--- title: "What Is Capsular Contracture and How Can It Be Treated?" url: https://drturner.com.au/blogs/what-is-capsular-contracture-and-how-can-it-be-treated/ date: 2024-12-11 modified: 2026-07-30 author: "Dr Scott J Turner" description: "Dr Scott J Turner | Specialist Plastic Surgeon (FRACS) Key Takeaways The body forms a scar capsule around any implant, which is normal. Capsular contracture is when that capsule tightens..." categories: - "Breast Augmentation" - "Breast Implants" image: https://drturner.com.au/wp-content/uploads/2024/04/blogplaceholder-img.svg word_count: 2178 --- # What Is Capsular Contracture and How Can It Be Treated? *[Dr Scott J Turner](https://drturner.com.au/dr-scott-turner-sydney-plastic-surgeon/) | Specialist Plastic Surgeon (FRACS)* > **Key Takeaways** > > > > > - The body forms a scar capsule around any implant, which is normal. Capsular contracture is when that capsule tightens and thickens around the implant, changing how the breast looks and feels. > - It is one of the more common reasons patients need revision surgery. Most patients with implants never develop a significant case, and many mild cases never need treatment. > - Severity is described using the Baker scale, grades I to IV. Grades I and II are usually monitored; surgery generally enters the conversation at grade III and is more clear-cut at grade IV. > - The common thread is low-grade inflammation around the implant, often driven by bacterial biofilm, which is why surgical technique matters so much for this particular complication. > - The risk cannot be eliminated, but it can be reduced substantially through a biofilm-minimising protocol at the time of surgery, and it can recur after revision. > - New firmness years after surgery is usually contracture, but it can occasionally signal BIA-ALCL, so any new change should be assessed rather than assumed. Ask patients with breast implants what they worry about, and capsular contracture often comes up first. It is a common reason for revision surgery, and it is what causes one breast to feel firmer than the other, look higher or rounder, or become uncomfortable years after an operation that went well at the time. Most patients with implants never encounter it, but for those who do, understanding what is happening and what actually helps makes a real difference. Capsular contracture is managed through revision surgery rather than the augmentation pathway, so the relevant service page is [breast implant revision and removal](https://drturner.com.au/procedures/breast-body/breast-implant-revision/). This article sits alongside the wider overview of [breast augmentation risks and complications](https://drturner.com.au/blogs/breast-augmentation-risks-complications/) and covers the basics in plain terms: what contracture is, why it happens, how it is graded, how it is prevented, and the treatment options when it occurs. ## What capsular contracture actually is The body forms scar tissue around anything it recognises as foreign, whether that is a hip joint, a pacemaker or a breast implant. Surgeons call this scar layer the capsule, and it is entirely normal. In most patients it stays soft and stretchy, the implant sits comfortably within it, and the breast remains soft from one year to the next. Capsular contracture is when that capsule tightens, thickens and begins to squeeze the implant. It can affect one breast or both, and the severity varies considerably. For some patients it is a subtle firmness they barely notice; for others the breast becomes visibly distorted or genuinely uncomfortable. The breast that was soft may start to feel hard or less mobile, the implant may ride higher on the chest or look rounder than before, the nipple may point differently, and there can be tenderness, pressure or a dull ache. In advanced cases the difference between the two breasts becomes obvious even at rest. ## Why it happens There is no single confirmed trigger. What is consistent across the research is that inflammation around the implant is the common thread, and several things can start that inflammation or keep it going. Bacterial biofilm is the most significant factor. Even trace bacterial contamination at the time of surgery, too low to register as an infection, can keep the immune system active for months or years afterward, and that low-grade chronic inflammation drives the capsule to thicken and contract. This is the main reason surgical technique matters so much for this particular complication. Other factors that raise the risk include bleeding or fluid collecting around the implant after surgery, smoking, since nicotine slows healing and produces poorer scar tissue, radiation therapy to the chest, and individual healing tendency, as some patients simply form more aggressive scar tissue than others. One point that comes up often at consultation: contracture is not caused by what is inside the implant. Silicone versus saline does not affect it, because this is the body's response to the implant's presence rather than its filling. ## The Baker grading system Surgeons use the Baker scale to describe how severe a case is, across four grades, and knowing where a case sits helps frame a sensible discussion about what to do. - **Grade I** is what most patients with implants have. The breast looks typical and feels soft, and the capsule is doing its job without causing trouble. This is the long-term state for most patients. - **Grade II** means the breast still looks typical but feels firmer than expected, with no distortion and no pain. This grade is almost always monitored rather than operated on. - **Grade III** is where the breast starts to look visibly different, with a distorted shape, riding higher, or looking rounder than before. It is not always painful, but the appearance has changed, and this is generally the threshold where surgery enters the conversation. - **Grade IV** is hard, painful and obviously distorted. At this stage surgery is usually recommended, both for comfort and because an untreated grade IV contracture rarely improves on its own. The practical point is that not everyone with contracture needs surgery. Mild cases are usually watched, and the conversation about operating really begins at grade III. ## How surgeons try to prevent it The risk cannot be eliminated, but it can be reduced significantly, and the protocol that does this is the Adams 14-Point Plan, an internationally recognised standard for minimising biofilm during breast implant surgery. The logic is straightforward: keep bacterial contamination as close to zero as possible from the moment the implant is opened until the wound is closed. The steps cover antibiotics given through the drip at the start of the operation, avoiding incisions around the nipple where possible since milk ducts harbour bacteria, using nipple shields to prevent spillage into the surgical pocket, careful dissection that preserves the blood supply, meticulous control of bleeding, avoiding cutting through the breast tissue itself, using a dual-plane or submuscular pocket, rinsing the pocket with an antibiotic or antiseptic solution, minimising the implant's contact with skin, opening the implant as late as possible and inserting it quickly, changing surgical gloves before handling the implant, using clean instruments, avoiding drainage tubes where safe, closing the wound in layers, and continuing antibiotic cover for later dental or surgical procedures that could spread bacteria. It is a long list, and each point contributes. Surgeons who adhere to it consistently see lower rates of contracture over time, and it is one of the more firmly evidence-based parts of implant surgery. ## Non-surgical options Non-surgical approaches can do relatively little for established contracture. Anti-inflammatory medication is sometimes tried in early mild cases, but the evidence for routine use is limited. Ultrasound therapy has been suggested as a way to soften an early capsule, but it remains investigational and is not something to rely on for a surgical result. Closed capsulotomy, where the breast is squeezed manually to break up the scar tissue, was done in the past but has largely been abandoned: the implant can rupture, there is a real risk of bleeding, and the contracture usually returns. For established grade III or IV contracture, non-surgical options are not a reliable solution, and surgery is the definitive approach. ## Surgical options Several surgical approaches exist, and the right choice depends on the severity, the implant type and individual anatomy. Capsulotomy cuts into the existing capsule to release the tightness without removing it. Pressure comes off the implant and symptoms often improve, but because the original capsule remains, the contracture frequently returns, so this is used less often now, particularly for more severe cases. Capsulectomy removes part or all of the capsule along with the implant. Total capsulectomy is usually preferred for severe cases because it leaves a clean pocket, and recurrence rates are lower than with capsulotomy alone; for grade IV contracture it is generally the more definitive answer. The clinical position on capsulectomy approaches and the en bloc terminology is covered in the article on [breast implant removal and capsulectomy](https://drturner.com.au/blogs/patient-safety-advisory-breast-implant-removal-and-capsulectomy/). Implant exchange and pocket repositioning often accompany capsulectomy. A new implant is placed, either into the existing pocket or a freshly created one, and changing the pocket plane, for instance moving an implant from above the muscle to below it, often reduces the chance of recurrence. A neopocket can also be formed between the old capsule and the muscle, with the old capsule collapsed against the chest wall. One point worth correcting, because older patient material still repeats it: the advice to switch from smooth to textured implants to reduce recurrence is outdated in Australia. Macro-textured implants were suspended from the Australian market in 2019 over the BIA-ALCL link, and practice has shifted toward smooth implants for most cosmetic cases. Micro-textured implants remain available under TGA approval for selected indications. The appropriate choice is worked out for the individual case rather than by a blanket rule. Fat grafting is worth knowing about for patients with multiple recurrences, or those who would prefer to be implant-free. The implants are removed completely and volume is restored using the patient's own fat, taken from elsewhere by liposuction, usually over two procedures to achieve adequate volume and shape. For some patients it is the way out of a recurrent contracture cycle. The explant pathway is covered in the guides to [recovery after breast implant removal](https://drturner.com.au/blogs/recovery-after-breast-implant-removal-procedure/) and [Medicare and breast implant removal](https://drturner.com.au/blogs/will-medicare-cover-my-breast-implant-removal/). ## What happens long term Contracture can recur after revision surgery. Reported recurrence rates sit somewhere between 15 and 30 per cent within the following one to two years, depending on the procedure and the patient, according to the published data. This is why prevention during the original surgery matters, and why the decision about whether to operate at all is worth working through carefully. Early detection helps considerably. Firmness picked up at grade I or II can often be monitored, and regular self-checks together with routine reviews mean contracture is caught before it becomes a grade IV problem, which generally means less surgery if intervention becomes necessary. One overlap is worth knowing: new firmness years after surgery can occasionally be a presenting sign of BIA-ALCL, a rare cancer linked to certain textured implants, so any new firmness, swelling or asymmetry should be assessed rather than assumed to be straightforward contracture. The distinction is covered in the [BIA-ALCL guide](https://drturner.com.au/blogs/bia-alcl-symptoms-diagnosis-and-treatment-of-breast-implant-associated-lymphoma/) and the [breast implant illness guide](https://drturner.com.au/blogs/latest-update-on-breast-implant-illness-symptoms-and-treatment/). If you are considering revision for contracture, the decision framework is set out in the guide on [deciding whether to remove breast implants](https://drturner.com.au/blogs/deciding-to-remove-your-breast-implants-yes-or-no/). ## Frequently asked questions **How common is capsular contracture after breast augmentation?** Most published studies suggest somewhere between 5 and 15 per cent of patients with implants develop some degree of contracture over the lifetime of their implants. The figure for an individual depends on surgical technique, implant type, personal risk factors such as smoking or prior radiation, and how long the implants have been in place. Most cases that do develop stay mild, at Baker grade I or II, and never need surgery. **Does the type of implant affect the risk?** To an extent. Modern smooth and micro-textured implants both carry a contracture risk, and the rates are fairly similar with modern surgical technique. Placement also matters: an implant behind the muscle generally has a lower contracture rate than placement above it. Since the 2019 suspension of macro-textured implants in Australia, the implant choices for both primary and revision surgery differ from what they were a decade ago. **Is there anything I can do myself to reduce my risk?** Yes. The most important factor is choosing a Specialist Plastic Surgeon who uses a rigorous biofilm-minimising protocol such as the Adams 14-Point Plan. After surgery, the things that help most are not smoking, avoiding unnecessary breast trauma in the early months, attending your post-operative appointments, completing any antibiotic course, and getting anything new such as firmness, distortion or pain checked promptly rather than waiting. **Is capsular contracture painful?** It depends on the grade. Grades I and II usually are not painful and often go unnoticed. Grade III may cause some tenderness or a sense of pressure, and grade IV is typically uncomfortable, sometimes significantly. Any new pain in an implanted breast should be assessed sooner rather than later, because it can point to contracture, infection or, rarely, other complications. **Can it come back after surgery?** Yes, and the numbers are not small: recurrence after revision runs at around 15 to 30 per cent within one to two years. This is why the original surgery matters so much, why the choice of revision approach matters, since capsulectomy has a lower recurrence than capsulotomy, and why patients with multiple recurrences are often better considering the implant-free fat grafting option rather than another revision. Dr Scott J Turner is a Specialist Plastic Surgeon (FRACS). A GP referral is required before an initial surgical consultation under the current Medical Board of Australia framework. If you are concerned about firmness, distortion or new discomfort in an implanted breast, [contact the practice](https://drturner.com.au/contact-us/) to arrange a consultation. Bringing any original implant records, operation notes and recent imaging assists the assessment.