Capsular Contracture: What It Is and How It Is Managed

If your breast implants have started to feel firmer, sit differently, or ache in a way they did not before, capsular contracture is one of the possibilities your doctor will consider. It is the change that brings implant patients back for review more often than any other. There are established procedures to correct it, and treatment is chosen according to how advanced it is. Understanding what it is, and what it is not, makes the difference between watching a change with worry and knowing when to have it looked at. In this blog post, we cover what capsular contracture is, how it is graded, what can contribute to it, how it is assessed, and what treatment involves.

Quick Overview

• Your body forms a capsule of scar tissue around any implant, and that capsule is a normal part of healing.
• Capsular contracture happens when that capsule becomes unusually tight and dense, which compresses the implant.
• Symptoms range from mild firmness to visible change in breast shape and breast pain, and one or both implants can be affected.
• Treatment is surgical, and several procedures are available depending on how advanced the contracture is.

Capsular contracture is easier to follow once you know what the capsule itself is doing, so that is where this starts.

What Capsular Contracture Is

A capsule is a layer of scar tissue that your body forms around anything it cannot absorb. It happens with breast implants, and it happens with other medical implants too. Usually the capsule stays thin, soft and unnoticed, and it helps hold the implant in position.

Capsular contracture occurs when that same tissue capsule becomes unusually tight, hard and dense. It develops as the fibrous scar tissue thickens and begins to contract. As it tightens, the implant gets compressed, and the result is pain, tightness, and changes in the shape and position of the breast. The implant itself does not change, so what you notice is the capsule squeezing it.

Thick scar tissue holds its shape, and the scar tissue capsule around an implant is no exception. Breast implant hardening is the plain description of what happens, and that firmness is the defining feature, along with what patients tend to notice first.

Two points are worth separating out. The capsule is not the implant, so capsular contracture is not the same thing as implant rupture, though the two can occur in the same breast. And capsule formation is expected, so being told you have a capsule is not a diagnosis of anything wrong.

The distinction between silicone breast implants and saline implants matters less here than you might expect. Both sit inside a silicone shell, and both develop a capsule, because the capsule forms in response to the shell, not to what fills it. Contracture is therefore possible with either type.

Why the Body Forms a Capsule Around an Implant

This is your immune system doing what it is designed to do. The body naturally forms a protective capsule around any object it recognises as foreign, and a breast implant qualifies. Cells arrive, collagen is laid down, and within weeks a membrane has formed that separates the implant from the breast tissue around it.

That process is useful. A stable capsule keeps the implant where it was placed and reduces movement against the surrounding tissue. Under normal circumstances, the capsule stays soft or only slightly firm; it is not noticeable, and it does not interfere with how the breast feels.

Contracture represents the same healing process going further than it needs to. Instead of settling into a thin layer, the fibrous capsule continues to build and then contracts. As the scar tissue thickens, it loses the flexibility a healthy capsule has. Scar tissue elsewhere in the body can tighten as it matures in much the same way. Chronic inflammation in the implant pocket is understood to be part of what drives it.

Why some patients develop contracture while others do not, is not well understood. The chance of developing capsular contracture varies between patients, and it varies between your own two breasts. What can be said is that it reflects how your own body responded to the implant.

The Symptoms to Watch For

Capsular contracture symptoms usually develop gradually, which is why they can go unremarked for months.

• Firmness. Increasing firmness or tightness in the breast is the earliest sign, and often the only one at first.
• Change in breast shape. The breast can look distorted, or move higher on the chest, as the tissue capsule pulls the implant into a tighter space.
• Asymmetry. Where contracture affects one side, the breasts become uneven in a way they were not before.
• Breast pain. Pain can range from mild to severe. It may present as a persistent ache, a tightness across the chest, or tenderness on pressure.
• Restricted movement. Movement of the breast and the chest can feel limited compared with before.
• Rippling or visible edges. The outline of the implant can become more apparent through the skin.

Both firmness and pain count on their own. A firm breast with no pain is still worth reporting, and so is pain without obvious firmness. Photographs taken over time can help, because a gradual change in shape is easier to see side by side than day to day.

How Capsular Contracture Is Graded

A four-point grading system, known as the Baker grades, is used to describe how far contracture has progressed. The grade guides what is recommended, so it is useful to know roughly where the boundaries sit.

Grade I. The breast feels soft and looks normal. A capsule has formed, as expected, and it is causing no symptoms. This is not usually described as contracture at all.

Grade II. Minor symptoms. The breast looks normal but feels firmer than it should on examination. Patients often do not notice grade II themselves, and it is commonly picked up at a review appointment.

Grade III. Moderate symptoms. The breast feels firm and now looks different as well, with shape change, a higher-sitting implant or visible asymmetry. Grade III is usually the point at which patients seek advice.

Grade IV. Severe contracture at this grade means the breast is firm, distorted and painful. Grade IV is the least common presentation and the one that leads to surgery being recommended promptly.

Grades I and II are generally monitored. Grades III and IV are where surgical intervention is discussed, because the changes affect both comfort and appearance. Your grade can also change over time in either direction, so a grade recorded at one appointment is not fixed.

What Can Contribute to Capsular Contracture

Several risk factors may influence the likelihood of capsular contracture, and no single cause accounts for every case. Capsular contracture risk cannot be predicted precisely for any individual beforehand.

• Bacterial contamination. A biofilm, meaning a thin layer of bacteria on the implant surface, can cause inflammation and is one of the recognised contributors. It can be present as a subclinical infection, without ever producing the fever or redness of an obvious one.
• Bleeding around the implant. A haematoma, which is a collection of blood in the pocket, is a recognised factor, and bleeding is among the possible complications of breast implant surgery.
• Fluid collection. A seroma is a build-up of fluid around the implant, and it is also relevant. Swelling or a collection of fluid around the breast is a recognised complication of the procedure.
• Implant rupture. Ruptured implants are associated with contracture, which is one reason a change in firmness prompts imaging.
• Implant placement. An implant placed in front of the chest muscle carries a slightly higher risk of capsular contracture than one placed under the chest muscle. Your doctor decides which approach suits your anatomy.
• The characteristics of the implant. The characteristics of the implant. Implants are manufactured with either smooth implants or textured implants available, and surface type is among the factors that may influence the likelihood of contracture. Your doctor can explain the considerations involved when recommending a particular implant for you.
• How you form scar tissue. Some patients are predisposed to more significant scarring after any surgery or injury, and that tendency is relevant here.
• A history of autoimmune disease. A personal or family history of autoimmune disease is among the recognised factors.
• Radiation therapy. Radiation to the chest raises the risk considerably. This is more often relevant to reconstruction than to cosmetic augmentation.

One further point sits across all of these. Breast implants are not lifetime devices, and the chance of needing revision surgery increases the longer you have them.

 

 

When It Tends to Develop

Symptoms can appear as early as a few months after breast augmentation surgery, or years afterwards. The first two years are when the capsule is forming and maturing, so firmness developing in that window is the pattern seen more than any other.

Later onset is also well recognised. Years after an uneventful recovery, a capsule that has been soft can begin to thicken. This sometimes follows an infection elsewhere in the body, an injury to the chest, or implant rupture.

Firmness that appears years later is worth having examined, because the same treatment options apply whenever it develops. An established capsular contracture does not resolve on its own, which is why the options are surgical. This is also why review appointments continue well beyond your initial recovery. Breast implants usually need replacing after ten to fifteen years, so ongoing monitoring serves two purposes: checking the implant, and checking the capsule around it.

How It Is Assessed

Capsular contracture management begins with clinical assessment, meaning your doctor examines both breasts and compares them. Firmness, position, shape and the presence of tenderness are all assessed by hand, and the grade is assigned based on what that examination finds.

Imaging plays a supporting role. An ultrasound can show a thickened capsule and fluid around the implant, and it is the usual first test where implant rupture also needs to be excluded. MRI gives more detail about the implant shell and is used where the ultrasound findings are unclear.

Your history matters as much as the examination. When the change started and how quickly it progressed both inform the assessment. So does any complication during your original recovery, and any recent infection elsewhere in your body. Bring dates if you have them, because a timeline often separates one likely cause from another.

Early detection is worth aiming for. A capsule identified at grade II gives you and your doctor a longer runway to monitor and plan than one presenting at grade IV. It also means any imaging findings can be compared against a baseline at your next review, which makes a slow change easier to confirm.

How Capsular Contracture Is Treated

Capsular contracture treatment options are surgical, because no medication reverses an established contracture. Which procedure is recommended depends on the grade, on whether the implant is intact, and on what you want to do about implants going forward.

Open capsulotomy. Incisions are made in the capsule to release the tension around the implant, giving it more room. Some of the capsule may also be removed, and the implant is sometimes replaced at the same time. It is a smaller procedure than removing the capsule entirely, and antibiotics given at the operation reduce infection risk as they would for any implant surgery.

Capsulectomy. The existing implant and the surrounding tissue capsule are both removed. A new implant is often placed at the same time. It may be wrapped in acellular dermal matrices, which are processed tissue sheets made largely of collagen, providing an extra layer. Your body then forms a new capsule around it.

Implant replacement. Because the pocket is already open, a new implant is commonly placed at the same time the capsule is treated. Where contamination is suspected, replacing the implant removes the surface the bacteria were sitting on.

Changing the pocket. In some cases, the implant is moved to a new position, for example from in front of the pectoral muscle to behind it. The implant then sits in fresh tissue instead of the site that contracted.

Implant removal. Removing the implants without replacing them greatly reduces the chance of contracture recurring. It is a reasonable choice and worth discussing openly. Do note that if implants are removed and not replaced, the breasts may be left scarred or dimpled.

Non-surgical approaches including massage and ultrasound therapy are sometimes raised. The evidence for reversing an established contracture with either is limited, and neither substitutes for treating the capsule.

Whichever procedure is chosen, revision surgery is a further operation with its own recovery and its own post-operative complications. General anaesthetic, a further period off work, drains and compression garments may all apply again. Your doctor will set out what your particular procedure involves before you decide. Expect that conversation to cover the prospect of future complications as well as the intended result.

What Is Done at Surgery to Reduce the Risk

Capsular contracture prevention is largely a matter of surgical technique, and it happens during your original operation, not afterwards.

Antibiotics are given at the time of the operation to reduce infection risk. Because bacterial contamination is one of the recognised contributors to contracture, keeping the bacterial load in the pocket low is part of the reasoning behind standard antibiotic prophylaxis.

Surgical technique matters for the same reason. Careful handling at implant insertion limits contact with skin. Keeping tissue trauma to a minimum, controlling bleeding, and irrigating the breast pocket before closing all aim to give the capsule less reason to become inflamed.

Managing fluid is part of it too. Drains are sometimes used to prevent fluid accumulation in the pocket during early healing, and compression dressings help reduce swelling.

Your own preparation contributes. Being physically fit, having a healthy body weight, and quitting smoking before surgery all support the healing process and are worth addressing well before your date.

After surgery, the instructions you are given about activity, support garments and wound care exist partly for this reason. Following them reduces the chance of bleeding into the pocket or fluid accumulating there while the capsule is forming. Contact your doctor if you develop a temperature above 38 degrees, spreading redness around the implant area, or increasing pain in your breasts. Those can then be treated promptly.

If It Comes Back

Recurrence risk is real, and it is one of the things to weigh when deciding between procedures. Where the body continues to react to an implant in the same way, contracture can develop again around a new one. It is also a reason to raise your full history of breast surgery at consultation.

This is part of why changing the implant, the pocket, or both is often preferred to releasing the existing capsule alone. Addressing an identifiable cause gives a better prospect than treating the tissue by itself.

It is also why some patients choose implant removal after a second contracture. That decision belongs to you, and there is no single right answer. What matters is being told plainly what each option involves, including the prospect of future complications and further surgery.

Book a Review If Your Implants Feel Different

A change in how your implants feel is worth examining rather than monitoring at home. Firmness, shape change and pain can each have more than one cause, and capsular contracture, implant rupture and fluid collection can present similarly. At Refine Clinic, we perform breast implant surgery and revision surgery, and your doctor will examine both breasts and arrange any imaging needed. They will explain which treatment options apply to your grade, whether something has changed, or you are due for a review. To arrange a consultation, please call us on (02) 8599 7161.

Frequently Asked Questions

Can capsular contracture affect only one breast?

Yes. Contracture can affect one implant or both, and one-sided contracture is common. Each breast heals independently, so the capsule around one implant can thicken while the other stays soft. This is often what makes the change noticeable, because a difference between your two sides is easier to detect than a gradual change in both.

Does capsular contracture affect breast screening?

Breast implants can make it harder to detect breast cancer during screening, and a thickened capsule adds to that difficulty. Mention your implants when you book your screening appointment, so the appropriate technique and views can be used. Keep to your usual screening schedule, and raise any questions about it with your doctor.

Can massage or chest exercises prevent it?

Neither has been shown to prevent capsular contracture, and advice on massage has changed over the years. Follow the specific post-operative instructions you were given, since what is appropriate depends on your implant and where it was placed. Ask your doctor before adding anything to your routine.

Is capsular contracture dangerous?

It is not cancer, and it does not threaten your general health. Research has not established that silicone breast implants cause autoimmune disorders, and there is no evidence that implants cause breast cancer. What contracture affects is comfort and appearance, and procedures are available to correct it. Let your doctor know promptly if new firmness arrives alongside swelling, a lump or a temperature, so those can be checked.

How often should implants be checked if I have no symptoms?

Annual review is a reasonable default, with imaging as advised, and it continues for as long as you have implants. Because contracture can develop slowly, a change is often easier to detect for someone examining you regularly than for you to notice at home.

Can I choose not to treat it?

Yes, for lower grades. Grade I and grade II contracture is commonly monitored instead of operated on, particularly where there is no pain and no visible change. Where the breast is distorted or painful, your doctor will explain why treatment is being recommended in your case, and the decision remains yours.

Any surgical or invasive procedure carries risks. Before proceeding, you should seek a second opinion from an appropriately qualified health practitioner.

References

https://www.sciencedirect.com/science/article/pii/S2405857215300140

https://www.jprasurg.com/article/S1748-6815(11)00536-5/fulltext