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Hard Breasts? The Usual Suspects.

Capsular contracture is a condition in which the tissues around a breast implant harden. When this happens, the breast can become distorted or painful. In some cases this pain or deformity is so bad, that surgery is required to remove the capsule and/or breast implant. There are many theories as to why capsular contracture develops. Probably, the most of common etiology is bacteria. One of the leading thoughts is that some bacteria either from surgery or even after surgery contaminate the breast implant. Following contamination, the body responds with regional inflammation. Inflammation can lead to an aggressive tissue remodeling within the breast pocket, surrounding the implant. For this reason, meticulous care for sterility is the rule when performing breast augmentation surgery. However, even under the most meticulous circumstances bacteria can still contaminate the implants.

Other risk factors for capsular contracture

Tim Neavin

Beverly Hills plastic surgeon Dr. Tim Neavin discusses capsular contracture.

include the type of breast implant used, the placement of the breast implant, and the incision used to place the implant. Silicone breast implants may have a slightly higher capsular contracture rate than its saline cousins. The data on this topic may change with the newer, more form stable implants that don’t “leak” with shell fracture. While the differences in rates for capsular contracture between saline breast implants and silicone breast implants are small, it is not zero. But it is small enough that it is generally not considered a determining factor between saline or silicone, even in the background of a prior contracture.

Of either saline or silicone breast implants, smooth implants have a higher capsular contracture rate then textured breast implants. The differences in the capsular contracture rates are likely related to the way that textured implants incorporate into the body. Surrounding tissues will adhere to the textured implants, but not a smooth implant. This may offer more protection from bacterial growth or biofilm development.

Breast implants placed under the muscle have a lower capsular contracture rate then breast implants placed over the muscle (a sub glandular position). This is likely a result of the mechanical massaging that occurs when an implant is placed below the muscle. Massaging either manually or from a sub pectoral position can break up scar formation around the implant as it developed. This can keep the breast implants soft and contracture-free.

When a breast implant is placed around the areola, the capsular contracture rate is higher then other incision approaches. This is likely related to contamination from the gland of the breast, that often harbors bacteria.

The armpit incision has a capsular contracture rate similar to the Ariola approach. This may have at the carpet harbors a lot of bacteria as well.

An inframammary approach (breast fold) has the lowest capsular contracture rate.

Note, the rate differences among different approaches are not huge. But it isn’t zero. Some plastic surgeons may even argue the data, particularly the ones that prefer the per-areolar and axillary approaches. In my humble opinion, I find very little advantage to the peri-areolar incision, but that is a topic for another discussion.

Another potential route for bacterial contamination is from dental procedures. Women with breast implants should probably take antibiotics before any dental procedure or dental cleaning. Or any invasive procedure, for that matter. When teeth are cleaned, bacteria may enter the bloodstream. The bacteria from the blood can then attach onto a breast implants. Because a breast implant had no blood supply directly Within itself, the bacteria can grow without resistance. Again, this bacterial growth can initiate inflammation resulting in an internal “scar” that is recognized as a capsular contracture. Unfortunately, antibiotics alone often can’t reverse a capsular contracture in advanced stages. However, some medications and protocols have errors have been shown to soften the breast or even reverse mild to moderate capsular contractures. But ultimately surgery is necessary and advanced cases. Surgical removal of the capsule, or surgical scoring or cutting the capsule followed by medical therapy have also been shown to be of benefit.

Like most things in medicine, the earlier it is detected the better the outcome. For that reason women with breast implants should see their plastic surgeon every year. Plastic surgeons can often the identify a capsular contracture before you can. And breast implant revision surgery for capsular contracture can be very expensive. Sometimes, new breast implants need to be purchased in addition to an acellular dermal matrix. This is getting beyond the scope of this blog but just know that breast revisions are often more expensive than the initial operation.

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