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Capsular Contracture or Capsular Constriction

 

 

Even though there is a list of potential complications, breast augmentation remains one of the safest and most conventional surgical procedures performed in plastic surgery. There is an extreme low incidence of complications, which has enticed many potential patients of undergoing this surgical procedure. This surgery has a way to provide the size and shape of an individual’s breast and keep it in proportion with the person’s overall body stature and size. It is the one procedure that the patient can see immediate results right after surgery.

Anything that is foreign to the human body will cause a reaction in which the body will naturally form a small amount of scar tissue around that object. Breast implants are no exception to this rule and the human body does this as a means of protecting itself from the foreign object. This capsule that the body makes is made up tightly woven collagen which forms a barrier between the implant the rest of the body.  

 

 

                                      Image showing the breast capsule and the placement of the breast implant

                             Copyright 2008 Nucleus Medical Art, Inc. - Used with permission

 

 

If the body has an over-reaction to the implant, then the scar tissue starts building up inside the capsule and starts contracting and compressing the implant. The excess or constricting scar tissue ends up resulting in capsular contracture. Depending on the severity of the scar tissue build up, the implant tends to be harder to move around in the pocket.  Breast implants do not become hard - it is the capsule that becomes hardened.  For one reason or another, the capsule becomes thickened and contracts, squeezing the implant into a smaller space and causing the feeling of "firmness".  Depending upon the severity of the capsular contracture, the breast can feel firm, hard, distorted, and begin to cause pain.

The prevailing theory on how capsular contracture starts has been linked to a low grade infection - however; there are many other contributing factors Capsular contracture causes are unclear.  There are outside variables which will increase your chances of this complication including hematoma, seroma, bacterial infection, non-sterile equipment, radiation therapy (pre or post operatively) and severe trauma to the breast.

Prevention of capsular contracture starts with the surgeon's technique in the operating room including the type of of irrigation he performs, the way the implant is handled and whether or not he endorses post operative massage with smooth shell implants.

The worse the capsular constriction gets the more visible the deformity will become with the implant shape being misshapen and pain is usually associated with the later stages.

 

 

There are four different levels of capsular contracture as determined by the Baker Grading System, named after a plastic surgeon who divided capsular constriction into four different sub-groups:

  • Grade 1 – the breast appears normally soft and looks natural.  No noticeable contracture.  Every patient who has breast augmentation has Grade 1 – due to the body’s natural immune response with sealing off a foreign object from the rest of the body.

  • Grade II - the breast appears slightly firm, but looks normal.  At this stage, surgery is not warranted, but it may be a sign that the capsule is beginning to contract.  This is the stage that prescription medication such as Accolate or Singular can be started.

  • Grade III – the breast is very firm and starts to look visibly distorted – slight pain might be associated with this stage.

  • Grade IV – this is the stage that the breast is hard, painful looks very abnormal with visible distortion.  To repair breast implants at a Baker grade three or four, surgery is usually required with either a full open capsulectomy or a capsulotomy.

 

 

                                  

The important factor to remember is all capsule formation is normal, as every patient who has breast implants has Stage 1 capsular contracture according to the Baker Grading Scale. It is only when this capsule becomes hardens or shrinks and compresses the implant that capsular contracture occurs. 

Early mild cases of capsular contracture can usually be helped with breast massage or the taking of prescription medication such as Accolate or Singulair.  Both of these medications have shown great promise with the lower level Capsular constriction.  With the lower level capsular constriction the patient also has an option of the capsular scar tissue to be surgically released or removed. Severe cases will likely require that the capsular scar tissue be surgically released or removed (either a capsulectomy or a capsulotomy), and the breast implant repositioned or replaced.

Capsular contracture usually occurs in about 5% of patients, and unfortunately can occur at any time the patient has implants. This is one complication that can be seen around three months post operative or anytime thereafter. 

 

 

                                    Patient has Grade III Capsular Contracture of the right breast

                                          2010 Copyright CosmeticSurgeryForums.com

 

Patient has Grade III Capsular Contracture of the right breast.

 

                                    Patient has Grade III Capsular Contracture of the right breast

                                        2010 Copyright CosmeticSurgeryForums.com

 

 

There are many factors about what might contribute to getting Capsular Contracture.

  • Smoking

  • Post operative infection or contamination

  • Hematoma or seroma formation post surgery

  • Leaking silicone gel inside capsule

  • Development of certain diseases or health conditions

  • Overactive immune system response

  • Radiation therapy in or near the breast

  • Surgical complication

  • Multiple breast surgeries

  • Breast reconstruction rather than simple augmentation

  • Old implants

 

Another factor that has to be taken into account is the severity of the contracture – which is increased by an acceleration of the inflammatory condition. The longer the breast stays inflamed, the better the chances that capsular contracture will happen.

 

 

Capsular Contracture has been treated with the following:

 

 

Pros:  Can help with the inflammatory response that is making the capsule contract around the prosthesis.

Cons:  Steroid irrigation can lead to mal-position of the implant in the pocket, as steroids tend to thin the tissue - leading to a downward migration of the implant.  

 

 

 

Irrigation of the surgical area with antibiotics has also been shown to reduce the risk of capsular contracture.  A antibacterial irrigation containing 50,000 units of bacitracin, 1 gram of cefazolin, and 80 mg. of gentamicin in 500 mL of normal saline are currently recommended to minimize capsular contracture formation.

Study on Antibiotic Breast Irrigation

 

 

 

 

The topic of massaging after breast augmentation is a controversial one. There are some surgeons who believe that patients who have smooth shell implants should perform daily massage or compressions with their implants in order to keep the pocket free of scar tissue. Women who have breast augmentation should ask their plastic surgeon about the need for massage, as each surgeon has their own post operative protocol. The main idea behind massaging or breast compression exercises is to help prevent the complication of excessive scar tissue formation that might squeeze the implant and contribute to visible mal-positioning and pain. 

The human body naturally closes off open spaces made inside of it, so it is very important to try and keep the surgical pockets open, so the implant can move around freely without restriction from scarring or adhesions that come with capsular contracture. 

If your surgeon recommends massaging - it is normally done daily with massage or breast compression exercises, forceful pushing the implant into the extremes of their pockets. Most start from approximately the first week post operative. Your surgeon will go over in detail what he or she would like you to do post operative with strict instructions, so if you are unsure about something, always call their office and find out.

Performing pocket quadrant exercises displace the implant, so the implants go toward the collarbone or shoulder. It can also be beneficial to push the breast implants laterally (to the sides) and towards the midline. Gravity for the most part takes care of pushing the breasts down.  Most surgeons have their own methods for massaging or breast compression exercises, so it is always best to first ask your physician what he recommends for you.  Every patient's treatment plan is unique and the recommendation for massage is equally individual for every patient.

 

 

 

 

Vitamin E was discovered in 1938, and has been used on surgical scars successfully with making the scars softer. Because of this, many surgeons will suggest that patients should take a regular dose of Vitamin E for the first year after augmentation, as it helps to keep tissue soft and pliable.  Vitamin E works by reducing the strength of the cross-linking of the three strands that form collagen - making them softer. Although there is no study available showing improvement with Vitamin E and capsular contracture, there are many surgeons that have seen a decrease of capsular contracture in their own practice by prescribing high doses of Vitamin E for a period of time after implantation.

 

                                     Vitamin E Capsules

                                                  Licensed image for CosmeticSurgeryForums.com

                                                                  Vitamin E Capsules

 

 

 

Another treatment that has recently gained a lot of popularity is external ultrasound. This combined with prescription drug therapy seems to help patients with capsular constriction see a reduction of the symptoms. External Ultrasound can be applied after surgery and before a capsular hardening begins. This is especially important for those who have had encapsulation in the past and have undergone a corrective surgery.

The best treatment is prevention and waiting till contracture occurs, lessens the effectiveness of this type of treatment. External ultrasound is a painless digitally adjustable instrument that sends sound waves to the affected breast. It is applied to the outside of the affected breast and can be used after a contracture has started. 

 

                                      Ultrasound of the breast for reduction of scar tissue

                                            2010 Copyright ADAM, Inc. - Used with permission

 

 

 

 

Surgical Procedures to Correct Capsular Contracture:

 

This procedure is the gold standard for most plastic surgeons when surgery is mandated due to capsular contracture.  The surgeon goes in and fully removes the entire capsule including the implant.  By taking the entire capsule and all the scar tissue with it, gives the patient the best odds of this not returning.  Capsulectomy is a more extensive operation than capsulotomy but has a higher rate of success in correcting contracture.

 

 

 

With an open capsulectomy - the plastic surgeon goes into the breast and “scores” the capsular tissue to loosen up the capsule pocket.  Because the scar tissue is not completely taken out in its entirety; the chances of the capsular contracture returning is much greater with this procedure. 

 

 

 

A closed capsulotomy procedure is not endorsed by the implant manufacturers – and if it is applied, it might void your warranty you have on the implants.  A closed capsulotomy is not done very often because of the unpredictable outcome with this procedure.  With a closed capsulotomy, the firm implant is manually squeezed tightly from the outside, in an attempt to disrupt or tear the scar envelope. When successful the result is instantaneous and the implant immediately feels soft.  However, this is a short term fix, as usually the scar tissue will reattach itself and the cycle will start all over again.

The closed capsulotomy can contribute to bruising, bleeding, or even rupture of the implant itself.  If a rupture occurs, then the patient will definitely need surgery to remove and replace the implant.

 

 

 

 

 

                                Full Open Capsulectomy with Stage IV Capsular Contracture

                              Full Open Capsulectomy - Stage IV Capsular Contracture

                                               2010 Copyright CosmeticSurgeryForums.c

                                  Surgically removed capsule - Stage IV Capsular Constriction

                              Surgical removed capsule - Stage IV Capsular Contracture

                                            2010 Copyright CosmeticSurgeryForums.com 

                                   Full Open Capsulectomy with Stage IV Capsular Contracture

                               Full Open Capsulectomy - Stage IV Capsular Contracture 

                                               2010 Copyright CosmeticSurgeryForums.com 

 

 

 

 

Textured implants were designed to help reduce the incidence of capsular contracture – because their design with the rough textured surface tends to deter a hard capsule of scar tissue from forming around the breast implant. This benefit however has only been shown to be successful in only sub-glandular (above the muscle) breast augmentations, and is still a very debatable issue. 

Because of the popularity of behind the muscle placement or partial sub-muscular placement, the benefits of textured implants is somewhat limiting and they tend not to be used for this purpose. Because textured implants are made with a thicker shell than smooth shell implants, the implant edges are thicker. 

Seeing the edges of the implant is more commonly seen with this type of surface implant versus smooth shell.  Also another disadvantage of textured implants is that they are more prone to rupture or leaks because of their surface. Textured implants can also give a patient what is called traction rippling. This happens when the implant grabs onto the surface of where the tissue grabs the textured surface and pulls on it – forming a much uniformed visible rippling pattern. 

 

 

 

 

 

CAPSULAR CONTRACTURE STUDIES

Leukotriene antagonists (Accolate) which is indicated for the use of asthma and lung diseases - has been potentially useful in counteracting  the inflammatory pathway which leads to a dense collagen membrane around the breast implant or prosthesis. This ends up preventing contracture of the capsule. Not every patient will respond with this medication however.

 

                                         Prescription drug - Accolate for Capsular Contracture

 

 

Accolate whose generic name is Zafirlukast - is an oral leukotriene receptor antagonist (LTRA) for the maintenance treatment of asthma - often used in conjunction with an inhaled steroid and/or long-acting bronchodilator. It is available as a tablet and is usually dosed twice daily. Another leukotriene receptor antagonist is generic name which is montelukast or Singular, which is usually taken just once daily. 

Both of these medications have shown great promise with the reduction of Capsular Constriction occurrence – along with existing contracture conditions if the contracture is not that far along.  Using prescription drug therapy with Accolate or Singular seems to work best if the Capsular Constriction is at the Baker Grade II level, so early detection of this is of utmost concern, so that you can get started on this drug regimen. 

Accolate (Zafirlukast) is marketed and distributed by Astra-Zeneca with the brand names Accolate, Accoleit, and Vanticon. This medication comes in pill form to treat asthma.  Zafirlukast mode of action in targeting capsular contracture works by it’s leukotriene receptor inhibitor which prevents the common inflammatory response caused by certain components of white blood cells called leukocytes.   

Zafirlukast when being prescribed for asthma blocks the action of the cysteinyl leukotrienes on the CysLT1 receptors, thus reducing constriction of the airways, build-up of mucus in the lungs and inflammation of the breathing passages.  With capsular constriction one school of thought is that it comes from an overactive immune response, just like an asthma attack would be triggered.  It is this drug Zafirlukast that literally fights the body’s immune reaction by preventing contracture from forming, and slowly softening and possibly releasing pre-existing low level contracture conditions.

 

 

 

Benefits of using Accolate with patients who have capsular contracture:

  • Asthma Medication may have Benefits in Treating most Common Problem of Breast Implant Surgery

Journal Article from Dr. Schlesinger, MD of Maui, Hawaii.

Preliminary Report Slated for ASAPS Meeting, Las Vegas

NEW YORK, NY (April 12, 2002) Accolate approved by the U.S. Food and Drug

Administration for the treatment of asthma; may be the newest weapon against capsular contracture, the undesirable breast firmness that sometimes follows breast augmentation or reconstruction with implants. A preliminary report based on several surgeons’ clinical experience will be presented at a special session on research and innovative technology during the Annual Meeting of the American Society for Aesthetic Plastic Surgery (ASAPS), April 27-May 3, in Las Vegas.

Capsular contracture, the most frequent problem following breast implant surgery, occurs when the naturally-resulting scar tissue around the implant contracts, squeezing the implant and making the breast feel firm. In severe cases, capsular contracture may cause significant breast distortion and discomfort. When severe contracture occurs, the only remedy is surgery; even then, the problem may recur months or years later.

Plastic Surgeon Larry Schlesinger, MD, of Maui, HI, reports on a series of cases in which the asthma medication Accolate was prescribed, as an off-label use, for capsular contracture following breast augmentation or reconstruction with implants. "In many cases, the patients and surgeon noted a very significant softening and improved appearance of the breast following treatment with Accolate for a period of one to three months," says Dr. Schlesinger. "For some women who otherwise would have needed surgical correction of their contracture, surgery was no longer needed.

 

ASTHMA MEDICATION

Dr. Schlesinger says that he has been using Accolate for approximately three years and has found it most effective in treating early-phase contracture (less than six months) and as a preventative treatment in patients considered "high risk" for contracture; this group includes those with a history of previous capsular contracture and patients with a tendency toward hypertrophic scarring. However, he says there has also been some success in using the drug to treat established contracture.

"Our preliminary findings do not suggest that Accolate is the answer for every patients with contracture," advises Dr. Schlesinger. "For patients whose capsular contracture is severe and long-standing, meaning a year or more, surgical intervention is still the best option. But for patients who are not good candidates for surgery or elect not to undergo surgery – such as breast reconstruction patients who may have experienced capsular contracture following radiation therapy it may be possible to achieve some degree of improvement using Accolate"

Dr. Schlesinger’s results are based on a treatment of 20 milligrams of Accolate administered orally twice daily – the same dosage indicated for the preventative and chronic treatment of asthma in adults and children 12 years of age or older. From November 1996 through 1998, Accolate tablets were prescribed more than 4 million times for asthma treatment and, reportedly, the drug is well tolerated. Side effects may include headache (12.9%) and nausea (3.1%).”

Dr. Schlesinger’s clinical experience with Accolate is very preliminary, but is consistent with other research suggesting that certain medications may be useful in helping to prevent or improve the symptoms of capsular contracture in properly selected patients," says James Baker, J r., MD, Breast Surgery Committee chair for the American Society for Aesthetic Plastic Surgery.

 

 

 

 

  • The effect of zafirlukast (Accolate) on early capsular contracture in the primary augmentation patient: A pilot study. 

R. Reid, S. Greve, L. Casas

Aesthetic Surgery Journal, Volume 25 , Issue 1 , Pages 26 - 30

The development of capsular contracture following breast augmentation presents a challenge to the plastic surgeon. Treatment of capsular contracture with the leukotriene antagonist zafirlukast (Accolate, AstraZeneca, Wayne, PA) has received much attention in the media; however, there is limited proof of its effectiveness.

The purpose of this study was to prospectively examine a single surgeon's experience using zafirlukast in the treatment of capsular contracture in primary, submuscular breast augmentation with saline-filled, smooth-walled implants.

Thirty-seven patients (74 breasts) who underwent primary sub-muscular breast augmentation with saline-filled, smooth-walled implants were evaluated at 1, 2, 4, 6, 12, 24, and 48 weeks postoperatively by 3 independent observers and rated for capsular contracture using a modification of the Baker classification. Patients who demonstrated any capsular contracture (higher than modified Baker 1.0) were offered off-label use of zafirlukast 20 mg PO BID for 3 or 6 months after full informed consent was reviewed and accepted.

In addition, patients were offered liver function chemistries at the start of treatment and at 1, 3, and 6 months following zafirlukast treatment. The patients were assessed for implant mobility and capsular contracture at the initiation of leukotriene therapy and then again at 3- and 6-month time points.

Forty-one breasts in this series (55.0%) were found to have early, mild capsular contracture. Specifically, 25 breasts were graded 1.5 (33.8% of total), 14 breasts graded 2.0 (18.9%), 1 breast graded 2.5 (1.4%), and 1 breast graded 3.0 (1.4%). Mean follow-up was 6.3 months. A positive response (complete or partial) was seen in a statistically significant proportion of treated breasts (75.7%, P < 0.05). This response was maintained on a long-term basis, with a mean follow-up of 16.5 months.

Zafirlukast appears effective in treating early capsular contracture after primary sub-muscular breast augmentation using saline-filled, smooth-walled implants. Further prospective studies with control groups and long-term follow-up will be needed to address many unanswered questions, including whether leukotriene inhibitors have long-term effects on capsular contracture following breast augmentation.

 

 

 

 

Other Methods of Treating Capsular Contracture

 

Enhancing patient outcomes in aesthetic and reconstructive breast surgery using triple antibiotic breast irrigation: six-year prospective clinical study.

Adams WP Jr, Rios JL, Smith SJ.

Department of Plastic Surgery, Parkland Health and Hospital System, Dallas, Texas, USA. dr@dr-adams.com

BACKGROUND: Capsular contracture remains one of the most commonly reported complications in aesthetic and reconstructive breast patients. Previous in vitro studies from the authors' laboratory have recommended an new triple antibiotic povidone-iodine irrigation (2000) and subsequently a triple antibiotic non-povidone-iodine-containing irrigant (2001) to optimize broad-spectrum coverage of various bacteria implicated in capsular contracture; however, the clinical efficacy of these in vitro studies remains unproven. The purpose of this study was to determine the clinical efficacy for the previously reported triple antibiotic breast irrigation. The cost-effectiveness of universal application of irrigation solutions in breast prosthesis surgery was analyzed as well.

 

METHODS: Patients undergoing aesthetic and reconstructive breast implant procedures were treated with a standardized operative technique, including the use of triple antibiotic breast irrigation by a single surgeon. Capsular contracture was assessed using a simplified Baker scale and graded by two independent caregivers to maximize objectivity and consistency. Additional complications were also recorded, including re-operation. Patient charges for antibiotic irrigation and re-operation for contracture were determined and compared.

 

RESULTS: A total of 335 patients operated on since 1997 were evaluated prospectively. They ranged in age from 18 to 86 years, and the mean follow-up was 14 months (range, 6 to 75 months)The rate of grade III/IV capsular contracture in the study groups was 1.8 percent for patients undergoing primary breast augmentation. Patients undergoing augmentation-mastopexy had a grade III/IV contracture rate of 0 percent. Breast reconstruction patients had a 9.5 percent rate of grade III/IV contracture.

 

CONCLUSIONS: Triple antibiotic breast irrigation is clinically associated with a low incidence of capsular contracture compared with other published reports, and its clinical efficacy supports previously published in vitro studies. Application of triple antibiotic irrigation is recommended for all aesthetic and reconstructive breast procedures and is cost effective.

 

 

 

The correction of capsular contracture by conversion to "dual-plane" positioning: technique and outcomes.

Spear SL, Carter ME, Ganz JC.

Division of Plastic Surgery, Georgetown University Medical Center, Washington, DC 2007, USA. spears@gunet.georgetown.edu

Little has been published regarding the treatment of patients with long-established capsular contracture after previous sub-muscular or sub-glandular breast augmentation. This study reviews 7 years of experience in treating established capsular contracture after augmentation mammaplasty by relocating implants to the "dual-plane" or partly sub-pectoral position. A retrospective chart review was performed on all patients who were treated for capsular contracture using this technique between 1993 and 1999.

Data collected included the date of the original augmentation, the original implant location, date of revision and type of implant used, length of follow-up, outcome, and any ensuing complications. Different surgical techniques were used, depending on whether the prior implant was located in a sub-glandular or sub-muscular plane.

All patients had revisions such that their implants were relocated to a dual plane, with the superior two thirds or so of the implant located beneath the pectoralis major muscle and the inferior one third located sub-glandularly. Of 85 patients reviewed, 54 had their original implants in a sub-muscular position and 31 had their initial augmentation in a sub-glandular position. Of the 54 patients whose implants were initially sub-muscular, 23 patients (43 percent) had silicone gel implants, 15 patients (28 percent) had double-lumen implants, and the remaining 16 patients (30 percent) had saline implants.

Of the 31 patients whose implants were initially sub-glandular, 20 patients (65 percent) had silicone gel implants, three patients (10 percent) had double-lumen implants, and the remaining eight patients (26 percent) had saline implants. Fifty-one patients (60 percent) had replacement with saline implants (37 smooth saline, 14 textured saline), whereas 34 (40 percent) had silicone gel implants (seven smooth gel, 27 textured gel). The average time from previous augmentation to revision was 9 years 9 months.

The average follow-up time after conversion to the dual-plane position was 11.5 months. Only three of 85 patients required re-operation for complications, all of which involved some degree of implant mal-position. Of patients converted to the dual plane, 98 percent were free of capsular contracture and were Baker class I at follow-up, whereas 2 percent were judged as Baker class II. There were no Baker level III or IV contractures at follow-up.

The dual-plane method of breast augmentation has proved to be an effective technique for correcting established capsular contracture after previous augmentation mammaplasty. This technique appears to be effective when performed with either silicone or saline-filled implants.

 

 

 

 











 

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