What capsular contracture is
Every breast implant is surrounded by a thin scar capsule that the body forms naturally. In most patients, this capsule remains thin, soft, and pliable. In approximately 5-15% of patients, the capsule thickens and contracts — squeezing the implant into a tighter, harder, often distorted shape.
The Baker scale describes the severity of this contracture, from I (no problem) to IV (severe).
Baker grade I
Findings: Breast feels soft, looks natural. The capsule is present (always is) but is normal thickness.
Treatment: None. This is the normal state of every implant.
Grade I is technically called "no contracture" — the breast is indistinguishable from a non-augmented breast in feel.
Baker grade II
Findings: Breast feels slightly firm but looks normal. The capsule is mildly thickened.
Treatment: Usually observation. Some clinicians try medical management.
Medical options sometimes used:
- Leukotriene inhibitors (Singulair / montelukast, Accolate / zafirlukast) — evidence is mixed but some patients respond
- Vitamin E supplementation — limited evidence
- Implant displacement exercises — for early grade II only
If symptoms are minimal and there's no shape distortion, watching is reasonable. If grade II causes patient bother, surgery is also reasonable — patient priorities matter.
Baker grade III
Findings: Breast feels firm and looks abnormal. The implant appears rounder, higher, sometimes "ball-like." Distortion is visible.
Treatment: Surgery indicated.
The standard approach for grade III is capsulectomy with implant exchange:
- The contracted capsule is removed (partial or complete capsulectomy)
- A new implant is placed
- Strategies to reduce recurrence are used (plane change, surface change, irrigation)
Baker grade IV
Findings: Breast feels hard. Pain may be present. Significant shape distortion. Sometimes painful with sleeping on stomach or with exercise.
Treatment: Surgery essential.
Grade IV is generally considered an indication for revision regardless of other factors. Pain alone justifies surgical management. The same surgical approach as grade III applies, often with more emphasis on complete capsulectomy due to severity of capsule disease.
Modern revision approach
Capsulectomy vs capsulotomy
Older approaches used capsulotomy (cutting the capsule to release tightness) without removing the capsule. This had high recurrence rates because the contracted capsule remained as the source of the problem.
Modern revision favours capsulectomy (removing the capsule) for grade III-IV disease. The thickened capsule is the problem; removing it gives the new implant a fresh tissue environment.
Plane change
If original implants were subglandular and developed contracture, moving the new implants to submuscular (or vice versa) reduces recurrence. The new tissue plane has a different vascular environment and, importantly, isn't the same plane that previously failed.
Surface change
Modern microtextured or smooth implants have lower contracture rates than older macrotextured implants. Switching surface at revision is a common strategy.
Antibiotic irrigation
Triple-antibiotic pocket irrigation reduces biofilm risk — a presumed cause of late-onset contracture. Modern revision routine.
Closed-funnel implant insertion
Inserting the new implant via a closed funnel (rather than open handling) reduces contamination of implant surface during placement.
Recurrence rates with modern technique
Older studies (capsulotomy alone) reported recurrence in 30-50% of cases. Modern approach combining capsulectomy + plane change + surface change + antibiotic irrigation typically achieves recurrence under 10%.
Patient-specific factors that increase recurrence risk:
- Multiple previous capsular contractures
- Recent radiation therapy
- Specific autoimmune conditions
For high-risk patients, consideration of explant without replacement may be appropriate.
What to expect from revision recovery
Capsulectomy recovery is similar to or slightly longer than primary augmentation:
- Day 1-3: moderate discomfort; drains often placed
- Week 1: drain removal, surgical bra
- Week 2-3: office work return
- Week 6-8: full activity
The new implant settles into the new pocket over 3-6 months. Final result assessment at month 6-12.
