Capsular contracture or encapsulation of implants is one of the problems of breast surgery with implants that most concerns patients and surgeons.
The periprosthetic capsule:
When an implant is inserted into the pocket of the gland, a natural defensive reaction occurs (because the body considers it a pathogen) consisting of a scar around the prosthesis. This reaction is called a foreign body reaction and occurs whenever an object is introduced into the body. The scar is mainly composed of connective tissue (scarring)
The capsule itself is a good phenomenon and indicates good healing. The main role of the periprosthetic capsule is a curative, scarring mission, allowing the adhesion of the implant to the tissues, preventing open cavities which prevents seromas and prevents infections. So the fact that the capsule is not formed is bad but so is the fact that there is an excess of capsule.
What does it consist of?
The normal periprosthetic capsule is composed at the microscopic level of fibroblasts and collagen fibers as well as blood vessels. At first glance the capsule is a thin fabric that surrounds the implant, whitish, shiny and the same size as the implant it contains inside.
Sometimes the capsule has abnormal characteristics : is thick, very firm, irregular, has non-whitish areas and irregularities, sometimes calcifications, is matte, can even be yellowish, and has a tendency to shrink compressing more and more to the implant.
Therefore we speak of encapsulation or capsular contracture in those situations that after the insertion of an implant that is formed is a pathological capsule and not a normal capsule.
What are the signs and symptoms of capsular encapsulation or contracture?
Capsular contracture can occur initially in the first months after surgery or late years after the implant and in this case indicates a deteriorated or ruptured implant.
So we can say that if a capsular contracture appears in a patient who was well we must think about rupture of the implant (if it happens before 7-8 years we can consider that the implant was defective)
The periprosthetic capsule is formed by a natural, physiological process and during the first 3 weeks after the insertion of the implant. The first symptoms of encapsulation or problems with the capsule usually appear between the 5th and 6th postoperative week, usually in the 2nd postoperative month. From 7 – 8 months the capsule is definitive and only has surgical treatment.
The usual evolution of encapsulation is the progressive hardening and traction of the tissues that are around the implant producing a bad placement of the prosthesis that is progressively placed upwards and externally, the nipple will be progressively arranged looking down and the usual rope of the lower pole disappears. In the case of prostheses introduced by areolar route, it will produce an umbilication of the incision scar.
What degree of encapsulation do I have?
To classify the degrees of contracture most surgeons have been using the following classification according to the degrees of encapsulation for many years:
- Grade I: the normal capsule that should always form.
- Grade I in: normal feel and shape of the implant.
- Grade I b: soft touch and slightly visible implant, is considered within normality.
- Grade II: firm touch and normal or acceptable shape.
- Grade III: firm touch and abnormal shape.
- Grade IV: hard touch, abnormal shape, may be annoying or painful.
In a generic way and always assessing each patient separately, the symptomatology, and the shape of the breast we can say that grade I does not require treatment, the II non-surgical treatment if we take it in time and grades III and IV surgical treatment.
Why did my breast encapsulate?
There are many factors that can favor the formation of a pathology capsule :
- Surgical factors:
- Aggressive surgery without respecting the plans.
- Undrained post-surgical hematoma.
- Placement of smooth prostheses in a subglandular plane.
- Contamination of the prosthesis during introduction.
- Post-surgical factors:
- Postoperative hematoma.
- Seroma as a result of aggressive efforts or massages during the first postoperative weeks.
- Lack of patient collaboration in the healing period. Not keeping enough rest for the first 3-4 weeks can cause bleeding or seroma to occur and this will cause greater fibrosis and contracture.
- Individual factors:
- They are anatomical and medical particularities of each patient in some known cases (such as poorly elastic skin due to radiotherapy, burns, etc.) and in others of unknown cause.
What solution does an encapsulated breast have?
Any non-surgical or preventive treatment of capsular contracture must be performed during the first postoperative months, being able to consider the state of the definitive capsule from the 7th or 8th month, at which time we can only solve it by surgical treatment.
The possibilities of treatment of capsular contracture that have shown efficacy are:
- Massages: They can be effective when done well and in the recommended period. We do not consider that it is indicated to start before the capsule is formed because they could affect the adhesion of the same to the prosthesis and favor a rotation of the same or a lack of adhesion producing a seroma and consequently be responsible for the contracture that you want to avoid. It is very important to follow the doctor’s instructions to make them and would be indicated only in the incipient pathological capsules from the 4th week when the capsule is formed and during the first 6 postoperative months, in which the periprosthetic capsule is maturing and is not yet definitive. They are the first therapeutic step.
- Capsulectomy: removal of the capsule. It is the surgical treatment of choice of encapsulation, highly effective and can even be repeated. It is important to perform the complete excision of the capsule if we want to avoid recurrence.
- Submuscular conversion: If the encapsulated prosthesis is subglandular, it is preferable to perform capsulectomy + the change of plane to subpectoral.
- Replacement of implants: A capsulectomy and replacement of the implants is performed. If they are smooth we change to textured and if they are textured we can consider the placement of polyurethane prostheses.
- Reconstructive techniques: One of the techniques that is increasingly used is the removal of prostheses and replacement by fatty tissue grafts. Since the fat must be implanted in the live plane in the first time, very little fat can be grafted and will require more than one surgical time to achieve an acceptable result.
Ineffective or dangerous techniques for the treatment of capsular contracture:
- Leukotriene inhibitors: these are drugs for the treatment of asthma, which have been proposed as effective in the treatment of mild degrees of encapsulation. The most used is the Acolate and in addition to not having scientifically proven its effectiveness in the treatment of capsular contracture can cause liver toxicity.
- Ultrasounds: Not only have they not shown efficacy but they can cause damage to implants and breast tissues.
- Closed capsulotomy: it was applied in the past and consisted of external maneuvers (without opening the skin) squeezing and bursting the capsule. This aggression caused ruptures of the implant and hemorrhages that sometimes forced to enter the emergency room in the operating room.
- Partial capsulectomy: That is, removing part of the capsule but not all of it. When leaving pathological capsule the recurrence of the problem is the most frequent.
Currently the incidence of capsular contracture has decreased a lot thanks to the greater training of surgeons and the greater collaboration of patients.