Capsular Contracture? – Causes of Breast Deformity and Solutions including Surgery

CocoRuby Plastic Surgery Blog Capsular Contracture - Causes and Solutions Main Image

Breast augmentation surgery with implants is one of the most in-demand cosmetic surgeries offered by our surgeons. Women who have; small breasts, asymmetrical breasts, or breast deformities all find breast enhancement the go-to solution to get bigger beautiful young-looking breasts.

how-long-does-a-breast-augmentation-last.

Like any other surgical procedure, there are some complications with breast implants that can arise over time. These complications cause distress to both the patient and the plastic surgeon. One of these undesirable outcomes is capsular contracture. So, what is capsular contracture?

In short, capsular contracture is when your body forms tight fibrous bands around your breast implants which pull on your breast tissue causing deformity and pain. Furthermore, capsular contracture is the most common breast implant complication. However, there are certain ways to reduce the risk of it happening. Several surgical and non-surgical treatments for capsular contracture are available and surgeons are developing new methods every day.

This article has everything you need to know about capsular contracture: what it is, why and how often it happens, what the risks are, how to prevent it, and how to treat it with or without surgery.

What is capsular contracture?

brands-of-breast-implant-sizes-types-motiva-

Capsular contracture is one of the undesirable complications of boob jobs. Whenever a foreign object is put in our body, our immune system tries to isolate it by surrounding it with tough scar tissue, this is known as the “fibrous capsule”. This is an entirely normal part of the healing process. It happens naturally in every woman who gets breast augmentation surgery. In most women, the resulting capsule is thin (1 mm) and does not interfere with the final shape of the breast. However, in some unlucky women, the immunologic process is exaggerated. This leads to the fibrous capsule that surrounds your implants becoming thicker, harder, and pulls your breast tissue tighter together leading to adverse outcomes.

There are several grades of severity of capsular contracture (Baker Classification), but in its most severe form, the tough fibrous tissue bands might cause your breast to become;

  • Firm
  • Hard
  • Deformed
  • Unnaturally round
  • And, even painful.

Capsular contracture can cause a lot of distress to both patients and their plastic surgeons. Due to this, there is a lot of research going on to find out the best ways to treat it.

Is capsular contracture common?

Since there’s a lot of different implant types, textures, brands, and models, it is a little bit difficult to say how common capsular contracture really is. According to the latest studies, a reasonable estimate would be that 8% to 15% of women who have had breast augmentation surgery develop clinically significant capsular contracture. However, capsular contracture is the most common complication of breast implant surgery. It is also the most common indication for breast implant revision. Capsular contracture can happen very soon after surgery (within a year), or much later throughout your lifetime. On average, it develops 2 years after breast augmentation surgery, but this largely depends on the many factors listed below.

Why does capsular contracture happen?

Doctors still don’t completely understand exactly why capsular contracture happens, and there is probably more than one factor that leads to its development. Researchers have proposed a couple of theories that might explain why capsular contractures occur:

Exaggerated immunologic response

As part of the normal healing process after breast enhancement surgery, your body will create a capsule composed of collagen, myofibrils, and other cells to surround and isolate your implant. This is a natural process and patients should expect it to happen. Luckily, in the vast majority of women, it does not affect the shape or feel of the breast. For some unexplained reason, some women develop a more excessive immune response, and the immune cells stimulate the formation of a thicker capsule with large and tough fibrous bands that cause capsular contracture.

Adverse inflammatory reaction

Some researchers believe that bacterial contamination of the implant and a subsequent inflammatory reaction might be behind the formation of a thick fibrous capsule. Your skin and nipple normally contain many bacteria, and some of these bacteria might contaminate the breast implant during surgery to cause an exaggerated inflammatory response later on. Many surgeons use triple-antibiotic irrigation of the breast and strict sterile techniques to prevent any contamination during surgery. There’s still not enough evidence to support this theory, and currently, it is thought that bacterial contamination merely increases the risk of capsular contracture but is not an actual cause.

What are the risk factors for capsular contracture?

Reason for surgery

The reason why you originally had breast enhancement surgery plays an important role in determining the risk of capsular contracture. Women who are getting their first boob job (a primary breast augmentation) have a lower risk of developing capsular contracture in comparison to those who are having breast implant revision or breast reconstruction after a mastectomy.

Breast cancer treatment

In patients who had received chemotherapy or radiotherapy as part of breast cancer treatment, the risk of capsular contraction is higher. These treatments are known to increase the rate of infection and subsequently more extensive fibrosis and contracture.

Breast implant brand

motiva-breast-implants-types-sizes-augment

Many studies have been done to assess the risk of capsular contracture with different implant brands

. Since there are innumerable types, models, and brands of breast implants available, it’s a bit hard to determine which brands incur a higher risk of capsular contracture. What we definitely know, however, is that your implant brand plays a role, so make sure you choose a reputable brand when discussing the matter with your plastic surgeon.

Implant filling type

Today breast implants are either silicone-filled or saline-filled;

  • Silicone implants are known to give a more natural look and feel to the breast
  • Saline implants are easier to place and adjust.

Each one has its pros and cons when it comes to the risk of capsular contracture, silicone implants seem to carry a higher risk. This, however, is open for debate, and the data is still not conclusive.

Implant shell surface

Breast implants either have a textured or a smooth surface. Textured implants are associated with less risk of capsular contracture, and can usually maintain their position better than smooth implants. However, it must be noted that textured breast implants have been associated with Breast Implant-Associated Anaplastic Large Cell Lymphoma (BIA-ALCL), a rare type of immunologic cancer that might arise in the breast.

Surgical technique

In breast augmentation surgery, your surgeon will either insert the implant under your chest muscles (submuscular) or above the muscle and underneath the breast tissue (sub-glandular). Submuscular implant placement carries a lower risk of capsular contracture formation. Moreover, using sterile techniques and washing the surgical area with antibiotics can also reduce the risk as it lowers the chance of bacterial contamination.

CocoRuby Plastic Surgery Blog Capsular Contracture - Submuscular Implant Image Illustration with Labels

Time since surgery

Since capsular contracture is a progressive complication, it is reasonable to say that the longer your implants have been in place, the more likely you are to develop capsular contracture.

How does capsular contracture feel and what does it look like?

Symptoms of capsular contracture are usually progressive and increase in severity with time. Early symptoms are usually very mild and may barely be noticeable. You might have capsular contracture if you have one of the following symptoms:

  • Change breast shape: Capsular contracture can cause breast deformity, where the affected breast might shrink and become more spherical with unnatural curvature and a heterogeneous contour (see the image below).
  • Change in breast consistency: As the capsule around your breast implant becomes thicker and tenser, your breast might become firmer, hard and inconsistent.
  • Pain: If the capsule becomes too tight it might start to cause pain in the affected breast.
  • Feeling as if your implant is out of place: Some patients report feeling that their breast implant has changed position and feels like it’s in their armpit.
CocoRuby Plastic Surgery Blog Capsular Contracture - Boobs Breast with Capsular Contracture Illustrated
Deformity of the right breast due to capsular contracture. (Baker grade IV) Courtesy of Walter Peters, Ph.D., M.D., F.R.C.S.C., University of Toronto. Available on the United States Food and Drugs Administration’s website (www.fda.gov)

How to diagnose capsular contracture

If you suspect you might have capsular contracture, you should plan a visit to your plastic surgeon to get a full assessment. Your plastic surgeon will ask you about your symptoms, your implant type, and some details about your boob job. After that, they will perform a thorough physical examination of your breast to assess the degree of deformity, firmness, and any tender points. Your surgeon might order one or more tests to diagnose capsular contracture and rule out any other causes of breast deformity. Tests to diagnose capsular contracture include:

MRI scanning

Magnetic Resonance Imaging (MRI) is considered the gold standard in diagnosing capsular contracture and other complications of breast implants. It provides high-resolution images that clearly outline your breast implant and surrounding tissue.

Mammography

You’re probably familiar with how mammography works. It is a test that’s common in screening women for breast cancer. Mammography can be useful in detecting mild and moderate capsular contracture. However, its use has its limits in cases of severe capsular contracture.

Ultrasound

Ultrasonography is good at detecting capsular contracture, however, the results are very subjective and depend on the experience of the doctor performing the test. Therefore, ultrasound might not be the best test to diagnose capsular contracture.

Based on; your symptoms, the characteristics of your breasts, and imaging results, your plastic surgeon will determine the severity of capsular contracture according to the Baker classification system:

  • Baker I: Your breasts look and feel natural
  • Baker II: Minimal contracture. Your surgeon can feel a little firmness and can tell that you’ve had breast augmentation. But you have no other symptoms or deformities.
  • Baker III: Moderate contracture. Your breast feels abnormally firm with some degree of deformity.
  • Baker IV: Severe contracture. Your breast looks obviously deformed, feels hard, and is causing you pain.

After determining your Baker grade, your doctor will discuss with you the possible treatment options. Capsular contractures with Baker grades I and II usually do not cause any concern and require no treatment. Baker grades III and IV, however, are more severe and treatment is necessary.

What are the surgical treatments for capsular contracture?

The most effective treatment for capsular contracture is revision surgery. Capsular contracture revision surgery is usually reserved for those with severe contractures (Baker III and IV), and it includes one or more of the following;

Capsulotomy

Also called an open capsulotomy (as opposed to the closed capsulotomy described below). The fibrous tissue capsule is made of thick tight bands that become tighter and abnormally pull your breast tissue distorting its shape. A capsulotomy is a surgical revision procedure where your plastic surgeon tries to cut the tight bands that are pulling on your breast. The aim is to try to release them to make your breast softer without completely removing the capsule. Your surgeon will cut the bands in multiple locations and in different orientations to relax the tissue and restore the normal breast shape. This technique is less extensive than capsulectomy (capsule removal), and it is preferred if your implants are submuscular.

Capsulectomy

A capsulectomy is a breast implant revision surgery in which your surgeon cuts out and removes all the fibrous tissue capsule surrounding your breast implant. This surgery is more invasive than capsulotomy and carries higher risks especially if your implants are submuscular. Submuscular implants are very close to your ribs, so extensive manipulation of the capsule around them can lead to; hematoma formation (blood collection) or pneumothorax (puncture of the lung). Nevertheless, some surgeons still prefer this technique to capsulotomy, since it’s thought that complete removal of all scar tissue ensures;

  • The removal of any contaminants
  • Reduces further contracture
  • Prevents calcium from building up in the leftover tissue
  • while also minimising interference with mammography results.

Implant re-placement

It is thought that repositioning the implant (changing the location) can reduce the risk of recurrence and improve outcomes after capsulotomy and/or capsulectomy. A new technique that has shown promise is the “neo-pocket” formation. A neo-pocket is a new space your surgeon creates for your implants to sit in.

Autologous fat transfer

There has been research into Autologous fat transfer as a potential treatment for capsular contracture. In this procedure, your doctor removes excess fat from another site of your body (like your thighs, hips, or abdomen) through liposuction. The fat is then injected into the breasts, researchers suggest that by doing this, the blood circulation will be enhanced around the capsule, and the breast will become softer. Nevertheless, this is still under investigation and is not a standard treatment. Fat transfer can, however, be used in combination with capsulotomy or capsulectomy, or as part of breast reconstruction if you choose to remove your implants.

Implant removalCoco Ruby Blog - Before and After Mandatory Breast Implant Removal Image

In very severe cases with multiple recurrences, your surgeon might suggest removing your breast implants completely as one of the options. Removing the implants usually solves the problem, however, the cosmetic results after explantation are usually undesirable. This is especially true if you’ve had large implants and are left with excess skin after surgery. After removing your breast implants, your surgeon can perform breast reconstruction with a combination of techniques. Reconstruction after implant removal can include mastopexy (breast lifting), removal of excess skin, or autologous fat transfer.

Is there a risk of recurrence of capsular contracture after revision surgery?

Unfortunately, the risk of recurrence after capsular contraction repair surgery is somewhat high. According to some estimates, nearly 1 in every 4 women develops contractures again within a year of her revision surgery. This can lead to multiple subsequent revision surgeries, and the risk of recurrence remains high each time. There is hope that the study of newer surgical techniques (like the neo-pocket method) will minimize the risk of capsular contracture recurrence.

What are the non-surgical treatments for capsular contracture?

While many believe the best way to remove Capsular Contracture is through breast revision surgery, some alternative non-surgical treatments that can help break up the scar tissue in the breast and make it softer include:

Closed capsulotomy

As the name implies, closed capsulotomy is when your plastic surgeon attempts to break the scar tissue forming the capsule in your breast without resorting to surgery. This means that your surgeon will attempt to manually manipulate your breast, pulling and pushing it in different directions in order to loosen the fibrous bands causing capsular contracture. This technique, however, is not very effective, and more than half the women usually need to undergo the procedure multiple times. Moreover, closed capsulotomy carries a risk of implant rupture and hematoma formation (blood collection). All of this has made closed capsulotomy a less-than-ideal method to treat capsular contracture without surgery.

Ultrasound therapy

Ultrasound therapy uses sound waves that are applied to your breast using a probe. This method has been used in treating breast engorgement and blocked mammary ducts. Recently, there have been suggestions that multiple sessions of ultrasound breast therapy might be an effective non-surgical way to treat capsular contracture by relaxing the tight scar tissue in the breast. This technique is still under investigation, but research shows it to be promising.

Topical vitamin E

Some doctors prescribe Vitamin E creams to rub on the breast to soften the scar tissue and reduce capsular contracture.

Injectables

Several injectable drugs have been tested as an alternative to surgery when treating capsular contracture. Triamcinolone (a steroid), when injected into the scar tissue in the breast, might be an effective way to get rid of capsular contracture. Some researchers have also suggested that Botulinum toxin A (Botox) injections can also make the capsule thinner and softer.

Zafirlukast (a new drug) has shown to successfully improve the Baker grade by softening the fibrous tissue capsule and loosening the capsular contracture. However these drugs are still under investigation, and they are yet to provide confirmation on the sustainability of the results.

Oral medications

Several medications have been suggested as a medical treatment for capsular contracture. Drugs like; Pirfenidone, Montelukast, and Zafirlukast all provide anti-inflammatory properties that can help you get rid of capsular contracture without surgery. As with the other non-surgical alternatives, these drugs are still undergoing further research before they become standard practice.

Will Medicare or Private Insurers cover capsular contracture repair surgery?

Medicare cover
 

A lot of patients ask how much breast revision surgery for capsular contracture costs and whether or not Medicare cover it. Medicare usually covers breast implant removal (without replacement) in any woman who develops complications like implant migration, rupture, or capsular contracture, regardless of the reason why she had had breast augmentation surgery in the first place. When it comes to covering breast implant replacement, however, Medicare is a bit more strict. If you had originally got implants to treat a breast deformity (like tuberous or asymmetrical breasts), trauma, or another breast disease, then Medicare and insurance will cover some cost of implant revision surgery if it’s needed. This also applies to women who had had breast augmentation surgery after a mastectomy for breast cancer.

On the other hand, in women who originally had breast enhancement for purely cosmetic reasons, Medicare does not universally cover the costs of implant replacement. In this case, you will be eligible for a rebate only if your surgeon can demonstrate that removing the breast implants without implanting new ones will result in a significantly unacceptable deformity. The term “significantly” is not very clear, however, and it usually refers to when there’s no more breast tissue left after explantation.

Doe my warranty cover capsular contracture?

motiva-breast-implant-image-breast-augmentation

Most reputable breast implant brands provide comprehensive warranty programs that cover a range of complications associated with breast implants long after surgery. The list includes implant rupture, capsular contracture, implant migration, and others. Here are the warranty policies for capsular contracture by some top breast implant brands in Australia:

Mentor

Mentor’s warranty program covers capsular contracture for the first 10 years after surgery. This means that if you develop Baker grade III or IV capsular contracture within 10 years, you can get free replacement implants similar to the ones you originally chose. Moreover, the company offers $1500 (Around 2000 AUD) in financial assistance to cover the costs of breast implant revision surgery.

Allergan

Natrelle breast implants by Allergan also cover capsular contracture in their warranty. The company promises to provide free replacement implants for the first 10 years, as well as up to $1000 (1350 AUD) in financial support.

Motiva

If you have Motiva implants and develop capsular contracture within 10 years of implantation, the company will provide replacement implants free-of-charge. Moreover, if your implant happens to have Q Inside® Safety Technology, you will be eligible for $2500 (3370 AUD) in financial coverage, if contracture develops within the first year of surgery. Motiva also offers paid warranty programs that provide more comprehensive coverage in case of implant rupture or capsular contracture.

Other breast implant brands used in Australia, like Eurosilicone, Nagor, Sebbin, and Silimed also offer similarly generous warranty programs to ensure your peace of mind long after your boob job.

How to prevent capsular contracture?

Preventing capsular contracture mostly starts before surgery, as it is closely related to your choice of implant and plastic surgeon. After surgery, breast massage can have a preventive role. So here’s what you can do:

Choice of implant

The characteristics of the implant you choose play an important role in determining the risk of capsular contracture. Choosing a breast implant brand with a good reputation guarantees minimal risks. Textured implants (aside from their risk of BIA-ALCL) have less likelihood of causing capsular contracture. You should discuss all the pros and cons of different implant types when planning your surgery with your plastic surgeon.

Choosing your plastic surgeon

Choosing the right plastic surgeon is critical to reducing the risk of complications after breast augmentation surgery. It’s also vital to get the most outstanding results possible. Top plastic surgeons follow strict sterile techniques and methods to reduce contamination during surgery. Moreover, experienced surgeons will try to place your implants using techniques that are less likely to cause contracture later on in life. In addition to all this, choosing the right plastic surgeon means that you will get a better follow-up long after surgery, shall any problems arise.

Breast massage

Daily breast massage for the first few months after surgery can help stimulate the blood flow around your implants. This in turn leads to a softer and thinner capsule. You should gently massage your breasts multiple times a day during the first 2 months after surgery. After the initial 2 months, you can reduce it to once a day.

Omega-3 supplements

According to early research, fish oil and omega-3 supplements might help during the healing process by making the capsule less-tough.

FAQ’s about capsular contracture?

Can capsular contracture go away by itself?

  • Capsular contracture is usually a progressive problem that gets worse with time. It’s unlikely that the breast deformity will go away on its own without medical or surgical intervention.

Can lifting weights cause capsular contracture?

  • No, lifting weights after full recovery from breast augmentation does not cause capsular contracture. In fact, evidence suggests that moving your pectoral (chest) muscles improves blood supply to the tissue around your implant.

Can capsular contracture happen overnight?

  • No, capsular contracture is a progressive complication. In other words, it starts with minimal symptoms that might get worse over an extended period of time. If you have a sudden change in your breast size, you might have an implant rupture.

Is capsular contracture dangerous?

  • No, capsular contracture does not pose any risks to your physical health. The only problem with not dealing with capsular contracture is that it may worsen with time.
  • This can lead to pain and severe deformity.

Like any other surgery, breast augmentation surgery has its complication. Capsular contracture is sometimes unavoidable. Even if your plastic surgeon follows all the possible preventive methods and offers you the most reputable implants. This problem can be distressing to deal with, however, enduring the treatment process will hopefully help you restore your beautiful and attractive breasts in no time.

Sources:

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4579163/

https://www.sciencedirect.com/science/article/pii/S2405857215300140

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2691025/

https://www.plasticsurgery.org/news/blog/what-is-capsular-contracture-and-how-can-it-be-treated

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7273769/

https://academic.oup.com/asj/article/22/4/329/208528

 

Last updated: 02/02/2021
Author profile image
Dr Craig Rubinstein - MBBS, FRACS (Plast)
Dr Craig Rubinstein MBBS, FRACS (Plast), a Specialist Plastic Surgeon, is one of Australia's most respected Melbourne Surgeons for Breast Augmentation, Breast Lift (Mastopexy), Breast Reduction surgery and Abdominoplasty procedures. Using advanced surgical techniques to gain better body contouring and natural-looking surgical results, Dr Rubinstein is highly regarded by peers and patients for best-practice Clinic Patient-care and patient education strategies. He published a chapter on corrective surgery for Breast Asymmetry. Qualifications/Training Fellow of the Royal Australasian College of Surgeons (FRACS) The Australasian Society of Aesthetic Plastic Surgery (ASAPS) The Australian Society of Plastic Surgeons (ASPS) The Australian Medical Association (AMA) American Society of Plastic Surgeons (ASPS) The International Society of Aesthetic Plastic Surgeons (ISAPS) Founder: Cosmetic Surgery for Women and Men - Plastic Surgeons Group Bio Page: https://cocorubyplasticsurgery.com.au/dr-craig-rubinstein-plastic-surgeon/