Capsular contracture: Baker grades, causes and treatment

What is capsular contracture?

Whenever an implant is placed in the body, the body forms a thin layer of scar tissue around it – the capsule. Normally, this capsule stays soft and thin and holds the implant in place. In capsular contracture, the capsule thickens and contracts, squeezing the implant. The breast becomes firmer, may look rounder or higher, and in advanced cases can become distorted and painful.

It can develop in one or both breasts, months or many years after surgery. Capsular contracture also occurs after implant-based breast reconstruction, particularly after radiotherapy.

Baker grades

Surgeons grade capsular contracture using the Baker classification:

• Baker grade 1: the breast is soft and looks natural. This is a normal capsule.
• Baker grade 2: the breast is a little firm to the touch but looks normal.
• Baker grade 3: the breast is firm and looks abnormal – rounder, higher, or with visible distortion.
• Baker grade 4: the breast is hard, painful and visibly distorted, often cold to the touch.

Grades 1 and 2 usually need no treatment. Grades 3 and 4 are generally treated surgically, both to relieve symptoms and restore shape.

Causes and risk factors

The exact cause is not fully understood, but several factors are linked to a higher risk:

• Bacterial contamination and biofilm: a low-grade colonisation of the implant surface by bacteria is thought to be a major factor.
• Blood or fluid around the implant after surgery (haematoma or seroma).
• Radiotherapy to the breast.
• Implant placement: implants placed over the muscle are generally associated with a higher risk than those under the muscle.
• Implant rupture, particularly with older implants.
• Previous capsular contracture, which increases the risk of recurrence.
• Smoking and other factors that impair healing.

Symptoms to watch for

• the breast feels progressively firmer or tighter;
• the implant rides higher or looks rounder, like a ball;
• the two breasts start to look different – see breast asymmetry;
• discomfort or pain, especially when lying on your front or exercising;
• visible folds, rippling or distortion.

A sudden change, swelling or fluid collection years after surgery is not typical of capsular contracture and should be checked promptly; see our page on BII and BIA-ALCL. Ultrasound or MRI can assess the capsule and check implant integrity; read more on imaging with implants.

Prevention

Surgeons reduce the risk with meticulous technique: careful control of bleeding, strict antiseptic measures, minimal handling of the implant (sometimes using an insertion funnel), changing gloves before handling the implant, an incision in the breast fold rather than around the areola in many cases, and placement under the muscle when appropriate. After surgery, follow your surgeon’s instructions about bras, massage (if recommended for your implant type) and activity. Stopping smoking, and getting prompt treatment for any infection anywhere in the body, may also help.

Treatment: capsulectomy and implant exchange

Non-surgical options – massage, ultrasound therapy or some medications – have limited evidence and are not a reliable solution for grade 3 or 4 contracture. The standard treatment is surgery:

• Capsulotomy: the capsule is cut to release it. Recurrence is more common, so this is used less often today.
• Total capsulectomy: the entire capsule is removed. This is usually preferred, especially with thick or calcified capsules.
• En bloc capsulectomy: the implant and capsule are removed together in one piece; often used when there is rupture or other concerns.
• Implant exchange: a new implant is placed, often in a new pocket (for example, moving from over to under the muscle), sometimes with a tissue matrix to reduce recurrence.
• Implant removal: some women choose to have the implants removed altogether, with or without a lift or fat transfer.

Our page on breast implant replacement explains the exchange procedure in detail.

Recovery and recurrence

Recovery after capsulectomy and exchange is similar to, or slightly longer than, the first augmentation: usually one night in hospital, sometimes drains, a supportive bra for six weeks, return to desk work after one to two weeks and sport after about six weeks. Capsular contracture can recur, but changing the pocket, using a new implant and careful technique reduce the risk. If the skin is stretched or the breast sags after removing a contracted implant, a lift with implants may be combined.

How New City Clinic can help

Send photos and any ultrasound or MRI reports via WhatsApp for a free online assessment. Our plastic surgeons will grade the contracture and explain the options – exchange, removal or a combination with a lift. More information is available on newcityclinic.com about breast implant revision, implant replacement and removal in Turkey and implant safety and aftercare. Surgery takes place in accredited hospitals in Istanbul.