Addressing Implant Rupture and Capsular Contracture

By Demetrius Coombs, MD, Ritwik Grover, MD, and Raffi Gurunluoglu, MD, PhD

In the United States, breast implant rupture rates range from 1.1% to 17.7% at six to 10 years after primary augmentation, 2.9% to 14.7% after revision augmentation, 1.5% to 35.4% after primary breast reconstruction, and 0% to 19.6% after revision reconstruction.

Unfortunately, the existence of multiple implant manufacturers, numerous implant generations and poorly standardized screening protocols and reporting systems make the true rate of implant rupture difficult to assess without definitive imaging or implant retrieval.

Damage from surgical instrumentation during implantation is the most common cause of silicone breast implant rupture (50% to 64% of cases). Other causes include underfilling and fold flaw from capsular contracture.

Leakage of silicone gel filler may be confined to the periprosthetic capsule (intracapsular rupture) or extend beyond and into the breast parenchyma (extracapsular rupture). One study reported that only 10% of intracapsular ruptures progressed extracapsularly, while 84% of patients with extracapsular involvement remained stable for up to two years, indicating that intracapsular rupture may not portend worsening disease.

Implant rupture occurs silently in most cases, with no clinically detectable signs or symptoms. In other cases, patients may present with alterations in breast shape and size, sudden asymmetry, firmness, pronounced capsular contracture, contour irregularity or pain.

Aside from physical examination, comprehensive diagnostic testing includes imaging — ultrasonography, mammography, computed tomography and magnetic resonance imaging (MRI). Of these, MRI is the method of choice, with sensitivity and specificity exceeding 90% for detecting implant rupture. Classic findings on MRI include the “linguine” sign from a deflating implant shell, or the teardrop sign from implant sagging. Classic findings on ultrasonography include the “snowstorm” sign of extracapsular rupture and the “stepladder” sign of intracapsular rupture.

Mammography effectively detects free silicone in breast tissue with extracapsular rupture (25% of ruptures according to some studies); however, it cannot detect rupture within the implant capsule.

Current FDA recommendations to detect implant rupture encourage women with silicone breast implants to undergo screening three years after implantation and then every three years thereafter; no long-term monitoring is suggested for saline implants. Many plastic surgeons evaluate silicone breast implant patients every one to two years for contracture and rupture. Of note, capsular contracture impairs the effectiveness of ultrasonography and may require MRI confirmation.

If implant rupture is confirmed, the current recommendation is to remove the implant and the capsule. Another implant may be placed depending on the patient’s preference. Rigorous washout remains a key feature of any surgical intervention for ruptured breast implants; however, in the event of extracapsular rupture, resection of silicone granulomas may also be required.

Reoperation rates for primary breast augmentation surgery approach 20% and are even higher for secondary augmentation over a patient’s lifetime — the highest rate of all aesthetic procedures.

Capsular contracture

Capsular contracture is the most common complication of breast augmentation, typically presenting within the first postoperative year, and the risk increases over time. It occurs with both silicone and saline breast implants.

In some studies, the incidence exceeded 4% in the first two years after surgery, and nearly 50% by 10 years. Other studies found rates of 0% to 20% over 13 years.

The etiology is not well understood and is presumed to be multifactorial, with proposed mechanisms and factors that include bacterial contamination, surface texturing, the implant pocket selected, the incision type, drain placement, antibiotic use and smoking.

A meta-analysis from 17,000 implants found that the risk of capsular contracture was significantly higher when an implant was placed in a subglandular pocket than in a submuscular pocket, and that although texturing decreased capsular contracture compared with smooth implants, the effect was modest when a textured or smooth implant was placed in a submuscular location. With regard to incision location, studies have reported that the incidence of capsular contracture is highest with transaxillary and periareolar incisions, and lowest with inframammary incisions.

The leading theory is that contamination of the implant (primarily from the mammary ducts) results in biofilm formation. Subclinical hematoma surrounding the implant may also provide key bacterial nutrients.

Textured implants induce a greater inflammatory response in the capsular tissue, resulting in a thicker capsule; however, contracture rates remain lower with textured than with smooth implants. Interestingly, lower rates of capsular contracture have been observed with later-generation, cohesive-gel, form-stable implants than with those of earlier generations.

Although more research is needed, silicone implants appear to confer a higher risk of capsular contracture than saline implants.

Irrigating the breast pocket intraoperatively with triple antibiotic solution (bacitracin, cefazolin and gentamicin) before placing the implant may decrease the capsular contracture rate.

Treatments for capsular contracture include pocket modifications such as capsulotomy (making releasing, relaxing incisions in the scar capsule encasing the implant), capsulectomy (removing portions of or the entire capsule) and replacing the implant in the other pocket (i.e., if the original implant was subglandular, the replacement is placed in the submuscular pocket). Patients who have contractures that fail to respond to these treatments may ultimately benefit from implant removal and autologous reconstruction (autoaugmentation) rather than implant replacement.

In a future post, we will discuss other complications of breast augmentation surgery.

Drs. Coombs and Grover are plastic surgery residents. Dr. Gurunluoglu is staff in the Department of Plastic Surgery.

This abridged article was originally published in Cleveland Clinic Journal of Medicine.