Breast Augmentation surgery is one of the most popular Plastic Surgery procedures performed every single year. As a Seattle-based Plastic Surgeon who specializes in cosmetic breast and body procedures, breast implants are utilized in a large number of procedures I perform from primary breast augmentations to breast lifts to mommy makeovers. When our surgical plan involves a breast implant, it’s imperative to not only review the surgery (incisions, postoperative care, etc.) during our consultation but also review the implant device itself. Although breast implants are considered very safe and are some of the most studied medical devices available, a breast implant is also a commitment that shouldn’t be taken on without fully understanding risks and potential complications that can come with it.
The most common complication with a breast implant is a condition called a Capsular Contracture, where the breast implant begins to harden over time. It can happen with any type of implant, saline or silicone, and will generally require surgical intervention at some point as it progresses. Now, while this may be a single line on your consent form, it’s actually a pretty complicated topic that, even today, isn’t completely understood in all its facets. There are just so many factors that are involved in this process– the implant device (size and type), patient-related factors, surgical technique–making every incidence of capsular contracture just slightly different from the one before it. In this blog post, I’ll tackle the first part of my series on Capsular Contracture– the process behind it, symptoms of it, and risk factors for development. In later posts, I will cover prevention techniques, treatment options, and review the most up-to-date statistics on the incidence of Capsular Contracture as it relates to the three main breast implant companies. If you have breast implants or have ever considered a breast augmentation, this is a must read.
FORMATION OF A CAPSULAR CONTRACTURE:
When a foreign body like a breast implant is placed within the body, there are two general scenarios that occur. The first is that your body will break down the material or implant (phagocytosis) and the second is that your body will basically learn to live with it. Breast implants are too large for the body to break down and silicone is widely considered to be an inert substance, though the latter has been heavily debated.
An ‘inert’ material basically means its chemical structure is such that it does not interact with other molecules in the body– it will not be broken down by the body and will not react with other biologic materials (i.e affect other surrounding tissues, the immune system, etc.). It’s important to note here that all breast implants, saline and silicone alike, are manufactured with a silicone elastomer shell. In the case of breast implants and other foreign materials which hold similar properties, the body simply learns to live with it. As a response, the body creates a thin layer of scar tissue around it called a capsule, a kind of way to designate it as "present but other.” Now this layer is very thin, like 1-1.5mm thin under normal circumstances. When a capsular contracture occurs, there is some trigger that causes that super thin capsule around the implant to begin to thicken, tighten, and contract. This can lead to a range of issues, from changes in the appearance and feel of the breast to chronic discomfort.
WHO DEVELOPS A CAPSULAR CONTRACTURE?
Now this is the million dollar question. There is a vast catalog of literature out there dedicated to analyzing and better understanding the causes of a capsular contracture and associated risk factors and, just like everything else in medicine and science, it is ever-evolving. What makes this so complex to try to figure out is that there are three categories of variables to consider– patient-related, breast implant-related, and surgery-related. And that “trigger” causing the normal layer of scar tissue to start the process of thickening and hardening can be related to any one or more of those variables.
The most common factor we tend to associate with a capsular contracture is a silicone breast implant rupture. The crack in the implant shell exposes the body to the cohesive silicone inside the implant, triggering a response by the body to attempt to separate it from the surrounding tissue. In fact, a capsular contracture is thought of as synonymous with a ruptured silicone implant such that we a) will often send patients for imaging to confirm a rupture prior to reoperation and b) will replace the silicone implant at the time of reoperation.
It is not that simple though. According to the most up-to-date research, the other biggest risk factors for development of a capsular contracture are subglandular implant placement (especially with a silicone implant), hematoma formation after surgery, chronic sub-infection (known as a biofilm), smooth implants (as opposed to textured), irradiation to the breast (in breast reconstruction post mastectomy), and periareolar and transaxillary access incisions. In addition, larger implants have been found to be associated with a higher incidence of capsular contracture than smaller implants. In the two most recent studies I read in regards to this, 420cc implants were the cut off from “small” to “large” implants.
SYMPTOMS OF A CAPSULAR CONTRACTURE:
Development of a capsular contraction can be insidious and is often slow to progress. As the scar tissue around the breast implant begins to thicken and shrink down, it constricts the breast implant which, in turn, makes the implant begin to feel firm. Importantly, this should be distinguished from normal swelling that can occur postoperatively in response to activity, which will be temporary and short-lived. An early onset capsular contracture, conversely, will be persistent and constant in its firmness.
The classic scale we use to describe a capsular contracture is the Baker Grading Scale, which places 4 grades along the continuum of feel, displacement and finally, pain. This grading scale is basic at its best and there are numerous proposed alternative methods of classification which will probably take over in the years to come. As a capsular contracture progresses, eventually the tightening around the implant will cause the implant to displace upwards, giving the appearance of a high-riding implant. Often, patients will begin to notice that their breasts don’t quite sit symmetrically in their bra and will look asymmetric in a low cut shirt or tank top. The last and final stage of a capsular contracture is the development of discomfort or overt pain. This pain comes from the tightness of the scar tissue and the pressure it puts on surrounding tissue. It can be associated with certain physical activities, direct pressure (like side sleeping) or just a generalized, low-level discomfort. It is important to note that not all capsular contractures are created equal– the timeline, progression, and severity can differ from patient to patient. I’ve seen dramatically tight and distorted implants that patients have lived with for years without developing pain and also slightly distorted yet painful capsular contractures that have developed quickly and relatively soon after an initial breast augmentation.
SO WHAT'S NEXT?
It is important to remember that capsular contracture is a physical diagnosis– there are no tests, imaging or lab work that can confirm it. If you are concerned you are developing one, the best course of action would be to schedule an appointment with your Plastic Surgeon for a proper physical examination and review of your before and after photographs. An even better idea would be to plan on seeing your Plastic Surgeon routinely (every couple of years) even without the onset of any issues. Though I will cover this in more detail in another blog post, there are some over-the-counter and prescription medications which have shown promise in altering the progression of a capsular contracture if initiated early enough. By following up routinely with your Plastic Surgeon, you serve a better chance of catching a capsular contracture in its earliest stages. If a capsular contracture is identified by your surgeon and you have a silicone implant, they may recommend you undergo imaging (Ultrasound, MRI) to check for an implant rupture.
While capsular contracture is an unfortunate risk with breast implants, it is important to remember that odds are in your favor it will not happen to you. In addition, your implant warranty (though it differs from company to company) was designed with this complication in mind. The most important factors that you can control are educating yourself (you are reading this so check done!), and keeping an open line of communication with your Plastic Surgeon. Stay tuned for my Part 2 of this series on Capsular Contracture, where I cover the surgical treatments, mitigating risks and emerging medications.
Dr. Megan Dreveskracht is a Seattle-based Female Plastic Surgeon who specializes in Aesthetic Surgeries of the Breast, Body & Face. To schedule your consultation, call 206.860.5582 or fill out a contact form here.