have a very nice and long lasting result from breast augmentation. A thin layer of healthy tissue soon forms around your new breast implant to make it part of you. This is called the capsule.
This occurs around any implanted material whether it is a pacemaker or an artificial hip. In some people, this tissue may thicken with time and the term for this is “capsulation “or “capsular contraction.”
Capsular contracture is the most common complication that occurs with breast augmentation and can happen at any time. It seems to be more common in the first few months after surgery, but the incidence then rises again several years after surgery.
How does Capsular Contraction occur?
At the time of the implant surgery, a pocket is made under the breast for the implant. The capsule that forms is made of fibrous tissue. Some patients lay down more collagen and scar tissue in this capsule, which naturally tends to shrink with time. In most people, this may cause a slight increase in firmness of the implant, or it may only be noticed by your specialist. In some people, the capsule will tighten gradually, and squeeze the implant. This makes the breast implant feel hard and alters the appearance of the breast. In the later stages, the implant feels very firm and may take on a ball-like look. Capsular contracture like this usually produces pain and discomfort.
How is capsular contraction graded?
Breast is soft and looks natural (this means there is no capsulation!)
Breast is a little firm but looks normal
Breast is firm and looks abnormal
Breast is hard, painful, and looks abnormal
What causes capsular contraction?
There are probably several causes that affect some patients and not others. There are some factors that may increase the risk of capsular contracture.
The rate of capsular contraction is twice as high in smokers. Mr Turton advises all of his patients not to smoke.
Capsular contracture is more likely following an infection. It may occur following sub-clinical infection.
Breast implants placed above the muscle tend to have higher capsular contracture rates, versus breast implants placed behind the muscle, which is also known as sub-muscular placement. But remember there are other pros and cons to be taken into account in deciding on implant placement, and your specialist will discuss these.
This is a collection of blood around the implant. It can cause an inflammatory reaction, which can lead to capsular contracture. It is advisable to place a temporary drain at the time of surgery which is removed immediately before your discharge home. This removes even small volumes of blood which otherwise would be left around your implant by those surgeons that don’t routinely drain.
Smooth Surface Implants
The smooth surface implants seem to be associated with a significantly higher capsulation rate than the rough surfaced type if placed in the sub-glandaulr position. The rates are otherwise similar if placed sub-pectorally. These rough surfaced implants were a new design change introduced over 10 years ago. The process called “texturing” makes the surface feel slightly different when held in the hand, but they feel quite similar inside the body. Different manufacturers have chosen different techniques to texture implants, and there is a wide choice now. Due to concerns that too much texturing might cause a slightly higher risk of a very rare lymphoma (BIA-ALCL) surgeons will talk to you about texturing, the pros and cons of the different types and what might be most beneficial in your circumstance. Sometimes using a totally smooth implant under the muscle is preferred, or otherwise a micgrotextured implant above or under the muscle is used. Only rarely these days in 2019, will we recommend to use the higher grades of texture due to the potential concerns. The original rational for texture was to inhibit the capsulation process and so dramatically reduce its occurrence. The higher grade of textured implants also united better to the back of the breast tissue reducing risks of a rotation of a shaped implant or general movement.
Ruptured or leaking implant
A ruptured implant or one that is bleeding small amounts of gel into the area around the implant might incite a chronic inflammatory response that leads to your capsule tightening around the implant. If this goes on for a prolonged amount of time, the capsule might thicken and after years it may even begin to calcify forming a very hard ball. Of note is that if you have had any previous capsulation it is much more likely to occur again. There may be a genetic reason for this related to wound healing. This is unknown, though. If you do get recurrent capsular contraction you should think about permanently removing your implants and accepting it is not for you.
How do you treat capsular contraction of breast implants?
My first advice is to stop smoking if you are a smoker. If there are no symptoms and the cosmetic result remains excellent you do not need to have anything done. It doesn’t always progress. It is also important to know that it is not usually associated with any implant rupture, a toxic or nasty systemic inflammatory processes, or an implant lymphoma.
If it causes discomfort, pain or an unwanted cosmetic result then a careful clinical review with a specialist in required. You may need breast imaging. Surgery is then the best way to deal with it.
No one should undergo the previously used but now out-dated technique of closed capsulotomy (the hardened implant was manually squeezed from the outside, to tear the scar envelope, but this could damage the implant).
Open capsulotomy, partial or full capsulectomy (e.g. total en-bloc capsulectomy): This involves a general anaesthetic. The previous incision is usually reopened and the capsule is either incised, or partly or totally excised either en-bloc or after removal of the implant depending on reasons.
A new implant can be reinserted if the patient wants to have replacement implants. After surgery, the breasts feel softer and quite often they look slightly lower and you may feel you have lost the fullness that you used to have, especially in the upper breast (the previously contracted capsule had acted to keep the breasts artificially high, so after it is removed the breasts drop back to their normal position).