Breast enlargement is still the most popular plastic surgery in Germany and is in first place with 17.8% according to the German Society for Aesthetic Plastic Surgery (DGÄPC). According to Statista, over 53,000 breast enlargements were performed in Germany in 2015.
Capsular fibrosis (capsular contracture) is the most common complication that can occur after breast augmentation with breast implants. The risk of capsular fibrosis after breast augmentation is 2-8%. This means that about 1,000 to 4,500 women in Germany developed capsular fibrosis.
Older statistics with smooth-walled implants (2nd generation breast implants, 70s / 80s), mostly introduced via the muscle, show capsule fibrosis rates of up to 30%. According to a scientific study, 60% of all capsular fibrosis occur in the first six months and 90% within one year after surgery. When comparing the implant position, 70% of all capsular fibrosis developed when the implant was placed over the pectoral muscle and only 30% when placed under the pectoral muscle. These studies, which were mainly carried out in the 1990s, showed alarming numbers. With the introduction of 3rd (4th / 5th) generation breast implants with a textured surface and optimized surgical techniques, the risk of capsular fibrosis was significantly reduced. Recent studies on implants with cohesive silicone gel and a rough surface show a risk of fibrosis of less than 5%.
What is capsular contracture?
Ultimately, capsular fibrosis is an unspecific reaction of the organism to the introduction of foreign material into the body. That means capsular fibrosis can occur with a glass splinter under the skin, a pacemaker, a hip prosthesis or just with a breast implant. It is therefore irrelevant what material this foreign body is made of and what shape it has. Capsular fibrosis develop regardless of whether the breast implant is filled with silicone gel, saline or another substance.
Capsular fibrosis always occurs when a more or less thick connective tissue covering made of collagen fibers forms around the foreign body (breast implant), which then tightens and presses on the implant.
Formation of capsules is natural reaction of the immune system to foreign objects. The capsule that forms during wound regeneration fixed the implant, and its structure reminds of the mammary gland. However, in case of capsular fibrosis, this capsule is very solid, and it pushes against the implant. As the result, it gets hard, deforms and causes pain.
Capsular fibrosis can occur any time after operation, and may affect one or both mammary gland.
Pretty often, women after breast surgery are embarrassed when they feel pain and unpleasant sensations in breast, or notice sudden changes. Can it be an early sign of capsular fibrosis? Sometimes women can complain because of the sensation of loading on breast: it may happen during the first year after operation, being caused by inflammatory reactions. Are there any symptoms of capsular fibrosis in this case?
Capsular fibrosis has a few pronounced symptoms experiencing which a woman should immediately visit a surgeon. Only the doctor can define whether there’s incapsulation of implant that should be quickly eliminated. When the following symptoms appear in one or both breasts, the chance of having capsular fibrosis are pretty high:
Causes of capsular fibrosis
Ultimately, the cause of capsular fibrosis after breast augmentation is still not entirely clear. Numerous factors (multifactorial events) are certainly important for the development of capsular fibrosis. Here, for example, an individual predisposition to the formation of capsular fibrosis can be mentioned. On the other hand, capsular fibrosis can only occur on one side after breast augmentation on both sides. So other aspects must also play a role. However, the attraction of the foreign body introduced into the organism (breast implant) certainly represents the decisive role for the development of capsular fibrosis.
Breast implant surface
Breast implants with a shell made of solid silicone have been used for breast enlargement for over 50 years. It has been recognized that the surface of the breast implant plays an important role in the development of capsular fibrosis. A roughened surface of the shell of the breast implants is advantageous with regard to the development of capsular fibrosis. If the implant surface is rough, it is more difficult for the capsule collagen fibers to align.
Breast implants with a shell made of solid silicone are either filled with saline or with silicone gel.
Leakage of silicone gel
If the shell of the breast implant tears, the silicone gel is an additional stimulus for the development of capsular fibrosis. In the event of ruptures of the implant shells, the breast implant should always be removed or replaced quickly.
Bruising, hematoma in the area of the breast implant
As part of a breast augmentation surgery, the plastic surgeon must first create a wound cavity into which the breast implant can then be inserted. A more or less large bruise can develop in this wound cavity after the operation. If larger amounts of a bruise are left in the wound cavity, the organism will break it down (resorb) in the period after the operation. Scar tissue or capsular fibrosis can develop from residual blood. It is therefore advisable to avoid major bruises after breast augmentation. In surgery, drains are used to avoid major bruises in the wound area. This means plastic tubes that are inserted into the wound cavity and have a connection with a vacuum bottle to suck up blood residues. These redon drainages can also be used for breast enlargement.
Symptoms of capsular fibrosis
- Serious pain and sensation of tightness in chest;
- breast deformation or changes of implant form;
- movement or deformation of the implants;
- a solid capsule inside the breasts;
- breast asymmetry and formation of wrinkles and folds.
According to four-grade Baker scale, capsular fibrosis has four stages, they are also called “Baker’s stages”. Depending on the severity of disease, it can be either minor hardening (I stage by Baker), or formation of pronounced capsules with visible deformation (IV stage by Baker).
- Stage I – normal state: the breast is soft at touch, it has natural appearance, visible or sensible chages are absent.
- Stage II – minor capsular contracture: minimal hardening of breast accompanied by absence of visual changes.
- Stage III – serious capsular contracture: breast hardening with visible deformation, but there’s no pain.
- Stage IV – pronounced capsular fibrosis: sensible breast hardening accompanied by severe pain and serious deformation.
Treatment of capsular contracture
Closed capsule detonation
A closed capsule detonation is a largely abandoned and no longer recommended procedure for treating capsular fibrosis after breast augmentation. An external pressure on the bulging capsule tries to tear it. In earlier times, this closed capsule detonation was often carried out without anesthesia, which was naturally associated with severe pain.
The only advantage of this method was that in the best case scenario, capsular fibrosis is treated without surgery. However, the disadvantages and risks here are considerable: First of all, capsule detonation was not always possible. If the capsular fibrosis was blown up with pressure using this closed procedure, there was no influence whatsoever on whether a sufficient, complete blast succeeded or whether this did not lead to displacements of the breast implant. In addition, there was a risk of injury to the breast implant due to the massive external force. For all these reasons, the closed capsule detonation process should no longer be used or recommended today. It is only described here for the sake of completeness.
Capsule notch in capsular fibrosis after breast augmentation (capsulotomy)
As a rule, pronounced capsular fibrosis are treated surgically today. One treatment method is the so-called capsulotomy. The old breast implant is first removed, usually via a cut in the breast fold.
Then you notch the capsule from the inside, but leave it in the tissue. This makes it possible to widen the implant cavity again so that a new implant can be inserted.
The advantage of this method is that the capsule can be left in the tissue. Occasionally, with complete, surgical removal of inflammatory capsular fibrosis, increased bleeding may occur. Of course, this can be avoided with notching alone. If the soft tissue is very thin, the implant capsules are sometimes directly under the skin. Under certain conditions, it may make sense to leave the capsule or at least parts of it for better "padding" of the breast implant. On the other hand, bacterially contaminated, left capsule can be responsible for the recurrence of capsular fibrosis (see above).
Surgical removal of the capsule in capsular fibrosis after breast augmentation (capsulectomy)
The complete surgical removal of the capsule is the standard procedure for pronounced capsular fibrosis of the breast after breast augmentation. The constricting tissue capsule is completely removed. A fresh, wide wound cavity is created, which can accommodate the new implants.
How to prevent capsular fibrosis?
Unfortunately, capsular contracture cannot be totally avoided in some cases, even if the risks are minimized when the factors promoting contracture are excluded.
During the last years, the frequency of capsular contraction has decreased considerably, because innovative structural implants are being introduced. Different researches have proved that use of texturized implants (with uneven surface) reduces the chance of capsular contracture in comparison with smooth implants. Today, experts often argue trying to decide whether the structure of implant has any meaning, though it’s supposed that it can have real connection with the risk of developing capsular fibrosis. Therefore, it’s recommended to use texturized implants.
Clinical data also shows that the location of implant is another factor promoting development of capsular fibrosis. It’s clear that there’s certain connection between the location of the implant and stage of disease by Baker. Therefore, the risk of developing capsular fibrosis when the implant lies under muscles (submuscular location) is lower than when the implant is placed above breast muscles (retroglandular location). It doesn’t mean though that submuscular implant location is always the best solution. It’s the surgeon who decides how to place the implant basing on patient’s overall health: the variant should be beneficial from both aesthetic and medical standpoints.
While location and structure of the implant are regarded as the factors connected with development of capsular fibrosis, there are some preventative measures for this disease. Modern units emit ultrasound waves that improve blood circulation and ensure oxygen supply of breast tissues: it helps to reduce the risk of developing capsular contracture. It is proved by numerous specialists of plastic and aesthetic surgery who have already implemented ultrasound treatment in their treatment. In a best-case scenario, a couple of preventative ultrasound sessions are enough to prevent development of capsular contracture.
Besides, regular massage helps to lower the risk of capsular fibrosis.