Capsular Contracture Stage Four

Stage IV capsular contracture describes a breast implant which is firm to touch with visible breast deformity and, most importantly, breast pain. Stage IV capsular contracture can occur anytime after breast augmentation. Patients may experience a firm breast implant from one week to a few decades after breast augmentation surgery. The key distinction from other Stages of capsular contracture is breast pain or tenderness. The implant essentially looks firm and deformed while it also feels hard to touch. Patients and surgeons have some work to do if patients are diagnosed with Stage IV capsular contracture or a tight breast implant. Given the most advanced Stage of capsular contracture, prevention of progressing capsular contracture is important. Make an appointment to visit your plastic and reconstructive surgeon as soon as you feel or visualize any change in the breast implant. It is unknown exactly what factors contribute to the progression of capsular contracture. Capsular contracture, particularly when it occurs early in the first six months after breast augmentation, predicts a higher risk for another early capsular contracture. With this trend in mind, patients with early Stage IV capsular contracture should consider implant removal versus replacement even before their consultation with a plastic surgeon. Following breast augmentation surgery, regular follow-ups by plastic and reconstructive surgeons are paramount in minimizing complications. To be able to stop a problem at its early stages is of utmost importance. Examination on the day after breast augmentation surgery, another examination one week after surgery, followed by another follow-up three weeks after surgery is recommended. These early visits serve to minimize the risks of early complications from breast augmentation surgery. Capsular contracture may begin any time after breast augmentation; from a couple of weeks to decades after breast augmentation. The intervals between plastic surgery office visits essentially double until patients reach the one-year mark after the surgery. The late follow-up appointments are to diagnose late complications after breast augmentation surgery. After the first post-operative year, patients should continue annual breast examinations by a plastic and reconstructive surgeon to evaluate patients' breasts for any masses, implant rupture, or capsular contracture. If patients are over forty, an annual mammogram is currently recommended to evaluate for breast cancer. Implant rupture is one of the causes for implant capsular contracture. Other causes for the onset of capsular remain generally unknown. You should have an examination by your plastic and reconstructive surgeon once you notice a firm breast implant. Your plastic and reconstructive surgeon may order an MRI to identify the source for the capsular contracture. If no implant rupture is present, off-label use of Accolate or Singulair medications have been shown to soften the implants in certain women. “Off-label" use indicates that these medications have not been approved by the FDA for use in treating tight breast implant capsules. Accolate and Singulair are called leutotriene receptor antagonists and are used to prevent asthma symptoms. They work by blocking the action of natural chemicals in our body which signal inflammation and swelling. It is believed that the same mechanism which leads to tightening of airways in asthmatics results in tightening of breast implant pockets. Singulair has the advantage of being a once a day medication versus Accolate which is taken twice a day. If your plastic and reconstructive surgeon feels it is indicated, off-label trial of one or two months of Accolate or Singulair can be taken before contemplating surgery. If the implant softens with the medications, no further treatment is necessary. More advanced stages of capsular contracture such as Stage IV are less responsive to Accolate or Singulair. Most patients choose to have surgery to address their Stage IV capsular contracture, given the associated breast pain and tenderness. Conservative management without surgery remains a less popular option if the implant does not soften with off-label medications. Termed “capsulectomy," surgery entails excising the tight scar tissue around the implant with or without replacement of the implant. If the implant was originally placed through a scar around the areola or beneath the breast, the same incisions can be used to remove the scar tissue. If incisions at the underarms or the bellybutton were used to insert the implants, then a new incision at the breast is typically necessary to remove the scar tissue around the breast. An episode of capsular contracture indicates a propensity for future repeat episodes particularly in patients who experience capsular contracture within the first six months of breast augmentation. To minimize the risk for repeat capsular contracture, factors contributing to tight scar formation around breast implants must be minimized. Breast implant replacement with a smaller breast implant is generally recommended if the original breast implants are excessively large for the breast pocket. Breast implants originally placed over the pectoralis muscle must be converted to under the muscle. A no-touch technique during surgery is important along with antibiotic irrigation of the implant pocket. In those wishing to continue monitoring the implants without any surgery, an MRI is indicated to evaluate for implant rupture. If implant rupture is not noted on examination or MRI, regular follow-up examination with your plastic and reconstructive surgeon every six months is recommended to follow the progression of your capsular contracture. If implant rupture is suspected on physical examination or MRI, then a capsulectomy and implant removal or replacement are recommended. Stage IV capsular contracture is a medical indication for implant removal or exchange. Health insurance companies will generally cover the surgeon's fees as well as surgery center fees for capsulectomy and removal of the breast implant. Replacement of the breast implants is typically not covered by health insurance companies in cosmetic breast augmentation cases. Breast implants used in breast reconstruction are always covered by health insurance. Keep in mind that most plastic and reconstructive surgeons are NOT contracted health insurance providers. Fees for capsulectomy, implant removal, and potential replacement vary among plastic and reconstructive surgeons and geographic areas. Copays may therefore apply for the procedures. The plastic and reconstructive surgeon can write a letter addressed to a patient's insurance company to request pre-authorization for capsulectomy and breast implant removal surgery. Pre-authorization will improve the chances for insurance company reimbursement. Stage IV breast implant capsular contracture may occur anytime after breast augmentation surgery. Prevention of capsular contracture or tight scar formation around breast implants is the main goal. Breast massage should begin by the second week after surgery once any pain has minimized. Regular breast massage, annual physical examination by a plastic and reconstructive surgeon, and mammograms after the age of forty are all imperative to excellent breast health. Once diagnosed with Stage IV capsular contracture without implant rupture, conservative management with Accolate or Singulair should begin immediately. One to two month trial of the medications is justified before undertaking any surgery. Given the associated breast pain, most patients pursue surgery. Patients wishing to have their original soft breast implants can have capsulectomy and implant replacement. Some may choose to have their implants entirely removed with capsulectomy. Regardless of treatments chosen, there is no rush to have any surgery in Stage IV capsular contracture without implant rupture. The degree of breast pain and patient's pain tolerance predict the timeline for surgical intervention. Bear in mind that even Stage IV capsular contracture can progress to development of a thicker scar capsule around the breast implant, though such progression has not been formally classified in plastic surgery scientific literature. In those patients diagnosed with Stage IV capsular contracture with implant rupture, timely capsulectomy with removal or replacement of breast implants is imperative. Ruptured saline implants can lead to future breast asymmetry even after replacement of the breast implant as the implant pocket scars in to collapse around a now deflated implant. There is also a risk for fluid collections developing in the open pocket. Ruptured silicone implants also have to be removed with capsulectomy within a few days to a few weeks after diagnosis. Leaving a ruptured breast implant can lead to migration of the ruptured silicone, breast deformity, and progression of the capsular contracture.

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