Complications Requiring Breast Revision Surgery
Capsular Contracture Resulting from Breast Augmentation Surgery
Capsular contracture, or hardening of the breast due to the formation of contracted scar tissue around the implant, is less common today than in the first decades of breast implantation dating from the late 1960’s.
All breast implants, either saline or silicone, whether smooth or textured, develop breast capsules, or scar tissue, around the breast. This is the body’s normal reaction to placement of a foreign object, the breast implant, into the patient. It only becomes a problem if the scar tissue capsule contracts and squeezes the breast implant. The implant itself does not become hard, but rather the squeezing force of the scar tissue makes the implant “feel” hard. Breast capsules are classified into different categories depending on the problem the patient is experiencing. Dr. Baker described these phenomena many years ago in the following manner, which is still used today to classify breast implant results.
- Grade I Soft, a soft natural appearing breast.
- Grade II Slightly to moderately firm breast with a natural appearance.
- Grade III Moderate to hard breast with visual distortion in appearance.
- Grade IV Grade II or Grade III above with pain or discomfort.
The exact mechanism of breast implant capsular contracture is not fully understood by the medical and scientific community. That being said, there are some known causes that increase the risk of capsular contracture. They include things such as sub-clinical infections, blood left in the breast implant pocket during the operation, and failure to create the correct size of the breast implant pocket during surgery. The role of the type of surface texturing, or lack thereof, is also a very important consideration in the prevention of capsular contracture.
Sub-clinical infections are defined as the presence of an infection without outward signs and symptoms of what is commonly recognized as an infection, such as fever, chills, redness at the incision site or the entire breast and/or pus drainage from the incisions. Most notably, sub-clinical infections can arise either at the time of surgery or anytime after surgery.
It is very important to make sure your operation is performed in a sterile environment such as a surgery center or hospital. Breast implant operations performed in the back room of a doctor’s office are generally substantially less sterile which can lead to increased risks of both clinical and sub-clinical infections. Sub-clinical infections, which are almost never noticed by the patient, can easily be the cause of capsular contractures. The use of antibiotics during and after surgery is extremely important in helping to minimize the possibility of infection. Sub-clinical infections can also occur anytime post-operatively if the patient undergoes any other form of surgical treatment that could potentially introduce bacteria into the bloodstream. Small treatments, such as deep teeth cleaning or even foot surgery, could introduce bacteria into the blood stream where the bacteria will seek out any prosthetic device including breast implants. Antibiotic precautions are necessary when treating any patient with prosthetic devices such as heart valves and knee or hip joints as well as patients with breast implants. Make sure anytime you receive additional medical treatments your physician or dentist prescribes prophylactic antibiotics to prevent breast implant complications.
Blood left in the pocket surrounding the implant, even a very small amount, can lead to post-operative capsular contracture. It is imperative that the surgeon takes the necessary care to make completely sure there is no blood left in the pocket whatsoever. This requires meticulous attention to detail during the operation.
Selection of the appropriate surface of the implant has the largest effect on the occurrence of post-operative capsular contracture. There are basically two types of implant surfaces. One surface is completely smooth and the other is textured. In addition, each of the two American manufacturers of implants has their own and distinctly different coarseness to the texturing. One manufacturer has a very fine texturing that acts almost like a smooth implant and the other manufacturer has a coarser texture that offers additional benefits in preventing capsular contracture. Although the exact mechanism is not clearly understood, it is felt that the correct amount of texturing may affect collagen cross-linking during the early phase of capsule formation. If the new collagen fibers in the scar tissue cannot cross-link as effectively, it may have less ability to squeeze the implant and cause contracture.
If your surgeon selects smooth implants, care must be taken during the operation to create a breast implant pocket that is much larger than the actual size of the implant. This will allow the implant to move around more inside of the pocket and prevent the capsular tissue from contracting down causing hardness. With a smooth implant it is imperative to follow your surgeon’s instructions and perform breast implant massage on a regular basis to help keep the pocket open. Textured implants do not require these steps either during surgery or post-operatively.
There are also disadvantages to using textured implants insomuch that they have slightly more implant rippling and implant feel through the skin, especially in a very thin woman. Both the patient and the surgeon together must weigh the advantages and disadvantages of using smooth versus textured implants. Smooth implants have a considerably higher contracture rate Some studies show a range from 2% to over 30% depending on whether the implant is saline or silicone. Textured implants show a contracture rate of 1% to 2%, again depending on whether the implant is saline or silicone. Placement of the implant below the breast muscle, rather on top of the muscle, can also reduce these rates substantially. It is important to discuss with your surgeon in detail the best choice for you.
So, if your surgeon could not, or did not prevent your capsular contracture, what can we do about it now, after it already has occurred? If we can catch this early enough, within a month or two after the breast starts to become hard, we can attempt a trial of a new asthma medicine that has been very successful in treating new onset capsular contractures. If it has been more than 4 to 6 months since the onset of the contracture, it is less likely that this medicine will be effective.
Historically, back in the 1970’s and 1980’s, some doctors used to squeeze the breast with their hands, breaking the capsule and softening the contracture. Most surgeons abandoned this in the late 1980’s due to associated damage to surrounding tissues including the breast muscle. This antiquated procedure frequently caused internal bleeding and reoccurrence of the contracture some months later.
The definitive treatment for capsular contracture is revision surgery. Either a capsulotomy (opening the scar tissue capsule) or capsultectomy (partial or complete removal of the scar tissue capsule) are the operations of choice. Additional benefits may be gained by moving the implant from on top of the muscle to beneath the muscle where the possibility of future contractures is lessened. Usually the operation is performed through the original incision unless the original incision was in the armpit or belly button. In those cases the surgeon cannot usually reach the entire scar tissue capsule and in those cases incisions will have to be made at either the areola edge or under the breast crease. Switching from smooth to textured implants may also be helpful.
A “one on one” in person consultation with your revision surgeon will provide additional information and guidance on selecting the best type of revision for your contracture.
Please contact our office if you are from outside the Southern California area for a preliminary telephone conversation with Dr. Moser personally to ascertain if an in-person consultation would be helpful to you.