Dealing with capsular contracture

Background

Capsular contracture has been a problem with breast implants ever since breast implants were first introduced in the 1960s. Although the incidence has been significantly reduced over the years, the problem still occurs in some people with breast implants.

This pamphlet will give you information on the issue and Dr. Silverton’s preferred methods to manage and correct the problem.

Normal healing

When an implant is placed in the breast a space is made for the implant. This is called “the breast pocket”. Typically this space is under or on top of the pectoralis major muscle. When the implant is under the muscle, it is only partially under the muscle because the lower part of the implant cannot be covered with the muscle. Therefore this is called “partially submuscular”. Techniques for muscle coverage of the lower part of the implant are available, but are not usually chosen for cosmetic breast enlargement. They unnecessarily increase the scope, pain, and risks of the surgery.

Dr. Silverton generally uses the partially submuscular option. It is thought that the frequent movement of the muscle over the implant helps to keep the breast soft.

Scar tissue forms all around the new implant after the surgery is completed and this takes about 4 to 6 weeks to happen. This can be likened to a lining to a pocket. This scar tissue is call “the capsule”. This capsule (or pocket lining) matures over the next 6 months. In normal healing it remains thin, translucent and relaxed allowing the implant to settle into position as it stretches out a little.

Mechanism of Capsular Contracture

In some cases the scar capsule can become thickened, opaque and tight, and it shrinks in size. This is called “capsular contracture”. Imagine what would happen if you put a balloon in your pocket and then the pocket lining shrunk. The balloon would become compressed, and round. Round or spherical shape gives it the smallest surface area. It is responding to the compression force of the capsular contracture, but eventually it cannot be compressed any more. Breast implants are either saline filled or silicone gel filled and they cannot get smaller when they are compressed. So the breast becomes deformed in shape and feels hard when capsular contracture occurs. Sometimes the capsule tightens more in one part than another. This pushes the implant out of place. Usually the implant is displaced upwards. This phenomenon of capsular contracture can occur on one side only, and sometimes on both sides.

Capsular contracture is unsatisfactory and may result in a hard, firm deformed breast. The good news is that this is not a disease, not cancer, and it does not make you sick. The bad news is that we do not know exactly why it happens, which makes it difficult to prevent and treat.

Theories of Causation

Although we are not certain what causes capsular contracture, there has been a lot of research and we now have some promising theories and leads. The most important theory is that capsular contracture might be caused by a biofilm.

Biofilm.

This is thought to be the most common cause of capsular contracture and is currently the most widely accepted. A biofilm is a microscopically thin layer of bacteria. Not all bacteria are bad. Not all bacteria cause infection. Some bacteria are a necessary part of healthy living – think of bowel bacteria.

Bacteria may gather on the breast implant surface or on the scar capsule surface. They multiply and form a microscopically thin layer called “the biofilm”. The biofilm may send signals to each other using a method called quorum sensing. It is thought that these chemicals can cause a reaction within the scar capsule. This makes it thicken, and shrink and create the compression of the implant which we call capsular contracture.

If this is correct, how do these bacteria get there? Well the answer is that we are not quite sure, and here again there are several theories.

1a. At surgery.

Surgical procedures are supposed to be absolutely sterile, but exceptions can occur.

First, the skin is sterilized by a special prep fluid applied before the surgery starts, and all surgical staff wear special sterile attire and gloves, and all instruments are sterilized. It is possible that there could be a breach of sterility at any point, but this is extremely rare.

Second, it is possible that bacteria residing deep down in the pores of the skin might not be reached by the skin prep fluid and may be squeezed out during the process of pushing the implant in, and contaminate the implant.

The Keller Funnel is shaped like a cake decorator. The implant is dropped into the funnel and then squeezed into the breast. The surgeon does not need to touch the implant. It costs about $125 extra and has not caught on widely as the surgeon often has to touch the implant after it has been pushed in to position it properly. Dr. Silverton does not routinely use this device.

Third, the peri-areola (or nipple) approach may divide some breast milk ducts. These milk ducts may harbor bacteria after pregnancy and, by dividing them, some bacteria may be released into the breast implant cavity during surgery. For this reason, the infra-mammary (or crease under the breast) incision is gaining more favor when putting breast implants in. This is because this incision allows the surgeon to go around the breast tissue rather than going through the breast tissue during breast implant surgery.

1b. After surgery.

Capsular contracture does not always start soon after surgery. It might start months or even several years after surgery. So, there must be some other causes that happen after surgery.

A bacteremia means “bacteria in the blood stream”. Occasionally bacteria can get into our blood streams. We have white cells in the blood poised to kill those bacteria off. This usually works amazingly well. The bacteria are killed off and we know nothing about it. We remain well and are not aware of this happening. However, the theory is that some or even just one bacteria might escape the white cells and land on the scar capsule, where there is not much blood, and it can remain safe and multiply and form a biofilm, which will lead to capsular contracture.

So, how do bacteria get into the blood stream and how often does this occur? The answer again is “We are not sure”. We do know that whenever we have dental treatments, especially teeth cleaning, that a brief bacteremia occurs.

So, it seems prudent to avoid non-emergency dental care for a period of time after surgery while healing is taking place. Dr. Silverton suggests two (2) months, but any time is just a guess. Whenever dental treatment is required it seems like a good idea to give one great big dose of antibiotics to you just before your treatment to try to help the white cells do their job of killing off any bacteria. There is no proof that this works. It just seems like a good idea.

How long should you do this for? Probably as long as you have breast implants.

However, this might not be the only time that a bacteremia occurs. Perhaps it can occur with any infection, cold, urinary tract infection, upper respiratory infection or simply a pimple. It is not possible to give you an antibiotic for everything. So
maybe this explains how capsular contractures occur a long time after the surgery. Many times there is nothing that the patient can think of that happened before the onset of capsular contracture.

“Dr. Silverton is meticulous about sterility …”

Dr. Silverton is meticulous about sterility during breast surgery. He changes gloves twice during surgery, just before handling each implant. The scrub tech never touches the implant. He irrigates the surgical pocket many, many times during the procedure with triple antibiotic fluid. During infra-mammary breast implant procedures he masks the nipples with Tegoderm to try to avoid touching the nipples during the procedure. He also uses antibiotics intravenously just before surgery and for a week afterwards.

2. Chemical.

When there is excessive amounts of blood around the implant after surgery this blood will form a clot. The body absorbs the clot by forming fibrosis throughout the clot, which brings in blood vessels. These vessels transport the white cells, which eventually absorb and disperse the blood clot. This is a chemical and physiological process which might result in a thick shrunken capsule – capsular contracture.

3. Trauma.

When trauma occurs to the breast the scar capsule could be injured. It can go on to heal with additional scar. This extra scar will be thicker and less elastic than the original scar. Repeated minor trauma might occur due to the implants bouncing in the pocket while jogging or similar activities. Little injuries can heal many times, leading to a thicker and tighter and non-elastic scar. Bigger implants are heavier. Heavier implants bounce with more force. Patients with over-sized implants are more likely to develop capsular contracture or may bounce their implants out of position over time. Please consider this issue when selecting larger implants.

4. Breast Feeding.

Breast feeding introduces a lot of unknowns. There is no danger to your baby if you choose to breast feed after saline or silicone gel breast implants. If you get breast infections (mastitis) during breast feeding the bacteria might reach the implant. In rare cases it might cause an infection, but more likely it might simply cause capsular contracture.

Diagnosis

As you can see this gets quite complicated and we have many theories and not much proof. This makes the management of capsular contracture rather difficult. However, the diagnosis of capsular contracture is quite simple.

If your breast becomes unnaturally hard and if the implant gets pushed out of position you almost always have capsular contracture. It often gets pushed upwards. No complicated or expensive tests are usually necessary. Mammograms, ultrasounds and MRIs might give more detailed information, but are not usually very helpful.

There is a classification of breast capsular contracture, which divides patients into helpful similar groups. It is called The Baker Classification or Grade, after the doctor who first described this system.

Baker Grade 1. Soft and normal. The implant can move around in a pocket which is slightly larger than the implant. No issues.
Baker Grade 2. The implant feels a little firm. The pocket is a little constricting. The shape looks good. It is acceptable, but not quite perfect.
Baker Grade 3. The implant is firm. Some unnatural shape is showing. If the other side is Baker Grade 1, there is significant asymmetry. It is not satisfactory.
Baker Grade 4. This is the same or firmer than Grade 3, but now with the addition of pain.

 

You can see that the condition of capsular contracture is not very well understood at this time. That makes management rather difficult and many plastic surgeons will approach it differently.

Another issue is that the presence of biofilms can only be seen by ultra specialized equipment in research labs. It cannot be detected in a clinical lab and so there is no routine test to prove that it is there.

Also, when a biofilm is grown in a research lab it is found to be not susceptible to treatment with antibiotics. Antibiotics poured over a biofilm will cause the outer bacteria to die. They then form a barrier and the antibiotics cannot reach the inner bacteria. So, when the antibiotics go away, the outer dead bacteria fall off and the inner ones recover. So, that means that antibiotics do not work on biofilms.

Initial Management

Non surgical.

The general rule of thumb is always “Try easier, safer, non-surgical remedies first, and only chose surgery as a last resort”. In actual fact the non-surgical options generally do not work very well.

1a. Breast massage. Many plastic surgeons advise this soon after breast implant surgery. The idea is that if the implant can be moved around to actually stretch the capsule out then shrinkage of the capsule might be less likely to occur.

Dr. Silverton feels that when the implant is placed under the muscle, that the muscle is already doing the massaging when the arm is moved and physical massaging is not necessary. It could also be harmful by perhaps over stretching the capsule when no capsular contracture is happening, and can cause inflammation and fluid development if done with textured implants.

“Dr. Silverton is in favor of massaging if the implants are smooth surfaced and on top of the muscle.”

Dr. Silverton is in favor of massaging if the implants are smooth surfaced and on top of the muscle. How often, how long and how firm is also a guess. Dr. Silverton suggests starting 4 weeks after surgery, 4 times a day in 4 different directions for 4 minutes each time quite firmly; and it is not really a massage, but a firm continuous pressure moving the implant inwards and outwards, upwards and downwards.

1b. Mechanical massagers. This is in addition to breast massage. Some electrical massaging devices might help.

1c. Ultrasound. There are some inexpensive machines that might help those with early capsular contracture (Class 2). They are not very strong. Some stronger machines might work better. There is no proof.

1d. Medications. Many medications have been tried, but have not been very effective. Mostly they have been asthma medications. Some had serious side effects on the liver and are no longer used, but Singulair is safe and is our current favorite. It is FDA approved for some asthma patients and works by reducing leukocyte activity, and reduces inflammation. In one small study it was not very effective, but might work on early Baker Class 2 capsular contracture. Currently, Dr. Silverton offers it to patents with early Class 2 capsular contracture for one month, with 2 refills if it seems to help. In this case it is used “Off Label”. Antibiotics might help if given very early or after a redo surgery, and since there is no proof it is only a guess as to how long to use them.

“Try easier, safer, non-surgical remedies first, and only chose surgery as a last resort”

2. Surgical

Surgery is more effective, but still uncertain and carries its own risks and is expensive, but often becomes necessary.

2a. Primary Management

The idea is to remove the thick capsule and the biofilm and hope that it does not happen again. Since we do not know where the biofilm is and it could be on the implant, we always replace the implant too. This procedure is called a capsulectomy (either partial or complete removal of the capsule) with implant replacement. It takes a bit longer than the original implant surgery because of the need to dissect away the thickened scar capsule. Drains are usually not necessary.

2b. Secondary Management

If capsular contracture comes back after a surgery to try to correct it, we call subsequent surgeries “secondary management or secondary surgery”. The implant will need to be replaced again and the capsule should be removed again, or a new space for the implant created on top of the capsule if it is under the muscle (neosubpectoral pocket). If the implant was on top of the muscle it should be replaced under the muscle, if both sides are having surgery. Preferably the infra-mammary incision should be used.

There is a material called Acellular Dermal Matrix (ADM). This is essentially processed skin taken either from a pig (xenograft) or a human (allograft). This is skin which is carefully processed so that there are no cells, no allergens, no bacteria, no viruses and can “take” inside the body as a graft.

Originally this material was used to help the surgeon shape a new breast or correct issues where the implant has pushed the breast into an unnatural shape.

The main uses were for breast reconstruction after mastectomy for cancer where there is no breast shape at all.

A very good side effect was noticed. It seemed to dramatically cut down on repeat capsular contracture. The rate is not zero, but it is a big improvement. The material is unfortunately very expensive, which makes it unattractive for use on everyone having capsular contracture surgery the first time. It is available, though, if you would like to use it. There are many choices through different suppliers, but not all have data to show reduction in capsular contracture.

Dr. Silverton will definitely recommend it if there is a recurrence of capsular contracture after a surgery to correct it. It does require that drains are used for about a week after inserting this material at surgery. The ADM will only “take” if it is applied to breast tissue with no capsule on it. So partial or complete capsule removal (known as “capsulectomy”) is necessary at the same time.

As you can see, capsular contracture is a complicated problem and we do not have all the answers yet. We are getting there and we have a few ideas, but a definitive cure is still some way off.

Dr. Silverton says: “If you have capsular contracture I hope that this document helps to explain the issue and clarify it for you. Please be assured that we take this problem very seriously and will try our best to make it right for you.”

Dr. Silverton keeps records of his own personal capsular contracture rates since 2008. Most plastic surgeons do not do this. He will be happy to show you his statistics on request. Many plastic surgeons are prone to make extravagant claims of extremely low rates of capsular contracture. Ask to see their raw data to provide proof. Some may even say they have no capsular contractures at all! They must back this up with proof. Dr. Silverton and the majority of plastic surgeons simply do not believe them. Dr. Silverton’s rates vary from year to year and are around 6% to 8%.

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