Breast Implant Exchange Surgery) by Jan Stanek at Surgical Aesthetics

Breast Implant Encapsulation (Hardening)

When breast implants are placed in their pockets, the healing process starts by the formation of scar tissue commonly known as the capsule.  All implants become enclosed by this capsule as it is the natural reaction of the body to all implanted foreign bodies.

The feel of breast implants is not only determined by the implants but also by the behaviour of the capsule.  If the capsule is thin and loose, the implant will feel ‘natural’ and soft.  If the capsule becomes thick and tight the implant can feel firm, or even hard.  The latter condition is known as the ‘capsule’ or ‘encapsulation’.

The degree of hardness can vary from firm to very hard and can be accompanied by discomfort, pain on touch and abnormal mis-shaping of the breast.

Some contributing factors are known, such as excessive accumulation of blood in the breast pocket (haematoma) or infection.  The surgeon will do his best to prevent these by careful control of bleeding and control of possible infection.  In the past the incident of significant capsule was very high, probably due to the use of old-fashioned silicone breast implants that leaked silicone and caused irritation in the scar.  Modern implants have much thicker shells that do not allow silicone to ‘bleed’.

Currently the incidence of significant capsule is as low as 3-10%.  Placing implants behind the chest wall muscle (pectoralis) seems to have reduced the incidence of this complication to reasonable levels.

If this complication occurs there are several options the surgeon has available.  If the implants have been placed between the breast and the muscle, he can create a new pocket behind the muscle and insert the implant in the new pocket.  Alternatively, he can enlarge the existing pocket by dividing the scar tissue (capsule) and hope that when the tissues have healed, the pocket will be larger and the breast s softer.  If the capsule is thick, it may not be sufficient to divide the scar, only because the scar tissue will still prevent the implant from stretching out the breast to a desirable shape.  In such cases the surgeon may have to remove all or some of the scar (capsulectomy).

In spite of all this, the chances of recurrence are high and some patients may have recurring problems that are hard to cure.  This applies particularly to those who have a very thick capsule.

As in all operations, there are risks involved however small and some of these are listed below:

Infection                                            

Infection of the implant is very uncommon and occurs in less than approximately 0.5% of patients.  It occurs in spite of antibiotic treatment during and after surgery and careful cleansing of the breast pocket during surgery with an antibiotic solution.  In some cases, it can be treated successfully with antibiotics, but, if unsuccessful, it is necessary to remove the implant for a period of six to eight weeks before the implant is replaced.

Bleeding (haematoma)                 

Haematoma is a collection of blood within the breast pocket and occurs very uncommonly in less than 1% of patients.  The most critical time is immediately after surgery.  There should be no complications arising from this complication if treated early, but in some cases may lead to a capsule formation.

Recurrent encapsulation               

If encapsulation has occurred, the chances are then higher that it will recur.  In some cases the problem can become intractable.  The surgeon can divide the capsule around its circumference, thus enlarging the size of the pocket, or choose to remove all or some of the capsule hoping that when the new capsule reforms it will be softer with larger space.  Although successful in most cases, none of these treatments are guaranteed to be successful.

Implant failure                                 

Breast implants are not life time devices and may eventually need to be removed or replaced. As the time after surgery increases, there is a greater risk of implant rupture. How long the breast implant remains without complications, depends on the type of implant inserted, the type of surgery and how much physical exercise the patient does. Injury to the breast and excessive compression of the implants against the chest wall may reduce the life of the implant.

Depending on the patient ages when they undergo augmentation, the implant may need to be replaced at some time in their life. There are reports that some implant recipients have experienced no problems after 25 years, which other have experienced problems almost immediately after the procedure. Recent studies indicate that the risk of experiencing problems with breast implants significantly increased to 10 years after the surgery.

Holmich et al., (2003) examined women using magnetic resonance imaging, to establish the incidence of rupture. The authors reported the overall rupture incidence rate for definite ruptures was 5.3 ruptures/100 implants per year. The rupture rate increased significantly with increasing implant age.  For third generation implants intact 3 years after implantation, authors estimated rupture-free survival of 98% at 5 years and 83% to 85% at 10 years.

Using US clinical data (involving the styles 40, 45, 10, 20, 110, 120 and 153) Inamed has estimated that the risk of implants rupture after 10 years implantation to be 14%.

Loss of sensation to the nipple      

This complication can occur, especially if the capsule is very thick and has to be removed entirely.  Fortunately, this is a rare problem.

Seroma                                             

Seroma is a rare problem where the breast pocket contains fluid that may continue to reform.

Wrinkling                                           

This is seen in patients who have very little breast tissue and undulations of the implant may be visible on the surface of the breast in certain positions.  This problem may be difficult to manage, especially in very thin patients.

Palpable implants                           

Modern implants are very thick an in certain parts of the breast where there is little or no breast tissue the implant may be felt, especially in the upright position.  There is no solution to this problem apart from changing the implant for a very soft one.

Unfavourable scar                          

Your surgeon will take great care suturing the wounds.  Some patients are prone to form thick and raised scars and in the extreme form, keloid scars.  These scars need careful management to improve them, and your surgeon will discuss their management with you.

Malposition of implant and asymmetry   

Sometimes, due to healing process, implants will be positioned unfavourably causing the effect of asymmetry.  This may necessitate their repositioning to correct the problem.

Muscle spasm

Some breast implants are placed under the chest muscle.  The muscle in the lower part of the chest is detached so that it cannot push the implant upwards.  Sometimes scar tissue can connect to the muscle and when it contracts, it can visibly flatten the implant.  The solution is to divide the scar tissue, and this will in most cases correct the problem.

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