Avoiding Capsular Contracture after Breast Augmentation

Capsular contracture is a tightening (“contracture”) of the scar tissue that forms around the breast implant after it is placed (the “capsule”). Mild contractures can feel firm. More severe contractures can be painful and may distort the breast by pulling the breast implant up significantly.

The rate of contracture varies greatly in medical studies and I have seen reported numbers from 10 as high as 50%. We do not know for certain what causes capsular contracture, but we now have some pretty good ideas.

If a patient has significant bleeding around the implant at the time of or shortly after surgery (a hematoma) and it is not removed, then the old blood can stimulate a tightening of the scar tissue capsule and cause a contracture. In a patient having a followup or “secondary” surgery, a drain is frequently used for a few days. I have found that drains are generally not needed in a patient having surgery for the first time. But we ask patients to avoid medications and supplements for two weeks before surgery that might increase the risk of bleeding, such as fish oil, extra vitamin E, Aspirin, Ibuprofen, etc. Your doctor should give you a list, and call to check if you are not sure. I have also found it to be helpful in my practice to avoid blunt dissection or “tearing” of the space for the implant and instead do a careful electrocautery dissection of the space.

But the more and more studies are suggesting that the main cause of capsular contracture is “Biofilm”. If bacteria gets on the implant it can “wall itself off” with a protective barrier that prevents the body from fighting it and getting rid of it. Tartar on the teeth that the dentist removes for you twice a year is one example of a Biofilm. Although the patient may not get a true infection, the body is fighting the biofilm, and the scar tissue is stimulated to harden. When patients have implants removed and immediately replaced for capsular contracture, the subsequent risk of repeat contracture is as high as 70%!. This now makes sense, because as long as a speck of bacteria is still in the old space, the biofilm and contracture can recur. And studies have shown that even when bacteria can not be cultured from a breast capsule contracture, that special assays can still detect bacteria. So prevention is key. Newly released long term studies of breast implant complications has shown a higher incidence of capsular contracture when the implant is placed through the axilla (armpit) or around the nipple, as compared to the inframammary (breast fold) incision. We know that nipple ducts harbor bacteria. So one way to decrease the risk of a contracture is to use the inframammary fold incision. I now place a temporary plastic patch over the nipple during surgery to shield the surgical field from this potential source of bacteria. I irrigate the pocket where the implant is going to be placed with a triple antibiotic mixture that has been shown to decrease the risk of capsular contracture, and is left in the pocket with the implant to be absorbed.1 This study reduced the rate of clinically significant capsular contracture (grade III/IV) to 1.8 % at 6 years in breast augmentation patients. In addition I will change our surgical gloves just before implant placement and place a temporary plastic barrier over the skin so that the implant does not touch the skin as it is being placed.

Finally, we have patients with breast implants to consider whether or not to take a single dose of oral antibiotics before dental procedures to decrease the risk of bacterial entering from the mouth through breaks in the gums and traveling through the bloodstream to the implants. There is some controversy regarding the benefit of dental prophylaxis for patients with breast implants and not all plastic surgeons agree. But this is commonly recommended for patients that have a heart valve because of the risk, so I discuss the pros and cons with patients and let them decide.

The above comments/procedures are my personal experience and practice and are representative of where I have personally evolved over the years in my practice. . And with these methods I have seen a similar reduction in clinically significant capsular contracture in my patients to mirror the study below.

Other surgeons may have other methods that work for them in their practices. You should expect some discussion with your surgeon as to methods that he/she uses to reduce the incidence of capsular contracture.