Capsular Contracture and Breast Implants

Capsular contracture is one of the most common complications following breast implant surgery. Statistics for its rate of occurrence can range from 0.5% to 30%. A breast should be soft and flexible with a natural drape, even a reconstructed breast after a mastectomy. If you have saline or silicone breast implants, capsular contracture can cause your reconstructed breast to shift, change shape, feel hard to the touch, or feel painful.

To treat this, both nonsurgical and surgical options are available, and the best option depends on the severity of the contracture and your personal preference. However, prevention is the best "cure," and there are several things you can do to lower your risk of developing a capsular contracture. These things can be done initially, as well as if it happens again after treating the initial contracture.

While capsular contracture can be dismaying or uncomfortable, there are ways to treat it. This article will examine things you can do to minimize your risk of developing the condition, as well as possible treatment options.

About Capsular Contracture

Your immune system knows when a foreign object has been put into your tissues. When an intruder (such as a breast implant) is detected, a capsule is formed around it.

Think of it this way: Your chest muscles and skin don't readily accept an implant as a natural part of your breast. In order to prevent the implant from growing, spreading, or wandering around, your body creates a sac, or capsule of scar tissue around it, to seal it off.

A capsule around a breast implant is a naturally occurring tissue that can be of benefit. If that capsule contracts or thickens, however, it can squeeze your implant. This contracture is what will cause pain, shifting, distortion, and hardening of the reconstructed breast.

Possible Causes

Capsular contracture can happen regardless of the type of breast implant that is placed in your breast. It occurs more often around silicone than saline implants, and appears to be less common with textured implants when they are placed subglandular, or placed right under the skin between the breast tissue and pectoral muscle. However, due to the risk of developing breast-implant-associated atypical large cell lymphoma, breast surgeons are now leaning away from textured implants.

Sometimes capsular contracture develops due to an infection that occurs during implant surgery. But other problems may also crop up, like a seroma (a pocket of blood serum within the surgical area) or a hematoma (a pool of blood below the skin). These may also contribute to the development of capsular contracture.

Rupture of an implant as well as having a genetic predisposition to scarring may also raise the risk of developing capsular contracture.

Diagnosis

A physical exam is often done to evaluate and diagnose capsular contracture. This is known as a Baker classification. While it has been used for decades, it has recently been challenged as being unreliable, and a new method of evaluation is needed.

However, many doctors use it, and along with other evaluation tools, it can be helpful.

Baker Scale Grade

Capsular contracture may be barely noticeable or severe enough to greatly impact your quality of life. Capsular contracture is graded by the Baker scale and follows these criteria:

• Grade I: The breast is soft and appears normal, and the capsule is flexible.
• Grade II: The breast looks normal, but is somewhat hard to the touch.
• Grade III: The breast is hard and has some distortion caused by contracture, or instead, the breast may be significantly distorted, having a rounded shape or an implant that's tilted upward.
• Grade IV: Grade IV contractures look more advanced than grade III, often involving severe hardening of the capsule and pain.

Treatments

If you develop stiff tissue around a breast implant, if the shape distorts, or if the implant wanders out of position, you can get help. A capsulectomy is surgery that removes the stiffened capsule, and the implant may be replaced during this procedure for best results.

A capsulotomy is surgery to loosen the scar tissue by slicing it, allowing expansion.

Fat grafting has been a relatively recent addition to reconstruction options, and has been used primarily to improve the cosmetic appearance and feel of the breast following reconstruction.

A small 2019 study (15 patients with Baker grade IV contractures) looked at the potential role of fat grafting in capsular contracture. The researchers found that fat grafting was very successful in relieving the pain due to contracture, and suggested that it may be a useful addition to available treatments for contracture.

Surgery may not always be needed. Conservative methods such as massage, ultrasound, and medications may help the stiff capsule relax.

One medication, Accolate (zafirlukast), a leukotriene antagonist, has been well published as a nonsurgical treatment that can soften the capsule and slow the contracture rate.

A Cautionary Note About Treatment

Given the impact of capsular contracture on a person's well-being, many scientists have begun searching for ways to both reduce the risk of and treat capsular contracture. This may increase the risk of being offered ineffective or dangerous treatments. In 2019, the Food and Drug Administration (FDA) sent a warning letter to a California healthcare provider who was illegally marketing an unapproved treatment that promised to prevent or treat scar tissue related to breast implants.

It's important to ask a lot of questions and investigate any claims surrounding potential treatments. At the current time, the FDA has not approved any treatment designed to prevent or treat capsular contracture.

Prevention

You and your surgeon can work together to try to prevent the development of a stiff capsule of tissue around your breast implant.

Your Surgeon's Role in Prevention

There has been a significant amount of research into methods of reducing the risk of capsular contracture or preventing it from occurring. Some surgeons prescribe preoperative medications such as steroids, vitamin E, or other medications, but others have not found this to be helpful.

The relationship between placement of implants and the tendency to develop contractures is being explored. Implants can be located beneath the mammary gland or within a muscle pocket, and those placed within muscle appear to be less likely to develop capsular contracture.

Your surgeon may also use Alloderm (a piece of human tissue but which lacks DNA) to line the muscle pocket to further reduce the likelihood of scar tissue buildup around your implant.

What You Can Do

If you have surgical drains to maintain after breast surgery, be sure to empty these on schedule, as this helps prevent seromas from developing.

Recovery From Breast Surgery

There are a few things you should avoid before and after breast implant surgery to help ensure a healthy recovery and minimize your risk of developing a contracture.

• Quit smoking before surgery: Smoking either before, during, or after your surgery increases your risk of both a capsular contracture and an infection. It will also delay healing and your recovery from surgery and increase the risk of complications such as blood clots. (These are only a few of the reasons why it's important to quit smoking after a cancer diagnosis.)
• Avoid being overly active: Take it easy on physical activities afterward, and avoid any that might cause injury to the newly reconstructed breast. The implant needs time to settle into place, so don't jostle, squeeze, or strike the surgical site at all. Ask your plastic surgeon specific questions about your activity level after surgery. Some activities that seem benign may be of concern, while others that you might think you should avoid are OK.

If you know you'll be having chest wall radiation after your mastectomy, consider delaying implant surgery until treatments are completed. According to a 2018 study, radiation following immediate construction is associated with a significantly greater risk of reconstructive failure, as well as complications such as infections and capsular contracture.

Treatment of these complications can be lengthy and challenging, so it may very well be worth your time to delay reconstruction until your radiation is completed and you are fully healed. If you choose to have immediate reconstruction, talk with your surgeon about what you might expect so that you can weigh your options carefully.

Summary

While capsular contracture with breast implants can be less than ideal, there are treatments available. It's important to take steps prior to and right after surgery to reduce your risk of developing capsular contracture, but sometimes it happens anyway. Talk with your doctor about the possible risks and the ways you can reduce the likelihood of this occurring.

A Word From Verywell

Capsular contracture related to breast implants can be very uncomfortable and may lower your quality of life. There are treatments available, but it's best to reduce your chance of this occurring in the first place. Your surgeon will make recommendations and explain the rationale and research behind the treatment plan. Make sure to be aware of and heed those factors that you can control.