After breast augmentation scar tissue forms around the breast implant, lining the pocket. This is called a capsule and is the body’s natural response to the presence of a foreign object. Usually the capsule remains thin and soft, and cannot be felt. However, in some women the capsule thickens and contracts and this is known as capsular contracture. This may progress causing the breasts to become hard, deformed and painful.
The Baker Classification for Capsular Contracture
The first step in the diagnosis of capsular contracture is to identify the severity of the problem using a grading scale known as Baker Classification for Capsular Contracture;
Grade 1 – Normal breast capsule. The breast is soft, looks normal and feels normal.
Grade 2 – Normal appearance of the breast but the breast feels firm.
Grade 3 – Abnormal appearance of the breast. The breast is hard and deformed.
Grade 4 – Abnormal appearance of the breast. The breast is hard, deformed and painful.
Mr Karri only performs corrective surgery on women with Grade III and IV capsular contracture. Women who present with Grade IV capsular contracture are often debilitated by pain and stiffness, and by removing the capsule and replacing the implant, pain can be dramatically improved and the natural appearance of the breast restored.
Causes of Capsular Contracture
No one really knows why some women experience capsular contracture and others do not. One popular theory is that the breast implant surface becomes contaminated with bacteria with subsequent formation of a biofilm. Biofilm is a term that describes a thin layer of microorganisms adhering to the surface of structure, held within a matrix of substances produced by the microorganisms themselves. This biofilm changes the nature of the scar tissue that normally forms around the implant so that it starts contracting, causing the implant to feel firm and become painful.
In one particular Australian study in which pigs underwent breast enlargement with miniature gel-filled breast implants, the investigators found the rate of capsular contracture was four times higher when the breast pocket was intentionally contaminated with Staphylococcus Epidermidis, a bacterium found naturally on human skin.
Although there is some evidence to indicate biofilm as the cause of capsular contracture, the link is not clear cut. Nonetheless, surgeons who take every effort to minimise bacterial contamination of the implant via contact with the skin report lower rates of capsular contracture.
For all breast enlargement cases, Mr Karri minimises handling of the breast implant and washes out the breast pocket with antibiotics to minimise bacterial contamination and kill any bacteria.
Preventing Future Capsular Contracture
There have been a number of studies that have looked at the factors associated with capsular contracture. Factors associated with a reduced risk of capsular contracture include;
- Placing the implant under the muscle
- Using an inframammary incision to insert the implant
- Triple antibiotic irrigation of the implant pocket
- ‘No touch’ technique i.e. only the surgeon with a fresh pair of gloves handles the implant
- Standard principles of plastic surgery i.e. aseptic technique, avoidance of haematoma, correct size of implant pocket
Capsular Contracture Surgery
If you have been diagnosed with capsular contracture, there are several surgical procedures that can be performed to correct the breast deformity and/or pain.
The most common surgical procedure is known as capsulectomy, in which the entire capsule is removed from the breast implant pocket. A variation of this is known as anterior capsulectomy, in which the anterior part of the capsule is removed whilst the posterior part is preserved. The decision on whether to perform a complete or anterior capsulectomy depends on a number of factors that Mr Karri will discuss with you.
Regardless, of whether a complete capsulectomy or anterior capsulectomy is performed, Mr Karri always replaces the implant with a new textured, cohesive-gel implant. If the original implant was placed over the muscle then the new implant may be placed under the muscle to reduce the risk of capsular contracture occurring again. Some women opt to have a larger implant at this time. The previous implant is not reused as this is associated with a higher risk of recurrence of the capsular contracture.
For some women, Mr Karri may undertake a procedure called capsulotomy. This is a surgical procedure in which multiple incisions are made in the capsule, relieving the tight constriction and allowing the capsule to expand. Capsulotomy can be performed in many ways, with an incision just around the base, multiple criss-cross incisions or a combination of both.
The decision on whether a capsulotomy or capsulectomy is needed depends on many factors, including if the implant has ruptured, if you suffer pain, thickness of tissue between the capsule and skin etc. During your consultation with Mr Karri he will discuss the most appropriate procedure for you.
Breast Implant Removal and Replacement with Fat Grafting
A procedure that is becoming increasingly popular for some cases of capsular contracture is fat grafting. In this procedure the breast implant is removed and volume restored with fat grafting. The advantage with this approach is there is no risk of capsular contracture recurrence and the breast has a softer, natural feel.
For breast fat grafting Mr Karri uses the innovative Bodyjet system which is associated with a high fat graft survival rate. Furthermore, fat grafting using Bodyjet can be performed under local anaesthetic and sedation as a daycase procedure.
Women with capsular contracture may have to undergo additional corrective surgery and with this in mind, it is important to choose the correct surgeon.
As with all surgical procedures, implant removal and capsulectomy (without implant replacement) has risks, which include;
Scars / poor scarring – in order to completely remove the capsule, the original scar from breast implant insertion may have to be lengthened or a new incision made. If a breast lift is performed after implant removal, there will be a new vertical scar on the lower half of the breast. In some women, scars can become thickened and remain red.
Bleeding / haematoma – bleeding after capsulectomy is common. To avoid accumulation of blood drains may be used after surgery.
Infection – infection is always a possibility after any surgery despite careful aseptic techniques. Should an infection occur, treatment with antibiotics or additional surgery may be necessary.
Firmness – after implant and capsule removal the breasts may feel firm or uneven, a consequence of internal scarring.
Inability to remove entire capsule – It may not be possible to completely remove the capsule.
Damage to adjacent structures – the capsule may be adherent to overlying breast tissue, nipple, muscle or to the underlying chest wall. During capsulectomy, any of these adjacent structures may be damaged or may need to be partly removed to remove all the capsule.
Breast asymmetry – after breast implant removal and capsulectomy the breasts may be different sizes. The size difference may be due to pre-existing difference in breast size or due to the removal of additional tissue from one breast, which may be necessary to remove all the scarring and any leaked silicone.
Change in nipple and skin sensation – Some change in nipple and skin sensation can be expected after breast implant removal and capsulectomy.
Chest wall deformity – deformity of the chest wall can occur due to pressure of the breast implant. In women who have very little breast tissue, the chest wall deformity may become visible under the skin after removal of the implants.
Change in appearance of the breasts – following removal of implants there will be a significant loss of breast volume, and the breasts will appear flatter and emptier. There may be an excess of skin causing the breasts to look distorted and sagging.