If non surgical treatments of capsular contracture are unsuccessful, surgery will be required. The exact surgical procedure, or set of procedures, needed to correct capsular contracture will depend on how severe the contracture is. In general, the more severe the contracture is, the more likely it will be to require multiple steps to fully correct it. These steps may or may not include removal of the implants, replacement of the implants, capsulotomy, capsulectomy, changing of implant pocket, application of acellular dermal matric and possible breast reshaping.
The first step in surgery is to remove the implants. If the capsular contracture is mild, the implants may be intact. However, in cases where the contracture is severe, the implants are often damaged or even ruptured.
REMOVAL OF IMPLANTS
This is a silicone implant which was ruptured because of capsular contracture.
This is a saline implant. Note the sharp crease in the edge of the implant at the approximately 11 0'clock position. This was caused by pressure from the contracture.
A capsulotomy is when incisions are made in the capsule in order to open ("-otomy") and expand the breast pocket. This creates more space for the implant, therefore making the breats feel more soft. A capsulotomy may be sufficient in mild cases of capsular contracture. In more advanced cases,, a capsul-ectomy will be needed.
A capsulectomy is when the entire capsule, or parts of it, are removed ("-ectomy"). This is necessary in more severe cases of capsular contracture. Sometimes, it is impossible to remove a section of the capsule because it is too adherent to the surrounding tissues. This commonly happens with the part of the capsule attached to the rib cage. In these areas, it may be necessary to leave the capsule in place, because attempts to remove it will increase the chances of bleeding or other complications. Leaving the capsule intact in these cases is better than the risk of removing it. It is very common to combine
capsulotomy (opening of the capsule) of some areas of the capsule with capsulectomy (removal of the capsule) of other areas of the capsule, depending on the need.
This patient's implants were originally above the muscle. During surgery, the new space below the muscle was created. This is the muscle being held between the fingers.
The space above the muscle has been closed with stitches. This will prevent the implant from "flipping" up into the old space. The new implant will now be placed below the muscle.
A capsulectomy is when the entire capsule, or parts of it, are removed ("-ectomy"). This is necessary in more severe cases of capsular contracture. Sometimes, it is impossible to remove a section of the capsule because it is too adherent to the surrounding tissues. This commonly happens with the part of the capsule attached to the rib cage. In these areas, it may be necessary to leave the capsule in place, because attempts to remove it will increase the chances of bleeding or other complications. Leaving the capsule intact in these cases is better than the risk of removing it. It is very common to combine capsulotomy
It is well known that placing implants above the muscle ("sub-glandular") increases the chances of capsular contracture. Thus, many of the patients who develop severe capsular contracture are patients who had their implants placed above the muscle. In order to correct the contracture in these cases, it will be necessary to change the position of the implant so that it is under the muscle ("sub-muscular"). Doing so will decrease the chances that the contracture will happen again.
When the implant is repositioned under the muscle, additional steps have to be taken to close the space where the implant used to be over the muscle. If this space is not closed, there is a risk that the implant can "flip" back into the space above the muscle. Thus, changing the position of the implant requires closing the sub-glandular ("above the muscle") space.
In summary, in patients with contracture whose implants are located above the muscle, two additional steps are recommended. One is to create a new pocket for the implant under the muscle and the second is to close the space left above the muscle.
CHANGE OF IMPLANT POCKET
This is a complete capsulectomy. The entire capsule was removed in one piece. Notice how much smaller the capsule is than the implant. The scar tightens around the implant and causes the breast to feel very hard.
This is a close up of the inside of the capsule shown above. The white material is calcium. The body deposits calcium in areas of severe inflammation.
This is the same capsule cut open. The calcium deposits also contribute to the hardness felt in severe capsular contracture.
(opening of the capsule) of some areas of the capsule with capsulectomy (removal of the capsule) of other areas of the capsule, depending on the need.
INSERTION OF NEW IMPLANTS
New implants can be inserted once the previous steps have been completed. The type of implant used will depend on the patient's wishes. Some patients request larger implants. Other patients request smaller implants. Either way, it is highly recommended that new implants are used. This is recommended for several reasons.
One reason is that the old implants may have been damaged by the capsule contracting around it. Even if the implant looks fine, there may be microscopic damage to the shell which may lead to rupture in the future if it is left in place.
Another reason to use new implants is that the old implants may have been contaminated by the capsule. This contamination may be caused by biofilm. Biofilm is a thin layer of molecules produced by bacteria. This is a potential cause of capsular contracture and if left in place, can cause the capsular contracture to recur. Unfortunately, washing the implant is not enough to ensure that all of the biofilm is removed. Thus, leaving the old implant in place may increase the chances that contracture will happen again.
APPLICATION OF ACELLULAR DERMAL MATRIX (ADM) OR SURGICAL SILL SCAFFOLD (SERI)
This is a relatively new technology for the treatment of capsular contracture and breast revision. Acellular dermal matrix refers to a variety of materials which are made up of a collagen framework. These materials are derived from human ("Alloderm") or pig skin ("Strattice). The skin that is harvested is processed to remove all cells, thus making it "a-cellular" or "without cells." Since it is derived from skin, it is composed of "dermal," or skin, components. The reason it is a matrix is because the only remaining part of the skin is the collagen framework. SERI, on the other hand, is a new synthetic material made of silk protein.
The use of these materials has revolutionized the treatment of capsular contracture and breast revisions. Acellular dermal matrix (ADM) like Alloderm and Strattice have been used to cover the implants after capsulectomy. Studies show a significant decrease in the risk of recurrence when ADM is used. Futhermore, these materials provide a cushion over the implant which can make complications, such as irregularities and rippling, less common.
SERI is a silk derived biological scaffold that encourages growth of breast tissue into it and around it. This process is referred to as "bio-replacement."It is used to provide extra tissue support for cases where the breast skin is weak or has been malpositioned.
Given that ADM (like Strattice) has been shown to significantly decrease the risk that capsular contracture will recur, its use is very strongly recommended.
This is a sheet of Strattice being used for severe capsular contracture. The sheet is shaped like a crescent to conform to the shape of the breast better.
The Strattice can be placed on top of the breast to determine how it will lay once it is inside the breast.
Stitches are used to secure the Strattice in place. The placement of the stitches is determined by laying the Strattice on the breast and adjusting the position based on the size of the implant being used.
This is the appearance of the breasts after the original implants were removed, capsulectomies were performed, Strattice was applied and the new implants were inserted. The incisions under the breast have not been closed yet. Note the natural and soft appearance of the breasts.
It is very common for there to be asymmetry in shape when capsular contracture occurs. Over time, it can distort the breast and cause it to become displaced in position. Sometimes, there is also sagginess of the skin that develops over time. In these cases, breast re-shaping will be necessary to create an aesthetically pleasing appearance.
This patient had severe Grade 4 capsular contracture of both breasts. The capsule and scar tissue were removed and new implants were inserted. Strattice was then used to cover the implants.
Breast reshaping will ensure that the best results are achieved. This may include a variety of techniques including pocket reconstruction with stitches, the use of SERI material, and/or a breast lift (mastopexy). The exact technique, or combination of techniques, necessary can only be determined after a thorough consultation is completed.
There are numerous surgical options to treat capsular contracture. More severe capsular contracture requires a combination of techniques to achieve the best result. These include removal of the affected implants, capsulotomy, capsulectomy, insertion of new implants, application of ADM or SERI and breast reshaping. The exact technique, or combination of techniques needed can be determined only after a thorough consultation has been completed.