Dr Scott J Turner | Specialist Plastic Surgeon (FRACS) | Sydney
Ask anyone with breast implants what they worry about most, and capsular contracture usually comes up first. It’s the reason most women end up needing revision surgery. It’s what causes one breast to suddenly feel firmer than the other, look higher or rounder, or become uncomfortable years after the original operation went fine. Most women with implants never run into it. For those who do, understanding what’s happening (and why, and what actually works) makes a real difference.
I’m Dr Scott J Turner, a Specialist Plastic Surgeon (FRACS) at our Bondi Junction and Manly clinics in Sydney. What follows covers the basics of capsular contracture in plain language: what it is, why it happens, how surgeons grade it, what can be done to prevent it, and the treatment options when it does turn up.
What Capsular Contracture Actually Is
Your body forms scar tissue around anything it recognises as foreign. That’s true for a hip joint, a pacemaker, or a breast implant. Surgeons call this scar layer the “capsule,” and it’s completely normal. In most patients it stays soft and stretchy. The implant sits comfortably within it, the breast feels natural, and nothing changes from one year to the next.
Capsular contracture is when that capsule stops behaving. It tightens, thickens, and starts squeezing the implant. Sometimes it happens in one breast, sometimes both. The severity varies enormously between patients. For some women it’s subtle firmness they barely notice. For others, the breast becomes visibly distorted or genuinely painful.
What does this look and feel like? The breast that used to be soft starts feeling hard or less mobile. The implant may ride higher on the chest, or look noticeably rounder than before. The nipple might point differently. 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
Nobody knows the single trigger. What researchers do know is that inflammation around the implant is the common thread, and several things can set that inflammation off or keep it going.
Bacterial biofilm is the biggest culprit. Even trace bacterial contamination at the time of surgery (too low-level to show up as an infection) can keep the immune system simmering for months or years afterwards. 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, and why the 14-Point Plan exists (coming up in a moment).
Other things that increase your risk: bleeding or fluid collecting around the implant after surgery (hematoma or seroma), smoking (nicotine from cigarettes and vapes slows healing and produces poorer scar tissue), radiation therapy to the chest, and plain old genetics. Some women form more aggressive scar tissue than others. Nothing wrong with them, just how their bodies work.
One thing worth mentioning because it comes up a lot in consultations: capsular contracture isn’t caused by what’s inside the implant. Silicone versus saline doesn’t matter here. This is about the body’s reaction to the implant’s presence, not its filling.
The Baker Grading System
Plastic surgeons use the Baker scale to describe how severe a case of capsular contracture is. There are four grades, each one worse than the last, and understanding where you sit helps you have a sensible conversation about what to do next.
Grade I is what most women with implants have. The breast looks completely normal and feels soft. The capsule is doing its job without causing any trouble. This is the long-term state for most patients.
Grade II means the breast still looks normal but feels a bit firmer than expected. No distortion, no pain, just a noticeable change in firmness. This grade is almost always monitored rather than operated on.
Grade III is where the breast starts looking visibly different. Distorted shape, riding higher on the chest, looking rounder than before. It’s not always painful at this grade, but the appearance has changed. This is generally the threshold where surgical treatment enters the conversation.
Grade IV is hard, painful, and obviously distorted. At this stage, surgery is usually recommended, both for comfort and because leaving a Grade IV contracture untreated rarely improves on its own.
The practical point is that not everyone with capsular contracture needs surgery. Mild cases (Grade I or II) are usually just watched. The conversation about operating really starts at Grade III and becomes clear-cut at Grade IV.
How Surgeons Try to Prevent It
You can’t eliminate the risk of capsular contracture completely. What you can do is reduce it significantly, and the protocol that does this is called the Adams 14-Point Plan. It’s the international standard for minimising biofilm during breast implant surgery, and the logic behind it is simple: keep bacterial contamination as close to zero as possible from the moment the implant is opened until the last stitch goes in.
The 14 steps cover everything you’d expect and a few things you probably wouldn’t. Antibiotics given through the drip at the start of the operation. Avoiding incisions around the nipple where possible (milk ducts harbour bacteria). Using nipple shields to stop spillage into the surgical pocket. Careful dissection that keeps the blood supply intact. Meticulous control of bleeding. Not cutting through the breast tissue itself. Using a dual-plane or submuscular pocket. Rinsing the pocket with a triple-antibiotic solution or betadine. Keeping the implant’s contact with skin to a bare minimum. Opening the implant as late as possible and getting it in quickly. Changing surgical gloves before touching the implant. Using clean instruments. Skipping drainage tubes where safe to do so. Closing the wound in layers. And continuing antibiotic cover for any later dental or surgical procedures that could spread bacteria.
It’s a long list. Every point matters. The surgeons who stick to it see noticeably lower rates of contracture over time. It’s one of the genuinely evidence-based parts of implant surgery.
Non-Surgical Options
Before we get to surgery, a quick note on what non-surgical approaches can and can’t do. The honest answer is: not much, in most cases. Anti-inflammatory medications are sometimes prescribed for early mild cases, but the evidence for routine use is thin. Ultrasound therapy has been suggested as a way to soften an early capsule, but it’s still investigational and nobody should bet their surgical result on it.
Closed capsulotomy (where the surgeon squeezes the breast manually to break up the scar tissue) used to be done but has largely been abandoned. The implant can rupture, there’s a real risk of bleeding, and the contracture usually comes back anyway.
The bottom line for established contracture at Grade III or IV: non-surgical options aren’t a reliable solution. Surgery is the definitive approach.
Surgical Options
Several surgical approaches exist. The right choice depends on how severe the contracture is, what type of implant you have, and your individual anatomy.
Capsulotomy cuts into the existing capsule to release the tightness without removing it. Pressure comes off the implant, symptoms often improve, but because the original capsule stays in place, the contracture frequently returns. This approach is used less often than it used to be, 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 gives the surgeon a clean pocket to work with. Recurrence rates are lower than with capsulotomy alone, and for patients with Baker Grade IV contracture, it’s generally the more definitive answer.
Implant exchange and pocket repositioning often happens alongside capsulectomy. A new implant goes in, either into the existing pocket or a freshly created one. A common strategy is changing the pocket plane (for instance, moving an implant from above the muscle to below it, or into a dual-plane position) because that often reduces the chance of the contracture coming back. Another option is neopocket formation, where a new pocket is created between the old capsule and the pectoral muscle, with the old capsule collapsed and fixed against the chest wall.
One thing worth addressing because older patient education still says this: 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 because of the BIA-ALCL link. Current practice has shifted toward smooth implants for most cosmetic cases. Mentor Siltex micro-textured implants remain available with TGA approval for selected indications. Your surgeon will work through what’s appropriate for your specific situation rather than defaulting to a blanket rule.
Fat grafting is worth knowing about if you’ve had multiple recurrences or you’d simply prefer to be implant-free. The implants come out completely, and volume is restored using fat taken from elsewhere on your body via liposuction. It’s usually done over two procedures to get adequate volume and shape. For some patients it’s the way out of the recurrent contracture cycle altogether.
For more on the explant pathway, see recovery after breast implant removal and the Medicare considerations for breast implant removal.
What Happens Long-Term
Here’s the uncomfortable truth about capsular contracture revision surgery: it can come back. Reported recurrence rates after revision surgery sit somewhere between 15% and 30% within the following one to two years, depending on the procedure and the patient. That’s a real number, not a theoretical one. It’s why prevention during the original surgery genuinely matters, and why the conversation about whether to operate at all is worth having carefully.
Early detection helps enormously. If you notice firmness at Grade I or II, you can often just monitor it. Regular self-checks of your breasts and routine reviews with your plastic surgeon mean the contracture is picked up before it becomes a Grade IV problem. Catching it earlier generally means less surgery if intervention does become necessary.
One overlap worth knowing about: new firmness years after implant surgery can occasionally be a presenting sign of BIA-ALCL, a rare cancer linked to certain textured implants. Any new firmness, swelling, or asymmetry should be checked out by your surgeon rather than assumed to be straightforward contracture. For more on the distinction, see our BIA-ALCL guide and the breast implant illness guide.
If you’re considering revision surgery for capsular contracture, the decision is worth working through carefully rather than reactively. For more on that process, see our guide on deciding about breast implant removal.
Frequently Asked Questions
How common is capsular contracture after breast augmentation? Somewhere between 5% and 15% of women with implants will develop some degree of capsular contracture during the lifetime of their implants, based on most published studies. The actual number for an individual depends on surgical technique, implant type, your own risk factors (smoking, prior radiation), and how long the implants have been in place. Most cases that do develop stay mild (Baker Grade I or II) and never need surgery.
Does the type of implant affect the risk? It does, to an extent. Modern smooth and micro-textured implants both carry contracture risk, and the rates are fairly similar when modern surgical technique is being used. Implant placement matters too: putting the implant behind the muscle (submuscular or dual-plane) generally has lower contracture rates than placement above the muscle (subglandular). Since the 2019 suspension of macro-textured implants in Australia, the implant choices available for both primary and revision surgery are different from what they were a decade ago.
Is there anything I can do myself to reduce my risk? Yes. The single most important factor is choosing a Specialist Plastic Surgeon who uses a rigorous biofilm minimisation protocol like the Adams 14-Point Plan. After the operation, the things that help most are not smoking, avoiding any unnecessary breast trauma in the first few months, turning up to your post-op appointments, completing any antibiotic course properly, and getting anything new (firmness, distortion, pain) checked promptly rather than waiting.
Is capsular contracture painful? Depends on the grade. Grade I and II usually aren’t painful and most women don’t notice them. Grade III might cause some tenderness or a feeling of pressure. Grade IV is typically uncomfortable, sometimes significantly so. 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 aren’t small. Recurrence rates after revision surgery run at around 15% to 30% within one to two years. That’s why how the original surgery was done matters so much, why choice of revision approach matters (capsulectomy has lower recurrence than capsulotomy), and why patients who’ve had multiple recurrences are often better off considering the implant-free fat grafting option rather than doing another revision.
Book a Consultation
If you’re worried about firming, distortion, or new discomfort in a breast with implants, or if you’d just like a clearer picture of your own risk of capsular contracture, I’m happy to see you at our Bondi Junction or Manly clinic in Sydney. I also consult at Brisbane, Canberra, and Newcastle.
A few practical things for the appointment: obtain a GP referral before you come if your concerns involve medical issues. Bring any records you have (original implant details, operation notes, any previous imaging). The consultation itself covers examination, Baker grading if contracture is present, a frank discussion of your implant type and what’s actually on the table for you, and whether any intervention is worth doing at all.
Contact our clinic on 1300 437 758, or email [email protected].
General information only, not medical advice. Capsular contracture varies significantly between patients, so surgical decisions require individual clinical assessment by a qualified health practitioner.
