FAQs: Capsular Contracture – Breast Augmentation & Breast Implants

Capsular Contracture of Breast Implants - What is it?

Information contributed by Edward Pechter, M.D. in Valencia, CA.

When any type of breast implant is inserted, the body reacts by forming a protective lining around it. This is referred to as the "capsule" or "tissue capsule". Some people refer to it as the "scar capsule" although it is not exactly the same as scar tissue. The capsule is formed by your own living tissue. It is normal and happens in everyone regardless of whether the breast implant is smooth or textured, silicone or saline.

Photos of removed capsules due to Capsular Contracture.

Photos of Capsular Contracture condition of Breast Implants.

In some women, for reasons we don't understand completely, the capsule has a tendency to shrink, squeezing the implant. This is referred to as capsular contracture. The tighter the capsule becomes the firmer the breast feels. A plastic surgeon named Baker divided capsular contracture into four stages:

Baker grade I means the breast looks and feels soft (there is a capsule but it is not contracted); Baker grade II means the breast looks normal but feels somewhat firm (there is mild to moderate contracture of the capsule); Baker grade III means the breast not only feels firm but is beginning to be distorted by the contracture, meaning it has begun to take on an abnormally round shape, like a ball, or the implant is being squeezed out of normal position, usually upward; Baker grade IV is the same as III but with the addition of pain caused by the progressive tightening of the capsule. No matter the degree of capsular contracture, it is not the implant that gets hard. If the implant is removed it is as soft as when it was inserted. It is the interaction of the capsule with the implant that can make the breast feel firm. Capsular contracture alone does not cause implant rupture because the force is exerted evenly around the surface of the implant.

Some doctors may try treating capsular contracture with Vitamin E or antibiotics, depending on what they view as the cause of the contracture, but medical therapy is rarely successful. Another treatment is called "closed capsulotomy." In this technique, the doctor forcefully squeezes the breast in an attempt to cause the capsule surrounding the implant to "pop" or tear. There are some risks to this procedure and most doctors are reluctant to do it because of medicolegal concerns and possible violation of the implant warranty.

The treatment of capsular contracture is usually surgical. In an "open capsulotomy" the surgeon scores, or cuts, the capsule to release its hold on the implant. In an "open capsulectomy", the entire capsule is surgically removed. The body then forms a new capsule but the hope is that it does not contract as the old one did. Capsulectomy is a more extensive operation than capsulotomy but has a higher rate of success in correcting contracture. Only a relatively small percentage of women with implants develop capsular contracture severe enough to require surgical treatment. The rare patient develops repeated capsular contracture but in the majority of cases it can be successfully treated.

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Scarring & Capsular Contracture

Information contributed by Dr. Joel Studin, New York, NY. 

Anytime something is implanted, whether it is a knee joint, heart valve or breast implant, our body forms a wall of scar tissue around it. This wall is usually soft, thin and unable to be felt. But just like one child falls on the playground and cuts their chin and has a bad scar, and the next child with the same injury and same plastic surgeon has almost no scar to speak of, the scarring inside around an implant is unpredictable.

It would seem logical that scarring inside could be predicted by past scarring from injuries or by their family history. Unfortunately, none of these help us predict who will form extra scar tissue inside. It is truly a random occurrence.

What happens when a little extra scar tissue forms?

If someone forms a small amount of scar tissue, they feel rippling through the skin of the breast. Is this rippling because the implant has not been filled enough? I don't think this is true. After removing implants for rippling, I found small bands of scar tissue in the wall of scar tissue around the implant. Which came first, the chicken or the egg? Did rippling of the implant cause the bands of scar tissue or did the bands of scar tissue cause rippling of the implant? Because there was no visible rippling of the implant itself upon opening the pocket, I believe that this rippling is actually the smallest form of capsular contracture, or over formation of scar tissue around the pocket.

In cases where a small amount of rippling occurs (you can feel it but not see it), I recommend only that the patient continue massage and take vitamin E. (I will explain vitamin E a little bit later.) Sometimes it goes away over time and sometimes it does not, but these breasts look perfect. While it is possible to feel a small amount of rippling if you try, there is nothing that looks abnormal.

What happens when a lot of extra scar tissue forms?

If someone really forms a lot of scar tissue, one of two things can happen. They get either visible rippling or hard breasts.

Solving Visible Rippling

If visible rippling occurs, it is usually seen on the outer part of the breast upon bending over. These patients should consider entering the silicone gel study called the "Adjunct Study" and change their saline implants to silicone gel implants. This can only be done by a plastic surgeon authorized as an investigator in this study. Changing from saline implants to silicone implants usually solves this problem. Capsular contracture with visible rippling is one of the indications that qualify someone for the silicone gel study. Only authorized investigators are allowed to place silicone gel breast implants presently.

Many patients think that because placing silicone gel implants involves an FDA approved study, that the surgery is free. Unfortunately, there is no subsidy from either the FDA or the implant manufacturers. If you have this problem, you should have a long consultation and discuss the pros and cons of changing to silicone gels. I find that when I replace rippled saline implants with silicone for a patient, it almost always solves the problem and that results in softer natural feeling breasts.

Solving Hard, Round, High-Riding Breasts

If firm high riding breasts occur, a lot of extra scar tissue has formed and needs to be removed. Formation of dense scar tissue will result in a pocket that is too small and squeezes the implant. The breast can appear round, feel firm and may ride too high or hurt. Fortunately, this is uncommon. To correct this problem the implant is removed, the scar tissue taken out, and the implant replaced. Years ago, it was common to try and squeeze the breast very hard to break this scar capsule. Most surgeons today, believe it is better to remove the scar tissue than to try and rupture it.

Can I stop scar tissue from forming in the first place?

As we discussed above, capsular contracture is a random occurrence. While it is not uncommon to feel a little rippling, especially in thin skinned to patients, it is not common for someone to have enough scar formation that they need to have it fixed. There is no way to test for a tendency to form extra scar tissue but there are two things that I believe may help to prevent it. Notice that I use the word "may". There is no good study to prove that the 2 suggestions I am about to make really work! It is my belief however, that they do.

Vitamin E

We have all heard that vitamin E helps scars. Actually, vitamin E does not melt scars it makes them softer. It works by reducing the strength of the three strands that form collagen, making them softer and more pliable. Technically, it reduces the strength of cross-linking of these strands.

If you take vitamin E after having implants, does it make the capsule around the implant softer and more pliable? While there is no good study showing that this works, I have my patients take relatively high doses of vitamin E for at least one year after having breast implants. (For exact dosages you must ask your own doctor). I believe that this has made a significant difference in decreasing the number of capsular contractures in my practice.

The Mladick No Touch Technique*

There are many surgeons that believe that one cause of capsular contracture might be a low-grade infection and that a super sterile technique in putting in these implants might lead to a lower incidence of capsule formation.

When you look at a beam of sunlight entering your bedroom window in the morning, you can see dust particles floating in the air. The air in an operating room has dust particles in it as well. Theoretically, these dust particles could settle on the implant and contaminate it slightly. After all, there are bacteria in dust particles.
It was theorized that these dust particles might lead to very low-grade infections later on and cause capsular contracture.

The No Touch Technique is designed to avoid even the air from touching the implant. Implants are packed in a sealed plastic container. As soon as the package is opened the implant is covered with an antibiotic liquid. After the pocket is made for both implants, the surgeon changes gloves and coats the new gloves and instruments with antibiotic solution. The pocket is washed out with antibiotics solution. The surgeon then picks up the implant and puts it into the pocket touching it only with gloves and instruments covered with antibiotic solution. Neither air nor skin bacteria are allowed to touch the implants.

Does this technique work?

Nobody has been able to prove statistically that the No Touch Technique actually works. My feeling is, though, that my rate of capsules dropped significantly since adding this technique to my practice. All of my implant surgery is done following these recommendations.

ALLURE MAGAZINE recently carried the following:

According to a recent study, an asthma pill may be an antidote to a troubling side effect of breast augmentation, the hardening of internal scar tissue. Up to 30% of women with implants either have or are likely to develop this condition, known as capsular contracture. It can occur within weeks or years of surgery, in one breast or both, and be mildly annoying or painful and disfiguring.

Doctors may prescribe massage, antibiotics, or vitamin E. Serious cases necessitate surgery. But at the annual meeting of the American Society for Aesthetic Plastic Surgery in late April of 2002, plastic surgeons Dr. S. Larry Schlesinger of Maui, HI, and Dr. Richard Ellenbogen of Beverly Hills, CA reported that the asthma drug Accolate, taken twice a day for three to six months, can often prevent contractures and soften existing ones. The medication blocks leukotrienes, by-products of white blood cells that trigger inflammation. New York, NY based plastic surgeon Dr. Alan Matarasso says he is "cautiously optimistic" until controlled studies are done, but if proven, the drug "could be beneficial to thousands of women." – Allure Magazine JOAN KRON June 2002