Capsular contracture is the most frequent complication following breast augmentation surgery, affecting approximately one in six women. This condition occurs when the body’s natural response to the implant—the formation of a fibrous capsule of scar tissue—becomes exaggerated. Instead of remaining thin and pliable, the capsule thickens, hardens, and contracts around the implant, which can lead to firmness, distortion, and sometimes pain in the breast. The severity of the hardening is typically graded using the Baker classification system.
Pre-Surgical Decisions Regarding Implants and Placement
The choices made regarding the implant and its placement before the procedure significantly influence the long-term risk of developing a hardened capsule. One primary decision is the placement of the implant, either subglandularly (over the chest muscle) or submuscularly (under the chest muscle). Placing the implant under the pectoralis major muscle is associated with a substantially lower incidence of capsular contracture. Some studies suggest the risk can be two to three times higher with subglandular placement.
The muscle provides a layer of tissue coverage that reduces the inflammatory response and physical micro-trauma to the implant pocket. The choice of implant surface—smooth versus textured—also plays a role. Historically, textured surfaces were believed to disrupt the formation of the contracting scar tissue, resulting in lower rates of contracture than smooth implants. However, this advantage is largely negated when the implant is placed submuscularly, where both surfaces show similar, low rates of contracture. The composition of the implant, whether saline or silicone gel-filled, does not appear to be a major independent factor in this risk.
Intraoperative Techniques to Minimize Contamination
Minimizing bacterial contamination during the operation is a highly effective strategy to prevent capsular contracture. Subclinical infection and the formation of bacterial biofilm on the implant surface are considered major precursors. Biofilm is a sticky layer of bacteria, often Staphylococcus epidermidis, that triggers a chronic inflammatory response, leading to the capsule’s thickening and contraction.
Surgeons employ a “No-Touch” technique to prevent the implant from contacting the patient’s skin or non-sterile instruments. This method involves strict protocols, ensuring the implant is only handled by sterile gloves and dedicated instruments. A key tool is the use of an implant delivery device, such as an insertion sleeve or funnel, which shields the implant from the skin edge as it is guided into the surgical pocket.
The use of antiseptic irrigation solutions within the breast pocket before insertion is another critical step to wash away residual bacteria. Surgeons often use a triple antibiotic solution or povidone-iodine to flush the cavity and eradicate potential contaminants. Additionally, meticulous surgical hemostasis, the careful control of bleeding, is necessary to prevent hematoma formation. A collection of blood provides a medium for bacterial growth and an inflammatory stimulus that can initiate contracture.
Long-Term Post-Operative Management
The patient’s adherence to post-operative instructions is crucial for controlling the inflammatory environment in the months following surgery. Activity restrictions are paramount in the immediate recovery phase, requiring the avoidance of strenuous activities, heavy lifting, or exercise that activates the chest muscles for four to six weeks. This limitation helps prevent excessive implant movement, reduces the risk of bleeding, and allows the initial capsule to form without trauma.
Post-operative breast massage is a commonly recommended practice, though its scientific evidence for prevention is mixed. Surgeons typically instruct patients to begin a specific routine within the first few weeks, performing the action multiple times a day for several months. The goal of the massage is to keep the implant pocket pliable and prevent the newly forming capsule from adhering too tightly to the implant shell.
Pharmacological interventions can also be part of the long-term management, particularly for patients with a history of recurrent contracture or high risk. Certain anti-inflammatory medications, such as leukotriene inhibitors (e.g., Montelukast), are sometimes prescribed off-label to modulate the body’s inflammatory response. Patients must also notify their surgeon of any planned dental work or procedures that could introduce bacteria into the bloodstream, as antibiotic prophylaxis is frequently advised to prevent late-onset infection.