Various therapies have been tried to treat capsular contracture including forceful manual external compression (closed capsulotomy), ultrasound, and medications. Closed capsulotomy has been abandoned by plastic surgeons because it is painful, unpredictable in its efficacy, and can cause serious complications such as hematoma formation.
Ultrasound has been advocated by some as a very effective non-surgical approach to capsular contracture. The Aspen Ultrasound System is a leading technique that applies external ultrasound to the breast with a hand held device. Up to ten treatments are spaced out over a month or more. Breast massage is an integral part of the treatment program. There have been a few scientific articles supporting the use of this modality as well as positive anecdotal internet commentary by patients. However the true efficacy of this approach and its limitations remains to be clarified by formal scientific study. It appears already that this method is not recommended for the most severe forms of capsular contracture (Baker IV).
Various medications have been advocated for the treatment of capsular contracture. The only group that has some scientific validity are leukotriene inhibitors. These are primarily asthma drugs that also appear to be useful in treating capsular contracture. They work by blocking certain white blood cell functions that contribute to inflammation. There are two popular brands used: Accolate (zafirlukast) and Singulair (montelukast). Accolate is associated with a rare risk of serious liver damage so Singulair is preferred for safety. When given as a preventative for three months after surgery a slight decrease in the incidence of capsular contracture has been demonstrated in several studies. These drugs appear to be much less effective for treating well-established capsular contracture that is more severe (Baker III or IV).
Conventional Surgical Treatment
The indications for surgical treatment are cosmetic deformity, pain, and failure of nonsurgical treatment. Lower grade capsular contracture (Baker II) typically does not require surgical intervention. Treatment is even optional for some cases of higher grade contracture (Baker III) where asymmetry or symptoms are absent. This is most commonly seen when both sides are affected similarly by the process. In any event, there is no urgency in surgically treating capsular contracture from an overall health standpoint.
The core tenets of the surgical treatment of capsular contracture are removing the scar capsule and replacing the implant. A new implant is used because of the belief that the original retains an inciting bacterial biofilm on its surface that cannot be eradicated. Implants that were originally positioned in front of the pectoral muscle (subglandular location) are usually switched to a new pocket under the muscle (submuscular or subpectoral) because there is strong evidence that the incidence of capsular contracture is lower when the implant is under the muscle. Other important principles such as minimal handling of the implant, irrigation of the implant pocket with an antibiotic solution, the use of intravenous antibiotics during the procedure and isolating the skin from the implant during insertion are standard practice. Drains are placed and removed after a week. Their purpose is to prevent an accumulation of fluid around the implant as the acute surgical inflammation subsides.
Surgical Treatment with Acellular Dermal Matrix (ADM)
Acellular dermal matrix, or ADM (LifeCell Corporation), is a processed tissue product in which host cells are eliminated while preserving the structure of the dermis tissue. It is harvested from either human cadavers or a porcine source. It comes in various sizes and thicknesses (Fig. 1).
The purpose of using ADM is to create a complete tissue barrier between the implant and the breast tissue. Studies have shown that this tissue interface can prevent capsular contracture. The ADM lines the inside of the pocket and is placed after the capsule is removed and before the implant is inserted. ADM placement is a very involved technical process (see procedure videos) and much more time consuming compared to conventional treatment.
Surgical Treatment Results
Our practice has conducted a ten year retrospective review of patients treated for capsular contracture with both conventional methods and the alternative using ADM. Patients in this study were surgically treated only if the breasts were very firm (Baker III or IV). The study included 166 patients who underwent a total of 195 corrective procedures with an average post-treatment follow-up period of 12 months. Most patients (147) had one episode of capsular contracture but some (19) were already treatment failures presenting for another attempt. The majority of patients had been treated by the conventional method. The use of ADM is a relatively recent development and there were only 16 of these patients included in the study group. However these were among the most challenging cases and the follow-up period was as long as three years in some patients.
The study showed that the chance of success with conventional treatment was 73% compared to 100% in the ADM treated population. Moreover, the chance of success with conventional treatment fell to 60% if there was a previous surgical treatment failure, and to 50% if there were two previous treatment failures. Success rates were higher with conventional treatment when only one breast was affected (78%) compared to both sides affected (66%). This difference is consistent with the suspicion that double capsular contracture is a more severe patient specific entity representing a hyperimmune response, compared to one sided cases that are more likely random events less likely to recur.
Surgical Time and Cost Considerations
|Product||Source||Dimensions (cm)||Unit Cost*||Number per Breast|
|Alloderm||cadavers||10 x 20||$8,189||2|
|Strattice||porcine||9 x 18||$2,730||2|
Conventional surgical treatment can take 1.5 hours or more for each breast. Using ADM adds an additional hour per side. Therefore conventional treatment of both sides will range from 3 to 3.5 hours whereas adding ADM to the process will run procedure time to 5 to 5.5 hours. While shorter operating time is always desirable to minimize the potential for complications, the extra time is worth the risk when ADM use is indicated as a superior option.
ADM material is very expensive, much more so than the breast implants themselves (Table I). Additional operating time is also expensive. Total fees including breast implants, ADM, surgical fees, anesthesia fees, and facility fees can equate to buying a small car. However, in the proper setting the use of ADM is ultimately cheaper than failure using a conventional approach without ADM.
Which Method is Best?
Procedure selection is based on cost and efficacy. Our recommendation is that a conventional approach is a reasonable first choice for a one sided case of capsular contracture, particularly when the opposite side is very soft and has therefore demonstrated a normal healing response by the body. One sided capsules occurring after a hematoma are another good indication for a conventional approach, as a specific cause such as this does not indicate an intrinsically poor healing tendency.
Double capsules (i.e. both sides) have a higher failure rate and a conventional approach in this instance risks much greater total cost if the condition recurs and additional surgery is needed using ADM. Therefore initial surgical treatment using ADM, despite greater comparative expense, is a more cost effective long-term option for cases of double capsules. Additionally, treatment with ADM is indicated for any case (one sided or double) where there has been a previous surgical treatment failure. When considering the balance between cost and efficacy it should be noted that the failure rate with conventional treatment is as high as 20 to 25%.