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Los Angeles Breast Revision Surgery: Beverly Hills Plastic Surgeon

Breast augmentation with silicone or saline breast implants have a very high safety record and can result in cosmetic enhancement of the volume and shape of the female breast.  Although the safety record for breast implants is high, there is a finite risk of developing complications from a breast augmentation that may change the cosmetic appearance and contour of the breast and nipple complex.  These changes may also result in a physical distortion of the breast mound and changes in nipple sensation and breast firmness.  In some more severe cases, capsular contracture may ensue with hardening of the breast and associated pain and discomfort along the axilla, breast, and upper shoulder.


The most common of these complications is known as breast implant capsular contracture.  The initial step towards identifying capsular contracture is to characterize the condition and describe the onset of the problem.  Breast implants are a medical device and are recognized as a foreign substance when placed into the breast implant pocket.  In the normal phase of tissue healing, the breast tissue surrounding the breast implant may create a normal tissue capsule that defines the interface between the breast implant itself and the surrounding breast tissue.  This tissue capsule may be formed in the submuscular or supramuscular plane above or below the pectoralis muscle.  The tissue capsule is similar to a fibrous lining that surround the implant.  If the breast implant causes continuous formation of a tissue capsule, a condition known as capsular contracture may ensue.  This condition is characterized by thickening and hardening of the tissue capsule that results in a layer of scar tissue around the breast implant.  This is likely caused by a chronic inflammatory state that results from an infection, inflammation, or an abnormal response to normal healing.


The onset of capsular contracture may occur in the immediate phase after breast implant placement or in the late phase after breast augmentation years or decades after surgery.  It is thought that stress, chronic inflammation, and several other factors that will be described herein, may contribute to the formation of capsular contracture.  The initial process of capsular contracture formation is known as tissue capsule development and is a normal process after breast augmentation.  Some of the more common causes for capsular contracture include infection, hematoma, and chronic inflammation for unknown reasons. 


Capsular contracture can be associated with breast implant rupture, tissue capsule metaplasia, or chronic disease.  The development of a thickened capsule around the breast implant is analogous to keloid formation or hypertrophic scar formation around a previous area of skin trauma.  The hardened breast implant capsule then begins to place pressure around the breast implant causing distortion and malposition of the breast implant on the chest wall.  This undue pressure on the breast implant may cause physical distortion of the breast mound as well as a chronic wearing of the breast implant shell. 


More severe cases along the Baker classification may result in breast implant rupture, a non cosmetic appearance of the breast, and breast asymmetry.  Grade IV classification may also lead to pain and discomfort along the breast in association with thickening of the breast tissue.


The first step in managing capsular contracture and initiating the process of breast revision begins with understanding the risk factors for breast implant capsular contracture.


Some of the more common complications, as described above, include infection, hematoma, and chronic inflammation.  The following list describes these risk factors in more detail.


  1. Subclinical infection:  Subclinical infection may occur as a result of bacterial feeding of the implant in the acute phase of breast augmentation or as a late complication of a previous breast augmentation.  The bacteria and microbial contaminants may cause a chronic inflammatory state around the breast implant shell that can lead to thickening of the tissue capsule.  The thickened tissue capsule is caused by an exaggerated and hyperactive fibroblastic response to normal healing.  This is very difficult to treat unless the breast implant is replaced and the breast implant pocket is decontaminated.
  2. Hematoma:  Hematoma formation is a technical term for a blood collection that is found around a surgical pocket.  Hematomas usually contain blood components and plasma that fill the area of surgical dissection.  In the absence of blood, a plasma filled fluid pocket is known as a seroma.  Both an infected seroma and a sterile hematoma may cause an inflammatory state leading to breast implant capsular contracture.  These two entities are commonly associated with capsular contracture and it is thought that the blood products can actually stimulate fibroblastic reaction.


Subglandular placement of breast implant:  Comparison of subglandular versus submuscular implantation has preliminarily determined that subglandular placement may increase the risk of capsular contracture.  It is thought that subglandular placement has a higher interface between breast ducts, the skin, and the breast implant, which increases the risk for subclinical infection among subglandular breast implants.  This data has been documented in research, but has been refuted anecdotally by patients who have undergone subglandular breast implant placement without complication.


The discussion of capsular contracture and the need for breast implant revision begins with characterization of the capsular contracture.  There is inter-physician variability in the description of capsular contracture and the symptoms associated with the problem.  Patients who have capsular contractures should seek the surgical expertise of an experienced breast implant revision expert.  Dr. Raffy Karamanoukian performs capsular contracture surgery and breast implant revision in his Los Angeles plastic surgery office.  By combining cosmetic plastic surgery techniques with reconstructive plastic surgery techniques, Dr. Karamanoukian can reconcile the two problems of cosmetic improvement of the breast and reconstruction of the capsular contracture deformity.  Among plastic surgeons the earliest known grading scale for capsular contracture is known as the Baker clinical classification of capsular contracture.  The capsular contracture grading scale varies form grade I which describes a normal tissue capsule in the absence of tissue hardening or cosmetic changes of the breast to a grade IV capsular contracture which refers to a breast that is physically distorted, thickened, in association with pain and discomfort.


Breast implant revision is a difficult procedure to perform because there are two basic tasks inherent in the surgical correction of a breast deformity.


In noncomplicated breast enhancement, the goal of surgery is to minimize risk and maximize cosmetic outcome.  In breast implant revision surgery, the second important goal is to reconstruct the breast tissue in order to regain normal function.  The two surgical options that are available for improvement of capsular contracture include a capsulotomy and capsulectomy.  These two procedures effectively release the hard tissue capsule and allow the breast implant to regain its normal shape.  The difference in the two capsular contracture techniques depends on the amount of breast implant capsular contracture that has removed. 


A capsulotomy refers to a surgical procedure wherein the thickened breast implant tissue capsule is incised in order to release the tight grip of the capsule on the breast implant.  By surgically incising the harden tissue capsule the breast implant is allowed to relax within the tissue pocket and in most cases, the breast mound resume a normal shape.  A capsulotomy is usually performed under general anesthesia using a small incision pattern very much like the initial incision used during the initial breast augmentation.  In certain cases, the surgical incision must be extended in order to accommodate the scope of surgery. 


A capsulectomy, on the other hand, is a more aggressive procedure designed to remove the entire breast implant capsule during surgery.  By removing anterior and posterior layer of the tissue capsule, the hardened and fibrous capsular layer is removed from the body and the breast implant is allowed to regain its shape.  The other benefit of the capsulectomy approach is that the ruptured silicone implant can be isolated and removed from the body without contamination of the surgical pocket.  Both capsulectomies and capsulotomies are ideal approaches to the treatment of capsular contracture. 


Dr. Karamanoukian performs both breast implant revision techniques in his Los Angeles plastic surgery office and can describe the benefits of both procedures for breast implant revision.  The goal of breast implant revision for capsular contracture is to restore normal anatomy to the breast mound and minimize distortion of the breast implant in relation to the breast mound and nipple areolar complex.  If you have questions regarding plastic surgery procedures related to breast enhancement, breast implant revision, or surgery for breast implant capsular contracture, please call our office at 310-998-5533.  Dr. Karamanoukian performs cosmetic plastic surgery in Beverly Hills and Santa Monica. 


Our Los Angeles plastic surgery patient care coordinator can answer basic questions regarding capsular contracture and can help you schedule a comprehensive consultation for breast implant revision with Dr. Raffy Karamanoukian.  During your consultation you will be provided with information regarding capsular contracture and be given options for surgical and nonsurgical repair of your condition.  Please call our Los Angeles plastic surgery patient care coordinator at 310-998-5533.  Call for options about Beverly Hills breast revision.

Raffy Karamanoukian, MD FACS

Plastic & Reconstructive Surgery, Los Angeles

1301 20th Street, Suite 240

Santa Monica, CA 90404

Phone: (310) 998-5533 

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