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Capsular Contracture

Breast implant capsular contracture after either silicone or normal saline breast implant surgery is very common. The contracture or breast scar tissue around the implant can affect one or both breasts. It can occur soon after surgery or 10-15 years or longer after surgery; there is no set time frame. The firmness of the breast contracture can be minor or severe. The discomfort and distortion of the breast will determine if a patient will seek breast revision surgery. The firmness is graded on a Baker scale of 1 to 4. Baker 1 is slightly firm and women can live with this fairly easily. Baker 4 is painful with breast distortion and needs to be addressed.

The true etiology of breast capsular contracture associated with silicone or normal saline breast implant remains elusive despite extensive scientific study. Two prevailing theories have emerged in the literature: the infectious hypothesis and the hypertrophic scar hypothesis. In spite of this we know neither the true cause nor how to prevent capsular contracture.

capsular-1 Plastic surgeons perform a variety of techniques to attempt to reduce the incidence of breast capsular contracture. The “No Touch Technique” is a common practice with the ideal of nothing coming in contact with the breast implant. A nice addition to this technique is the Keller Funnel. This is a device which is shaped like a funnel with a smooth inner lining which when wet allows no touch transfer of the silicone implant into the breast pocket. This is a new addition to breast augmentation surgery and allows a large implant to be inserted through the smaller side of the Keller funnel. The normal saline implants are inserted unfilled so use of the Keller Funnel is not required.

We use various antibiotics: both as a pill the patient takes and a solution to bathe the breast implants. Breast massage is performed early; vitamin E is given; and sometimes external ultrasound is performed. Nevertheless, breast contracture still occurs on occasion.

It is widely held that “newer generation” implants result in lower contracture rates than their predecessors. However, even with modern devices, there is a significant incidence of capsular contracture. Cumulative six-year data reported to the Food and Drug Administration (FDA) by Mentor Corporation revealed that 7.7% of patients receiving saline implants and 9.8% of patients receiving cohesive silicone gel implants for augmentation developed Baker III or IV contracture.

capsular-2There are several drugs given to treat capsular contracture, among them Singulair and Accolate (both drugs are for the treatment of asthma). These drugs are not FDA approved for the treatment of capsular contracture resulting from breast implants. Research has shown these drugs to be fairly effective except for Baker III and IV contractures. Accolate has shown to have significant liver complications and is perforce not recommended. Singulair is well tolerated with minimal side effects; therefore, it is reasonable to be considered in patients with capsular contracture.

It has shown effectiveness in Baker 1 and 2 breast contracture, and may benefit patients who have had previous capsular contracture and plan to undergo a revision breast surgery. For patients who already have moderately advanced capsular contracture, or Baker III and IV breast contractures, Singulair is unlikely to reverse symptoms to the degree that revision can be avoided. Each case must be evaluated independently with the proper disclosures pertinent to use of these drugs.

What do we know about the mechanism of capsular contracture?

Breast fibrous capsule formation is a normal phenomenon following insertion of breast prostheses for breast augmentation. This is a similar process which occurs with other foreign body placement such as hip or knee replacements, rods or pins, or even a bullet in the body, where the body will form a scar capsule around –walling off- the foreign body. This occurs through transforming growth factor production of collagen I, collagen III and fibrin by fibroblasts during the body’s foreign-body response.

Breast Augmentation is the number 1 cosmetic procedure performed in the United States. In spite of the issues with capsular contracture and revision breast surgery the patient satisfaction is extremely high and for most patients well worth the maintenance.

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