Distinguishing between pseudocapsule and capsular contracture
Pseudocapsule occurs when the breast becomes hard right after surgery and does not soften over time. While pseudocapsule shares some similarities with capsular contracture, which causes stiffness in both standing and lying positions compared to implants outside the body on palpation, they differ in their underlying causes.
Both pseudocapsule and capsular contracture, if left untreated over time, can lead to premature implant rupture and aging at breast fold sites due to pressure in the pocket.
Pseudocapsule after breast augmentation from an expert's perspective
Master of Medicine, Dr. Ho Cao Vu, who graduated with a master's degree from the University of Medicine and Pharmacy in HCMC and currently works at Cho Ray Hospital, specializes in benign and malignant pathology surgery. Dr. Vu has over 15 years of experience and has performed more than 2,000 aesthetic and reconstructive surgeries using the new-generation ultrasonic surgical scalpel technology. He has also corrected numerous cases of defective, asymmetrical, exposed, or ruptured implants, pseudocapsule, severe grade III and IV capsular contracture, and more.
Below are insights from MMed, Dr. Ho Cao Vu on the signs, causes, prevention, and management of pseudocapsule before and during breast augmentation surgery.
Causes of pseudocapsule
● Selection of inappropriate implants
Women should choose implant sizes that are compatible with their anatomical structure. Many surgeons fail to assess three common abnormalities in chest structure: protruding, concave, and irregularly shaped chests.
This leads to the selection of implants that are not suitable in terms of diameter, projection, gel consistency, softness, and pressure within the pocket, which then creates pressure on the implants. Consequently, this results in the implant being compressed, leading to a sensation of breast hardness immediately after surgery that does not soften over time.
Choosing implants that do not align with the anatomical structure of the body is a primary cause of pseudocapsule following breast augmentation.
Some breast implants on the market lack the softness of certain well-known brands. Implants that do not feel as soft as or softer than natural breast tissue may be unsuitable for individuals with abnormal anatomical structures, thin skin, or limited glandular tissue. This can result in implant exposure, hard implants, and palpable rippling at certain border areas of the pocket where tissue coverage is minimal or too thin.
● Inaccurate creation of the implant pocket
Creating an implant pocket that is too small or not appropriately shaped for the size and contour of the implant can lead to complications, especially in individuals with unusual anatomical structures.
If the pocket diameter is smaller than the implant diameter or if the pocket is incorrectly positioned, the implant will not be evenly distributed in the upper, lower, inner, and outer poles. This creates pressure on the implant, leading to pseudocapsule shortly after surgery.
Furthermore, prolonged external pressure can cause the implant pocket to expand forward, leading to deformation. This can also result in the implant sitting predominantly above the nipple (a condition known as "high-riding breast"), below the nipple ("bottoming out"), primarily in the inner area (creating a "symmastia" effect), or mainly in the outer area ("lateral displacement"). Another noticeable sign is when the nipple is not centered within the breast mound.
The second major cause of pseudocapsule is the incorrect creation of the implant pocket.
If the pocket size is larger than the implant, the implant can move within the pocket, leading to an uneven appearance and altered sensation.
Some surgeons may not anticipate the risks associated with patients having abnormal anatomical structures such as chest bones, spine alignment, or the distribution of breast tissue, leading to complications and aesthetic issues over time. Therefore, the precise creation of the implant pocket is crucial.
Recognizable signs of pseudocapsule
● Immediate post-surgical breast hardness
Many patients experience breast hardness immediately after surgery and assume it is normal. However, this is a sign that should be monitored closely for the first six months post-surgery.
Typically, the implant's softness and breast shape change during this period. If the breasts do not soften after six months, a consultation with a specialist in breast pathology and aesthetics is necessary.
Hardness of the breasts immediately after surgery is a clinical sign of pseudocapsule, although many women mistakenly believe this is normal.
For cases of pseudocapsule, clinical examination is often sufficient for detection. Advanced breast MRI may not reveal abnormalities or implant damage until six months to a year post-surgery.
● Persistent breast hardness
There is no need for concern for cases where the implants gradually soften over six months. Only if the implants remain hard overtime should a specialist be consulted to determine the best action.
● Breasts harder than pre-implantation
In some instances, implants with a thick shell may feel hard to the touch. After implantation, this hardness usually persists. Patients might be advised to undergo fat grafting to enhance softness.
While fat grafting can help enhance softness, it carries risks. Non-resorbed fat can form palpable calcified lumps, which can be mistaken for microcalcifications in mammography screenings, leading to potential misdiagnoses and overlooked lesions. Therefore, careful consideration is required when opting for fat grafting in the breasts.
Preventive measures and complication management
● Selecting an implant size that suits the individual's anatomical structure: Avoid overly large implants with high projection or lack of softness, especially in cases with unusual anatomical structures.
● Accurate pocket dissection techniques: Use precise dissection techniques rather than blunt dissection methods, which rely solely on tactile feedback and do not provide direct visualization of the tissue being dissected.
Using an Ultrasonic surgical scalpel for precise dissection in breast augmentation can accelerate the softening process of the breasts compared to using electrocautery.
Traditional breast augmentation methods via the armpit, inframammary fold, or periareolar using blunt dissection and electrocautery have several drawbacks. These include the necessity of injecting large amounts of vasoconstrictors and anesthetics at the attachment points of the pectoralis major muscle, a higher risk of bleeding, tissue trauma, excessive fluid secretion, and difficulties in accurately shaping the implant pocket in the inner and outer poles.
Important Note: After implant placement, the softness of the implant should match the current softness of the breast glandular tissue. Typically, implants are softer than natural breast tissue. Therefore, women must assess the softness of their breasts before and after implant placement to determine if they are experiencing pseudocapsule.
In such instances, implant placement may not resolve this issue. In some cases, fibrocystic breast tissues, due to genetic factors or extensive breastfeeding and frequent milk expression, do not improve even after implant placement.
