Capsular contracture is the most frequent complication following breast augmentation surgery. The condition occurs when the body’s natural response to a breast implant results in the formation of a fibrous capsule of scar tissue. While a soft capsule forms around every implant, capsular contracture is the process where that tissue tightens and hardens around the device. Whether capsular contracture can resolve on its own depends almost entirely on the degree of its progression, though definitive, long-term resolution typically requires intervention.
Understanding the Formation and Severity
The initial formation of a soft, thin capsule around an implant is a standard biological reaction. Capsular contracture develops when this capsule begins to constrict and thicken excessively, often driven by chronic inflammation or a subclinical bacterial infection that creates a biofilm on the implant surface. This inflammatory response causes the collagen fibers within the capsule to organize and tighten, ultimately squeezing the implant.
Clinicians use the Baker Grading System to classify the severity of capsular contracture across four grades. Grade I indicates a normal capsule where the breast remains soft and appears natural. In Grade II, the breast feels slightly firm but still looks relatively normal.
The condition progresses significantly at Grade III, where the breast becomes noticeably firm and the implant is palpable, often leading to visible distortion. Grade IV represents the most advanced stage, marked by a breast that is hard, painful, and severely misshapen. Once the scar tissue has tightened to a Grade III or IV level, spontaneous resolution is highly unlikely.
Limits of Non-Invasive Management
Non-invasive methods are generally limited to prevention or the earliest stages of capsular contracture. Conservative management strategies, such as specialized massage techniques, aim to keep the capsule pliable and prevent the collagen fibers from tightening excessively. These techniques are usually most beneficial in the immediate post-operative period or for very mild firmness.
Medications are also sometimes used, primarily for mild or early Grade II contracture, to interrupt the inflammatory cycle. A common example is the off-label use of leukotriene inhibitors, such as montelukast. These drugs work by blocking specific inflammatory agents implicated in excessive scar tissue formation.
Studies show that leukotriene inhibitors may improve or resolve contracture in patients with milder cases (Grade II or less). However, once the contracture is firmly established at Grade III or Grade IV, non-surgical options rarely provide a complete or lasting reversal. At this stage, the mechanical force of the severely constricted capsule requires physical release or removal.
Surgical Procedures for Definitive Removal
For established capsular contracture classified as Grade III or IV, surgical intervention is the standard for definitive treatment and resolution. The primary goal of this surgery is to remove or release the hardened capsule that is constricting the implant. The two main surgical approaches are capsulotomy and capsulectomy, and the choice depends on the severity and specific characteristics of the contracted tissue.
A capsulotomy is a procedure where the surgeon strategically scores or cuts the scar tissue capsule to release the tension it exerts on the implant. This technique essentially opens the tightened capsule, allowing the implant to regain a softer, more natural position and feel. Capsulotomy is often recommended for less severe cases where the capsule is not overly thick or calcified.
The alternative and more comprehensive approach is a capsulectomy, which involves the complete removal of the scar tissue capsule from the surrounding breast tissue. This procedure is generally considered the definitive treatment for advanced contracture, particularly Grade III or IV, because it eliminates the source of the problem. A capsulectomy is also necessary if the implant has ruptured or if there is a suspicion of other implant-related conditions.
During both capsulotomy and capsulectomy, the existing breast implant is almost always removed, and a new one is often placed, sometimes with a change in the implant pocket location. A specific type of capsulectomy, called an en bloc capsulectomy, involves removing the capsule and the implant as a single, intact unit.
Factors Influencing Recurrence
Even after successful surgical removal, the body will naturally begin forming a new capsule around the replacement implant. Recurrence of capsular contracture is possible because the underlying biological tendency to form excessive scar tissue may still exist, though the risk is significantly lower than the initial occurrence. Surgeons employ several strategies to help maintain the corrected state.
Changing the implant pocket from the subglandular (above the muscle) to the submuscular (below the muscle) plane has been shown to reduce the risk of recurrence. The submuscular position provides a greater cushion of soft tissue, which helps minimize tension and inflammatory response. Another preventative measure involves meticulously controlling the surgical environment to reduce the risk of bacterial contamination, which is a known trigger for contracture.
The choice of implant is also a factor, as some data suggests that using textured implants can result in a lower rate of capsular contracture compared to smooth implants. The best prognosis for preventing recurrence involves combining a complete surgical removal of the old capsule with changes in surgical technique and implant characteristics. Patients are often advised to implement post-operative protocols, such as specialized massage, to encourage a soft, pliable new capsule formation.