ALL ABOUT CAPSULAR CONTRACTION

BY ROBERT YOHO, M.D.

Capsular contraction or firming of the breast implant after surgery is the most common problem we face in implant surgery, and many surgeons hardly mention it to their patients. Hopefully, with the counseling prior to the surgery, the patients understand all about it. The Allergan® study, which involved thousands of some of the best surgeons in the country, showed a reoperation rate for silicone breast implants by 5 years of roughly 30% and a capsular contraction rate of over 20%. These figures are perhaps a little better for saline implants, but this is not completely clear based on medical journal articles.

Capsular contraction has several causes. Two that are commonly implicated are: low-grade infection and excess blood in the implant pocket after the surgery. However, many capsules form for unknown reasons. While most capsules occur in the first 6 months after surgery, some form up to many years later.

The classification of capsular contraction consists of:

Grade 1, a completely soft breast and natural implant with no apparent firming

Grade 2 some firming of the implant but no distortion

Grade 3 there is some distortion

Grade 4 where the implant is very hard and there is distortion and pain.

We do not like grade 2 capsules, although many surgeons accept grade 2 capsules and do not treat them. We attempt to treat them medically by prescribing the asthma medicines Accolade and Singular, which are “off-label use” of these medications. Like many medicines, these are being used here for a something not formally approved by the FDA. This is perfectly legal in the United States; many medications are used in this fashion. These medicines are considered very safe although there are very rare cases reported of liver failure for Accolade. This problem, if it really is true, exists on the order of one in a million or 2 million cases.

Another medicine that we have become convinced really helps is fish oil. We recommend all our patients postoperatively take fish oil about 4 grams or 4 rather large pills a day. This can be obtained at Costco or Trader Joe’s. More expensive fish oil, which does not have a fishy taste, can be purchased at vitamin stores. These have been more carefully tested for mercury. Mercury is not good for the human body in high levels and might be concentrated in fish oil. Two brands we recommend are Nordic Naturals or Carlson. Fish oil seems to have an anti-inflammatory effect on tissues and for swollen joints and other problems. Since the capsular contraction seems to be an inflammatory process in some cases, the fish oil may possibly prevent this. Fish oil in all likelihood is very helpful for your heart health as well. Some authorities even recommend higher doses, but we generally stick with the 4 grams or 4 large pills a day.

Another treatment, no longer standard practice, is squeezing or massaging the breast implants aggressively, cracking the implant capsule. Although patients are encouraged to massage breast implants several times a day in order to keep the pockets open, this other massage is a bit rougher and the doctor might do it. This has fallen into disfavor because of a relatively low success rate perhaps 50%, plus a small risk of implant rupture and/or bleeding requiring another surgery. We think that it has some value for select cases, but it does not work for higher-grade capsules.

Note: The “gummy bear” implant has been said to have lower capsular rate. However, this is because the gummy bear implant is firm kind of silicone that does not feel as soft and natural to begin with. It has a feel like a grade 2 capsules when you have the implants placed, right after surgery. Since grade 2 capsules are accepted by majority of surgeons and nothing is done about them, the gummy bear implant in theory would have a lower capsule rate. However, we try to have every patient keep their implants/breasts completely soft, in other words a “grade 1” capsule. This is not always possible of course.