Capsular Contracture: Symptoms, Grades, Causes and Treatment

Capsular contracture is when the scar tissue that normally forms around a breast implant tightens and squeezes it. The breast can become firm, painful and misshapen. The FDA lists it among the most common complications of breast implants. In one large manufacturer study, 18.9% of cosmetic augmentation patients had developed it by 10 years (Plastic and Reconstructive Surgery, 2014).

What capsular contracture is

Your body forms a thin layer of scar tissue, called a capsule, around anything implanted in it. That is normal. Usually the capsule stays soft, and you cannot feel it. In capsular contracture, the capsule thickens and shrinks. The FDA describes it as hardening of the breast around the implant, which can be painful and can happen on one or both sides.

Symptoms

Common signs include:

• A breast that feels firmer or harder than before
• Tightness, aching or pain, sometimes worse when lying on that side
• An implant that looks rounder, higher or "ball-like"
• One breast that no longer matches the other

Other problems can look similar. Late swelling or a lump near an implant should always be checked, because the FDA lists persistent swelling, a mass or pain as the main symptoms of BIA-ALCL, a rare lymphoma linked to implants. A silicone rupture can also cause hardness or lumps. That is why a new change needs an exam, and often imaging, before anyone calls it contracture.

The four Baker grades

Surgeons grade contracture with the Baker scale. The FDA uses these plain-English definitions (FDA):

When studies report contracture rates, they usually count grades III and IV.

How common is it?

The answer depends a lot on the study, so here are three numbers side by side:

• 18.9% at 10 years in cosmetic augmentation patients in Allergan's silicone implant core study, which followed 715 women (Plastic and Reconstructive Surgery, 2014).
• 4.7% at 10 years (grades III/IV) in 777 cosmetic augmentation patients from one U.S. practice using smooth Mentor silicone implants (Aesthetic Surgery Journal, 2021).
• Higher rates after revision and reconstruction: 28.7% and 24.6% at 10 years in the same Allergan study.

Why such a spread? Studies differ in implant type, placement, surgeon, follow-up and how hard they looked. Both studies above were funded by, or included staff of, the implant maker. Treat any single number as a rough guide, and ask your surgeon for their own rate.

When does it happen?

It can appear early or years later. In the 777-patient study, complications showed up on average 3.9 years after surgery, ranging from 19 days to almost 12 years (Aesthetic Surgery Journal, 2021). A review of 40 studies found that a longer time since surgery was linked with a higher risk (Journal of Plastic, Reconstructive & Aesthetic Surgery, 2018).

What causes it, and what raises the risk

The FDA says the cause is not known, but contracture may be more common after infection, a hematoma (a collection of blood) or a seroma (a collection of fluid). A systematic review of 40 studies found a likely higher risk with (JPRAS, 2018):

• Longer time since surgery
• Reconstruction after breast cancer
• Implant placed over the muscle (subglandular)
• A hematoma after surgery
• A textured implant surface

The review found little or no good evidence for many other suspected factors, and studies defined contracture in different ways.

Where the evidence conflicts

Texture is a good example. That review linked textured implants with more contracture. A 2022 meta-analysis of 13 studies found the opposite: less contracture with textured implants (Gland Surgery, 2022). Meanwhile, the FDA says textured implants carry a higher risk of BIA-ALCL (FDA). Ask your surgeon how they weigh these.

Placement has clearer data. In the Allergan study, contracture was 15.7% under the muscle and 26.3% over it (PRS, 2014). Some surgeons rinse the implant pocket with an antiseptic. A meta-analysis found less contracture with povidone-iodine rinses (2.7% vs 8.9%), but the authors said most of the studies were of low quality (PRS, 2015).

How it is diagnosed

Diagnosis starts with a physical exam: the surgeon compares both breasts, feels how firm they are and assigns a Baker grade. Imaging helps rule out other causes. For silicone implants, the FDA says MRI is the most effective way to find a silent rupture, and ultrasound is an acceptable alternative for screening people without symptoms (FDA). If there is fluid around the implant months or years after surgery, doctors may test it for BIA-ALCL, because a confirmed diagnosis changes the type of operation needed (FDA).

How it is treated

Grades I and II

Mild firmness that does not bother you is often just watched. Some surgeons try medicines. A 2020 meta-analysis of five studies reported that leukotriene blockers, which are asthma drugs, helped prevent or treat contracture (PRS, 2020). This use is off-label. One of these drugs, montelukast, carries an FDA boxed warning about serious mental health side effects (FDA). The FDA has not cleared or approved any device to treat or reduce contracture (FDA).

Grades III and IV

The FDA says severe contracture may require another operation, usually removing the implant with or without a replacement. The surgeon may also remove all or part of the capsule (capsulectomy) or release it. The FDA warns that contracture can come back after surgery to correct it (FDA). It also says "closed capsulotomy," squeezing the breast by hand to break the capsule, is not recommended for saline implants because it can cause rupture.

Questions to ask before your first surgery

You cannot control every risk, but you can choose a surgeon who plans for this one. Useful questions:

• Will the implant go over or under the muscle, and why for my body?
• Smooth or textured, and how do you weigh contracture against BIA-ALCL risk?
• How do you reduce the risk of bleeding and infection during and after surgery?
• If I develop grade III or IV contracture, what would you do, and what would it cost me?
• How many of your patients have needed surgery for contracture?

Who pays for the fix

The FDA warns that the cost of implant removal or replacement may not be covered by insurance, even for complications (FDA). Some implant makers offer warranties, and terms differ by brand and country. Ask for the warranty in writing before surgery. Our guide to what insurance covers abroad explains complication cover. For typical surgery prices, see our breast augmentation cost page.

If you had implants abroad

• Keep your records. A U.S. surgeon will want the implant card (brand, model, size, surface), the operative note and any imaging.
• Get a local exam first. Sudden swelling, redness, fever or a new lump should be seen promptly near home, not saved for a return trip.
• Weigh a return trip. Revision for contracture is a full operation. Ask the original clinic whether it covers revision surgery and travel, and compare that with local care.

Before choosing a clinic, use our plastic surgeon question checklist and ask directly: "What is your capsular contracture rate, and how do you define it?" Country checks are in our Turkey breast implant safety guide.

Related reading: Breast Implant Sizes: CC, Profile and How Size Is Chosen, Breast Augmentation Recovery: A Week-by-Week Timeline, Silicone vs Saline Implants: What the FDA Data Shows.