One of the banes of the cosmetic plastic surgeon’s existence is the formation of scar tissue or a capsule around a breast implant.  We know little about why it occurs and nothing about why it only affects some people. We don’t know why our treatments help some patients and why it recurs in others.

The capsule, or scar tissue,  is in fact a normal response of the body to a foreign object. The body essentially walls off whatever foreign material is placed into it, be it a breast implant or a pacemaker. With breast implants, however, the capsule seems to be a little different than normal scar tissue. In 10% of cosmetic patients with breast implants, be they silicone or saline, the capsule contracts (hence the term “capsular contracture”)! There are actually smooth muscle cells that have been found in the scar tissue of the capsule, and these are the cells that contract. These smooth muscles then squeeze down on the soft and squishy breast implant and cause a series of unwanted problems that have been classified by the Baker system of breast capsule formation. The breast first becomes firm, then progressively hard and deformed and finally causes pain. 90% of cosmetic patients who develop contractures do so during the first year after surgery.

Another puzzling fact is that the rate of breast capsular contracture is almost double for patients undergoing breast reconstruction with implants after treatment for breast cancer. No one has ever told me why.

The Baker classification for capsular contracture

Grade 1 – Normal breast capsule. The breast is soft, looks normal and feels normal.

Grade 2 – Normal appearance of the breast but the breast feels firm.

Grade 3 – Abnormal appearance of the breast. The breast is hard and deformed.

Grade 4 – Abnormal appearance of the breast. The breast is hard, deformed and painful.

Causes of capsular contracture

Did I mention that no one knows why some people get capsules that contract? A number of unproven theories exist, but the current favorite is that the scar tissue is transformed into a contractile state by a chronic infection in a bio-film that forms over the breast implant. But this is just a theory, though surgeons who pay extra attention to decreasing the bacterial contamination of the implant via contact with the skin are reporting lower rates of contracture. I routinely bathe the implants I use in a solution of antibiotics and steroids to decrease any reactions by the body and kill bacteria.

Making sure a large pocket is created by the plastic surgeon during the surgery also seems to be important. It makes sense that if a pocket is large, the breast capsule’s smooth muscle cells will have to contract a lot more to squeeze the implant. In cases where breast augmentations were performed through endoscopic techniques or through the belly button, the pocket created was small or non-existent and the capsular contracture rate was higher.

Morad Tavallali, M.D., FACS