Capsular Contracture & Capsular Contracture Surgery

Capsular contracture is a common sequelae of breast augmentation surgery. When a breast implant or other medical device is placed in the body a lining may form around the device. The lining that is created is the body's natural response. In some individuals or in some scenarios the lining that forms can contract or thicken aggressively which is an unnatural or undesirable response of the body to the breast implnat. When the lining contracts around something that is soft, such as a breast implant, the surface area: volume ratio of the lining: implant changes.

When the surface area lining decreases around the fixed implant volume, the construct becomes hard. This hardening of the implant can cause significant pain to the patient and may temporarily disfigure the breast until the capsule is released or removed. There is a four grade classification scale, the Baker Grading Scale to describe capsular contracture:

Grade I - The breast is soft, and appears natural.
Grade II- The breast is firm, but still appears natural.

Grade III - The breast is firm, and is beginning to appear distorted in shape. Grade IV- The breast is hard, distorted in shape, and is painful.

Typically patients present to our office when a Grade III or Grade IV capsule has developed. Often patients choose to undergo surgery for their capsular contracture for these grades secondary to pain or because the distortion has changed the appearance or begins to interfere with mammography.

The above patient presented with bilateral painful Baker IV capsular contracture that was surgically corrected with bilateral "en bloc" capsulectomy, change of implant plane, and replacement of the breast implant.

Capsular contracture surgery is commonly performed in both the Beverly Hills and Newport Beach, CA locations.

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Secondary Mastopexy Augmentation/Reductions

Secodary Mastopexy/Augmentation reductions are common operations where women want their implants removed and then exchanged for smaller implants. Frequently patients also need a simultaneous lift when the volume of the breast is reduced. These operations are typically challenging. As one reduces the size of the breast or changes the shape of the breast, it is important to respect the blood supply of the nipple areola complex.

For example, this patient had a prior mastopexy augmentation via a superior crescent incision in the submuscular position. Therefore, one needs to be cognizant of the remaining blood supply when attempting to raise the nipple areola complex.

This patient underwent capsulectomy, bilateral removal and replacement of saline implants for Mentor smooth round high profile silicone gel implants, and mastopexy via an oblique pattern.

I have found that the vertical, oblique, and helium balloon pattern mastopexy (described by Dr. Ed Pechter of Valencia, California) to provide excellent projection while removing excess skin. I have found that many women appreciate the breast projection that these patterns in combination with the high profile implant provide.

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Breast Augmentation Consultation & Bra Sizing: The Challenges & The Basics

Breast augmentation consultations and procedures may be challenging when trying to determine post-operative bra size. I have found the bra-sizing system designed by Dr. Edward A. Pechter from Valencia, CA to be the most effective method for successful breast procedures.

The breast augmentation consultation can often bring anxiety to the patient as there are many questions to be addressed or discussed. These variables can range from topics pertaining to the patient (medical conditions, height & weight, bra size, pre-operative breast shape); surgeon (preference for above vs. below the muscle, incision choice); or implant (saline vs. silicone, smooth vs. textured, profile).

Determining bra size in breast procedure consultations creates a common frame of reference for the physician and patient to discuss post operative bra size. The first step in the physical examination is observation. In the observation step, both the patient and I stand in front of the mirror and with the same perspective identify any asymmetries between the breasts. Breasts are more often than not asymmetric with either a discrepancy in breast volume, breast fold position, nipple position, shoulder height, and chest wall asymmetry. After this step of the physical examination we proceed to pre-operative bra sizing.

Bra Sizing: The Basics

The size of a bra is determined by two factors: 1) The Band Size & 2) The Cup Size.

1) The Band Size

Step 1. The band size of the bra is relatively a fixed number determined by the circumference of a woman’s chest. This number can be measured with a measuring tape in inches, just beneath the breasts, in the crease where the band of the bra would be placed.
Step 2. Add five to the number of inches determined from this measurement. For example, if the measured number is 27” then if you add the number 5, the result is 32. Therefore the band size of the bra necessary is 32. If the measured number were 28” adding 5 would result in a 33 band. One quickly realizes when bra shopping that there are no odd number band sizes, so one would try on a 32 or 34 band bra to see which fit best. In this scenario, the 32 bra would be worn on the last of three clasps and a 34 bra would be worn on the first of three clasps.

The band size is relatively consistent in women of adult age as the bony ribcage has completed growing. This number will change to a small degree if a woman gains or looses weight around the chest where the band of the bra would normally be placed. The so called “bra fat”.

2) The Cup Size

I have found the “Size Me Up” system designed by Edward Pechter in Valencia, CA to be the best system for determining cup size. In the “Size Me Up” system, the dome of the breast is measured by starting the measurement from where the breast begins on the side of the chest, passing over the nipple and finishing towards the sternum where the breast ends. The resulting measurement is then compared on the “Size Me Up” chart to determine the cup and bra size.

One point I have learned is that the “cup volume” or “measured breast dome” increases depending upon the band width. That is, a “C” cup represents a smaller volume breast for a woman with a small ribcage (i.e.32 band size bra, C-cup) than a woman with a larger ribcage (i.e. 36 band size bra, C-cup).

In my experience, the best manner in which to predict the post-operative cup size is to determine the pre-operative bra size measurements and base diameter of the patient. The post-operative cup size can be predicted by using these measurements with the volume per base diameter of the breast implant.

While the prediction of post-operative cup size is not exact, I find this step to be helpful, as it facilitates a common frame of reference between the patient and surgeon.

Photograph: Revision breast augmentation. Bilateral Capsulectomy, Conversion of total submuscular saline breast augmentation to dual plane silicone breast augmentation.

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Revision Breast Augmentation in Elite Athlete’s, Fitness Models, & Runway Models

Revision breast augmentation procedures may be challenging for the Plastic & Reconstructive Surgeon as there are many variables to consider. I find these revision breast augmentationoperations to be particularly enjoyable as there are often significant anatomic and aesthetic variables to address so that the outcome is successful.

Common variables in “Fitness Models” & “Runway” models include:

1) Prior breast augmentation surgery
2) Implant Malposition (Most Commonly Lateral/Axillary Displacement of Implant)
3) Muscle Contraction Induced Deformity
4) Initial scar placement
5) Capsular contracture
6) Avoiding or minimizing loss of strength
7) Low body fat
8) Desire for early return to exercise

It is important for the Plastic & Reconstructive Surgeon to be aware of dimensions and profiles of implants available to the patient to best camouflage the implant. In the “Fitness Model” and “Runway model” population the variables mentioned above make the margin for error small and the visibility of the implant may be very unforgiving. Appropriate selection of implant based on the base diameter of the patient, soft tissue characteristics of the patient, and implant profile may optimize the outcome. It may require several discussions between the surgeon and patient to make sure that everyone is on the same page with respect to implant size, shape, desired cup size, and realistic expectations.

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Revision Breast Augmentation: Correction of Capsular Contracture & The Double Bubble Deformity

While I enjoy all aspects of Aesthetic Surgery, correction of capsular contracture and revision breast surgery is particularly enjoyable to me. Not only do I enjoy anatomic and aesthetic challenges of these operations, but also the degree of patient satisfaction is high.

This patient had painful capsular contracture and left breast double-bubble deformity. Correction of this asymmetry was done with bilateral "en bloc" capsulectomy, re-set of the inframammary fold, and change of implant profile.

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