Probably the most common complication of breast augmentation surgery is scar tissue that forms around the breast implants making them feel harder than desired. It is important to remember that the body is programmed to form a layer of scar tissue around any internal "foreign body" to isolate it from the rest of the body. This is not a rejection reaction but simply the body's normal and healthy response to any foreign material. A "capsular contracture" is then, an envelope of heavy scar tissue that forms around the implant [either saline or silicone] making it feel firm or hard. A capsule is important only if it occurs to such a degree that patients have symptoms [discomfort], asymmetry [one breast is soft and the other breast is hard], or distortion [breast has a rounded, spherical shape, or is pulled by the scar tissue out of alignment with the other breast]. In these instances, patients usually submit to additional surgery to remedy the problem.
It is very difficult to determine exactly what percentage of women will experience "capsular contracture," since perceptions of firmness of implanted women vary widely from patient to patient. Thus one patient may be delighted with the degree of firmness to her breasts whereas another woman may think it was "too firm."
It is important to know that most "capsular contracture" occur within the first year of surgery, but patients are never ever completely free from the risk of capsule formation and can unfortunately form problematic "capsular contracture" at any time following surgery.
Capsular contracture is never a health risk, but can be very bothersome [pain or discomfort], and can often trigger the need for additional unanticipated surgery to the augmented breast.
After 29 years of performing breast augmentation I am still intrigued and occasionally frustrated by capsular contracture. No one understands exactly why a breast will form a "capsule" or envelope of scar tissue around the implant. In my experience it is actually most common for the scar capsule to only form around one breast with the result that one breast is very soft and natural and the other breast is firm and quite "different." Oftentimes the patient will be led to think that the breast implant itself has hardened and they will come to the office thinking that the implant is defective. However, in reality the implant is almost always completely normal and it is the dense scar tissue that surrounds the implant that actually makes the implant feel firm or hard.
The widely quoted national statistics for breast implant scar encapsulation is around 15-20%. We are very proud of our statistics, which show an encapsulation rate of less than 4%.
There are certain circumstances that tend to increase the risk for capsular contracture. The list below is certainly not complete, but in my experience has proven to be true:
- subglandular placement of the implants "above the muscle"
- silicone implants are slightly more prone to capsule issues than saline implants.
- patients with very tight skin envelopes [not much room for the implant]
- patients who request and/or receive implants that seem to exceed the capacity of the overlying skin envelope [implants seem very tight at implantation]
- any infection following surgery [especially staphylococcus epidermidis in the ductal system]
- any collection of fluid within the breast pocket [blood or clear seroma fluid]
- a previous personal history of capsular contracture
- non-compliant patients who do not faithfully follow the post-operative instructions and exercises
- patients with a history of silent infections [frequent urinary tract infections, sinus infections, advanced gingivitis or teeth abscesses]
- patients who have had radiation therapy to the breasts [in association with treatment for breast cancer]
Our very successful approach to preventing capsular contracture is to:
- place the implants "under the muscle" or at least "partially under the muscle" whenever possible
- be very careful to balance the size of the implant with the patients existing and available soft tissue resources. In other words, one needs to balance the patients "wishes with her tissues." This is often a topic that takes up a large portion of the consultation. There must be room for the implant to "move around" inside or the implant will "stop moving" and a capsular contracture will occur.
- we wash the surgical pocket our with a considerable amount of saline solution before washing the pocket out with antibiotics.
- we use very high-dose antibiotics at surgery both through the patients veins into their blood stream, but also to irrigate the surgical pocket [three different kinds of antibiotics and a powerful germicide].
- we take extraordinary care to be sure that there is absolutely no bleeding present before closure and that the surgical field is completely dry.
- we completely re-prep the surgical area and change all the surgical gloves before opening and handling the new implant.
- we believe that the implant must move effortless within the surgical pocket, thus we advise patients not to wear a bra at all following surgery for a period of at least 2 months. Thereafter we allow patients to wear bras 'when they must," but to remove the bra as soon as "feasible and reasonable." This recommendation alone has diminished our office capsular contracture to less than 4% which is an excellent number.
- we do not have patients "massage" or otherwise manipulate their breasts. Instead we have them move the breast implants passively by lifting their arms over their heads and by bending forward and touching their fingers to the floor [allows the implants to fall forward and upward]. We have patients do these exercises 4 times on the day following surgery and double the frequency daily until they reach 32 times a day. Patients will continue this exercise for two months and then cut back to 8 times a day thereafter.
- we also recommend preventative antibiotics for dental care. This is controversial, but we feel the risk of a capsular contracture problem so outweigh the tiny risk of the one time dose of antibiotics that it is proper and reasonable to "overprotect" the patient in this way.
- If patients have very severe or recurrent capsule problems, then we also use a special graft material to line the pocket. This material is called “Strattice,” and has been shown to be 98% effective in preventing a re-occurrence of the problem. The only downside of Strattice is that it is very expensive.
