Key points
- Capsular contracture is considered the most common complication of breast implant surgery, but its exact cause has not yet been identified [1, 2].
- A 2015 review put the overall incidence at 10.6% and named smooth implants, placement under the breast gland, silicone gel implants, and previous radiation therapy to the breast as risk factors [2].
- Textured implants appear to lower the risk of capsular contracture, but the same research also concluded that they may be associated with an increased risk of anaplastic large cell lymphoma, so both need to be weighed together [3].
- Capsular contracture that has already developed is mainly treated with surgery to remove or cut the capsule, and substantial recurrence rates have been reported with almost every treatment [2].
What is capsular contracture?
When a foreign object such as an implant enters the body, the body surrounds it with a thin fibrous membrane. The formation of this capsule is itself a normal response. A 2015 review described capsular contracture as an excessive fibrotic (scarring) reaction to the implant as a foreign object [2].
A 2022 review described capsular contracture as a condition in which a capsule of scar tissue forms and tightens firmly around the implant, and stated that this often distorts the shape of the breast and leads to chronic pain [4].
Capsular contracture is a problem in both cosmetic breast augmentation and breast reconstruction. A 2020 systematic review described capsular contracture as one of the most distressing complications of implant use [5]. It is also one of the common reasons for revision surgery [2].
How much is known about the cause?
According to a 2021 review, there is general agreement that fibrosis of the capsule begins with inflammation [1]. However, the review explained that inflammation appears to have many possible triggers, so it is difficult to know in advance why capsular contracture develops in some people but not in others [1].
One 2015 review regarded capsular contracture as a common but preventable complication and summarized it as the result of interactions between factors that promote it and factors that suppress it [6]. Another review from the same year also viewed capsular contracture as a fibrotic process involving multiple factors and stated that its exact cause is still unknown [2].
Factors that raise or lower the risk
A 2015 review examined 82 publications that met its criteria and put the overall incidence of capsular contracture at 10.6% [2]. The risk factors it named were smooth implants (compared with textured), placement under the breast gland (compared with under the muscle), silicone gel implants (compared with saline), and previous radiation therapy to the breast [2]. Placement under the muscle and polyurethane-coated implants were also named as conditions with a lower rate of capsular contracture [2]. However, the surface type is tied to the risk of lymphoma, which is explained just below.
There is more organized evidence about the implant surface. A 2017 meta-analysis that reanalyzed 15 studies, including 13 randomized clinical trials, concluded that textured implants appear to lower the risk of capsular contracture compared with smooth implants [3]. However, the same study also stated that textured implants may be associated with an increased risk of anaplastic large cell lymphoma [3].
The surface type is therefore not something to choose based on capsular contracture alone. The research summaries reviewed here did not address what other risks polyurethane implants may carry. Breast implant-associated lymphoma (BIA-ALCL) is explained in detail in a separate article in this Surgery Guide. In addition, the research summaries do not state the ethnicity of the study participants, so it is difficult to say for certain that the same rates would be seen in Korean patients.
Methods used for prevention
A 2014 review of breast augmentation explained that techniques for positioning the implant accurately and handling it under sterile conditions help prevent problems with shape, such as capsular contracture and implant malposition [7]. A 2022 review summarized that cleansing the skin before surgery and rinsing the space where the implant will go with antibiotics have been used as surgical strategies to reduce capsular contracture [4].
Prevention using medication is also being studied. The same 2022 review examined intravenous medication around the time of surgery, oral medication, coating the implant surface with medication, rinsing the implant or surrounding tissue with medication, and placing medication in the implant shell or fill, and these include both methods used in actual practice and methods still at the experimental stage [4]. A 2015 review described reports that leukotriene receptor antagonists used off-label (outside their approved uses), acellular dermal matrix, botulinum toxin, and creating a new space for the implant (neopocket) helped reduce the severity of capsular contracture or prevent it [2].
However, these research summaries did not give figures for how effective each method is or for whom. Whether to use medication is a decision for a specialist to make based on your individual health.
Treatment after capsular contracture develops
Capsular contracture that causes symptoms is usually treated with surgery [2]. The main operations are capsulectomy, which removes the entire capsule, and capsulotomy, which releases the capsule or removes only part of it to enlarge the space for the implant [4].
Nonsurgical treatments are also being studied. A 2020 systematic review evaluated the effectiveness of nonsurgical treatments in general for capsular contracture that has already developed, but the research summary reviewed here does not include its conclusions [5]. Recent research has focused on ways to keep capsular contracture from developing and on treating it with fat grafting using your own fat (autologous fat transfer) [2].
Caution is needed even after treatment. A 2015 review stated that recurrence rates are substantial with almost every treatment [2]. For this reason, when planning revision surgery, it is a good idea to consider the method of the first surgery, the condition of the implant, and the severity of symptoms together, and to get an explanation that includes the chance of recurrence.
What to check during your consultation
Capsular contracture is a complication for which it is difficult to know in advance who will be affected [1]. A 2014 review considered that analyzing body characteristics and involving the patient in choosing the implant increases overall satisfaction and reduces requests for secondary surgery [7]. It is a good idea to check the following together before surgery.
- The surface type and fill of the implant, and why they were chosen
- For textured implants, an explanation of the lymphoma risk and a follow-up plan
- The layer in which the implant will be placed (under the breast gland or under the muscle)
- Individual risk factors, such as previous radiation therapy to the breast
- How infection is prevented and how the implant is handled
- What steps to take if your breast becomes firm or changes shape
Frequently asked questions
- How common is capsular contracture?
- Based on 82 publications, a 2015 review put the overall incidence at 10.6% [2]. However, this figure is a pooled result from many studies, and the risk can vary depending on the type of implant, the layer in which it is placed, and whether you have had radiation therapy [2]. This figure was not analyzed separately for Korean patients, so the most accurate way to understand your individual risk is to get an explanation through an examination.
- Can textured implants prevent capsular contracture?
- A 2017 meta-analysis concluded that textured implants appear to lower the risk of capsular contracture, but it also pointed out that they may be associated with an increased risk of anaplastic large cell lymphoma [3]. They therefore cannot be considered a way to completely prevent capsular contracture, and both risks need to be weighed together. Lymphoma is covered in a separate article.
- Do I have to have surgery if capsular contracture develops?
- Capsular contracture that causes symptoms is usually treated with surgery such as capsulectomy or capsulotomy [2, 4]. There is also a systematic review that evaluated the effectiveness of nonsurgical treatments, but its conclusions could not be confirmed from the research summary [5]. The timing of treatment depends on how severe your symptoms are and how much discomfort you have, so it is decided after an examination.
- Will it come back after revision surgery?
- It can come back. A 2015 review reported that recurrence rates are substantial with almost every treatment [2]. The method of revision surgery and the chance of recurrence depend on the method of your first surgery and your current condition, so it is best to discuss them thoroughly in advance.
References
- Safran T, Nepon H, Chu CK, et al. Current Concepts in Capsular Contracture: Pathophysiology, Prevention, and Management. Semin Plast Surg. 2021.PubMed 34526867DOI
- Headon H, Kasem A, Mokbel K. Capsular Contracture after Breast Augmentation: An Update for Clinical Practice. Arch Plast Surg. 2015.PubMed 26430623DOI
- Cifuentes I, Dagnino B, Rada G. Do textured breast implants decrease the rate of capsular contracture compared to smooth implants? Medwave. 2017.PubMed 28863131DOI
- Guimier E, Carson L, David B, et al. Pharmacological Approaches for the Prevention of Breast Implant Capsular Contracture. J Surg Res. 2022.PubMed 35969932DOI
- Papaconstantinou A, Koletsa T, Demiri E, et al. Nonsurgical treatment of capsular contracture: Review of clinical studies. J Int Med Res. 2020.PubMed 32496144DOI
- Chong SJ, Deva AK. Understanding the Etiology and Prevention of Capsular Contracture: Translating Science into Practice. Clin Plast Surg. 2015.PubMed 26408434DOI
- Hidalgo DA, Spector JA. Breast augmentation. Plast Reconstr Surg. 2014.PubMed 24675209DOI
This article is an English translation of general health information that DOY JUN Plastic Surgery compiled in Korean from the summaries (abstracts) of papers in international academic journals. Treatment methods and results vary depending on each person's condition, so please consult a specialist for an accurate diagnosis and treatment plan.
