Definition and Overview

Open breast periprosthetic breast capsulotomy is a surgical procedure that removes scar tissue that has formed around breast implants. Called capsular contracture, this is the most common complication of breast augmentation with implants. It occurs in more than 10% of breast implant patients and can present as early as a month after the procedure or several years later. The scar tissue makes the breast look different and hard. It also causes discomfort when the tissue tightens around the implant.

The scar tissue can be removed with surgery (open capsulotomy) or noninvasive method (closed capsulotomy). In an open capsulotomy, the scar tissue is released through an incision in the breast area. In closed capsulotomy, doctors attempt to break the scar tissue using ultrasound, massages, and other noninvasive methods.

Who Should Undergo and Expected Results

More than 10% of breast implant patients develop scar tissue or capsule composed of blood vessels, collagen, and fibroblast. It is the immune system’s protective response when it senses foreign objects inside the body. The formation of the capsule is the most common complication of breast augmentation procedures. It makes the breast thicken and causes them to contract. As such, the breast feels different and the patient experiences discomfort. It can occur in breast reconstruction and first-time breast augmentation patients. It can also recur and affect those who have been previously treated for capsular contracture.

Capsular contractures are a normal occurrence and in some cases, they even help enhance the results of a breast augmentation procedure. In mild cases, they make the breast feel soft and look natural. They only become a problem when they tighten around the implant. Doctors recommend their removal if they distort the breast shape and cause pain and discomfort. Capsular contractures are categorised into four stages, namely:

  • Stage 1 – A normal capsule forms and helps make the breast look natural and soft to the touch.
  • Stage 2 – A slightly firm capsule develops. The breast is slightly firm to the touch, but the breast still looks natural.
  • Stage 3 – A firm capsule develops and distorts the breast appearance. The breast may tilt upwards and hard to the touch.
  • Stage 4 – A firm capsule develops and distorts the breast appearance. It also makes the breast cold and hard. It also causes pain and discomfort.


Despite thorough physical examination and pre-surgery preparation, surgeons currently do not have a way to predict if a patient will develop scar tissue following breast augmentation. To reduce the risk, they recommend the use of saline breast implants instead of silicone gel implants, which tend to cause calcifications. The risk of developing scar tissue also increases if the implants do not receive enough lubrication or coverage. In some cases, the formation of scar tissue is blamed on bacterial contamination of the implant’s shell.

As for the expected results, the procedure restores the normal appearance of the breast and relieves patients from symptoms, which include pain and discomfort.

How is the Procedure Performed?

It is good to note that not all cases of capsular contracture require surgery. Treatment usually starts with conservative approaches such as massage and ultrasound. These methods aim to break the scar formation without using incisions, helping patients avoid complications of another surgery. However, surgery is the mainstay treatment if the contracture is recurrent.

Open periprosthetic capsulotomy is performed under general anaesthesia or IV sedation with local anaesthesia. It is more complex than breast augmentation surgery and can last up to three hours. It can be performed either as a day surgery (patients are allowed to go home after the procedure) or inpatient (the patient stays in the hospital for at least a night after the procedure for close monitoring).

The surgery uses the same incisions made during the breast augmentation procedure so patients do not have to worry about new scars. The surgeon then removes the implants and the capsule. The partial removal of the capsule is also possible but only if the implant has not moved or is still intact. After the damaged capsule has been removed, the surgeon will insert a new implant that will last longer than the old one. The incisions are closed using either absorbable or non-absorbable sutures. Surgical tapes are also used if additional support is needed.

Patients are encouraged to get up and move around as soon as possible. This helps prevent the formation of blood clots in the legs. It is normal to feel sore, bruised, tired, and groggy for up to 48 hours. As such, patients are asked to arrange for a ride home after surgery. After a couple of weeks, patients must go back to their surgeon where their wound is checked and the sutures removed (if the non-absorbable type was used).

Possible Risks and Complications

Open periprosthetic capsulotomy is safe but no surgery is without risks and possible complications. The most common is the recurrence of capsules as they are the immune system’s natural reaction to foreign materials inside the body. Others include:

  • Allergic reaction to anaesthesia
  • Reduced nipple sensitivity
  • Infection
  • Bleeding
  • Blood clots
  • Nerve Injury
  • Shortness of breath
  • Pain
  • Breast asymmetry

    References:

  • Adams WP Jr, Capsular contracture: what is it? What causes it? How can it be prevented and managed? Clin Plast Surg. 2009 Jan;36(1):119-26, vii. doi: 10.1016/j.cps.2008.08.007

  • Camirand A, Doucet J, Harris J. Breast augmentation: compression — a very important factor in preventing capsular contracture. Plast Reconstr Surg. 1999 Aug;104(2):529-38; discussion 539-41.

  • Headon H, Kasem A, Mokbel K. Capsular Contracture after Breast Augmentation: An Update for Clinical Practice. Arch Plast Surg. 2015 Sep;42(5):532-43. doi: 10.5999/aps.2015.42.5.532. Epub 2015 Sep 15.

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