DR. EPSTEIN’S COMPREHENSIVE Breast Augmentation Guide

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Capsule Contracture

Breast augmentation is a wonderful procedure. I have performed thousands of them, and even my own daughters have undergone this procedure. I find it very rewarding to see how breast augmentation can help a woman to improve her self-esteem and confidence. However, it is important to understand that these are not lifetime devices, and if you undergo this procedure, at some time in your lifetime, you will probably need to undergo an additional procedure for some reason or another. My goal is to delay that next procedure for as many years as possible by performing the first procedure in accordance with my knowledge and experience,while following established scientific principles.

Capsule contracture remains one of the most common reasons for a revision of a previous breast augmentation. In order to understand what “capsule contracture” is, lets first discuss what a “capsule” is.

If you implant any foreign body of any kind, including silicone, into the human body, the body will recognize that there is something foreign inside of it and try to “wall it off, “or isolate it. This is a process already programmed into our wound healing biology in our DNA and there is no way to prevent it. This is not necessarily a bad thing either.

When a breast implant is placed, either between the breast and the pectoralis major muscle (“above the muscle”) or between the pectoralis major muscle and the bony ribs comprising the chest wall (“below the muscle”), over the next several weeks, the body will slowly produce a scar tissue lining along the surface of the tissue surrounding the implant called a “capsule.” Normally, the capsule is thin, pliable and exists in harmony with the implant. You cannot see it or feel it. However, sometimes, there is stimulation of the scar tissue, possibly due to the presence of certain types of bacteria (but not always) around the implant, which causes the scar tissue to become thick, and contract, that is – try to shrink. Whereas a thin, pliable capsule does have any effect upon the look and feel of the breast, a thickened, contracting capsule will squeeze the implant and make if feel hard. As this process continues, the breast starts to take on a spherical shape, sometimes elevating itself on the chest wall, resulting in the breast now appearing higher up than it did previously. There are different degrees of capsule contracture:

  • Grade I — the breast is normally soft and appears natural in size and shape
  • Grade II — the breast is a little firm, but appears normal
  • Grade III — the breast is firm and appears abnormal
  • Grade IV — the breast is hard, painful to the touch, and appears abnormal

What causes capsule contracture?

While we do not have definitive proof, we do have some theories. One of these theories involves the formation of a “bio-film”, a thin membrane of proteins that coats the implant shortly after surgical implantation. The bio-film can then contain certain types of bacteria and protect them from the body’s defense systems. This can then result in a chronic inflammatory response which makes the capsular tissue thicken and the breast feels harder.

How do we prevent capsule contracture?

While we cannot reduce the risk to zero, there are several things the surgeon can do at the time of breast augmentation to reduce the risk of capsule contracture. Most likely, these things will probably have more effect on the early development of capsule contracture than on development of capsule contracture years later. Quite often we have no idea what causes the capsule contracture to occur. Sometimes, later development of capsule contracture has been noted to follow a recent infectious process, such as a sinus infection. I am not aware of any connection to urinary infections.

Among the recommended things the surgeon can do to help prevent capsule contracture:

  • Use prophylactic antibiotics to reduce the risk of infection
  • Use an inframammary (breast crease) incision. Armpit and nipple incisions are in areas of increased bacteria and may lead to contamination of the implant and resultant capsule contracture
  • Use nipple shields – a clear, plastic adhesive dressing to keep nipple bacteria from encountering the implant, the surgeon’s hands or surgical instruments
  • Careful surgical dissection with minimal bleeding – use electrocautery rather than blunt (“ripping tissue”) dissection to create the breast pocket
  • No active bleeding or oozing present when implant is inserted
  • Do not cut into the breast tissue – bacteria may be harbored in the milk ducts
  • Use submuscular (below the muscle) / dual plane pocket (I use this always for augmentation)
  • Use Betadine/triple antibiotic irrigation – Betadine is an antiseptic that kills many types of bacteria on contact
  • Use a funnel device (I use the Keller funnel) to minimize potential contamination of the implant as it is inserted into the breast pocket
  • Change gloves before inserting the implant
  • Close the wound in layers (I use a four-layer closure)
  • Re-prep the skin with antiseptic prior to implant insertion
  • Avoid the use of drains
  • Prophylactic antibiotics with certain types of procedures (i.e. dental) after surgery

The above are excellent ways, but again do not guarantee, to prevent capsule contracture. In clinical studies, the use of Betadine has been a proven way to reduce the risk of capsule contracture. I have been using Betadine for many years to reduce the risk of capsule contracture.

How is Capsule Contracture treated?

There are no proven non-surgical treatments for capsule contracture. Some have tried montelukast (Singulair), a drug used to treat asthma due to its effect on the inflammatory process, but results have not been impressive, and I do not recommend this form of treatment. Capsule contracture is not an emergency, and if it did not bother you, you could ignore it. Most women, however, do not want to have a hard, distorted looking breast. Others have tried ultrasound therapy, again, in my opinion, results are not that impressive.

The gold standard for treatment of capsule contracture is surgical. Current recommendation is to first remove the breast implant, then remove the scar tissue capsule, and then replace the implant with a new one, as the previous one is presumed to have contaminated bio-film on it. All the same precautions used to prevent the formation of a capsule contracture during a primary (first) breast augmentation are again taken when a capsulectomy is performed. Drains are placed at the discretion of the operating surgeon based upon the findings at surgery. I personally rarely place drains during this procedure.

Can Capsule Contracture occur again? What if I have a recurrence of capsule contracture?

Capsule contracture can occur again, however this is uncommon. Some women may be biologically prone to develop capsule contracture, although there is no way to test for this. If this is a repeat problem, then consideration should be given to using an acellular dermal barrier such as Strattice to reduce the risk of capsule contracture from occurring a third time. This product is also used in abdominal wall reconstruction and in some hernia repairs.

Case studies:
Examples of before and after case studies following surgery for capsule contracture can be found here.

Next Section: Explantation (Removal of implants) »

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