Breast augmentation surgery using implants is one of the most in-demand cosmetic surgeries offered by our surgeons to hundreds of women each year. Women who have small breasts, asymmetrical breasts, or breast deformities all find breast enhancement the go-to solution to get bigger beautiful young-looking breasts.
Like any other surgical procedure, there are some complications with breast implants that can arise with time and cause distress to both the patient and her plastic surgeon. One of these undesirable outcomes is capsular contracture. So, what is capsular contracture?
To answer shortly, capsular contracture is when your body forms tight fibrous bands around your breast implants which pull on your breast tissue causing deformity and pain. It is the most commonly observed complication with breast implants, however, there are certain ways to reduce the risk of it happening to a minimum. Several surgical and non-surgical treatments for capsular contracture are available and surgeons are developing new methods every day.
This article has everything you need to know about capsular contracture: what it is, why and how often it happens, what the risks are, how to prevent it, and how to treat it with or without surgery.
What is capsular contracture?
Capsular contracture is one of the undesirable complications of boob jobs. Whenever a foreign object is implanted in our body, our immune system tries to isolate it by surrounding it with tough scar tissue usually referred to as a “fibrous capsule”. This is considered part of the normal healing process, and it happens naturally in every woman who gets breast augmentation surgery. In most women, the resulting capsule is thin (1 mm) and does not interfere with the final shape of the breast. However, in some unlucky women, the immunologic process is exaggerated, and the fibrous capsule that surrounds your implants becomes thicker, harder, and pulls your breast tissue tighter together leading to adverse outcomes. There are several grades of severity of capsular contracture (Baker Classification), but in its most severe form, the tough fibrous tissue bands might cause your breast to become firm, hard, deformed, unnaturally round, and even painful. Capsular contracture can cause a lot of distress to both patients and their plastic surgeons, so there’s a lot of research going on to find out the best ways to treat it.
Is capsular contracture common?
Since there’s a lot of different implant types, textures, brands, and models, it is a little bit difficult to say how common capsular contracture really is. According to the latest studies, a reasonable estimate would be that 8% to 15% of women who have had breast augmentation surgery develop clinically significant capsular contracture. That being said, capsular contracture is the most common complication of breast implant surgery, and it’s the most common indication for breast implant revision. Capsular contracture can happen very soon after surgery (within a year), or much later throughout your lifetime. On average, it develops 2 years after breast augmentation surgery, but this largely depends on the many factors listed below.
Why does capsular contracture happen?
Doctors still don’t completely understand why exactly capsular contracture happens, and there is probably more than one factor that leads to its development. Researchers have proposed a couple of theories that might explain why capsular contractures occur:
- Exaggerated immunologic response: As part of the normal healing process after breast enhancement surgery, your body will create a capsule composed of collagen, myofibrils, and other cells to surround and isolate your implant. This process is natural and is to be expected, and luckily, in the vast majority of women, it does not affect the shape or feel of the breast. For some unexplained reason, some women develop a more excessive immune response, and the immune cells stimulate the formation of a thicker capsule with large and tough fibrous bands that cause capsular contracture.
- Adverse inflammatory reaction: Some researchers believe that bacterial contamination of the implant and a subsequent inflammatory reaction might be behind the formation of a thick fibrous capsule. Your skin and nipple normally contain many bacteria, and some of these bacteria might contaminate the breast implant during surgery to cause an exaggerated inflammatory response later on. Many surgeons use triple-antibiotic irrigation of the breast and strict sterile techniques to prevent any contamination during surgery. There’s still not enough evidence to support this theory, and currently, it is thought that bacterial contamination merely increases the risk of capsular contracture but is not be an actual cause.
What are the risk factors for capsular contracture?
- Reason for surgery: The reason why you originally had breast enhancement surgery plays an important role in determining the risk of capsular contracture. Women who are getting their first boob job (called a primary breast augmentation) have much less risk of developing capsular contracture compared to those who are having breast implant revision or breast reconstruction after a mastectomy.
- Breast cancer treatment: In patients who had received chemotherapy or radiotherapy as part of breast cancer treatment, the risk of capsular contraction is higher. These treatments are known to increase the rate of infection and subsequently more extensive fibrosis and contracture.
- Breast implant brand: Many studies have been done to assess the risk of capsular contracture with different implant brands. Since there are innumerable types, models, and brands of breast implants available, it’s a bit hard to determine which brands incur a higher risk of capsular contracture. What we definitely know, however, is that your implant brand plays a role, so make sure you choose a reputable brand when discussing the matter with your plastic surgeon.
- Implant filling type: Breast implants used today are either silicone-filled or saline-filled. Silicone implants are known to give a more natural look and feel to the breast while saline implants are easier to place and adjust. While each one has its pros and cons, when it comes to the risk of capsular contracture, silicone implants seem to carry a higher risk. This, however, is open for debate, and the data is still not conclusive.
- Implant shell surface: Breast implants usually either have a textured or a smooth surface. Textured implants are associated with less risk of capsular contracture, and can usually maintain their position better than smooth implants. However, it must be noted that textured breast implants have been associated with Breast Implant-Associated Anaplastic Large Cell Lymphoma (BIA-ALCL), a rare type of immunologic cancer that might arise in the breast.
- Surgical technique: In breast augmentation surgery, your surgeon will either insert the implant under your chest muscles (submuscular) or above the muscle and underneath the breast tissue (subglandular). Submuscular implant placement carries a lower risk of capsular contracture formation. Moreover, using sterile techniques and washing the surgical area with antibiotics might reduce the risk as well by lowering the chance of bacterial contamination.
- Time since surgery: Since capsular contracture is a progressive complication, it is well established that the longer your implants have been in place, the more likely you are to develop capsular contracture.
How does capsular contracture look and feel like?
Symptoms of capsular contracture are usually progressive and increase in severity with time. Early symptoms are usually very mild and may barely be noticeable. You might have capsular contracture if you have one of the following symptoms:
- Change in the shape of your breast: Capsular contracture can cause breast deformity, where the affected breast might shrink and become more spherical with unnatural curvature and a heterogeneous contour (see the image below).
- Change in breast consistency: As the capsule around your breast implant becomes thicker and tenser, your breast might become firmer and even hard in consistency.
- Pain in the breasts: If the capsule becomes too tight it might start to cause pain in the affected breast.
- Feeling like your implant is out of place: Some patients report feeling that their breast implant has changed position and feels like it’s in their armpit.
How is capsular contracture diagnosed?
If you suspect that you might have capsular contracture, you should plan a visit to your plastic surgeon to get a full assessment. Your plastic surgeon will ask you about your symptoms, your implants’ type, and some details about your boob job. After that, he/she will perform a thorough physical examination of your breast to assess the degree of deformity, firmness, and any tender points. Your surgeon might order one or more tests to diagnose capsular contracture and rule out any other causes of breast deformity. Tests to diagnose capsular contracture include:
- MRI scanning: Magnetic Resonance Imaging (MRI) is considered the gold standard in diagnosing capsular contracture and other complications of breast implants. It provides high-resolution images that clearly outline your breast implant and surrounding tissue.
- Mammography: You’re probably familiar with how mammography works. It is a test that’s usually used to screen for breast cancer in women. Mammography can be useful in detecting mild and moderate capsular contracture, however, it has limited use in severe capsular contracture.
- Ultrasound: Ultrasonography is good at detecting capsular contracture, however, the results are very subjective and depend on the experience of the doctor performing the test. Therefore, ultrasound might not be the best test to diagnose capsular contracture.
Based on your symptoms, the characteristics of your breasts, and the imaging results, your plastic surgeon will determine the severity of capsular contracture according to the Baker classification system:
- Baker I: Your breasts look and feel natural
- Baker II: Minimal contracture. Your surgeon can feel a little firmness and can tell that you’ve had breast augmentation, but you have no other symptoms or deformities.
- Baker III: Moderate contracture. Your breast feels abnormally firm with some degree of deformity.
- Baker IV: Severe contracture. Your breast looks obviously deformed, feels hard, and is causing you pain.
After determining your Baker grade, your doctor will discuss with you the possible treatment options. Capsular contractures with Baker grades I and II usually do not cause any concern and require no treatment. Baker grades III and IV, however, are more severe and treatment is indicated.
What are the surgical treatments for capsular contracture?
The most effective treatment for capsular contracture is revision surgery. Capsular contracture revision surgery is usually reserved for those with severe contractures (Baker III and IV), and it includes one or more of the following procedures:
- Capsulotomy: Also called an open capsulotomy (as opposed to the closed capsulotomy described below). The fibrous tissue capsule is formed of thick tight bands that become tighter and abnormally pull your breast tissue distorting its shape. A capsulotomy is a surgical revision procedure where your plastic surgeon tries to cut the tight bands that are pulling on your breast, trying to release them to make your breast softer without completely removing the capsule. Your surgeon will cut the bands in multiple locations and in different orientations to relax the tissue and restore the normal breast shape. This technique is less extensive than capsulectomy (capsule removal), and it is preferred if your implants are submuscular.
- Capsulectomy: A capsulectomy is a breast implant revision surgery in which your surgeon cuts out and removes all the fibrous tissue capsule surrounding your breast implant. This surgery is more invasive than capsulotomy and carries higher risks especially if your implants are submuscular. Submuscular implants are very close to your ribs, so extensive manipulation of the capsule around them can lead to hematoma formation (blood collection) or pneumothorax (puncture of the lung). Nevertheless, some surgeons still prefer this technique to capsulotomy, since it’s thought that complete removal of all scar tissue ensures the removal of any contaminants, reduces further contracture, and prevents calcium from building up in the leftover tissue and interfering with mammography results.
- Implant re-placement: Repositioning the implant into a new location has been suggested to reduce the risk of recurrence and improve outcomes after capsulotomy and/or capsulectomy. A new technique that has shown promise is the “neo-pocket” formation. A neo-pocket is a new space created by your surgeon to re-insert the implants in.
- Autologous fat transfer: Autologous fat transfer is being researched as a potential treatment for capsular contracture. In this procedure, your doctor removes excess fat from another site of your body (like your thighs, hips, or abdomen) through liposuction. The fat is then injected into the breasts. Researchers suggest that by doing this, the blood circulation will be enhanced around the capsule, and the breast becomes softer. Nevertheless, this is still under investigation and is not a standard treatment. Fat transfer can, however, be used in combination with capsulotomy or capsulectomy, or as part of breast reconstruction if you choose to remove your implants.
- Implant removal: In very severe cases with multiple recurrences, your surgeon might suggest removing your breast implants completely as one of the options. Removing the implants usually solves the problem, however, the cosmetic results after explantation are usually undesirable. This is especially true if you’ve had large implants and are left with excess skin after surgery. After removing your breast implants, your surgeon can perform breast reconstruction by a combination of techniques. Reconstruction after implant removal can include mastopexy (breast lifting), removal of excess skin, or autologous fat transfer.
Is there a risk of recurrence of capsular contracture after revision surgery?
Unfortunately, the risk of recurrence after capsular contraction repair surgery is somewhat high. According to some estimates, nearly 1 in every 4 women develops contractures again within a year of her revision surgery. This can lead to multiple subsequent revision surgeries, and the risk of recurrence remains high each time. Newer surgical techniques (like the neo-pocket method) are being studied and are hoped to minimize the risk of capsular contracture recurrence.
What are the non-surgical treatments for capsular contracture?
Although breast revision surgery is considered the best way to get rid of capsular contracture, several alternative non-surgical treatments have been suggested to break up the scar tissue in the breast and make it softer:
- Closed capsulotomy: As the name implies, closed capsulotomy is when your plastic surgeon attempts to break the scar tissue forming the capsule in your breast without resorting to surgery. This means that your surgeon will attempt to manually manipulate your breast, pulling and pushing it in different directions in order to loosen the fibrous bands causing capsular contracture. This technique, however, is not very effective, and more than half the women usually need to undergo the procedure multiple times. Moreover, closed capsulotomy carries a risk of implant rupture and hematoma formation (blood collection). All of this has made closed capsulotomy a less-than-ideal method to treat capsular contracture without surgery.
- Ultrasound therapy: Ultrasound therapy uses sound waves that are applied to your breast using a probe. This method has been used in treating breast engorgement and blocked mammary ducts. Recently, it has been suggested that multiple sessions of ultrasound breast therapy might be an effective non-surgical way to treat capsular contracture by relaxing the tight scar tissue in the breast. This technique is still under investigation, but research shows it to be promising.
- Topical vitamin E: Some doctors prescribe Vitamin E creams to be rubbed on the affected breast to soften the scar tissue and reduce capsular contracture.
- Injectables: Several injectable drugs have been tested as an alternative to surgery when treating capsular contracture. Triamcinolone (a steroid), when injected into the scar tissue in the breast, might be an effective way to get rid of capsular contracture. Some researchers have also suggested that Botulinum toxin A (Botox) injections can also make the capsule thinner and softer. A new drug that’s being used is called Zafirlukast. Zafirlukast was shown to successfully improve the Baker grade by softening the fibrous tissue capsule and loosening the capsular contracture. These drugs are still being investigated, and the sustainability of the results they provide is not yet confirmed.
- Oral medications: Several medications have been suggested as a medical treatment for capsular contracture. Drugs like Pirfenidone, Montelukast, and Zafirlukast all provide anti-inflammatory properties that can help you get rid of capsular contracture without surgery. As with the other non-surgical alternatives, these drugs are still undergoing further research before they become standard practice.
Is capsular contracture repair surgery covered by Medicare or private insurers?
A lot of patients ask how much breast revision surgery for capsular contracture costs and whether it’s covered by Medicare or not. Medicare usually covers breast implant removal (without replacement) in any woman who develops complications like implant migration, rupture, or capsular contracture, regardless of the reason why she had had breast augmentation surgery in the first place. When it comes to covering breast implant replacement, however, Medicare is a bit more strict. If you had originally got implants to treat a breast deformity (like tuberous or asymmetrical breasts), trauma, or another breast disease, then Medicare and insurance will cover implant revision surgery if it’s needed. This also applies to women who had had breast augmentation surgery after a mastectomy for breast cancer. On the other hand, in women who originally had breast enhancement for purely cosmetic reasons, Medicare does not universally cover the costs of implant replacement. In this case, you will be eligible for a rebate only if your surgeon can demonstrate that removing the breast implants without implanting new ones will result in a significantly unacceptable deformity. The term “significantly” is not very clear, however, and it usually refers to when there’s no more breast tissue left after explantation.
Is capsular contracture covered by warranty?
Most reputable breast implant brands provide comprehensive warranty programs that cover a range of complications associated with breast implants long after surgery. The list includes implant rupture, capsular contracture, implant migration, and others. Here are the warranty policies for capsular contracture by some top breast implant brands in Australia:
- Mentor: Mentor’s warranty program covers capsular contracture for the first 10 years after surgery. This means that if you develop Baker grade III or IV capsular contracture within 10 years, you get free replacement implants similar to the ones you had. Moreover, the company offers $1500 (Around 2000 AUD) in financial assistance to cover the costs of breast implant revision surgery.
- Allergan: Natrelle breast implants by Allergan are also covered byz warranty in case of developing capsular contracture. The company promises to provide free replacement implants for the first 10 years, as well as up to $1000 (1350 AUD) in financial support.
- Motiva: If you have Motiva implants and develop capsular contracture within 10 years of implantation, the company will provide replacement implants free-of-charge. Moreover, if your implant happens to have Q Inside® Safety Technology, you would be eligible for $2500 (3370 AUD) in financial coverage if contracture develops within the first year of surgery. Motiva also offers paid warranty programs that provide more comprehensive coverage in case of implant rupture or capsular contracture.
Other breast implant brands used in Australia, like Eurosilicone, Nagor, Sebbin, and Silimed also offer similarly generous warranty programs to ensure your peace of mind long after your boob job.
How to prevent capsular contracture?
Preventing capsular contracture mostly starts before surgery, as it is closely related to your choice of implant and choice of plastic surgeon. After surgery, breast massage can have a preventive role. So here’s what you can do:
- Choice of implant: The characteristics of the implant you choose play an important role in determining the risk of capsular contracture. Choosing a breast implant brand with a good reputation guarantees minimal risks. Textured implants (aside from their risk of BIA-ALCL) would have less likelihood of causing capsular contracture. You should discuss all the pros and cons of different implant types when planning your surgery with your plastic surgeon.
- Choice of plastic surgeon: Choosing the right plastic surgeon is critical to reducing the risk of complications after breast augmentation surgery, in addition to getting the most outstanding results possible. Top plastic surgeons follow strict sterile techniques and methods to reduce contamination during surgery. Moreover, experienced surgeons will try to place your implants using techniques that are less likely to cause contracture later on in life. In addition to all this, choosing the right plastic surgeon means that you will get a better follow-up long after surgery, shall any problems arise.
- Breast massage: Daily breast massage for the first few months after surgery might help stimulate the blood flow around your implants, leading to a softer and thinner capsule. You should gently massage your breasts multiple times daily during the first 2 months after surgery, and then at least once daily afterward.
- Omega-3 supplements: According to early research, fish oil and omega-3 supplements might help during the healing process and by making the capsule less-tough.
What are some other frequently asked questions about capsular contracture?
Can capsular contracture go away by itself?
- Capsular contracture is usually a progressive problem that gets worse with time. It’s unlikely that the breast deformity will go away on its own without medical or surgical intervention
Can lifting weights cause capsular contracture?
- No, lifting weights after full recovery from breast augmentation does not cause capsular contracture. In fact, it is thought that moving your pectoral (chest) muscles might improve blood supply to the tissue around your implant making it softer.
Can capsular contracture happen overnight?
- No, capsular contracture is a progressive complication, which means that it starts with minimal symptoms that might get worse over an extended period of time. If you have a sudden change in your breast size, you might have an implant rupture.
Is capsular contracture dangerous?
- No, capsular contracture does not pose any risks to your physical health. The only problem with not dealing with capsular contracture is that it may worsen with time and start causing pain and severe deformity.
Like any other surgery, breast augmentation surgery has its complication. Capsular contracture is sometimes unavoidable even if your plastic surgeon follows all the possible preventive methods and offers you the most reputable implants. This problem can be distressing to deal with, however, enduring the treatment process will hopefully help you restore your beautiful and attractive breasts in no time.