A Complete Insight into Capsular Contracture

Introduction

Capsular contracture, or encapsulation, is an excessively contracted scar tissue that forms around the breast implant after a breast augmentation surgical procedure. It is a complication that occurs after breast implant treatment. One out of six patients who undergo surgical breast augmentation procedures is reported to have this complication. Such contracted capsular tissue tightens the breast and causes esthetic unacceptability and pain in the breast. During breast augmentation surgery, implants are placed in the breast, and a capsule of scar tissue surrounds the implant during healing. These capsular scar tissues harden excessively and result in contracture.

How Does Encapsulation Occur?

Scar tissue formation is a part of the normal healing process; in breast augmentation procedures, scar tissue or capsules form around the implants placed. Initially, the capsule is thin and thickens over time to form hard and firm tissue around the implants. This alters the contour of breast implants, making them distort and painful.

What Are the Precipitating Factors for Capsular Contracture?

Several risk factors can cause capsular contracture, which includes:

• Post-surgical Infection: Post-operative infection occurs due to biofilm formation in the skin, thus leading to inflammation. After surgery, the surgical site heals by capsular scar tissue formation. Secondary infection in the surgical site interferes with the normal healing process. The surgical wound heals with excessive capsular scar formation to combat this, eventually resulting in encapsulation (capsular contracture).

• Hematoma: Extravasation of blood into the subcutaneous tissue and muscles of the breast during surgery or in the post-operative period leads to the formation of a hematoma. In later stages, this hematoma organizes to form excessive scar tissue and results in capsular contracture.

• Patients With Immunological Disorders: A patient with autoimmune disorders like systemic lupus erythematosus and systemic sclerosis is more prone to get capsular contracture as a post-surgical complication of the breast augmentation procedure.

• Irradiation: Irradiation of the surgical site post-operatively during chemotherapy poses a high risk of developing capsular contracture.

• Defective Quantity and Quality of Implant Material: An inadequate amount of implant material slips or gets displaced from the surgical site. This displaced implant material disrupts the normal healing process of the surgical site and results in excessive scar tissue formation, leading to capsular contracture. Poor-quality implant materials fail to be biologically inert and act as foreign objects. The tissue, in response, forms a barrier surrounding this foreign material, resulting in excessive scar formation and capsular contracture.

What Are the Symptoms of Capsular Contracture?

The following are common signs and symptoms of capsular contracture.

• Asymmetrical breast after augmentation procedure.

• The breast becomes firm and hard on palpation.

• Displaced breast implant.

• Pain or tightening sensation in the breast.

What Are the Grades of Capsular Contracture?

Baker’s classification is a widely used grading system that explains the intensity of capsular contracture based on clinical symptoms, visible deformity, and firmness in the breast. It is a 4-grade classification.

• Grade I: Augmented breasts feel soft, like unaugmented breasts. There is no visible deformity, and the breasts maintain a natural appearance. However, upon palpation, the tissue surrounding the breast implant may feel slightly firmer than normal breast tissue. Grade I capsular contracture is often asymptomatic and may not require intervention unless it progresses or causes discomfort for the patient.

• Grade II: Breasts appear normal but feel firm on palpation. Patients may describe a slight tightness or firmness in the breasts, but there is usually no visible distortion or pain. Grade II capsular contracture may be managed conservatively with massage techniques or medication.

• Grade III: Breasts appear abnormal and firm on palpation. As capsular contracture progresses to Grade III, the breasts begin to show visible signs of deformity, such as asymmetry, distortion, or elevation of the implant. Additionally, the breast tissue feels significantly firmer and may be tender or uncomfortable to the touch. Grade III capsular contracture often requires intervention, which may include surgical techniques.

• Grade IV: Breasts appear abnormal, painful, and firm on palpation. In Grade IV capsular contracture, the breasts exhibit pronounced deformity, pain, and firmness upon palpation. Patients may experience severe discomfort, inflammation, or even restricted movement of the affected breast. Grade IV capsular contracture is considered the most severe form of the condition.

How to Diagnose Capsular Contracture?

Capsular contracture can be diagnosed in the following ways.

• Clinical examination of the breasts. Thorough palpation is done to diagnose and grade capsular contracture.

• Investigations like ultrasonography and magnetic resonance imaging (MRI) give an accurate diagnosis.

How to Treat Capsular Contracture?

There are two ways to treat capsular contracture.

• Surgical correction.

• Non-surgical treatment.

Grade I and II capsular contracture are treated non-surgically, while the surgical procedures treat Grades III and IV.

Surgical Treatment of Capsular Contracture: These invasive treatment modalities involve surgical removal of scar tissue. They are

• Capsulotomy: This surgical treatment modality removes the capsule of scar tissue. In this procedure, an incision creates a space to facilitate the implant's movement and remove the thickened capsule.

• Capsulectomy: Capsulectomy involves removing scar tissue and replacing existing implant material with a new one with scar tissue conductive material such as collagen (dermal matrix material), enhancing normal scar tissue formation.

• Autologous Reconstruction: This involves breast reconstruction with flaps obtained from different body parts, like the thigh or gluteal muscle. This eliminates the risk of capsule formation.

Non-surgical Treatment of Capsular Contracture:

These are non-invasive procedures that include:

• Use of ultrasound waves.

• Drugs like Leukotriene-pathway inhibitors (Singulair, Accolate) and Vitamin E.

• External massage.

• Pulsed electromagnetic field therapy.

What Are the Methods to Prevent Capsular Contracture?

The following are the most common methods surgeons suggest to avoid capsular contracture.

• Placement of breast implant under the pectoral muscle.

• Preoperative and post-operative antibiotics.

• Gentle massage on the implant.

• Submuscular Implant Placement: Placement of breast implants below the pectoral muscles of the chest is recommended to discourage scar tissue formation post-operatively. The muscle fibers provide a constant massage to the breast implants placed, thus preventing encapsulation.

• Administration of Antibiotics: Post-operative infection is considered a high-risk factor in the causation of capsular contracture. This can be eliminated by administering antibiotics preoperatively and thoroughly rinsing the surgical sites post-operatively with antibiotic solutions.

• Gentle Massage of the Implant: A gentle massage of the implants is recommended shortly after the breast augmentation surgical procedure. Exercises that compress the implant to retain its flexibility are taught to prevent the formation of excessive scar tissue.

Conclusion

Capsular contracture is not a life-threatening complication. However, it is always advisable to become familiar with the potential complications of breast augmentation procedures beforehand for better treatment planning. Consult the surgeon in case of any further complications.