When a breast implant is placed the body attempts to wall it off forming a capsule around the implant. This capsule can be
present within a week after surgery & is eventually present in all breasts containing implants. The end result look of a breast
containing implants is due to

• the implant itself
• the patient’s breast tissue-skin,gland,fat, chest wall muscle & rib cage
• the capsule formed around the implant.

The capsule can be of variable thickness & have different properties from patient to patient & even right breast vs. left breast. Thicker capsules can contract mishaping the breast & in some cases also cause pain. It is not known exactly why some capsules become more problematic cosmetically speaking than others. It is thought that blood around the implant at the time of surgery or low grade infection early or late after surgery is the culprit. Some capsules cause problems early after surgery & some take years to transform into a problematic capsule. It’s not known whether all capsules eventually become problematic but this is a distinct possibility. In the mid 1980s texturing was added to implant surfaces in an attempt to decrease the incidence of capsular contracture. Some surgeons now use only textured implants & others use only smooth surfaced implants saying one is better than the other for cosmetic or other reasons. At least in animal experiments texturing decreases the contracture rates.

The vast majority of breast augmentation patients have some degree of capsular contracture. It is only the more severe degrees with symptoms whose treatment would be covered by health insurance in which they only pay for capsule removal and they do not pay much. The less severe degrees of contracture are not associated with symptoms and only detract from the appearance. Their correction is cosmetic and not covered. 11 months is a little early to have revision surgery and may start you down a path of repeat surgeries because each surgery including capsule removal to some degree stimulates the scar formation response. Only get additional surgery if you really need it.

When reoperating on a breast with implants in place the preoperative situation & goals of the surgery should be kept in mind. If the patient just wants the implants out it’s important to remove as much of the capsule as possible unless the capsule is gossamer thin. If the implant is removed & the capsule left behind virtually intact various problems can occur:

• the capsule can contract down into a small sphere since there is no longer an implant to maintain its size – this would crenate the breast
• the capsular surface in some cases can secrete fluid similar to serum or joint fluid which would require drainage

Capsulectomy, in which the scar capsule is removed along with the implant, is generally a more involved operation than simple implant removal. The surgery usually takes longer, may be more expensive, and more often requires general anesthesia. On the other hand, simple implant removal without capsulectomy may leave scar tissue behind which may be detectable by touch, mammography, or other imaging studies. Having said all that it is probably impossible to remove every single cell & non-cellular part of a capsule. Firstly because that’s just the way the human eye & hand work-we can’t see microscopically. Secondly because especially in very thin individuals it may be dangerous to scrape the back of the capsule off the chest wall. No one wants to enter the chest cavity especially if gel from a ruptured gel implant is present. The problems of crenation & fluid production should be adequately treated by removing the vast majority of the capsule.

When I was in medical school surgeons would squeeze the breast until the capsule broke. The problem with this is it seems barbaric by today’s standards, some implants were ruptured in the process & breaks in the capsule through which implant protrudes can be unsightly. Nowadays closed capsulotomies as this was called is probably considered malpractice. When I was training we used to just score the capsule & then place a new implant. The problem with this technique was the old capsule was left in place & the scored edges would heal over leaving the same capsule with the same properties. What is apparent now is that the capsule should be removed even if new breast implants are placed so that a new capsule with different make up/properties forms. It should also be noted that some breast tissue is inevitably removed at the time of capsule removal no matter how much of the capsule is removed. Thus the breast can never be returned to what it originally looked like prior to placing any breast implants. Also, in some cases implant removal & capsulectomy without placement of a new implant can leave a breast with an uneven surface contour. Even if every effort is made to place incisions in inconspicuous areas, the implant-removal procedure may leave a longer scar than that which resulted from the original implant-placement procedure. Breast sensation may be diminished or altered. Times change & with them so do what are considered the standards of medical care.

There are no external balms, medications etc. that effectively treat capsular problems. The capsule needs to be surgically
removed & all consent forms for breast implant surgery should discuss the existence of/possible problems with capsules.
Interestingly, of all the non-plastic surgeons out there performing breast augmentation I’ve never heard of one of them willing to perform breast reconstruction or treat capsular problems.

More recently endermology (deep massage with roller surface suction device) has been found to non-surgically resolve some visible contractures although the process & the longevity of its effect have not been well studied. All of my patients undergoing implant removal with capsulectomy & new textured implant placement have 4 weeks of endermology treatments afterwards. This is done to lower the high risk of recurrent capsule problems. I will not do the surgery otherwise & cannot rely on someone squeezing their breasts at home to prevent reformation of the capsule.

 

 

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