SILICONE OR SALINE BREAST IMPLANT CAPSULAR CONTRACTURE
Breast implant capsular contracture, scar tissue formation, and breast implant hardening are a difficult topic of discussion for many patients. Some women may be embarrassed by the look and feel of a hardened breast implant and may delay treatment for many years thinking that there are no options for them. Fortunately, there are many options available to improve the look and feel of a breast implant even if there is severe hardening and thickening of the implant capsule.
Even today, we do not know exactly what causes implant capsules to thicken and harden. The process is known as capsular contracture and it can happen with any type of implant, regardless of whether it is a silicone or saline breast implant. Technically, a periprosthetic shell of collagen-rich scar tissue forms around an implant which ultimately leads to malformation of the implant contour, movement of the implant, and hardening of the tissue around the breast implant.
Plastic surgeons generally classify breast implant hardening and capsular contracture using the 'Baker's classification of capsular contracture.' The classification is listed below, but this is mainly used for plastic surgeons to characterize the implant capsule in a more standardized fashion so that it can be reliably interpreted from plastic surgeon to plastic surgeon. For instance, if I am practicing in Los Angeles and I would like to refer a patient to a colleague in New York, I would simply tell them that this 56 year old female patient has Class I capsular contracture of the right silicone breast implant and Class III capsular contracture of the left silicone breast implant.
BAKER'S CLASSIFICATION OF IMPLANT CAPSULAR CONTRACTURE
Class I: Breast appears natural. There is no identifiable signs of a breast implant on examination.
Class II: Minimal breast implant contracture. There is a palpable scar around the implant but thereis minimal visible change in the breast.
Class III: Moderate breast implant contracture. There is palpable thickening and hardening of the breast in addition to a visible change in the shape of the breast.
Class IV: Severe breast implant contracture. There is palpable thickening and visible changes in the breast that is similar or more severe than Baker's Class III, but with associated pain.
Although the physical forces around a breast implant may contribute to breast implant thickening or scar tissue, we still cannot identify a single etiology or cause of breast implant contracture. Some patients have it in only one breast, making the link even harder to determine. Some causes of breast implant capsular contracture include silicone gel migration outside of the breast implant, bacteria, hematoma or bleeding after breast implant surgery, trauma, connective tissue disorders, keloid history, predisposition to developing poor or hypertrophic scars, lack of massage of the breast after surgery, prior encapsulation of a breast implant, radiation, and foreign body reaction. All of these may stimulate an enhanced fibroblast reaction that leads to the deposition of scar tissue around the implant.
It is thought that certain leukotriene inhibitors may work to decrease the incidence of capsular contracture after breast implant surgery. The use of these medications should be discussed with Dr. Karamanoukian during your consultation.
In addition, submuscular breast implant placement also leads to a lower incidence of breast implant capsular contracture in comparison to subglandular placement of an implant.
OPTIONS FOR BREAST IMPLANT REMOVAL OR EXPLANTATION
On your initial consultation with Dr. Karamanoukian, a comprehensive evaluation of your medical history, physical examination, and mammograms (if needed) are assessed. It is always a plus to have your original operative note and breast implant information if that is available. Do not worry if you do not have them as they can be obtained if necessary.
The examination will focus on your breasts and armpits to determine the extent of capsular contracture of the breast implants and whether or not the breast implants are intact or have ruptured. Sometimes it is not so easy to tell and Dr. Karamanoukian will order a mammogram, ultrasound, or even an MRI. We know that submuscular implants have lower rates of capsular contracture and the placement of the implant is important to determine during the examination.
If a breast implant surgery was performed over the muscle, it is sometimes necessary to change the position of the implant so that it lies under the muscle after revision. This can be done as a purely subpectoral implant placement, a submuscular implant placement, or using a dual plane approach that is half under the muscle. Dr. Karamanoukian can explain all of these options during your consultation. Remember, there are many options to improve your breast shape and size and these breast revisions techniques are safe and affordable.
There are three main categories of surgery that can be performed to improve breast implant capsular contracture. Explantation of the breast implant, capsulotomy of the breast implant shell, capsulectomy of the breast implant shell, or breast implant revision.
EXPLANTATION OR REMOVAL OF BREAST IMPLANTS
Although explantation or removal of the entire implant without replacement may seem like a good option for patients who are just tired of dealing with the capsular contracture, the utility of doing so depends on how much breast tissue there is left to maintain a normal breast contour. If you have very little breast tissue remaining, simply removing the implants may not be aesthetically pleasing.
The decision to remove implants altogether is an important one and it remains a viable option for many patients. During your consultation, Dr. Karamanoukian will discuss the alternatives to explantation, including breast contour revision, scar revision, capsulotomy, and capsulectomy.
During explantation, the breast implant will be removed during surgery. A decision to remove the entire capsule will also be made prior to surgery depending on the degree of scar thickening. In the setting of thickened capsules or calcified capsules, it is advisable to remove the entire capsule or the anterior aspect of the breast capsule.
Capsulotomy - Capsulectomy - Los Angeles
A capsulectomy procedure involves removal of the thickened fibrous capsule from the implant, with or without removal of the breast implant. In cases of implant rupture, the entire implant and capsule are removed en bloc. Segments of the capsule can also be removed during a partial capsulectomy. The most common partial capsulectomy performed involves removal of the anterior side of the capsule while the posterior (rib surface) of the capsule is left intact.
Capsulectomy can be performed using small incisions and involves meticulous dissection of the implant capsule and the associated calcification. Breast implant revisions often involve some element of capsulectomy, especially when the shape of the breast implant is distorted by the breast implant capsule.
In some cases, a drain will have to be placed into the surgical pocket to reduce fluid accumulation and improve tissue adhesion along the surgical plane. This decision will be made based on the specifics of your case.
QUESTIONS ABOUT BREAST IMPLANT CAPSULAR CONTRACTURE
What causes capsular contracture of the breast? Breast capsule formation is likely due to chronic inflammation around the implants as a result of foreign body reaction. Not all patients will develop this type of reaction. It is also thought that low-grade infection, subclinical infection of implants, or seepage of silicone oil around the implant may contribute to the formation of breast capsules.
What causes breast capsule formation? Baker et al. demonstrated that the myofibroblasts, which help regulate wound healing are involved in capsular contracture of the breast.
Does surgical technique influence the formation of breast capsules after silicone implantation? Yes, it is thought that certain factors may contribute to the formation of breast capsule thickening. Submuscular implant placement, adequate dissection of the breast pocket, surgical hemostasis, meticulous sterile technique, and prevention of infection can improve the chances of normal postoperative recovery and lessens the formation of capsular contracture.
SCHEDULE A CONSULTATION WITH DR. KARAMANOUKIAN
Dr. Karamanoukian will discuss your options for capsulectomy during your consultation. Please schedule a consultation for breast capsular contracture with Dr. Karamanoukian by calling (310) 998-5533.