Capsular Contracture: Causes, Prevention, and Treatment

Anytime you implant a foreign body — whether it's a breast implant, a pacemaker, or anything else — your body recognizes it as foreign and walls it off with a scar tissue sac called the capsule. This is a normal response. Capsular contracture happens when that capsule becomes abnormally thick, compressing the implant and causing firmness, visible distortion, or pain.

Most contractures happen for two main reasons:

When a silicone implant ruptures, the internal silicone gel is irritating to the capsule and causes chronic inflammation, which leads to thickening.

Certain bacteria can form a biofilm on the implant surface. In some patients, this triggers inflammation that leads to a thickened capsule. Biofilm doesn't always cause contracture, but certain people seem to have more trouble with it than others.

Women who have a bleeding complication (hematoma) around their implant — especially when that collection is left to resolve on its own rather than being drained in the operating room — also have a higher risk of contracture. The body's inflammatory response to the blood collection appears to contribute to capsule thickening.

Over the years, plastic surgeons have gotten significantly better at preventing capsular contracture:

• Sterile funnels (Keller funnels) are used to place implants without touching them
• Special irrigant solutions reduce bacterial contamination
• Better incision choices — avoiding incisions with higher contracture rates
• Properly sized incisions so implants aren't damaged going in

The results speak for themselves: older implant approval studies showed contracture rates of 10–15%. More recent studies show rates of less than 2%.

Patients ask me this constantly, usually some version of was this someone's fault? The honest answer: it could be a little bit of both.

There is definitely a list of things a surgeon does or doesn't do in the operating room that raises your risk. I'd rather name them plainly than be diplomatic about it, because these are things you can ask about before surgery.

• Choosing a periareolar or transaxillary incision. If your surgeon selects an incision under the areola or in the armpit, they are choosing to increase your contracture rate. In my opinion, that's a technique issue. (Here's the full incision comparison.)
• Not using a Keller funnel. Or, worse, trying to re-sterilize the funnel. These are disposable. Re-using one to save money is, frankly, horrific.
• Forcing a large implant through too small an incision. Shoving very large implants through an undersized incision risks rupturing the implant, and that's a technique issue that leads to contracture.
• Not using proper irrigants in the operating room. (The full OR protocol, and the questions to ask about it, are here.)
• Mismanaging a hematoma. A moderate or larger collection left to resolve on its own is more likely to end in contracture than one that's evacuated.
• Mishandling a minor infection. This one is less obvious and matters a lot. If you have a mild infection around the implant, there's leakage from the breast, and the surgeon puts in a little stitch to stop it, starts antibiotics, and salvages the original implant — in my experience that is more likely to lead to a contracture. Washing everything out and replacing the implant is less likely to. (My actual salvage algorithm is here.)

To be fair about my own language: calling these technique issues doesn't mean the surgeon did something wrong in every case. It means these are choices, and choices have consequences that land on you.

Contractures are a genuinely complicated problem with several different causes, so I don't want to leave you thinking this is all attributable to the person holding the scalpel. It's often not our fault at all — but sometimes things we do raise your risk, and those are the parts worth scrutinizing.

Because here's the counterweight that no technique can fix:

Some people simply scar more aggressively than others, inside and out. Which is exactly why, as surgeons, we try to control everything we can in the operating room — because we can't control your genetics.

While there's some debate about the specifics, the general approach includes:

1. Remove the entire scar tissue capsule (capsulectomy)
2. Check and treat for biofilm — because if bacteria are driving the problem, it needs to be addressed
3. Reconstruct with recurrence prevention — using some type of support product to minimize the chance of contracture returning

Treatment continues to evolve:

• Dermal matrix was used first — both human and porcine versions. Multiple clinical trials on PubMed document results with these materials for capsular contracture and various breast surgeries.
• Mesh products have become more popular in recent years. One major driver for this shift is cost — for cosmetic patients, the support portion of the surgery is typically not covered by insurance, and mesh is significantly less expensive than dermal matrix.

Capsular contracture rates have dropped dramatically thanks to better surgical techniques and prevention strategies. When it does occur, treatment has also improved — with capsule removal, biofilm management, and evolving support materials giving patients much better outcomes than in years past.

Research continues into which meshes and capsulectomy techniques are superior, with the goal of finding the best possible treatment for every patient. If you're experiencing firmness or pain with your breast implants, learn more about capsular contracture treatment.