Capsular contracture

Key Points

TORONTO, CANADA — Clinicians are studying various means to limit the incidence of capsular contracture, the leading cause of breast implant re-operations. "We have tried to make the incidence of capsular contracture as low as possible," says Mitchell H. Brown, M.D., M.Ed., F.R.C.S.C., a Toronto plastic surgeon who spoke at the recent 7th Annual Toronto Breast Surgery Symposium. "Our goal should be preventing capsular contracture from happening rather than treating it once it has already happened. We don't know the true underlying cause of capsular contracture." Dr. Brown, an associate professor in the Department of Plastic Surgery at the University of Toronto in Toronto, defines capsular contracture as abnormal tightening or constriction of a capsule or scar tissue around a prosthetic implant, noting the wide variation in the published incidence of capsular contracture, with rates ranging from 0 to more than 50 percent.

RISK FACTORS Other surgical factors such as hematoma/fluid collection and infection or contamination can increase the potential for capsular contracture. Furthermore, procedural factors including pocket location, incision, drains, post-operative massage, bandages and bras have been studied to asses their role in capsular contracture. Moreover, implant factors such as fill material, implant surface, shell characteristics, and implant size may affect the potential for capsular contracture. Genetic predisposition, exposure to radiation on the breasts, and smoking are factors that all heighten the potential for capsular contracture. "A patient who has had a breast cancer and has undergone radiation treatment and then implant surgery may be at risk for capsular contracture," Dr. Brown tells Cosmetic Surgery Times. "If a person has had it before, they are at risk of having it again. We don't know why some patients are uniquely predisposed."

DIVERSE EVIDENCE Within the realm of published studies, Dr. Brown refers to the orthopedic literature, which indicates that most artificial joints demonstrate loosening after a decade. The loosening is felt to be related to infection or contamination. To avoid this loosening, lifelong antibiotic prophylaxis has been recommended and newer models of joints will contain slow release antibiotics and antibiotic impregnated cement.

Dr. Brown also cites several studies from the medical literature aimed at identifying causes of capsular contracture in breast augmentation and breast reconstruction. One study examined the role of implant surfaces in the threat of capsular contracture, comparing the effect of texturing, combined with povidone-iodine irrigation around saline-inflatable breast implants. The investigators found a decreased incidence with Betadine pocket irrigation and textured surface.

However, Dr. Brown notes that labeling pocket location as a source of capsular contracture is a debatable issue, pointing out that no definitive difference has been shown in incidence when subpectoral mammary augmentation has been performed versus subglandular mammary augmentation. A Montreal series of 319 patients who underwent augmentation mammoplasties were subject to total submuscular implantation, blunt dissection, the use of intravenous antibiotics and pocket irrigation, and received saline implants. Suction drain was performed over 24 hours. Surgeons found no capsular contractures occurred after an average of 17 months of follow-up. In another Montreal series of patients, a total of 830 augmentations were followed for at least one year. No capsular contractures or displacement occurred. Patients lay prone for one to two hours per night and compressed their breasts every hour for three months. Investigators attributed compression to the prevention of capsular contracture. One six-year prospective clinical study found the use of triple antibiotic breast irrigation enhanced patient outcomes in aesthetic and reconstructive breast surgery. The use of the antibiotics decreases contamination and infection. The role of prophylactic antibiotics in breast augmentation and breast reconstruction is in evolution, notes Dr. Brown. Research is ongoing to assess if antibiotics should be administered at the time of surgery or following surgery.