What is Capsular Contracture?
Every time an implant is placed, the body makes a layer of tissue that surrounds the implant called a “capsule.” Most of the time, the capsule is not troublesome. If the capsule remains loose around the implant, the implant can slide within its pocket and have a more natural look and feel. Sometimes the capsule mirrors the implant shell shape without any excess room. Textured implants are designed to have the capsule do so. Smooth implants may also have the capsule just hugging the implant gently and have a very natural look and feel. Some patients like the upper breast fullness provided by the slightest degree of contracture.
Capsular contracture implies the capsule tightening around the implant has become a problem. The capsule may squeeze tightly around an implant giving it a different feel and appearance than before. Worse, this process often affects just one side. The troublesome side often settles higher and narrower than the other normal side. The resultant asymmetry may be distressing in or out of clothes. Asymmetries of breast volume and nipple show can make difficulties in fitting clothing and fitting brassieres. Asymmetry is often what causes the patient to seek improvement.
Sometimes the capsule continues to tighten such that the capsule squeezes the lozenge-shaped implant into a sphere (the smallest surface area for any given volume is a sphere). This distorts the shape of the implant and can make it feel hard as an orange or rock. There can also be pulling or pain with arm motion.
Causes of Capsular Contracture
The cause of capsular contracture is still being investigated. The most common cause is felt to be bacteria: enough bacteria to cause the body to react (biofilm), but not enough bacteria to cause an infection.
Procedures to Correct Capsular Contracture
To eliminate bacteria, an operation for a contracture-related problem involves removal of the capsule and insertion of a brand new implant, even if the new implant is the same size, shape, and surface as the original implant.
The patient’s skin is prepped to be very clean but cannot be sterilized. Deep glands in the skin and nipple/areolar complex can be a source of such bacteria. Therefore, great efforts are undertaken to minimize the risk of exposing the implant to bacteria. Antibiotics are started the night before surgery, and surgical scrub soap is used for total body bathing the night before and the morning of surgery. Multiple surgical solutions are used to prep the patient right before surgery. A check for any nipple discharge is also performed, and the nipples are covered during the procedure. The surgeon’s and assistant’s gloves are changed multiple times throughout the procedure, and skin is never touched by the same gloves that might touch the implant. A “no touch” insertion technique is used to place the implant through the skin opening, and a Keller Funnel is usually used to minimize contamination with skin bacteria.
The procedure often includes the use of acellular dermis (ACD), most often Strattice. ACD seems to dramatically reduce the capsule from contracting again. Without the use of ACD, there is a recurrent capsular contracture rate after revision surgery of about 33 percent (one in every three cases). Early results using ACD show that the rate of capsular contracture is much lower at about two percent (one in every fifty cases). ACD for this condition in cosmetic patients has only been used since 2012, so it is hoped over time these statistics will remain valid. Strattice is my current favorite ACD.
In addition, changing the implant to a textured, form stable implant may also reduce the chance of recurrent capsular contraction.