What is the treatment for recurrent breast augmentation capsular contracture after capsulectomy and Strattice (porcine-derived biocompatible material) implant wrapping?

Treatment of Recurrent Capsular Contracture After Strattice-Wrapped Implant Reconstruction

For recurrent capsular contracture following capsulectomy with Strattice wrapping, the most effective approach is complete anterior capsulectomy with implant exchange to a different volume (either larger or smaller than the original), which demonstrates significantly lower recurrence rates compared to capsulotomy or total capsulectomy alone. 1

Primary Treatment Approach

Anterior capsulectomy with volume modification is the preferred surgical technique, as this approach achieved the lowest recurrence rates in comparative studies 1. Specifically:

• Perform anterior capsulectomy rather than total capsulectomy or capsulotomy, as this reduces recurrence risk significantly [OR for total capsulectomy = 2.36; OR for capsulotomy = 4.33 compared to anterior capsulectomy] 1

• Change the implant volume from the previous size—either increase or decrease the volume [OR for greater volume = 0.30; OR for smaller volume = 0.14], as maintaining the same volume increases recurrence risk 1

• Exchange the implant with a new device, as this is a core component of successful treatment 2, 1

Critical Consideration: Radiation History

Before proceeding with any implant-based treatment, you must determine if the patient has a history of chest wall radiation, as this fundamentally changes management:

• In previously radiated patients, tissue expanders/implants are relatively contraindicated due to significantly increased risk of capsular contracture, malposition, poor cosmesis, and implant exposure 3, 4

• Autologous tissue reconstruction is strongly preferred over implants for patients with radiation history 3, 4

• If the patient received radiation after the initial Strattice reconstruction, conversion to autologous tissue flap reconstruction (latissimus dorsi, TRAM, or perforator flaps) should be strongly considered rather than repeat implant-based surgery 3, 4

Alternative Surgical Options

Option 1: Repeat Acellular Dermal Matrix Protocol

If no radiation history exists, repeat capsulectomy with acellular dermal matrix (ADM) placement and implant exchange can be considered:

• The SPICES protocol (Strattice placement, implant exchange, capsulectomy, possible site exchange) demonstrated only 2.7% recurrence rate in primary treatment 2
• However, no high-quality evidence exists specifically for treating recurrence after failed ADM-wrapped reconstruction 2
• This approach carries theoretical risk since the initial ADM technique already failed 2

Option 2: Subpectoral Precapsular Repositioning

Subpectoral precapsular implant repositioning offers an alternative that avoids aggressive capsulectomy:

• Develop a plane between the anterior capsule wall and posterior pectoralis major muscle 5
• Fix the anterior capsule wall to the posterior capsule wall (which remains adherent to chest wall) 5
• Insert new implant into the subpectoral space, anterior to the capsule 5
• This technique demonstrated good results with reduced trauma compared to total capsulectomy 5

Option 3: Open Capsulotomy (Less Preferred)

Open capsulotomy with implant exchange is a less invasive option but has higher recurrence rates:

• Achieved 77.3% success with one procedure, 97.3% with two procedures 6
• Overall recurrence rate of 22.7%, significantly higher than anterior capsulectomy 6, 1
• Should be reserved for patients who are poor surgical candidates or refuse more extensive surgery 6

Important Caveats and Pitfalls

Avoid these common errors:

• Do not perform capsulotomy alone—it has 4.33 times higher recurrence risk compared to anterior capsulectomy 1

• Do not use the same implant volume—volume modification is essential for reducing recurrence 1

• Do not proceed with implant-based surgery in radiated patients—the failure rate is unacceptably high 3, 4

• Screen for breast implant-associated anaplastic large cell lymphoma (BIA-ALCL) if there is new seroma formation, as this can mimic capsular contracture and typically presents 8-10 years after implantation 3

Evaluation for BIA-ALCL

Before any surgical intervention, rule out BIA-ALCL if the patient presents with:

• New effusion/seroma formation 3
• Breast swelling or asymmetry occurring years after implantation 3
• Any palpable mass 3

If effusion is present, perform ultrasound-guided aspiration (minimum 10-50 mL) for cytology with CD30 immunohistochemistry and flow cytometry before proceeding with capsulectomy 3

Pharmacological Adjuncts

No pharmacological interventions have proven efficacy for treating established capsular contracture, though various agents have been studied for prevention 7. Surgical intervention remains the definitive treatment 2, 1.