Breast augmentation with saline or silicone breast implants can have complications like any other surgery. Most of these complications are explainable, understood, anticipated and easily treated. One complication, though, is none of the above: capsular contracture of breast implants. Common complications of breast implant enlargement surgery include:
- Bleeding – less than 2% of patients
- Infection – less than 2%
- Implant malposition – less than 5%
- Implant rupture – less than 6%
- Capsular contracture – 10%
- Large cell Lymphoma – less than 0.0001%
What is breast implant capsular contracture?
This common complication’s pathogenesis is an enigma to plastic surgeons. It is also a cause of great heartache and frustration for patients who undergo breast enlargement surgery in order to feel better about their bodies and end up with the need for multiple breast implant surgeries. The cosmetic surgeon can only shrug his or her shoulders and look bewildered!
Whenever any object, be it a breast implant or a pacemaker, is placed under our skin, our bodies form a protective scar, or capsule, around it to keep it away from the rest of our body.
Usually, capsules of breast implants are thin. As thin as tissue paper. However, in 10% of patients the implant capsule gets thicker, and in some of those patients it starts to contract. This contraction can continue to the point of causing deformity and pain in the breasts. The breast implants get squeezed and the breasts can get so hard and round that they feel like coconut shells !
Causes of abnormal breast implant capsule formation
Plastic surgeons know of a number of situations that can lead to an increased risk of capsular contracture:
- Hematoma after surgery – bleeding
- Contamination of implant with bacteria
- Prior history of a capsular contracture
- Leakage of a silicone implant
Capsular contracture grading system
The capsular contracture of breast implants is subjectively quantified by plastic surgeons with the Baker system:
- Grade 1 – the normal response of the breast. A soft, pliable capsule.
- Grade 2 – the capsule is firm but the breast still looks normal.
- Grade 3 – the breast is deformed and hard.
- Grade 4 – deformation, hardness and now the breast also causes pain.
How does the scar/capsule contract?
As with many medical discoveries, serendipity played a role in allowing surgeons to discover what was happening to the capsule around implants.
Plastic surgeons noted that 80% of their patients who had developed capsular contracture and then took asthma drugs had a softening of the contracture and a normal appearance and feel after three months.
It turns out that the same type of smooth muscle cells that line our lung bronchi, which tighten up in an asthma attack, are also present within the scar tissue of the breast capsule. The asthma medications that stop the smooth muscle contraction, leukotrienes such as Singulair or Accolate, also help capsules soften.
(As an aside about leukotrienes, I take one every day for my seasonal allergies—and they work for me, whereas anti-histamines do not!)
How to prevent this complication
Since we do not know what causes capsular contracture, there is a lot of “voodoo” involved. The goal is to limit the causes known to increase the risk.
- Excellent surgical technique to prevent bleeding
- Minimal handling of the implant to decrease infection
- Irrigation of the chest pocket with antibiotics and steroids to decrease the chance of a sub-clinical chronic infection (I learned this from my professor, Dr. Gerow, the man who invented breast implants)
- Making the breast pocket large enough so it takes a lot of contracture before it deforms a breast!
- Placing the implant under the pectoral muscle; this cuts in half the rate of complications
How to treat capsular contracture
I remember doing a “closed capsulotomy” in the late 1980s. You held the hard breast implant between your thumb and fingers and squished fiercely. Sometimes you heard a pop and, like magic, the round, hard breast became soft.
This procedure is no longer done. Not only did many implants burst (silicone implants were used at that time and there was no easy way to see a ruptured implant), but many surgeons ended up with severe thumb injuries from the procedure (gamekeeper’s thumb = dislocated thumb).
These days I treat patients with the first sign of a hardness with three months of Accolate or Singulair. If there is no improvement and they go on to develop Grade 3 or 4 Baker classification contracture, I recommend surgery. This happens in about 1% of my patients. The procedure takes two hours and removes the scar tissue; new breast implants are placed. Use of saline or silicone implants makes no difference.
Other methods, such as external ultrasound, magnetic fields and other voodoo, have not worked for me. Only my voodoo has.
Anaplastic large cell Lymphoma
This is a recent complications that has been noted in breast implant surgery with silicone implants of a particular type of texture. It rate of occurrence is between 0.35 -1 case per million. Though a very few cases have been reported with other implant types, it seems that the textured silicone implants are particularly responsible for this low grade lymphoma. Signs include seroma, fluid collections, in the breast, and capsular contracture. The lymphoma seems to be cured by removal of the implants and the breast capsule. More research into this rare condition is continuing as of 2020.
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