Capsular Contracture after Breast Reconstruction

Sir:FigureAlthough capsular contracture is a well-described complication of breast augmentation, the picture is not as clear in breast reconstruction, particularly after radiation therapy. By definition, non–radiation-induced capsular contracture describes a variably contracted capsule with unaffected overlying skin, whereas radiation-induced contracture may involve a tight capsule with or without tight, contracted overlying skin and is referred to here as “contracture” rather than “capsular contracture” to clarify that the tightness is not limited to contracture of the capsule; with radiation, the tightness may occur in all layers of the implant cover and is not limited to the capsule alone. Consequently, the treatments for non–radiation-induced capsular contracture and radiation-induced contracture may be different, with the former being treated by numerous procedures, including capsulectomy or capsulotomy, and the latter being most frequently treated by the addition of autologous tissue. In addition, the two types of contracture may have different pathophysiologies. Capsular contracture in nonirradiated breasts may be associated with subclinical contamination of the implant with bacteria.1–3 The underlying mechanism of radiation-induced contracture is unclear but seems to be caused by radiation-induced fibrosis in the skin and radiation-induced fibroproliferative disorder in the periimplant capsular tissue.4 Given that the presentation, cause, and treatment of radiation-induced contracture is different from non–radiation-induced capsular contracture, there should be a clear mechanism in place to differentiate them. Based on a previously described system,5 we propose the following modified system for the classification of capsular contracture (Table 1).Table 1: Modified System for the Classification of Capsular ContractureBy adding the modifiers (R) and (RS), the new classification conveys that radiation is involved and provides information about the overlying skin, which can help guide surgeons toward reconstructive options. For example, a class IV contracture may be treated with capsulotomy, a class IV(R) contracture may be treated with capsulotomy and acellular dermis, and a class IV(RS) contracture would likely necessitate the addition of autologous tissue. In the authors' experience, most patients who undergo tissue expander placement followed by postmastectomy radiation therapy experience some degree of pain/tightness. During the tissue expander stage, it is difficult to determine whether these symptoms are attributable to the firmness of the expander or to a true contracture. Thus, the diagnosis of capsular contracture based on previous classification systems has not been conclusive until the tissue expander has been exchanged for a permanent implant. However, our proposed system clarifies that pain and tightness in an irradiated tissue expander with normal overlying skin, class IV(R), may be attributable to tightness of other internal layers such as the capsule, muscle, or deep subcutaneous tissue and may resolve with capsulotomy, exchange for a permanent implant, and the potential addition of acellular dermis. However, if the overlying skin is affected, class IV(RS), the symptoms are unlikely to resolve without explantation or the addition of autologous tissue (Figs. 1 and 2).Fig. 1: Class IV(R) contracture. Note the presence of normal-appearing skin despite previous radiation therapy.Fig. 2: Class IV(RS) contracture, showing severe radiation-induced skin changes.Similarly, if the symptoms are present after the tissue expander has been exchanged for a permanent implant, the condition of the overlying skin may again help guide treatment decisions. If patients with permanent implants and a history of radiation therapy experience pain/tightness, but do not demonstrate severe stigma of irradiation in the overlying skin, they might be successfully treated by one of the measures previously described. However, if the overlying skin appears tight and hard, the pain and tightness will likely not resolve without explantation or the addition of autologous tissue. Having this added level of specificity should improve accuracy of diagnosis and ultimately help all clinicians and researchers involved with this challenging condition. Elliot M. Hirsch, M.D. Akhil K. Seth, M.D. Neil A. Fine, M.D. Division of Plastic and Reconstructive Surgery, Northwestern University Feinberg School of Medicine, Chicago, Ill. DISCLOSURE The authors have no financial interest in any of the products mentioned in this article. They received no funding from the manufacturers of any products mentioned in this paper, and have no corporate or financial affiliations with the manufacturers.