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Capsular Contracture
This specimen
photo shows the intact capsule containing the breast implant immediately
after removal from the breast (a complete capsulectomy)
What is Capsular Contracture?
Capsular contracture (CC) is the term used to
describe scar tissue that can form around breast implants which may cause
the breasts to harden, may cause the breasts to look or feel different, and
may cause some discomfort from the tightening of the capsule. Capsular
contracture is an unpredictable complication, but it is also the most common
complication following breast augmentation. Although presently we do not
know what causes a capsular contracture to form in one woman and not in
another, or why one breast may harden while the other remains completely
soft and natural, there are some techniques that have reduced the risk in
our patients.
How can the risk of Capsular Contracture be reduced?
Textured implants help
deter capsular contracture formation because their rough surface discourages
a hard capsule of scar tissue from forming around the breast implant. In
scientific studies, however, this benefit has been shown only in
subglandular (above the muscle) breast augmentations. Since most breast
implants today are placed fully behind the chest wall muscle (submuscular or
subpectoral), the benefits of textured implants is limited, and they are not
commonly used. The disadvantages of textured implants is that the texturing
process makes the wall of the implant thicker, making it more likely that
you will be able to see or feel the edges of the implants.
Under the muscle placement
(subpectoral or 'partially submuscular') placement of the implant
reduces the risk of capsular contracture to approximately 8- 12% over
your lifetime. Over the muscle (in front of the muscle, 'submammary' or
‘subglandular’) has a 12-18% chance of capsular contracture. Complete
unders (totally submuscular or totally submusculofascial) provide even
more protection, with your risk of capsular contracture being reduced to
4-8% over your lifetime.
Massage may or may not
help prevent capsular contracture formation. Although there are no good
studies proving the effectiveness of this technique, many plastic
surgeons do believe in massage. Dr. Revis believes in massage on an
individual basis. He is not convinced that massage can help prevent
capsular contracture formation, but he does believe that massage can
help the breasts soften postoperatively, may hasten implant “dropping
and fluffing” (implant settling into the pocket as the muscle relaxes
and the implants descend into the proper position), and may also help
reduce swelling and make a patient feel better faster postoperatively.
Just like a massage at a spa, breast massage can loosen the muscles and
make a patient feel better.
The "no-touch" technique.
Dr. Revis believes in the “no touch” technique. In this method, the sterile
container the implants are packaged in is opened only at the moment they are
ready to be inserted into the body. No one else handles the implants except
Dr. Revis. He resterilizes the skin of the breasts with betadine, redrapes
the operative field surrounding the breasts with new sterile towels, and
replaces his own gloves. He washes the surface of his new gloves to remove
any powder, and only then will he touch the implants. When the implants are
inserted into the body, he takes care not to allow the implants to touch any
instruments, the skin of the patient, or any sterile drapes surrounding the
operative field. In this manner, there can be little chance of surface
contaminants on the implants once they are inside the body. All of these
measures help ensure that no foreign substances attach themselves to the
implant, which could inflame the surrounding tissue and cause complications
such as capsular contracture.
Closed filling system (when saline implants are being used).
Dr. Revis also believes that a closed filling system reduces the potential
for capsular contracture. With this technique, the saline used to fill your
implants flows from a sterile bag through sterile tubing into the sterile
implant. There is no possibility of foreign bodies or bacteria or fungus
entering the implants.
How is Capsular Contracture diagnosed?
A capsular contracture is usually diagnosed on
physical examination by a plastic surgeon. You may notice that one or both
of your breasts are not as soft as they once were or may actually begin to
harden, your breasts may begin to look or feel different, or you may
experience some discomfort from the tightening of the capsule. The
appearance of any of these signs should alert you to the need to have your
breasts examined by a plastic surgeon at your earliest convenience.
Your plastic surgeon will examine you to
determine if indeed you have a capsular contracture. The examination of each
breast is classified on a scale of I to IV:
Grade I:
The breast is soft and normal
Grade II:
The breast is less soft than normal, and the implant can be palpated
Grade III:
The breast is firm, the implant can be palpated easily, and an asymmetrical
distortion of shape can be appreciated
Grade IV:
The breast is hard, tender, painful, and the shape
distortion is pronounced or severe
Can Capsular Contracture be seen on a
mammogram?
It is often possible to visualize the thickened
capsules radiologically with a mammogram, ultrasound or MRI, although this
is not necessary for the diagnosis to be made. The photos below demonstrate
a patient who had silicone implants placed 25 years previously and presented
to my office with bilateral ruptured silicone implants and capsular
contractures. The image on the left represents the entire breast (hazy
black), capsule (gray) and implant (white). The image on the right is a
closeup of the capsule surrounding the implant.
What treatment
methods are available for Capsular Contracture?
Zafirlukast
(Brand Name: Accolate) taken twice a day for 90 days has been shown to
result in a softening of the scar tissue around the implants in
approximately 50% of cases.
Forty randomly chosen patients
with capsular contractures were given zafirlukast (Accolate) and experienced
dramatic softening of the breasts over 3-6 months. In another study, thirty
patients with capsular contractures used Accolate for 12 months and 50%
experienced softening of the breasts. Accolate has also been shown to
decrease the recurrence of capsular contracture in patients undergoing
capsulectomy. If you have a capsular contracture, Dr. Revis will most likely
recommend a trial of Accolate before considering surgical intervention. If
you are having a surgical capsulectomy, then Dr. Revis will likely recommend
a short course of Accolate pre- and postoperatively.
Suggested dose: 20mg Zafirlukast twice daily for 3 months. The same
dose
is used for preventive treatment 2 weeks prior to surgery.
Risks: Allergic rashes. Long term effects are unknown as
Zafirlukast has only been available
in the US since 1999.
Other benefits: Zafirlukast is used chronic rhinitis so patients
may notice improved breathing which
also may lead to decreased snoring.
Capsulectomy- For those patients without significant
softening during a trial of Accolate, the only other effective alternative
is to completely remove the scar tissue surrounding the implant. Although
this does not eliminate the possibility of future scar tissue forming around
the implant, it does reduce the risk of subsequent capsular contracture when
compared to other methods. Other methods which have fallen out of favor with
most surgeons include capsulotomy (which means only a scoring or breaking up
of the scar tissue, not complete removal), or a closed capsulotomy (where
the surgeon squeezes the breast so hard that there is actually an audible
popping noise from the scar tissue breaking open) which is rarely performed
anymore because it almost always fails, may break your implants, may cause
internal bleeding around the implant, and probably invalidates your
warranty.
Capsulectomy (complete removal of the scar capsule)
 The
most appropriate treatment for capsular contracture is complete
capsulectomy, or removal of the entire thickened capsule surrounding the
breast implant such as in the specimen shown above. This is the most
likely procedure to prevent future recurrent capsular contractures from
forming. Capsulotomy, or merely cutting the capsule to release the scar
formation, is much more likely to lead to a recurrence of the problem.
The specimen to the right is the same specimen at the top of the page,
but the capsule has now been incised without removing any of the
capsule.
The fact that the
capsule appears to spring open demonstrates the considerable compressive
forces exerted on the implant by the thickened capsule. This is why capsular
contractures often lead to increased firmness of the breast.
A close-up view of
the cut edge of the capsule, demonstrating the thickening that occurs during
capsule formation. A normal capsule is a flimsy, transparent structure. As
thickening occurs, collagen is laid down in layer upon layer, ultimately
becoming apparent as a change in the shape of the breasts, a change in the
softness of the breasts, and in some cases causing pain.
The final photo in this series showing the capsule fully opened with the
implant removed.
Breast
Augmentation Revision Main Page
Please call (954) 630-2009 for further information or to schedule your
complimentary consultation.
Email: DrRevis@SouthFloridaPlasticSurgery.com.
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