The Management of Breast Capsules after Breast Augmentation
Whenever a foreign body is inserted in to living tissue, nature tries to make sure that it is sealed off from the outside world by forming a natural barrier or capsule around it.
When a breast implant is inserted this process will occur naturally and capsule formation is a normal healing response. For the majority of patients the capsule stays healthy, soft and pliable and you will not even notice it is there. However, sometimes the response is too aggressive or abnormal and the capsule can become hard and palpable and, in some patients, the capsule distorts the breast.
In severe cases not only can the breast shape become distorted but discomfort and pain can arise. This extreme scenario will only occur in a small minority of patients, but probably some form of capsule formation will occur in at least 10% of all patients who undergo breast augmentation.
The rate of capsule formation and the causes are complex; the type of implant used, surgical technique and patient factors all play a role. The rate is definitely less when polyurethane breast implants are inserted. However, I presently do not use these types of implants because of possible rare toxic effects of polyurethane and generally the biological effects of silicone are better understood.
When capsules do cause cosmetic problems or discomfort the treatment is further surgery. The old implant is removed and the abnormal capsule is carefully taken out. This surgery is called capsulectomy.
Then a new implant is inserted. Usually this solves the cosmetic problem and the discomfort but unfortunately there is no guarantee that a new palpable capsule does not return. In these unfortunate patients polyurethane implants may be entertained as an option, or even the option of not replacing the implants at all. Clearly, for this group of patients, careful discussion about the different options will need to take place between surgeon and patient.
At The Westbourne Centre capsulectomies are carried out under local anaesthetic and sedation as day cases. The recovery is generally the same as for all breast augmentations. Within ten days the external wounds should have healed. The number of days off work is very variable and depends on the individual and the type of employment. Usually, within two weeks, an office worker should be able to return to normal activity. Heavy manual work should be avoided for about six weeks.
Is capsulectomy procedure common for most women who have breast implants?
Probably more than 10% of women who have silicone implants will develop capsules. Capsulectomy can be carried out if the capsule causes unacceptable distortion of the breast or if the capsule is painful.
Are you happy to perform a capsulectomy if you did not perform the original breast implant surgery?
Yes. There are many reasons a person changes surgeons, which I discuss in the Frequently Asked Questions regarding Consultation.
In placing the implants under the muscle, does this damage the muscle in any way? What happens to the muscle if the implants need to removed for any reason?
This is a good question. The reasons for any muscle changing in function if it is not used for any reason, injured, the nerves been damaged or the muscle length and therefore its tension has changed. Initially the muscle is damaged because we have to incise it partially to get the implant under it. This is why sub-muscular implants are more painful postoperatively than implants placed directly under the breast. Also initially because it is stretched the muscle will function slightly differently, but nature is forgiving because the muscle will learn to behave as normal after a period of recovery.
I have not detected any long term functional problems with the muscle (called the pectoralis major muscle). However, if you were a professional swimmer, tennis player, athlete (such as a javelin thrower, gymnast) I would not recommend any sub muscular implants to be inserted. For “normal people” in the long term, I do not think that there should be any impediment to sporting activities and every day life. Long term the muscle, I believe, fully recovers.
If the implant is removed the muscle will function as before but I suspect that there will be a relatively short period of full functionally recovery as the muscle gets used to the decreased length and tension after the implants have been removed.
MRI scans – should I do this every few years to check for any ruptures?
This is a complex and important question. There is no indication for regular MRIs in my opinion to check the state of the implants. An MRI should be carried out only if there is clinical suspicion that there is something wrong with the implant. For example a volume change, a change in shape or the presence of pain, may indicate rupture (implant failure) or capsule formation. I also believe if the patient is anxious , or feels she is experiencing odd symptoms or the implants has been in a very long time; then a scan should be done. A simple ultrasound is probably as good as an MRI in the right hands for detecting implant rupture. If an implant is damaged then they should be removed with the option to replace them with a different implant, perhaps consider fat filling.
What is a long time? This is not really known but after 10 years it maybe prudent to have an ultrasound. This is an arbitrary figure based upon the fact that nothing man-made lasts for ever and the cause of implant failure is multifactorial. Unfortunately, sometimes I am sure that an implant maybe damaged and ruptured but not detected clinically. This is because the natural capsule that forms around the implant keeps the implant in shape and in position. This logically begs the question of whether it is dangerous to have a ruptured implant in your body with internal extrusion of silicone. The opinion of the majority of medical practitioners and available research of statistical data (known as meta analysis), indicates that it is not dangerous. There is no evidence that silicone is harmful to the human body although of course, if the silicone used in implants is of low-industrial grade (such as in the PIP implants), then I believe that they can cause side effects and abnormal internal inflammatory responses. In my practice with Nagor, Allergan and Mentor implants I have not seen ruptured implants causing serious systemic problems. For some PIP cases, I have seen bad abnormal capsule formation and lymph node involvement and also historically in patients who have had implants that ruptured many years ago with old generation implants.The patient has to listened to and examined carefully should there be some change in.
The other reason for scans and investigations would be for diseases that may affect your breast in the future. This is a separate issue and must be treated on their own clinical merits. The implants would not affect the efficacy or the way diseases of the breast itself can be investigated. There is no evidence that you are more at risk or there is less chance of diagnosing breast disease because of silicone implants. There is certainly no evidence that they cause cancer.
What would be the likely costs of re-operation or replacement?
Any emergencies will be covered free of charge.
But long term surgery is not free. For example, if a hard capsule forms around the implant after several years, the cost of the implant will be covered (as this is under warranty) but not the cost of the surgery. The rate of capsule formation is about 10%.
If the patient wants bigger implants or the implants removed then there will be a cost in the region of £2900 to £4900 dependant upon the surgery required/requested.