What is capsular contracture?

When a surgeon creates space for the implant, fibrous tissue naturally forms a capsule around it, often referred to as the "pocket."

This capsule serves as a protective layer that isolates the implant from surrounding tissue. In most cases, the tissue remains soft and pliable.

However, in some patients, excessive fibroblast activity and disorganized tissue formation can lead to the development of dense, rigid scar tissue. This condition, known as capsular contracture, can occur after breast augmentation surgery and negatively affect both aesthetics and comfort.

Detection

Breast implant manufacturers aim to create implants that feel soft and mimic the natural structure of breast tissue. Softness is a critical factor in determining the success of a breast augmentation procedure, making it essential for patients to monitor changes in breast firmness post-surgery.

The surgeon used an Ultrasonic surgical scalpel to perform capsulectomy. Photo courtesy of Dr. Vu

Typically, the breasts soften over a period of three months to one year following implant placement. By the one-year mark, the implants should feel nearly identical to the surrounding tissue.

If breast firmness persists between six months and a year, patients should self-examine regularly in both standing and lying positions, as early signs of capsular contracture (grades 1 or 2) can be subtle. In such cases, a high-resolution breast MRI is recommended for early detection.

In more advanced cases (grades 3 or 4), symptoms may include pain, sharp discomfort, and visible breast deformities. The breast may appear distorted, with asymmetrical projection, uneven inframammary folds, or irregular cleavage. In severe instances, the entire breast contour may become misshapen.

Below is insight from Dr. Ho Cao Vu on the causes, symptoms, and surgical procedures involved in treating capsular contracture through capsulectomy and pocket reconstruction.

Causes

Capsular contracture may result from factors related to both the surgeon and the patient. Common causes include:

- Creating an implant pocket that is too narrow for the implant size

- Choosing implants too large for the patient's anatomy

- Excessive bleeding or fluid buildup during surgery

- Failure to follow proper postoperative care protocols

In rare cases, capsular contracture may stem from an individual immune response to implanted materials.

Double capsulectomy performed using the Ultrasonic Surgical Scalpel. Photo courtesy of Dr. Vu

Narrow implant pocket design

A pocket that is too tight or unevenly shaped can limit implant expansion, especially if it doesn't match the patient's chest anatomy (e.g., a protruding or sunken chest wall). Over time, tight corners or fibrous bands can exert pressure on the implant, leading to contracture.

Tissue damage during surgery

Aggressive surgical techniques or improper use of electrocautery can cause burns or tissue trauma, resulting in pain, hematoma or seroma, delayed healing, and eventual capsular contracture.

Hematoma or seroma

Postoperative bleeding or fluid accumulation increases the risk of inflammation and stimulates excess collagen production. This response causes the body to encapsulate the fluid, leading to a stiff, fibrotic capsule.

Additionally, fluid pressure within the pocket can displace the implant and compress nearby tissue, worsening injury and scarring.

Postoperative care

Inadequate postoperative care is a major risk factor. Since every surgeon has different methods, patients must strictly adhere to individualized aftercare instructions to minimize complications.

Signs of capsular contracture

- Grade 1: Breast appears normal and feels soft; a slightly firm capsule may be felt while lying down.

- Grade 2: Breast appears normal but feels noticeably firmer to the touch, especially with applied pressure.

- Grade 3: Breast becomes firm and rounded due to contracture. The implant may shift, leading to deformities. Patients may experience dull pain and tightness.

- Grade 4: Breast is visibly distorted, asymmetrical, and painful. The capsule is severely contracted, causing ongoing discomfort.

Ruptured implant was explanted prior to capsulectomy. Photo courtesy of Dr. Vu

High-resolution breast MRI is crucial for evaluating breast tissue, capsule integrity, implant condition, and detecting abnormalities. It offers more accurate results than traditional MRI, ultrasound, or X-ray, especially in cases involving ruptured or aged implants.

MRI results help surgeons decide on the most appropriate surgical strategy for each patient.

Procedure: Implant removal and capsulectomy with ultrasonic surgical scalpel

Step 1: Conduct a high-resolution breast MRI to evaluate the implant, capsule, and surrounding tissue.

Step 2: Screen for cancer risk and assess any implant-related damage.

Step 3: Perform a clinical examination and finalize a surgical plan addressing capsular contracture, implant rupture, displacement, or pocket complications. Determine whether a new implant is needed.

Step 4: Complete preoperative testing at a specialized general hospital. A standard implant removal takes 30–45 minutes. Complex cases may require longer anesthesia.

Step 5: Make a 3–3.5 cm incision (around the areola or in the inframammary fold), then use an ultrasonic surgical scalpel to access and inspect the implant.

Step 6: In cases of rupture or fluid presence, clean the pocket thoroughly. Cloudy fluid should be cultured and tested for antibiotic resistance.

Step 7: Excise the fibrous capsule using the ultrasonic scalpel. Send tissue samples for histopathological examination. Prepare a frozen section if malignancy is suspected.

Step 8: Reconstruct the pocket (if a new implant is indicated), correcting pocket width, asymmetry, or displacement.

Step 9: Apply a compression garment. Patients undergoing basic implant removal and replacement may be discharged the same day. For capsulectomy or cases with significant tissue damage, drainage is required and an overnight hospital stay is recommended.

Breast implant removal, capsulectomy, and re-implantation using an ultrasonic surgical scalpel are often minimally invasive. Many patients experience little to no downtime, require no pain medication or antibiotics, and can return home the same day.