Surgical treatment of breast implant capsules are varied and diverse. Today, I want to review the available options and outline when they are used.
What is the Capsule?
Capsulectomies are an important component of Breast Augmentation Revision Surgery. The term literally means to remove the capsule, but what is the capsule?
The body forms a pocket of scar around the breast implant called the capsule. It is the magenta layer surrounding the implant in grey shown above.
When a Breast Implant, or any implant for that matter, is inserted into the body, a layer of collagen scar forms around it. This is the capsule. The Breast Implant Capsule serves several functions including:
- Holding the Breast Implant in Place
- Supplying a Novel Blood Supply around the Breast Implant
- Protecting the Breast Implant from Infection
- Providing a Shield Around the Breast Implant in Case of Leakage
Why Modify the Breast Implant Capsule?
Normally, the capsule around a breast implant is thin, soft and transparent. It is strong enough to support the breast implant, but not hard enough to be felt. If the capsule is too weak or too strong, capsule work may be needed.
The Capsule is too Week
A capsule which is too weak will not support the breast implant. This can lead to Bottoming Out, a situation when the implant falls below the normal breast crease. Additionally, the breast implants may displace laterally and move under the armpits, especially when you are laying on your back. This can be exacerbated by overly large breast implants.
When the capsule is not supporting the breast. implants treatments may include:
- Capsulorrhaphy – tightening the capsule
- Mesh – artificial reinforcement of the capsule
- Reducing the blast implant size
- Removing the breast implant altogether
The Capsule is too Strong
A capsule which is too strong will distort the breast implant. It can move the implants up and out, or squeeze the implants reducing their apparent size and making them feel hard. This is termed Capsular Contracture.
Capsular contracture squeezes the breast implants, making them appear smaller and feel harder. The red color is not unusual in grade III and IV contractures. After the capsulectomy, the breasts have a more natural shape and feel. The capsule removed with a complete capsulectomy are shown below.
Treatment for Capsular Contracture includes:
- Noninvasive Treatment – massage, ultrasound, various medications
- Capsulotomy – dividing the capsule
- Capsulectomy – removing the capsule
Noninvasive treatments tend to work best when started early, and are less effective for established capsular contracture. For tight, thin capsules a Capsulotomy opens the scar tissue and allows the pocket to expand. Thicker areas of scar tend to respond better to Capsulectomy or removal of the scar. The “gold standard” treatment is a Complete Capsulectomy and implant replacement (or removal).
Consensus Statement on Breast Implant Capsulectomy Definitions
The FDA recently created the Breast Surgery Collaborative Community
The BSCC consensus statement defines four types of capsulectomy. From least to most invasive they are:
- Partial Capsulectomy: Removal of the breast implant capsule where some capsule is left behind.
- Total Capsulectomy (total precise capsulectomy): Complete removal of the breast implant capsule, not necessarily done as a single unit or in one piece.
- Total Intact Capsulectomy: Complete removal of the breast implant capsule as a single unit.
- En Bloc Capsulectomy: Removal of the breast implant capsule with a margin of uninvolved tissue for treatment of suspected or established breast implant-associated cancers after appropriate medical workup.
Above are the capsules that surrounded the breast implants before breast revision surgery. The whitish color comes from the tough collagen fibers they are made of. These capsules were about half the size of the implants that they surrounded, explaining the small and firm appearance of the breasts before the capsulectomies.
En Bloc Capsulectomy is only indicated for cancer. There are many Internet opinions on using En Bloc Capsulectomy to treat symptoms associated with breast implants; however, this is not supported by current scientific evidence. In fact, removing the Breast Implants and leaving the capsule intact has the same cure rates as En Bloc Capsulectomy.
The debate reminds me of the historical radical mastectomy vs. modified radical mastectomy debate in general surgery for treating breast cancer. Some surgeons felt strongly that removing the pectorals major muscle from behind the breast gave a better margin and should therefore improve cure rates. Others felt the loss of function and increased disfigurement was not worth it. The science showed the cure rates were the same for both operations, so the more disfiguring operation was abandoned except in cases where the tumor involved the muscle.
Breast Implant Revision Surgery Consultations
If you are considering breast implant revision surgery in the San Francisco Bay Area, give us a call at (925) 943-6353. Choosing a Board Certified Plastic Surgeon is a good start, combined with thirty years of experience, we have treated a wide variety of Breast Implant Complications with good results.
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