Capsular Contracture & Breast Implant Illness

Two Very Different Problems, Each of Which Can Be Treated with En Bloc Capsulectomy

This page clarifies capsular contractures and breast implant illness, which are very different problems. It also explains why and how each can be treated with en bloc capsulectomy

Capsular Contractures

Capsular contractures are hardening of the breast implant due to tightening of the scar which forma around the implant. Before going any further, it is important to understand that scar tissue forms around all implants as a natural part of healing, so the scar itself is not a problem. It only becomes a problem if it tightens. An abnormally tight scar is known as a capsular contracture. It may cause the breast to feel firm, unnatural, or even painful. When you see a breast that looks round and hard, it is probably due to capsular contracture. The most severe cases are sometimes called "coconut breasts." Capsular contractures may occur at any time, but tend to occur in two waves referred to as early capsular contracture and late capsular contracture, which are explained below.

Capsular contractures may be treated by a surgeon in one of three ways. A capsulectomy is the surgical removal of the scar tissue around the implant and the placement of a new breast implant. A closed capsulotomy is the use of force to disrupt the surrounding scar tissue, in turn softening the breast (this is an old method and is no longer considered safe or effective). Lastly, Dr. Loftus may suggest an incontinuity or en bloc capsulectomy removal to achieve the greatest likelihood that the capsular contracture does not return. Each of these is explained below.

Classification of Capsular Contractures

Grade I = None: Oddly enough, plastic surgeons refer to breasts with no capsular contracture as being Grade I. There is no such thing as Grade 0

Grade II = Mild: The breast feels slightly firm, and the implant edges can be felt through the skin. Plastic surgeons call this a Grade II capsular contracture.

Grade III = Moderate: The breast feels firm, and the implant can be both felt and perceived visually through the skin. The breast may appear unnaturally round or spherical. Plastic surgeons call this a Grade III capsular contracture.

Grade IV = Severe: The breast is hard, distorted, and painful due to the hardening scar tissue. Plastic surgeons call this a Grade IV capsular contracture.

Timing of Capsular Contracture Corresponds to Cause:

Early Capsular Contracture: Capsular contractures that occur within the first year of surgery are known as "early". Most of these are thought to be due to a bacteria called staph epidermidis, which is present on everyone’s skin and which usually causes no problems. Staph epi, as it is called, is generally benign unless it is in association with a prosthetic implant, such as an artificial joint, heart valve, pacemaker, or … you guessed it…breast implants. Because staph Epi is so benign, it does not cause the classic signs of infection: redness, swelling, and fevers. Instead, it remains dormant around the implant until it incites the surrounding scar tissue to tighten and contract….thus resulting in a capsular contracture. If you get a capsular contracure during the first year following breast implant placement, then the your capsular contracture may very well be related to staph Epi. Dr. Loftus sees many women from across the country who have early capsular contractures and whom she is able to treat with en bloc capsulectomy.

Late Capsular Contractures: Capsular contractures that occur years after surgery are known as "late." These are frequently related to silicone gel implant ruptures, and they occur when the scar tissue around the breast implants becomes irritated or inflamed in response to silicone gel which has extruded from the implant. Saline breast implants are unlikely to cause a late capsular contracture because when saline implants leak, the saline does not cause a reaction and instead gets absorbed by the body rapidly, causing the implant to deflate completely. Late capsular contractures, like early capsular contractures, are most effectively treated by en bloc capsulectomy, according to Dr. Loftus, who has been performing en bloc capsulectomies since 2005, long before the plastic surgery literature even suggested this procedure.

Risk and Prevention of Capsular Contracture

Numerous studies have been published with capsular contracture rates varying between 10% and 50%. Perhaps the most meaningful way to interpret these apparently discrepant values is to consider that the risk of severe capsular contracture is close to 10% and the risk of mild capsular contracture may be as high as 50%. Implant surface, implant type, implant position, and site of incision may affect your risk of capsular contracture. Generally speaking, smooth saline implants placed under the muscle through an inframammary incision have the lowest rate of capsular contracture, and textured silicone breast implants placed over the muscle through an areolar incision have the highest rate of capsular contracture. Combinations of these placements and implant types will have capsular contracture rates somewhere in between. Dr. Loftus takes extra precautions during placement of imparts to reduce the rate of capsular contracture, and as a result, the rate of capsular contracture among her patients is less than 1 % per implant per year.

Efforts to prevent capsular contracture include the implant decisions noted above as well as repeated sterilization of the skin during surgery. Following surgery, implant displacement exercises are very important. Displacement exercises are thought to stretch surrounding scar tissue, thereby reducing the rate of capsular contracture. Displacement exercised are so important that Dr. Loftus teaches patients how to do these herself, about 2 weeks after surgery

Treatment of Capsular Contractures

If you have a mild capsular contracture, you may choose to do nothing. And there is no reason that you should feel compelled to do anything, as a capsular contracture is not an emergency. Nor is it even an urgent problem. However, if you have a moderate or severe capsular contracture, you will most likely want to have it treated.

Closed Capsulotomy: Capsular contractures were once treated by a procedure known as closed capsulotomy. Closed capsulotomy was a non-surgical procedure in which the surgeon manually squeezed the implanted breast, sometimes with tremendous force. This disrupted the surrounding scar, thereby softening the breast. Plastic surgeons now condemn this procedure because of its propensity to cause implant rupture, implant displacement, hematoma, unnatural appearance, and redevelopment of capsular contracture. Closed capsulotomy is mentioned here to make you aware of it: if your surgeon suggests closed capsulotomy, you should wisely decline and seek another plastic surgeon.

Standard Capsulectomy: Capsulectomy basically means "removal of the capsule." Because the capsule surrounds the breast implant, this operation cannot be performed without removing the breast implant. The way that a standard capsulectomy is typically performed is as follows:

1. The surgeon makes an incision through the skin and down to the capsule.
2. The surgeon then cuts through the capsule to expose the breast implant.
3. The surgeon then pulls the breast implant out through the opening that she just created.
4. Then, with the implant out of the way, the surgeon lastly peels the capsule out, as she separates it from the surrounding healthy tissue.
5. If the patient wants to keep her implants, then new implants are used (even if they are the same size as the removed implants. This is because the rate of recurrent capsular contracture is much higher when the pre-existing implants are placed back in the same patient.
6. In an effort to further reduce the rate of recurrent capsular contracture, the implants are moved to the [plane below the pectoralis muscle (in the event that they were above the muscle previously).

In spite of all of these measures, a capsular contracture may recur following a standard capsulectomy. The thinking is that the recurrence increases because the factors which caused the original capsular contracture persist following capsulectomy because the capsule was opened, and its contents were exposed to the wound. One way to prevent this is to perform an en bloc capsulectomy (explained below).

En Bloc Capsulectomy (In-continuity Capsulectomy): An "En Bloc" capsulectomy differs from a standard capsulectomy in that the capsule and implant are removed together as a single unit and without opening the capsule or exposing the capsule contents to the open wound. So, in order for a plastic surgeon to accomplish this, the following must be done:

1. The plastic surgeon must make a much longer incision (typically as long as the implant is wide)
2. The surgeon must then separates the outside of the capsule from the surrounding healthy tissue. This is done circumferentially around the enclosed implant, with the implant still in place.
3. The surgeon then removes the implant and scar tissue together ("en bloc") as a single unit without entering the capsule and without exposing the inside of the capsule to the open wound.

The idea behind this type of surgery is as follows: If there are suspected to be any factors which caused the capsular contracture , such as bacteria or silicone, which may have promoted the capsular contracture, then removing the capsule en bloc will reduce the likelihood of contaminating the open wound with eth same factors, as the en bloc method contains the factors which were problematic. Dr. Loftus feels that there is significant validity to this: it is supported by studies which show that the incidence of recurrent capsular contracture is lower when performed en bloc; it is also supported by Dr. Loftus' own experience with this operation since she began it in 2005, long before other plastic surgeons recognized its importance. Dr. Loftus has since operated on numerous women who have come to her after developing capsular contractures from implants placed by other surgeons. These women typically had the experience of the capsule returning after standard capsulectomy by their plastic surgeon. Only after Dr. Loftus performed their en bloc capsulectomy did they finally achieve a soft natural result from their breast implants. Dr. Loftus has found that fewer than 1% of capsular contractures recur when she uses this technique, and she now recommends it as the procedure of choice for all women with symptomatic capsular contractures.

Breast Implant illness

Breast Implant Illness is a term that has been assigned for women who have part of all of the constellation of problems (and it is not associated with capsular contracture):

• Fatigue, weakness, lack of ambition
• Memory loss, inability to focus or follow discussion
• Joint stiffness and pain
• Muscle aches, soreness, pain, weakness, spasms
• Headaches
• Other problem (may vary)

There are many women who have developed some or all of these symptoms following placement of breast implants (both saline and silicone). Some of the women who have their implants removed report complete resolution of al symptoms. If you are among these women and if you seek breast implant removal, then you should also be aware of the following:

1. Capsulectomy en bloc (with implant removal) is the most complete way to remove the implant, the capsule, and any factors which may be in association with the implant, without exposing the same factors to you during the removal process;
2. Strictly speaking, there is no published evidence that performing this operation (or implant removal at all) will help women resolve the above symptoms - there is only case evidence;
3. if you have these symptoms and have your implants removed en bloc, there is no guarantee that your symptoms will resolve or eve improve.

Whereas Dr. Loftus is cognizant of all of these issues, she is also keenly aware that many women simply seek the soundness of mind that comes with implant removal en bloc, and that this enables them to know that they have removed the implant and capsule entirely. For this reason, Dr. Loftus very supportively performs en bloc capsulectomy for women who seek it, provided that they understand that performing this operation is not a guarantee that their symptoms will resolve.