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Breast Augmentation: Why do some people get hardening of the breast(Capsular Contracture)

First let’s define what Capsular Contracture (C.C.) is vs. simply a capsule around a breast implant.  Anyone who gets a breast implant will form a capsule of natural tissue around that implant.  A capsule is your body laying down a thin layer of collagen and cells around the object.  Any medical device placed in the body will get this capsule made around it.  Pacemakers have capsules, joint replacements have some capsule, and internal insulin pumps have capsules.  The formation of thin scar tissue around the scar around the implanted object is pretty normal.  So every patient with an implant has a capsule, but most patients don’t have a “Capsular Contracture”(C.C.).  The contracture part of the equation is the piece we wish to avoid.  Contracture means the capsule is getting stiffer, thicker or hard enough to distort the breast.  Years ago Dr. Baker gave a simple grading scale on how to access how firm a capsular contracture (C.C.) was.  Baker’s Class goes form I to IV.  A Baker’s class I means a soft normal feeling breast without evidence of C.C.  A class II looks normal, but on palpitation the surgeon or patient can tell the breast is firmer than normal.  Class III typically has more hardening and perhaps some visual distortion of the breast.  Baker’s class IV has even more hardening, distortion and possibly even pain in the breast or pain with palpitation.  This classification scheme is not very detailed or scientific, but it is a standard way to follow and grade the degree of C.C. a patient has.

So what causes capsular contracture?  Why do some people get it and some people don’t.  Also why does it happen to one breast and not the other?  The reality is we don’t have definitive proof of one single cause, there appears to be several potential culprits leading to capsular contracture.  The underlying process that leads to C.C. is anything that increases inflammatory reactions in the breast space around the implant.  The likely contributors can be extra blood around the implant at time of surgery, any extra foreign body like surgical glove powder, cellular debris, serum, or bacteria in the space that generate inflammation, but not infection.

As surgeons have become more aware and sophisticated with our performance of breast augmentation the occurrence of C.C. has decreased over the years.  First you want your surgeon to be very meticulous about the dissection decreasing the risk of extra blood or serum getting in the space around the implant.  If there is extra blood the body has to generate more inflammation to clear it just like absorbing a bruise over time.  More inflammation can lead to more capsular reaction and then contracture.  Also extra blood or serum can act like culture medium if there are bacteria in the space around the implant.  For the last 25 years better studies have been done looking at bacteria as a reason people might get a capsular contracture.  Bacteria do live normally on our skin, there are bacteria in the air around us and even the most sterile environment can have a few bacteria hanging around.  While a true implant infection is extremely rare in breast augmentation the chance of some bacteria getting on the implant is real.  This risk of bacteria getting on an implant is one reason we prefer not to use incision around the areola as much as we used to.  Breast tissue and glands have bacteria in them naturally, and there is the hypothetical chance of periareolar incisions causing more chance of bacteria coming in contact with implant.  This is not a proven hard scientific fact, but it does make sense.

The position and surface style of an implant also changes the capsular contracture risks.  Smooth implants above the muscle (subglandular placement) in most studies have a higher C.C. rate than if the implant was placed under the pectoral muscle (submuscular placement).  However a textured (rough surface) implant placed above the muscle doesn’t have as much C.C. risk as the smooth implant.  The belief is the textured surface can break up the alignment of scar tissue so it can’t organize in one direction to pull on the surface of the implant.  The understanding of this is not precisely understood for both smooth and textured implants under the muscle have fairly low capsular contracture rates.  Its implants placed above the muscle that seems to make a bigger difference here.  Studies will be going on for many years before we have a better and more complete understanding of capsular contracture and how to prevent it.  For now a key way I keep capsular contracture as low as possible is to not open an implant until right before it goes into the patient.  The moment we open an implant it is immersed in antibiotic solution to make it hard for a bacteria to even land on the implant.  My surgical gloves are changed to new gloves and washed with antibacterial solution.  No one but me ever touches the implant to decrease chance of contamination.  I irrigate the space for the implant with antibiotic solution also.  These and other sterility maneuvers have been documented to have lower C.C. rates with breast augmentation.

Capsular Contracture will continue to be an area of active research and as of yet we don’t have all the answers, but we keep getting the incidence lower and lower so C.C. are much lower than several decades ago.  If you wish greater details on this topic give us a call and set up an appointment to fill in any gaps in your understanding of this component of breast surgery.

 

 

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