Common Breast Augmentation Questions

Capsular contracture seems to be the outcome of prolonged inflammation. There are many causes of inflammation, which is the fancy name for the body’s response to irritation. It is believed that the inflammation underlying most capsular contractures is caused by bacteria stuck to the surface of the implant. These bacteria do not cause a infection per se, but linger on the surface of the implant. These bacteria group together and secrete something called "biofilm" which shields them from the body’s effort to destroy them. The result of this longterm battle is the build up of this scar tissue. Where do these bacteria come from? These bacteria normally inhabit the milk ducts that course through the breast. Other causes of contracture are thought to be blood in the pocket after surgery as a result of either excessive bleeding during or after surgery, irritants such as talc on surgical gloves, and a high burden of damaged tissue as a result of surgical trauma. There is a lot of active research going on about capsular contracture and we are learning more about it all the time.

Capsular contracture occurs when the tissue surrounding the breast implant that is known as "the capsule," tightens around the implant. As the capsule tightens around the soft implant, the breast implant starts to feel firm. The implant gradually looks more round, usually becomes pulled upward, and in some circumstances becomes painful. Patients and even doctors will say, "that breast implant got hard." But the implant itself does not get hard; it merely feels hard because tissue made by the body squeezes against it from the outside, just like fluffy down jacket feels hard when stuffed into a small pouch.

There is no synonym for capsular contracture, but patients will refer to it as having "hard breasts" or "scar tissue around the implant."

In addition to being hard, the implant often looks more spherical, its edges are more visible, and it can bulge on top. It can make it difficult to look natural even in clothing, and sometimes finding a bra to fit well can be problematic with a hard implant. Patients will report that they are embarrassed to hug people, have difficulty sleeping on their stomach, or can’t lay on their stomach for a massage. But it is occasionally also true that some patients with one contracted breast and one non-contracted breast will prefer the contracted one because it looks rounder, perkier, and younger in their mind, albeit firmer. One should also be aware that longstanding contracted implants can cause changes to the breast, such as creating a depression in the rib cage, thinning breast tissue, and stretching skin as a result of the high pressure from the implant concentrated in one area. The most important issue for women of mammogram age is whether the contracted implant prevents a good mammogram. Patients with implants need special views with the breast tissue pulled away from the implant and put onto the mammogram plate without an implant. With firm implants, this can be difficult to accomplish and the mammogram can be compromised. Though MRIs can see around a contracted implant, there are some breast tumors that mammograms do not detect. Even if you do not mind being hard and round, you need to consider revision surgery if your implants are preventing you from getting a satisfactory mammogram.

Capsular contracture remains the most common reason for breast augmentation revision surgery. But it is highly technique dependent, with some surgeons having lower capsular contracture rates than others. The rate is affected not just by surgical technique, but the incision location, whether the implant is behind or in front of the muscle, and the surface of the implant all may matter. In addition, post operative mobility and other factors may play a role.

There is a grading system for capsular contracture called The Baker System. In a Baker I the implant can barely be found, soft with no obvious capsule. A Baker II has some firmness around the implant, but there is no distortion in the appearance of the breast. Baker I and Baker II are normal and do not require treatment. A Baker III is firm and most importantly creates a distortion, frequently looking somewhat round, high, and bulgy on top. A Baker IV means that there is also breast pain.

Most surgeons believe that bacteria on the surface of the implant can lead to capsular contracture. Sometimes these bacteria get on the implant at the time of the implantation and never cause an obvious infection, but simply cause smoldering inflammation that gradually leads to contracture. Other patients who go on to have capsular contracture first have a bout of their breast becoming swollen and tender, sometimes with a fever, and sometimes without a fever.

You should see your plastic surgeon right away. He or she will consider prescribing you antibiotics with the goal of eradicating the supposed infection. Sometimes the breast promptly responds and stays soft. Other times the breast responds but ultimately starts to get hard. In extreme cases the breast stays swollen and tender despite antibiotics and the implant needs to be removed. In addition to antibiotics, some surgeons prescribe the asthma medicines Accolate or Singulair in the hope that they will prevent the build up of scar tissue, but there is relatively weak evidence to support this practice.

The diagnosis is made by physical examination. No XRays or special tests are necessary. While the process can occur on both breasts, it more commonly involves one breast. If a breast that was once soft becomes hard and more round, then capsular contracture is the likely diagnosis. While capsular contracture can occur out of the blue, some patients will give a history of having had extra bruising, swelling, or bleeding on that breast at the time of the original surgery. Others will report having had a dental cleaning, severe diarrhea, or some other infection in the weeks or months prior to the development of the contracture. But most patients will give no such history.

If an implant is so large relative to the breast that the breast tissue is tight around it, the implant will feel firm even if the capsular tissue around it is thin and pliable, just like a large pillow would feel firm if forced into a small pillowcase. But these patients will report always feeling firm after surgery. Capsular contracture patients will generally report that their breasts started off soft and then had a distinct change over some weeks or months after surgery. "Overfilled" saline implants can also mimic capsular contracture. Saline implants are filled by the surgeon and some "overfill" them in an effort to make them ripple less. If overfilled, the implant will start to feel firm and look round. Unlike capsular contracture patients, the overfilled firm saline patients will say that they have looked and felt that way since surgery with no particular change. Capsular contracture patients also do not typically have enlargement of their breasts. Firmness along with enlargement can occur in the days after surgery – and in rare cases months or even years later – from bleeding in the body around the implant. A build up of fluid around the implant also known as a seroma can occur. But both hematoma and seroma are distinguishable from capsular contracture in that they involve an increase in size. A hematoma is considered a surgical emergency if it is large, painful, or enlarging. Seromas are often treated with drainage and antibiotics, and often also surgery, though they are not generally considered an emergency. Another cause of enlargement and firmness is an infection. Surgeons take infections around breast implants very seriously as in some cases the infection can get very severe and the implants need to be urgently removed. Even if the infection is treated successfully, an acute infection around an implant can lead to capsular contracture in the long term.

While the gears may be set into motion at the time of surgery by factors such as bacterial contamination, tissue trauma, or excessive bleeding, capsular contracture usually is not apparent for months later. Some patients will give a history of always being hard since the time of surgery or will describe one breast as having been bruised after surgery and never looking right. More typically, patients will describe one or both breasts becoming firmer and rounder over a period of weeks, usually during the first 6 months after surgery. Late capsular contracture can also develop, but most occur in the first year.

Some surgeons believe – though there is no consensus – that there is a difference between capsular contractures developing in the initial months following surgery and one that occurs a year or more later. The early contracture is thought to be due to factors present around the time of surgery, eg bacteria, blood, and the body’s healing response. Late contracture is thought to occur as a result of some breakdown of the immune system, secondary "seeding" of the implant by bacteria, or even inflammation caused by a microscopic "bleed" of silicone from within the implant shell. Some patients will give a history of their breasts becoming painful and swollen following a tooth cleaning, a severe bout of diarrhea, or after an infection elsewhere in their body. Some surgeons feel that early contracture is a more intense process and harder to treat.

Surgeons can take steps to reduce capsular contracture, but even when everything we know to do is done, capsular contracture can still occur. Steps to prevent it include avoiding the nipple incision (this incision puts more bacteria in contact with the implant,) draping off the nipple during surgery to prevent contamination of the implant with bacteria on the nipple, bloodless, precise, and atraumatic dissection techniques, proper IV antibiotics, irrigation of the implant and pocket with antibiotics, textured implant surface, early mobility after surgery, talc-free gloves, and other things. But even when all of these things are done, contracture can still occur. There is a lot about contracture we do not know, and in fact not all surgeons agree with the steps that I have outlined here.

Capsular contracture can occur when everything is done right, so one never really knows if their contracture is due to something their surgeon did differently. And not all surgeons agree with one another about the factors that contribute to contracture. Furthermore, some things that might help with contracture, such as avoid the periareolar incision, are felt by some surgeons to not be worth the trade-off. Finally, you must recognize that whatever your surgeon did, he or she probably does that on most of their patients, yet still infrequently has patients develop contracture. Indeed, capsular contracture is ultimately the way your own tissue reacted to the breast augmentaiton.

Some surgeons believe that the asthma medicines Accolate and Singulair help reduce the inflammation in capsular contracture and they prescribe it to all their patients after surgery. Most surgeons do not do this. Those that do will say that their capsular contracture rates seem to be lower since they have used it or that they have had patients with early contracture get better with it. Naysayers argue that the evidence is scant that it really does anything, that many of the what-seem-to-be early contractures get better on their own anyhow, and that the drugs have serious side effects. But in any case, no surgeon should be criticized for not prescribing these drugs; most don’t, and the evidence to support their use is weak.

A few plastic surgeons tell their patients up front that they will fix capsular contracture if they develop it in some specific period of time after surgery, such as one year. Few of those plastic surgeons with this policy cover all expenses; more commonly, the surgeon will waive their own fee, but not the operating room and anesthesia fees, as well as the cost of new implants (most surgeons today feel that the implants need to be replaced with new implants when there is capsular contracture.)

The warranties only cover manufacturing flaws or a rupture/leak; they do not cover capsular contracture. Remember that though a contracted implant feels firm, the implant is not firm. It only feels firm because a layer of the body’s tissue around it is tightening around it. It really is the patient’s biological process.

Since the early 1990’s, all silicone implants sold in the United States had a barrier lining in the shell that prevents microscopic gel migration. Some believe that this barrier lining has done a lot to reduce the incidence of capsular contracture.

Some patients do not see their plastic surgeon until after their breasts have become round, hard, and high. But other patients see their doctor a few days after noticing their breasts have become a bit swollen, tender, and firm, but not yet a "full-blown" capsular contracture. It is thought that these patients have some inflammation and fluid around their implant, perhaps a very mild, low-grade infection or bacterial contamination of the implant. There is no consensus about what to do. Many doctors, myself included, believe it is very important to prescribe antibiotics at this stage to treat any bacteria if indeed, as we suspect, this problem is of an infectious etiology. Some doctors prescribe the asthma medications Accolate or Singulair, some prescribe Vitamin E, some prescribe ibuprofen, some recommend massage, and others use ultrasound therapy. All surgeons will describe to you cases in which one or more of these methods has helped turn the tide in what seemed to be a developing contracture, but it is uncertain which of these methods really makes a difference. This is really something that must be left to a discussion between you and your plastic surgeon. But the take away lesson is that if your breast becomes tender, swollen, or painful, you should see your plastic surgeon right away.

When a capsular contracture is just starting to develop, surgeons may try antibiotics, massage, vitamin E, Ibuprofen, and perhaps external ultrasound treatments. The asthma medicines Accolate and Singulair are also sometimes prescribed. Though these medicines have serious side effects and the evidence objectively supporting their use for capsular contracture is weak, some surgeons believe very strongly in them because of their personal experiences with it.

Up until the mid-1990’s, surgeons would forcefully squeeze a contracted breast with their hands until they broke the capsule. This would make the breast soft. However, these breasts almost always became hard again. And the force sufficient to break the capsular tissue would often break the implant, and the severe squeezing would cause more liquid silicone of that era to squirt into the breast. No one realized at the time how bad a practice that was, but it has long been abandoned. And it also was very painful.

An implant should never be reused when treating capsular contracture. To do so risks contracture occurring again because of the "biofilm" on the surface of the implant, which is a layer of bacteria that has the potential to cause capsular contracture – and may have been responsible for it in the first place. This cannot be washed off; a new implant is the only option.

If your implant is hard and has been that way for a long time, it probably will not get softer without surgery. But it is not a required surgery. If you do not mind your breast being hard and spherical, it is permissible for you to live with it. But there are two important things for you to also consider: first, hard implants over time will stretch the breast skin, thin the breast tissue, and sometimes even make a depression in the rib cage. Second, and most important of all, mammograms are very difficult in patients with capsular contracture because the special implant views, which require the breast tissue to be pulled forward off of the implant and onto the mammogram plates, simply cannot be done satisfactorily. Some patients do not mind being hard and round, but have surgery so that their breasts become more suitable for mammography.

Usually contracture will start off a bit swollen and tender, but then will stabilize over time. It is generally preferred not to operate during the "acute phase" when the contracture is in an active state. It is always difficult to operate on inflamed tissues: they are swollen, filled with fluid, tend to bleed more, and it is difficult to separate the capsule from the surrounding tissues. Surgeons generally want to wait until the contracture has stabilized. This can be as soon as a few months after the process began or as long as a year. Do not push your surgeon to operate sooner than they believe is ideal for you.

The first step in treating capsular contracture is usually to remove the whole capsule, a procedure called a "complete capsulectomy." Removing only part of the capsule, a "partial capsulectomy," is not as effective as a complete capsulectomy. But sometimes if it is difficult to separate the capsule from the normal tissue, the surgeon will leave some capsule behind. Merely cutting the capsule – a "capsulotomy" – is regarded today by many surgeons to not be as effective as a complete capsulectomy. The current theory of capsular contracture is that there are bacteria in the space around the implant, so unless the capsule is removed, bacteria would be left behind if a capsuelctomy is not done. The surgeon will then use a new implant. Since "biofilm" on the surface of the implant is believed to be a cause of contracture, most surgeons do not reuse implants when operating on capsular contracture. Most surgeons will also leave a drain in after surgery to remove blood and fluid from pooling around the implant.

No, you always have the option of not replacing the implants. However, most surgeons feel that even when you do not replace the implant, that the thickened capsule tissue should be removed because sometimes it can be felt or it can fill with fluid.

That is something your surgeon would discuss with you after examining you. Generally speaking, a large implant with thin tissue and stretched skin would look very empty and unattractive, and a small implant with thick tissue and tight skin will look very good.

If the implant is in front of the muscle, your surgeon will discuss with you whether it would be advantageous to move your implant behind the muscle. This is thought to reduce the chance of the capsular contracture occurring again. But it does have tradeoffs of there being more motion of the implant with tightening of your chest muscles, and if your breast is droopy and your skin envelope stretched, the breast may look less perky.

Some surgeons devoutly believe that textured implants reduce the chance of capsular contracture, and others do not. The evidence is equivocal unless the implant is in front of the muscle, in which case texturing seems to have an advantage. And in most but not all cases, most surgeons suggest placing the implant behind the muscle for capsular contracture. Opponents of textured implants will say that textured implants are more prone to folds and that the evidence does not show an advantage to them behind the muscle. Keep an open mind and discuss this issue with your surgeon.

A complete capsulectomy cannot be done through either the belly button or armpit incisions. A capsulectomy can usually be done through either the periareolar or inframammary incisions, though the periareolar incision may not be a viable choice if the areolas are small. Most surgeons will use whichever of these two incisions was used the first time. But the growing evidence that capsular contracture is related to the staph epidermidis bacteria living within the milk ducts of the breasts has made many suregeons encourage their patients to select the inframammary incision.

Years ago there seemed to be a lower chance of capsular contracture with saline implants, but that is no longer true today. It is believed the rates are the same today because of better manufacturing processes, such as the barrier shell that reduces the amount of gel bleed through the shell of silicone gel filled breast implants.

Recent experience using Alloderm® and Strattice ™ in breast reconstruction and revision breast augmentation cases demonstrates a reduced rate of capsular contracture, which some surgeons are describing as "near-zero." The reason is not yet totally understood, but appears that a capsule does not form over the tissue graft and that there needs to be a complete, circumferential capsule in order for it to squeeze the implant and make it hard. This is something that has only been spoken about since about 2009, but the experience with these is growing and confidence is increasing. Most surgeons are still unaware about this benefit of these materials, and of those who are aware, some only use it when there has been multiply recurrent contractures. But there is a growing group of doctors who are suggesting it even for a first attempt at treating contracture. Dr. Teitelbaum has used these for prevention of contracture in patients who have had it recur multiple times and thus far the success rate has been outstanding.

There is a lot of variability depending upon the severity of the contracture, the size of the breast, the incision that is selected, what actually is being done (eg whether the implant needs to be moved behind the muscle) and the skills and style of the surgeon. But generally it takes about 45-90 minutes for each side.

The drainage tubes are usually removed about 4-7 days after surgery, and most surgeons let their patients shower once the drains come out. Most patients would take about a week off of work. Depending upon what is done, your surgeon may ask you to not exercise for about a month, but a light walk is usually permitted the next day. Like others, this answer is just for general information, but it is important to listen to exactly what your surgeons tell you to do after surgery.

Most patients have this done as an outpatient and go home the day of surgery. Unless you have medical problems, this is typically not done in a hospital nor do you need to stay in one. Some communities have "aftercare facilities" which take care of plastic surgery patients after surgery. While most capsulectomy patients are not in need of all the care these centers can provide, they are frequently a good choice for recovery for patients who couldn’t get peace and quiet at home or someone to look after them and bring them all their food and medicine after surgery, as well as bringing them back to the office for post operative visits with the plastic surgeon.

There is a lot of variation in how people respond to pain and not all capsular contracture operations are the same. Generally speaking, however, your plastic surgeon will give you enough pain medicine so that you do not need to be afraid of the pain. The pain builds up gradually as opposed to some kind of pains that just suddenly attack. So you will always be able to stay ahead of the pain with your pain medicines and not suffer.

The most common complication following a capsulectomy is bleeding the night of or in the first few days following surgery. There is a lot of "raw" tissue after removing all of a capsule, and though a plastic surgeon will not finish the operation until the bleeding is all stopped, sometimes a blood vessel will bleed again after surgery. If this happens, the breast will swell, get hard, and become painful. You should call your plastic surgeon immediately and they will consider taking you back to surgery to drain and stop the bleeding.

We must never forget that to begin when capsular contracture is a disorder of the biology of the tissues surrounding an implant, and though we know some of the factors that affect this process, we do not fully understand it and we are far from being able to control it. So even when everything is done correctly, there is still a risk of the capsular contracture coming back. If a patient has a contracture on both sides, it is possible that one side will end up a little softer than another. If a patient has a contracture on only one side and the surgery is done on just that one side, there is a possibility that the operated side will end up a bit harder or a bit softer than the non-operated side.

Capsular contracture is unrelated to the size of the implant.

This is a term introduced by Dr. Teitelbaum to describe an undesirable outcome from the successful treatment of capsular contracture. How can a successful treatment create an undesirable outcome? In patients with thin tissue and underlying droopiness, the scar tissue can tighten and pull up what would otherwise be a droopy breast. The scar tissue tightens around the implant, smoothing out any potential folds in its surface, and the scar tissue itself adds some thickness to the coverage. When that scar tissue is removed, the underlying "occult" droopiness becomes apparent. A breast that was hard and high may now be soft and low. With the release of the tightening effect of the scar tissue, the entire breast envelope becomes loose and lax, thereby allowing the implant to form more folds. It is sad but true that there are occasionally unhappy patients with hard, smooth, high implants with capsular contracture, who after removal of the contracture, are miserable with implants that are soft, rippling, and low. This is not in any way the surgeon’s fault whatsoever; it is due to laxity, thinness, and inelasticity of a patient’s tissues. The most any surgeon can do is to predict it ahead of time, and even that is difficult.

We generally recommend treatment of capsular contracture in order to make mammograms better and to make the breast softer and less uncomfortable. However, it is also true as mentioned in the last question, that removing scare tissue can occasionally turn a hard and tight breast into a loose, saggy, and even rippling breast. This can never be perfectly predicted ahead of time, but generally it occurs in women whose tissue is thin and stretched out, as documented by a tape measure showing that certain dimensions of the breast that are elongated. There are patients who upon hearing this possibility may choose to leave their breasts alone. Finally, there are a few patients who have had repeated surgery for capsular contracture and it has recurred each time. If the surgeon doesn’t have anything new to offer, then it is not likely that the next surgery will produce a different outcome. In these situations, either implant removal without replacement or simply living with the contracture are options that need to be considered.

Insurers are becoming increasingly parsimonious about paying for any surgery, particularly if it has anything to do with cosmetic surgery. Most insurers will only pay for capsular contracture surgery if the patient has painful symptoms from the contracture or is inhibited from working. Even in these cases, the insurance companies pay the surgeon a paltry fee, and they do not cover the cost of putting in a new implant. While there are some surgeons who accept these fees in total, many do not. Other insurers refuse to cover anything at all related to breast implants unless those implants were initially placed for reconstructive purposes. You need to check with your insurer directly; these issues are buried somewhere in the fine print of any policy, and even so, the insurer almost always reserves the right to change their approach to these issues, which they typically do in an arbitrary and illogical manner.