What are the treatment options for breast capsular contraction?

Treatment Options for Breast Capsular Contracture

The most effective treatment for breast capsular contracture is surgical intervention via capsulectomy or capsulotomy, especially for severe cases (Baker grades III and IV). 1

Understanding Capsular Contracture

Capsular contracture is the most common complication following implant-based breast surgery and a leading cause for reoperation. It results from an excessive fibrotic reaction to the breast implant as a foreign body, with an overall incidence of approximately 10.6%. 1

Risk Factors

• Previous radiotherapy significantly increases risk of capsular contracture 2
• Smooth (vs. textured) implants 1
• Subglandular (vs. submuscular) placement 1
• Silicone (vs. saline) filled implants 1
• Periareolar incision site 3
• Smaller implant size 3
• Development of hematoma or seroma 3

Treatment Options

Surgical Management (First-Line)

• Capsulectomy: Complete removal of the capsule surrounding the implant 1
• Capsulotomy: Surgical release of the capsule 1
• Implant replacement with site change: Moving from subglandular to submuscular position when indicated 4
• Neopocket formation: Creating a new pocket for the implant 1

Medical Management

• Leukotriene receptor antagonists (e.g., Zafirlukast): Used off-label to reduce severity and help prevent capsular contracture formation 1
• Corticosteroid therapy:
  • Novel technique involving instillation of rapid-acting water-soluble glucocorticosteroid in the implant pocket during early proliferative phase of wound healing 5
  • Administration through an indwelling catheter 2-3 days post-surgery has shown promise in preventing recurrence 5

Adjunctive Approaches

• Acellular dermal matrices: May help reduce recurrence rates 1
• Autologous fat transfer: Emerging approach for managing capsular contracture 1
• Botulinum toxin: Has been reported to help with capsular contracture 1

Prevention Strategies

• Implant selection: Textured implants have lower contracture rates than smooth implants 1, 3
• Implant placement: Submuscular placement has lower contracture rates than subglandular 1, 3
• Surgical technique:
  • Precise, atraumatic, bloodless dissection 4
  • Appropriate triple antibiotic breast pocket irrigation 4
  • Minimizing contamination during procedure 4
• Antibiotic irrigation: Reduces bacterial colonization that may contribute to contracture 3

Important Considerations for Radiation Patients

• In previously radiated patients, tissue expanders/implants are relatively contraindicated due to significantly increased risk of capsular contracture 6
• When post-mastectomy radiation is required and reconstruction is planned:
  • For autologous tissue reconstruction: Delay reconstruction until after radiation therapy completion 6
  • For implant reconstruction: A staged approach with immediate tissue expander placement followed by implant placement is preferred 6
• Immediate placement of implants in patients requiring postoperative radiation significantly increases risk of capsular contracture, malposition, poor cosmesis, and implant exposure 6

Controversial Approaches

• Breast massage and implant displacement: Despite being commonly recommended, evidence does not strongly support its efficacy in preventing capsular contracture 7
  • Studies show similar contracture rates: 31% in massage groups vs. 40% in non-massage groups 7

Treatment Algorithm

1. For mild contracture (Baker grade I-II):

   • Consider non-surgical approaches first (leukotriene antagonists) 1
   • Monitor for progression 1

2. For moderate to severe contracture (Baker grade III-IV):

   • Surgical intervention via capsulectomy or capsulotomy with implant replacement 1, 4
   • Consider site change from subglandular to submuscular position 4
   • Consider using textured implants for replacement 1, 3
   • Consider adjunctive corticosteroid therapy 5

3. For patients with history of radiation:

   • Autologous tissue reconstruction is strongly preferred over implants 6
   • If implants must be used, expect higher complication rates 6