The body forms a layer of scar tissue, called a capsule, around any implant, which is a normal process. Capsular contracture (CC) is a complication of implant surgery that occurs when this capsule thickens, hardens, and contracts, squeezing the implant. This condition causes discomfort, distortion, and firmness. Capsular contracture can be fixed, as various medical and surgical treatments exist to address the condition and restore the breast’s appearance and feel.
Understanding the Stages of Contracture
The severity of capsular contracture is universally classified using the four-grade Baker system, which guides treatment decisions based on symptoms and physical examination. Grade I is the mildest form, where the breast feels soft and appears natural. The implant is present but not noticeable to the touch.
In Grade II contracture, the breast feels slightly firm when palpated, though its visual appearance remains mostly normal. Progression to Grade III means the firmness becomes obvious, and the breast shape begins to look distorted or unnaturally round.
The most severe form is Baker Grade IV, where the breast is very hard to the touch and often painful. At this stage, the breast is clearly misshapen, sometimes appearing high on the chest or having a ball-like appearance due to the extensive constriction of the scar tissue. Grades III and IV typically necessitate surgical intervention, while the earlier grades may respond to less invasive methods.
Non-Surgical Management and Early Interventions
Treatment for capsular contracture begins with conservative, non-surgical methods, particularly for early or mild cases classified as Baker Grade I or II. These interventions aim to soften the existing capsule or reduce the inflammatory response contributing to its thickening. Physical therapy, such as external massage techniques, is often recommended to help stretch and loosen the scar tissue surrounding the implant.
Pharmacological treatments focus on interrupting the biological processes that lead to excessive scar tissue formation. Leukotriene inhibitors, such as zafirlukast (Accolate), are sometimes prescribed because they block inflammatory pathways thought to contribute to the contraction of the capsule. Studies have shown that a course of zafirlukast can lead to partial or complete resolution of contracture symptoms in a significant percentage of patients with early-stage disease.
Another historically practiced but now largely abandoned non-operative method is closed capsulotomy, which involved forcefully compressing the breast to break the contracted capsule inside the body without an incision. However, this technique carries significant risks, including implant rupture, uncontrolled bleeding, and damage to the surrounding breast tissue, leading to its general disuse.
Surgical Procedures for Correction
For moderate to severe cases, typically Baker Grade III and IV, surgery remains the most reliable and definitive way to correct capsular contracture. The surgical approach depends largely on the severity of the scar tissue and the patient’s history. One primary surgical option is a capsulotomy, which involves making strategic incisions into the thickened capsule to relieve the pressure squeezing the implant.
An open capsulotomy releases the constricting tissue without removing it entirely, allowing the capsule to expand and the implant to assume a more natural shape. While less invasive than a capsulectomy, open capsulotomy is sometimes associated with a higher risk of contracture recurrence. The alternative and often preferred method for severe contracture is a capsulectomy, which involves the physical removal of the scarred tissue.
A capsulectomy can be performed as a partial removal, where only the most contracted sections are taken out, or as a total capsulectomy, where the entire capsule is removed from the implant pocket. The most comprehensive form, called an en bloc capsulectomy, removes the implant and the surrounding capsule as a single, intact unit. During this corrective surgery, the surgeon may change the implant’s position, such as moving it from above the muscle (subglandular) to beneath the muscle (submuscular), which helps reduce the chances of future contracture.
Strategies for Preventing Recurrence
Preventing the return of capsular contracture is important, as the risk of recurrence can be as high as 30% following initial surgical correction. Several strategies are employed during the revision surgery to create a healthier environment for the new implant. Meticulous surgical technique is used to minimize tissue trauma and ensure complete hemostasis, which means controlling bleeding to prevent the formation of hematomas.
Surgeons use strict protocols to minimize bacterial contamination, including the use of antibiotic irrigation solutions to wash the implant pocket and the adoption of a “no-touch” technique when inserting the new device. This no-touch approach aims to prevent the implant from touching the skin or surrounding tissue during placement. The theory is that subclinical bacterial presence, or biofilm, is a significant trigger for the chronic inflammation that causes the capsule to contract.
In cases of recurrent or severe contracture, acellular dermal matrix (ADM) may be used to reinforce the implant pocket. ADM is a processed, biological scaffold material that provides coverage for the implant and promotes better integration with the body’s own tissue. The use of ADM has been associated with reduced recurrence rates, likely by providing a biological barrier that limits inflammatory cell infiltration. After surgery, some surgeons may also prescribe leukotriene inhibitors for a period to dampen the initial inflammatory healing response and aid in long-term prevention.