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En Bloc Capsulectomy

The Best Treatment for Capsular Contracture and Breast Implant Illness

Capsular contracture and breast implant illness are two very different problems, but each of these can be most effectively treated with En Bloc Capsulectomy. On this page, Dr. Loftus explains each of these conditions as well as the best treatment (en Bloc Capsulectomy) and worst treatment for each.

Capsular Contractures

Capsular contractures are hardening of the breast implant due to tightening of the scar which forms 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 likened to "coconut breasts." Capsular contractures may occur at any time, but tend to occur in two waves following surgery: early capsular contracture and late capsular contracture, which are explained below.

Classification of Capsular Contractures

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

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 Capsular Contractures". 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 contracture during the first year following breast implant placement, then 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 who she is able to treat with en bloc capsulectomy.

Late Capsular Contractures: Capsular contractures that occur years after surgery are known as "Late Capsular Contractures." These are frequently related to silicone gel implants that have ruptured, and they occur when the scar tissue around the breast implants becomes irritated or inflamed in response to silicone gel which has extruded from a ruptured implant. Saline breast implants are unlikely to cause a late capsular contracture because when saline implants rupture and 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 acknowledged that this was the procedure of choice.

Prevention of Capsular Contracture

Numerous studies have been published reporting capsular contracture rates 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 the risk of capsular contracture. Generally speaking, smooth saline implants placed under the muscle through an inframammary incision have the lowest rate of capsular contracture, whereas 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 implants 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, starting about 2 weeks after surgery

Treatment of Capsular Contractures

Capsular contracture treatment has evolved meaningfully over the past 60 years:
  • Closed Capsulotomy: was performed from the 1950s through the 1990s. It involved the use of force to disrupt the capsule (the scar tissue). THis technique is mentioned only to be condemned. It is the worst way to manage capsular contracture for reasons explained below.
  • 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:
  • En Bloc capsulectomy has been performed by Dr. Loftus since 2005 and has recently been recognized as being the best treatment for capsular contracture. Like Standard Capsulectomy, it involves removal of the capsule. Unlike Standard Capsulectomy, it always involves complete removal of the capsule in one piece and is performed in such a way that the interface between the implant and the capsule is not exposed to the patient during removal, thus reducing the potential for re-exposure to the patient of bacteria (Staph Epi) or silicone (if silicone is present within the capsule).

Treatment for capsulectomy is often dictated by the severity of the capsular contracture. If you have a mild capsular contracture, you may choose to do nothing, as the symptoms are minor, and it may not be worthwhile to have surgery. 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 because the symptoms can be unpleasant (cosmetic deformity and/or pain) and because you may be concerned about an implant rupture.

Closed Capsulotomy: Capsular contractures were once treated by a procedure known as closed capsulotomy (1950s-1990s). Closed capsulotomy was a non-surgical procedure in which the surgeon manually squeezed the implanted breast, sometimes with tremendous force. This was most often perfumed during a routine office visit in which the patient was noted to have firmness of the breast. Picture this: A woman with a firm breast lying down on an exam table with two surgeons (or a surgeon and a nurse) standing over the patient, each with their thumbs and forefingers on a quadrant of the firm breast, pressing down and inward. They would continue to press firmly with greater and greater pressure until the felt (and sometimes heard) the capsule pop. This was done with such intense pressure and force that it was extremely painful for most women, and it was performed without any anesthetic. The purpose of all of this pressure was to tear or rupture or disrupt the capsule, as doing so often (at least temporarily) resulted in softening the breast. Because this treatment did nothing to treat the underlying problem that caused the capsular contracture, the contracture typically returned again and again. Further, because of the intense force being applied, the closed capsulotomy often caused an implant rupture when none was present or worsened ruptures when they already existed by propagating the spread of the silicone. In some cases, it caused bleeding around the implant and capsule, requiring emergent surgery. Plastic surgeons now condemn this procedure because it was ineffective in treating capsular contracture and because it caused so many complications. Closed capsulotomy is mentioned here to make you aware that it is the worst treatment possible for capsular contracture, and yet some plastic surgeons still perform it today. If your surgeon suggests closed capsulotomy, you should wisely decline and seek another plastic surgeon.

Standard Capsulectomy:Standard capsulectomy progressively replaced closed capsulotomy from the 1960s through the 1990s, and it is far superior to closed capsulotomy. "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 carries the dissection down to the capsule (the scar tissue around the implant).
  2. The surgeon then cuts into the capsule to expose the breast implant.
  3. The surgeon then pulls the breast implant out through the opening.
  4. Then, with the implant out of the way, the surgeon peels the capsule out, by separating it from the surrounding healthy tissue. This is typically performed in sections. Sometimes it is perfumed completely (complete capsulectomy) which means that 100% of the capsule is removed. Sometimes it is performed partially (partial capsulectomy) which means that only some of the capsule was removed. In these cases, the portion of the capsule that remoains is most often the portion that is adjacent to the rib cage because it is technically more difficult to remove.
  5. The removed implants are discarded, because they are either ruptured or are presumed to be contaminated with Staph Epi. The implants that are associated with a pre-existing capsular contracture are never re-inserted because the rate of recurrent capsular contracture is much higher when the pre-existing implants are placed back in the same patient for the reasons just noted.
  6. Depending upon the patient's preference, either brand new implants are then placed or the breasts are closed without new implants being inserted.
  7. If the pre-existing implants were above the muscle (retroglandular), then, in an effort to further reduce the rate of recurrent capsular contracture, the implants are moved to the plane below the pectoralis muscle, which reduces the rate of recurrence of capsular contracture, especially in cases involving silicone implants.
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 (sometimes called 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. This has been shown to be the best treatment for capsular contracture. In order for a plastic surgeon to accomplish this, the following must be done:
  1. The plastic surgeon must make a much longer incision, because the implant and capsule must be removed intact as a single unit. The scar is typically as long as the implant is wide. For a 500 cc implant, the scar may be 14 cm, which is 4x as along as a standard breast augmentation scar. This is the main disadvantage (and Dr. Loftus believes the only disadvantage) to en bloc capsulectomy.
  2. The surgeon must then separate the outside of the capsule (the scar) from the surrounding healthy tissue, while trying to prevent rupture of the implant which is sitting in the way of the operation through most of the procedure. This meticulous methodical separation is performed circumferentially around the capsule, bit by bit, until the entire capsule (with the implant still contained inside the capsule) is freed from the patient. Because the implant itself obstructs the surgeon's view, the incision must sometimes be extended even longer than anticipated to accomplish en bloc capsulectomy properly.
  3. The surgeon then removes the implant and scar tissue together ("en bloc") as a single unit through the opening. If properly performed, the implant and capsule will have been removed without exposing the patient to the interface between the implant and the capsule.

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 the 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 used for women who have part of all of the constellation of problems:
  • Fatigue, weakness, lack of ambition
  • Memory loss, inability to focus or follow discussion
  • oint stiffness and pain, aches
  • Muscle aches, soreness, pain, weakness, spasms
  • Headaches
  • Other problem (may vary)
Very important to note is that Breast Implant Illness is not typically associated with capsular contracture.

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 all symptoms. If you are among the women who feel that they have breast implant illness, 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. There is no published evidence that performing this operation (or implant removal at all) will help women who have breast implant illness resolve their symptoms - there is only case evidence;
  3. If you have symptoms of breast implant illness and if you have your implants removed en bloc, there is no guarantee that your symptoms will resolve or even improve.

Whereas Dr. Loftus is keenly aware of all of these issues, she also respects that many women simply seek the soundness of mind that comes from 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 or even improve.

Dr. Loftus has the very highest ratings in patient satisfaction in the region, according to an independent ratings website which shows the ratings of the best and worst plastic surgeons in the country. Follow these links to see how Dr. Loftus compares to all other plastic surgeons in the Greater Cincinnati Area and All of Kentucky. Once you meet Dr. Loftus, you will understand why her ratings are so high, why patients are so happy with their care, and why they never see another plastic surgeon again.

Dr. Loftus

About Dr. Loftus

Dr. Loftus is a female plastic surgeon who is considered a national authority on plastic surgery, having appeared on numerous talk shows as an expert. Her book has become a best-selling book on plastic surgery and has earned her the reputation as a vocal advocate of patient safety, satisfaction, and education in plastic surgery. No wonder her patients have such great things to say about her…
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My results are amazing - Dr. Loftus is amazing!
My friends can't believe how natural I look!
I had no pain after surgery and recovery was so easy.
The entire experience was fabulous!
I am a nurse who has worked with many doctors, Dr. Loftus is the best!
The care was exceptional and results are incredible!
My results are better than I ever imagined!
Dr. Loftus is a rare surgeon: highly skilled, personable and compassionate!
My experience from start to finish was completely extraordinary!
Awesome results from a skilled and caring doctor.
I love love love Dr. Loftus and everyone in the office!
I've never felt so comfortable and understood in a doctor's office.
I felt so comfortable and barely had any pain at all.
I never knew I could look this good! Thank you Dr. Loftus!!!
Never met such a warm and caring staff anywhere else.
If only every doctor could be like Dr. Loftus, how very fortunate we would be.

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Cincinnati: The Christ Hospital 2139 Auburn Avenue, Suite 201
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