Overview
Definition:
Capsular contracture is the most common complication following breast augmentation or reconstruction with implants, characterized by the hardening and tightening of the fibrous capsule that naturally forms around the implant
This process can lead to pain, distortion, and palpability of the implant.
Epidemiology:
The incidence of capsular contracture varies widely, reported from 2% to over 30% depending on the implant type, surgical technique, and follow-up duration
Factors such as implant surface texture, bacterial contamination, and patient susceptibility influence its occurrence.
Clinical Significance:
Capsular contracture significantly impacts patient satisfaction and outcomes, often necessitating revision surgery
Understanding its pathophysiology, risk factors, and management is crucial for all surgeons performing breast implant procedures, directly affecting patient care and aesthetic results.
Clinical Presentation
Symptoms:
Breast hardness
Discomfort or pain, often described as a dull ache or tightness
Visible distortion or asymmetry of the breast mound
Palpable implant edges or rippling
Change in breast shape or position
In severe cases, pain can be sharp and debilitating.
Signs:
Increased firmness of the breast on palpation
Restricted breast mobility
Implants may be visibly displaced or distorted
Rippling or wrinkling of the implant surface may be apparent, especially in thinner patients
Palpable or visible scar tissue around the implant.
Diagnostic Criteria:
The Baker Classification is commonly used to grade the severity of capsular contracture: Grade I (normal, no visible or palpable contracture)
Grade II (breast is firm, implant slightly palpable, mild distortion)
Grade III (breast is firm, implant easily palpable, noticeable distortion)
Grade IV (breast is hard, immobile, implant deformed, pain present)
Diagnosis is primarily clinical, supported by imaging if uncertainty exists.
Diagnostic Approach
History Taking:
Detailed history of the initial surgery, including implant type, placement, and any previous complications
Onset and progression of symptoms, particularly pain and breast hardness
Previous treatments or interventions for contracture
Patient's expectations and desire for revision surgery.
Physical Examination:
Careful palpation of the breast tissue and implant to assess firmness, mobility, and detect any irregularities or pain
Assess for symmetry, position, and any signs of implant rippling or extrusion
Evaluate the overlying skin quality and any scarring
Palpate axillary and supraclavicular lymph nodes.
Investigations:
Ultrasound: Useful for assessing implant integrity, capsule thickness, and detecting fluid collections or implant displacement
MRI: Highly sensitive for detecting subtle capsular contracture, implant rupture, and intracapsular fluid
Mammography: Can be used but may be limited in visualization of implant-related changes
specific techniques like Eklund views are recommended.
Differential Diagnosis:
Implant rupture (intracapsular or extracapsular)
Seroma or hematoma formation
Infection
Breast implant-associated anaplastic large-cell lymphoma (BIA-ALCL)
Tumors of the breast
Normal post-operative scarring.
Management
Initial Management:
For mild cases (Baker Grade I/II), conservative management may involve observation and reassurance
If acute inflammation or infection is suspected, prompt investigation and treatment are necessary
Pain management with analgesics as needed.
Medical Management:
Limited role for medical management alone
However, leukotriene receptor antagonists (e.g., Montelukast) have been explored as adjunctive therapy in some cases to reduce inflammation and fibrosis, with mixed evidence
Antibiotics are crucial if infection is present.
Surgical Management:
Surgical intervention is the primary treatment for symptomatic capsular contracture (Baker Grade III/IV)
Options include: Capsulectomy (excision of the fibrous capsule), implant removal and replacement (with or without new capsule formation), or revision of implant position
Techniques aim to minimize trauma and bacterial contamination..
Current recommendations favor smooth, round implants with a textured surface being largely phased out due to BIA-ALCL concerns.
Supportive Care:
Post-operative care involves wound care, pain management, and close monitoring for signs of infection or hematoma
Graduated compression garments may be used
Long-term follow-up is essential to monitor for recurrence or new complications.
Complications
Early Complications:
Hematoma
Seroma
Infection
Wound dehiscence
Capsular flap formation
Implant malposition.
Late Complications:
Recurrent capsular contracture
Implant rupture
Rippling
Pain
Altered sensation
Breast implant-associated anaplastic large-cell lymphoma (BIA-ALCL).
Prevention Strategies:
Meticulous surgical technique to minimize trauma and bacterial contamination
Use of antibiotic irrigation and peri-operative antibiotic prophylaxis
Optimal implant pocket creation
Placement of smooth implants in a submuscular plane
Avoiding drains where possible
Careful patient selection
Minimizing electrocautery use in the pocket
Thorough irrigation of the pocket.
Prognosis
Factors Affecting Prognosis:
Severity of initial contracture
Choice of surgical technique and implant type
Presence of infection or other complications
Adherence to post-operative care
Patient factors such as scar tissue formation tendency.
Outcomes:
Successful treatment of capsular contracture can significantly improve patient comfort and aesthetic outcomes
However, recurrence is possible, especially in severe cases or with less optimal surgical techniques
Revision surgery offers a high chance of improvement but not always a complete resolution.
Follow Up:
Regular clinical follow-up is recommended at intervals determined by the surgeon, typically 1 week, 1 month, 3 months, 6 months, and then annually
Longer-term follow-up is crucial to monitor for late complications such as implant rupture or BIA-ALCL.
Key Points
Exam Focus:
Understand the Baker classification system for grading capsular contracture
Know the incidence, risk factors, and presentation of capsular contracture
Recognize the surgical indications and options for management (capsulectomy, implant exchange)
Differentiate capsular contracture from implant rupture and BIA-ALCL.
Clinical Pearls:
Bilateral, symmetric, firm breasts without pain raise suspicion for Baker Grade II contracture
Always consider the possibility of BIA-ALCL in patients with unilateral breast hardening and effusion
Smooth implants are generally associated with lower rates of contracture than older textured implants, though BIA-ALCL risk is lower with textured implants.
Common Mistakes:
Underestimating the importance of meticulous sterile technique during revision surgery
Delaying surgical intervention for symptomatic contracture
Inadequate capsulectomy, leaving behind significant scar tissue
Failing to consider or investigate for BIA-ALCL in suspicious cases
Poor patient selection for revision surgery.