Capsular Contracture Treatment
What is capsular contracture?
Capsular contracture is the hardening of the breast after breast implants. The breast implants themselves don’t harden, just the scar tissue (capsule) around the implant. There can be pain associated with capsular contracture. The implant becomes more palpable and often takes on a rounder shape. Severe disease can cause significant distortion of the breast shape.
What are the causes of capsular contracture?
There are a number of theories related to the cause of capsular contracture. Generally, it is believed that either a low-grade infection or excessive inflammation and scarring is to blame. Bleeding in the implant pocket either at the time of surgery or from subsequent trauma has been shown to increase the risk of capsular contracture. There are certain individuals that may have increased risks of capsular contracture, including smokers and patients with certain autoimmune disorders.
The predominant theory implicates biofilms as the primary cause of capsular contracture. Biofilms are multi-organism bacterial colonies that surround themselves with a covering that protects them from the immune system and antibiotics. It is thought that bacteria present at the time of surgery create this biofilm around the implant. The bacteria release chemicals that protect them from the host. They do not form an acute infection in the way that we usually think of infection. It does not become red, hot, or swollen. There is no pus. It becomes a chronic, low-grade infection. The inflammation associated with this biofilm may lead to a thick, tight breast implant capsule – the hallmark of capsular contracture.
How common is capsular contracture?
According to FDA and implant manufacturer data, the rate of significant capsular contracture at five years is 10%. This study looked at a variety of implant types, surgeons, and surgical techniques. Dr. Yates has found that his rate of capsular contracture is substantially less than this (about 1%), likely for the reasons stated below.
The rate of capsular contracture is VERY dependent on the type of implant used, the location of the implant pocket, the incision choice, and the nature of the surgical setting the procedure are performed in.
The risk of capsular contracture is lowest with textured implants, placed beneath the muscle through an inframammary incision done by a surgeon with low capsular contracture rates. In these cases, one should expect a 1% capsular contracture rate.
Do the breast implants get hard with capsular contracture?
The implants themselves do not harden with capsular contracture. It is only the scar tissue, or capsule, around the implant that hardens.
How can I prevent capsular contracture?
Dr. Yates believes that although surgeons cannot eliminate the risk of capsular contracture, there are steps that can be taken to reduce these risks.
- Operating room sterility is a must. A certified, in-office surgical suite has the advantage of not having sick patients and not having hospital-acquired bacteria
- Maintain implant sterility during insertion. Some surgeons use a protective barrier between the skin and the implant during placement. Bathing the implant in antibiotics and irrigating the implant pocket with antibiotics prior to placement reduces the risk of contamination.
- Patients should be encouraged not to smoke before breast augmentation
- Breast implants placed beneath the muscle have a lower capsular contracture rate than breast implants placed above the muscle
- Contamination from invisible bacteria in the glands beneath the nipple makes the nipple incision a higher risk for capsular contracture. Some surgeons use “nipple shields.”
- Textured implants have a lower risk of capsular contracture than smooth implants when placed above the muscle (not as much advantage beneath the muscle)
- Revision breast augmentation and breast reconstruction have higher risks of capsular contracture
- Oral and intravenous antibiotics before and after breast augmentation surgery should be given
- Massage of smooth-walled implants after surgery? This is recommended by most plastic surgeons, including Dr. Yates, the actual value of this is likely overstated
- Oral medications such as Vitamin E and Accolate taken after surgery. Used by Dr. Yates if there are early signs of capsular contracture but not prophylactically
How is capsular contracture treated?
Early Capsular Contracture (less than a year)
For mild, early cases of capsular contracture, Vitamin E, Singulair and oral antibiotics taken orally may improve the contracture. This is rarely helpful, and most patients eventually require nonsurgical or surgical management if the contracture is significant.
Z wave radial shock wave therapy is a new tool in the treatment of capsular contracture. This is a nonsurgical treatment option that utilizes external high-intensity sound waves to help release and break up scar tissue. We offer Z Wave as a noninvasive treatment option with mixed success. We have found it to be most successful with newly diagnosed contracture. When unsuccessful, we apply what the patient has paid for the procedure towards surgical fees.
Late Capsular Contracture
Rarely is late capsular contracture treated with nonsurgical options. Understanding the likely infectious cause of capsular contracture helps to direct treatment. The risk of capsular contracture recurrence is significantly less if the capsule (and biofilm) are removed completely and a new implant placed (even if it looks normal). Antibiotics should be given after surgery and can be irrigated into the implant pocket after the capsule has been removed.
An old treatment for capsular contracture was closed capsulotomy. The surgeon literally squeezed the implant until the capsule cracked. This is no longer recommended. Another common alternative to complete removal of the capsule (capsulectomy), is the internal release of the capsule (capsulotomy). This has a much higher rate of recurrence but is a simpler procedure.
A modern tool in the treatment of capsular contracture is the addition of acellular dermal matrix (ADM). This is a sling of dermal tissue that is placed around a portion of the implant to disrupt the scar forces that contribute to capsular contracture. The early studies would suggest that this is a very effective and exciting new option for those cases of difficult capsular contracture, decreasing the rates of recurrence to as low as 1 – 2 %. The downside is the expense. These ADM products are quite expensive.
In the following videos, we have performed total capsulectomy of a subglandular augmentation; followed by conversion to a submusclar plane and addition of Strattice ADM to cover the lower pole of the implant. We would generally reserve this aggressive treatment for patients with recurrent capsular contracture. This has a very good success rate.
Nonsurgical treatment of capsular contracture options?
We have been pleasantly surprised by the Z Wave treatment for early capsular contracture.
In our experience, Zwave is more effective than medications + massage. It is not as effective as surgery, but is much less expensive and has no downtime. It is not recommended for patients with longstanding capsular contracture but is effective 75% of the time for early contracture. For patients who have early contracture, this can in some cases prevent surgical options. We have a “no-risk” guarantee for the Z wave. If it doesn’t improve the contracture and requires surgery we will apply all of the costs of Z wave treatment towards surgical fees.
When is the addition of ADM for capsular contracture most useful?
Einstein was quoted as stating the definition of insanity is “doing the same thing, over and over again, but expecting different results.” For recurrent capsular contracture, the expense of the acellular dermal matrix is likely worth the potential benefit.
Do I need new implants if I develop capsular contracture?
Generally yes. If the capsular contracture is significant enough to require surgery, a new implant for replacement is recommended.
Are implants guaranteed against capsular contracture?
Good news! As of November 2013 one of the implant manufacturers “guarantees” some of their implants against capsular contracture for two years. Sientra, the newest implant manufacturer has launched its CapCon Care (C3)program as of November 2013. With the completion of a simple device tracking form, all Sientra textured implants are automatically enrolled. This is regardless of incision choice or implant pocket location. In the event of Baker III or Baker IV contracture, Sientra will provide free implant(s) for the correction surgery. Although the guarantee is only for two years, the majority of capsular contracture cases will be seen in this time span.