Tightening of the Scar Tissue Around the Implant
Scar tissue forms around all implanted materials as a natural part of healing. Scar tissue around a breast implant is not troublesome unless it tightens. An abnormally tight scar is known as a capsular contracture. As the tightening scar tissue around the breast implants form, it may cause the breast to feel firm, unnatural, or even painful. When you see a breast that looks round and hard, it is probably due to capsular contracture. The most severe cases are sometimes called “coconut breasts.” Capsular contractures may occur at any time, but tend to occur in two waves referred to as early capsular contracture and late capsular contracture.
Capsular contractures may be treated by a surgeon in one of three ways. A capsulectomy is the surgical removal of the scar tissue around the implant and the placement of a new breast implant. A closed capsulotomy is the use of force to disrupt the surrounding scar tissue, in turn softening the breast. Lastly, an incontinuity or enbloc removal may be suggested if staph epi or silicone rupture are factors. This procedure removes the implant and scar tissue at the same time. Dr. Vennemeyer and Dr. Loftus provide information on all the procedures, but discussing it with your surgeon will help you make an informed decision.
Classification of Capsular Contractures
Grade I = None:
Oddly enough, plastic surgeons refer to breasts with no capsular contracture as being Grade I. There is no such thing as Grade 0.
Grade II = Mild:
The breast feels slightly firm, and the implant edges can be felt through the skin. Plastic surgeons call this a Grade II capsular contracture.
Grade III = Moderate:
The breast feels firm, and the implant can be both felt and perceived visually through the skin. The breast may appear unnaturally round or spherical. Plastic surgeons call this a Grade III capsular contracture.
Grade IV = Severe:
The breast is hard, distorted, and painful due to the hardening scar tissue. Plastic surgeons call this a Grade IV capsular contracture. These breasts may sometimes resemble “coconut breasts.”
Early Capsular Contracture
Capsular contractures that occur within the first year of surgery are known as “early”. Most of these are thought to be due to a bacteria called staph epidermidis, which is present on everyone’s skin and usually causes no problems. Staph epi, as it is called, is generally benign unless it is in association with a prosthetic implant, such as an artificial joint, heart valve, pacemaker, or breast implants. Because it is so benign, it does not cause the classic signs of infection: redness, swelling, and fevers. Instead, it remains dormant around the implant until it incites the surrounding scar tissue to tighten and contract. A capsular contracture due to staph epi is usually evident within a year of surgery.
Late Capsular Contractures
Capsular contractures that occur years after surgery are known as “late.” These are frequently related to silicone gel implant ruptures, and they occur when the scar tissue around the breast implants becomes irritated or inflamed in response to silicone gel which has extruded through the implant shell. Saline breast implants are less likely to cause a late capsular contracture as they contain no silicone gel. Hence, when a saline implant ruptures, saline leaks out, is absorbed by the body, and the implant deflates. Because saline is inert, it does not trigger a capsular contracture. Late capsular contractures may occur at any time but tend to do so years after surgery.
Risk and Prevention
Numerous studies have been published with capsular contracture rates varying between 10% and 50%. Perhaps the most meaningful way to interpret these apparently discrepant values is to consider that the risk of severe capsular contracture is close to 10% and the risk of mild capsular contracture may be as high as 50%. Implant surface, implant type, implant position, and site of incision may affect your risk of capsular contracture. Generally, smooth saline implants placed under the muscle through an inframammary incision have the lowest rate of capsular contracture, and textured silicone breast implants placed over the muscle through an areolar incision have the highest rate of capsular contracture.
Efforts to prevent capsular contracture include meticulous sterile technique during surgery and implant displacement exercises following surgery. Displacement exercises are thought to stretch surrounding scar tissue, thereby reducing the rate of capsular contracture. Do not begin this until your surgeon advises you to do so.
Capsular contractures were previously treated by a procedure known as closed capsulotomy. Closed capsulotomy was a non-surgical procedure in which the surgeon manually squeezed the implanted breast, sometimes with tremendous force. This disrupted the surrounding scar, thereby softening the breast. Plastic surgeons now condemn this procedure because of its propensity to cause implant rupture, implant displacement, hematoma, unnatural appearance, and redevelopment of capsular contracture. If your surgeon suggests closed capsulotomy, you may wisely choose to seek another opinion.
Treatment involves surgical removal of the scar tissue (capsulectomy) and placement of a new implant. The implant might also be moved to a different plane (above or below the pectoralis muscle). If you have a moderate or severe capsular contracture, you may choose to undergo this operation. Realize, however, that capsular contracture may recur, as additional surgery is not guaranteed to solve your problem. Further, any time your breast is operated on, you introduce the risk of infection, capsular contracture, implant displacement, and other risks. Therefore, if your contracture is mild, as many are, you might choose to avoid surgery and simply live with it.
Whenever staph epi or silicone rupture are a concern or when the capsular contracture is moderate or severe, an in-continuity (also called enbloc) removal may be suggested This involves removing the implant and surrounding scar as a single unit, rather than removing the implant followed by the scar. The advantage of in-continuity removal is that if staph epi or silicone gel exist between the capsule (scar) and the implant, they can be more effectively removed with a lower risk of re-contaminating the new implant pocket, thereby potentially lowering the risk of recurrent capsular contracture. The main disadvantage of in-continuity (enbloc) removal is that is requires a longer scar. Yet, if risk of recurrence is a concern, it may be worthwhile.