Capsular fibrosis, also known as capsular contracture, is a condition that can occur after a medical device is implanted in the body. While a fibrous capsule normally forms around any foreign object, capsular fibrosis happens when this capsule becomes abnormally thick and hard. This hardening can lead to complications, especially with breast implants, as the soft protective layer becomes a rigid, constrictive barrier.
The Body’s Response to Implants
The human body possesses a natural defense mechanism that initiates a foreign body reaction when an implant is introduced. This process begins almost immediately, with proteins from the blood adsorbing onto the implant surface, forming a provisional matrix. Immune cells, including neutrophils and macrophages, are then recruited to the site. If the foreign material cannot be degraded, fibroblasts activate and begin to lay down collagen fibers, forming a protective capsule around the implant.
This initial capsule is usually soft and pliable, serving to stabilize the implant. However, in cases of capsular fibrosis, this normal process undergoes a pathological change. Chronic inflammation can drive excessive stimulation of collagen production, leading to an overabundance and irregular arrangement of these fibers. The capsule then thickens, hardens, and may begin to contract around the implant, resulting in a rigid, fibrotic structure.
Factors Influencing Fibrosis Development
Several factors can contribute to capsular fibrosis.
Implant Characteristics
Implant characteristics play a role. Smooth-surfaced implants may have higher contracture rates compared to textured varieties, as smooth surfaces can allow fibroblasts to align in a way that promotes contraction. While both silicone and saline implants have a silicone outer shell, some observations suggest saline implants might have lower rates of capsular contracture, though reliable data remains limited. Implant rupture or leakage can also initiate an inflammatory response, contributing to fibrosis.
Surgical Factors
Surgical technique, including tissue damage during the procedure and implant handling, can influence the body’s reaction. Post-surgical complications like hematoma (blood collection) or seroma (fluid collection) can create an environment conducive to fibrosis. These collections can provide nutrients for bacteria and contain inflammatory mediators that stimulate scar tissue formation.
Infection
Infection, particularly low-grade bacterial infection, is a leading theory. Bacteria can form a “biofilm” on the implant surface, triggering a chronic inflammatory response that leads to excessive fibrous scar tissue production. Even common skin bacteria like Staphylococcus epidermidis have been implicated in this process.
Patient-Specific Factors
Individual healing responses and genetic predispositions can increase susceptibility, including a family history of thick scar tissue formation or autoimmune diseases like lupus or scleroderma. External trauma or injury to the implant area can contribute to fibrosis. Radiation therapy, especially after mastectomy, is another risk factor.
Recognizing the Signs
Identifying capsular fibrosis involves recognizing changes in the implant area, which can range from subtle to severe.
Physical Changes
The implant may feel increasingly firm or hard, making the area abnormally rigid compared to normal tissue. This firmness can progress, sometimes making the breast feel like a hard ball or apple. Other physical changes include:
Distortion of the breast shape, making it appear misshapen, overly round, or asymmetrical.
The implant sitting higher on the chest.
Visible rippling or wrinkling of the skin over the implant.
Restricted implant mobility within the breast pocket.
Sensory Changes
Discomfort, pain, or tenderness in the affected area are frequently reported. This pain can range from mild and intermittent to severe and persistent, potentially interfering with daily activities. Changes in breast sensitivity or increased pressure may also be experienced.
Diagnosis and Grading
The severity of capsular fibrosis is often graded using the Baker classification system, which ranges from Grade I (soft, natural appearance) to Grade IV (hard, painful, and distorted appearance). Diagnosis primarily involves a physical examination by a healthcare professional, who can assess the firmness and appearance of the breast. In some instances, imaging techniques like ultrasound or MRI may be used to confirm the diagnosis or rule out other issues, such as implant rupture. However, the diagnosis is largely clinical, based on the signs and symptoms observed and reported.
Treatment Options
Managing capsular fibrosis involves conservative methods and surgical interventions.
Conservative Treatments
Conservative treatments, such as massage and certain medications, are sometimes suggested. However, these are generally less effective for established fibrosis. Massage may be attempted for milder cases, such as Baker Grade II.
Surgical Interventions
Surgical intervention is often the primary treatment for more advanced capsular fibrosis, particularly for Baker Grade III and IV cases. Common procedures include:
Capsulectomy: Removal of the entire fibrous capsule surrounding the implant to eliminate constricted tissue.
Capsulotomy: Incising or scoring the fibrous capsule to release constricting pressure without complete removal.
Surgical treatment often includes implant exchange, where the existing implant is removed and replaced. This may be combined with a capsulectomy. Surgeons may also change the implant’s plane of insertion to reduce recurrence risk. The goal of these procedures is to alleviate symptoms and restore a more natural breast appearance. However, capsular fibrosis can recur even after surgical correction, with recurrence rates reported. Factors influencing recurrence include surgical techniques, implant type, and individual healing responses.