Dr. Koehler (00:00): We do know that when patients do develop capsular contracture and then we do whatever any of those treatments like a capsulectomy and we put a new implant in, there's a 25% chance that it's going to happen again. So unfortunately, if you get a capsule contracture once, it can be a frustrating problem and it can tend to recur. Announcer (00:25): You're listening to Alabama the Beautiful. Kirstin (00:28): I'm Kirstin Jarvis and I'm here with our host cosmetic surgeons, Dr. James Koehler and Dr. Vincent Gardner. Hey doctors. Dr. Koehler (00:36): Hey Kirstin. Dr. Gardner (00:37): Hey Kirstin. Kirstin (00:38): Hey. So one thing that people don't always get warned about when they get breast implants is that their breasts can change months or years after the surgery. And the women who feel it first almost always assume they did something wrong. So we're going to talk about the first sign, what women notice when they call when they have signs of capsular contracture. What does capsular contracture actually feel like when it's just starting? Dr. Koehler (01:07): When it's mild, the breast is just maybe a little firmer than usual. It's not painful, it doesn't look distorted. It just feels a little bit firmer. And a lot of times these mild forms of contracture people don't even really even sometimes recognize. But as capsular contracture progresses, then it does become a lot firmer. And it doesn't typically happen on both sides. It can, but maybe not at the. Usually one side will get firm, the other side may not be firm. Sometimes they'll both get contracted, but when it happens, one side will get significantly firm and then ultimately it'll start to look different and they usually start riding up and look distorted. Instead of looking around, they can start to look kind of more oblong in shape. And then when they're really severely contracted, they can actually be painful. Kirstin (02:03): How much firmness is normal as part of healing and then when does it cross the line into something wrong? Dr. Koehler (02:10): It's sometimes hard for the patients to judge. I mean, I guess when is it problematic? Well, I guess when it's bothersome to the patient, but there's some patients that will come in, they'll be like, "Oh, my breast feels firm," but yet it's really they might have chose a cohesive implant and that feels a little firmer than let's say one of the other implants that is not as cohesive. And so that firmness is a bit of a subjective thing, but if it's changed from when the original augmentation was, well then that may be something of concern. Kirstin (02:46): How long after surgery does something like this usually show up? Is it almost immediate or does it take months or years? Dr. Koehler (02:54): Varies. And so that's the thing. Sometimes you might see a patient three to six months out from surgery and they're totally fine and they may think, "Oh good, I'm out of the woods, no problems, I'm set." And that may be very true, but capsular contracture is a cumulative risk. So the longer you have your implants, the more chance that you're going to get that. So you might be fine for one year, five years, maybe even 10 years. And I've seen women go 30 years with implants and not have capsular contracture, but it absolutely can happen months after surgery or you may go 15 years and then all of a sudden one side starts getting hard. So it's a cumulative risk. It's something that you don't kind of like, "If I didn't get it by this time, I'm never going to get it." No, you might. It just may take a long time. Kirstin (03:48): Do you find that patients blame themselves when something like this happens? Dr. Koehler (03:55): Sometimes they don't notice it until something happens. Maybe, I don't know, they had some kind of accident or something like that and then maybe their breast is hurting and they become more aware of it and then they start comparing it and they're like, "Okay, this side doesn't feel the same as the other." So it might've been there, but they become aware for some reason. So I don't know that I necessarily feel like women blame themselves for it. I think it's a frustrating problem and they just don't understand why. They were good and then now they're not. So it's just frustrating, but it is one of the risks of implant surgeries. And like I said, some people are very lucky and they'll never develop it. And other people are just more prone to developing it and it can be a frustrating problem to treat. Kirstin (04:40): Tell us what a capsule actually is and why does everybody form one? Dr. Koehler (04:46): Well, all it is is whenever you implant a foreign substance in the body, the body will form a thin layer of scar tissue around that foreign body. So I always tell patients, if you had a pacemaker put in, if you went to take that pacemaker out, there's a capsule, a little thin layer of scar tissue that forms around that implanted device. So it's something that we see with all implantable devices, but that thin layer of scar tissue is normal. It's not abnormal. It only becomes abnormal when, not to get into all the technical explanation, but what can happen is the fibroblasts can kind of, well, you can get these myofibroblasts which align a certain way and when they do that, the scar tissue can be either thickened or even if it's not thickened, it can start to tighten up around that implant. And when it does that, that's when it starts to become firm. (05:46): And sometimes the women feel like, "Oh, my implant got hard." Well, no, your implant's the same as it always was. The implant didn't get hard. It's the scar tissue around the implant, which is now so tight around the implant that the implant doesn't move freely and it makes the implant feel like it's hard. Kirstin (06:04): So what can make one person's capsule tighten when most never do? Dr. Koehler (06:10): Well, there's a lot of factors and there's a lot of theories. The whole thought process behind capsular contractures really can be multiple things that can contribute to it. One of the theories is this, we call it the slime layer theory, which is basically when an implant is placed into the body, there's bacteria and that bacteria is actually healthy bacteria. It's within our bodies. So inside of your breast tissue is bacteria. And one particular strain of that bacteria is staph epidermidis. And in some people that bacteria can get on the surface of the implant and it doesn't create an infection, but it creates what we call a slime layer. And that layer of bacteria stimulates a chronic inflammatory process, which then results in thickening of scar tissue. That is something that we do a lot of different things at surgery to minimize that. And it's one of the reasons why implants are more often placed under the muscle versus on top because when implants are placed on top of the muscle, the implant is exposed to all of that bacteria in the ducts of the breast. (07:26): Whereas if you go under the muscle, although there is contact still with some breast tissue, there's less exposure, so less potential bacteria. But we do things at surgery like irrigate the pocket out with antibiotics before we put the implant in. We use things like the Keller funnel to try to not touch the implant or change our gloves. We do all these things to minimize any contamination that could potentially result in this slime layer on the implant surface. But other things like if you had some bleeding after surgery, like a hematoma, although the blood's a great culture medium for bacteria, but also it stimulates further inflammation. And so things that stimulate inflammation after surgery can also contribute to capsule contracture. So those are things that, especially the early contractures, it can contribute. But again, nobody fully, fully understands why. And certainly why does it happen 15 years later versus not right away? So anyhow, it's a frustrating problem, but that's the theory. Kirstin (08:35): Have you ever used the term slime layer face-to-face with a patient? Dr. Koehler (08:40): Yeah, I used the term slime layer. Yeah. You're kind of slimy, to be honest. And they used it in Ghostbusters too, by the way. You slimed me? There you go. Kirstin (08:55): All right. Let's talk about where does the Baker scale start and what does each grade actually look and feel like? Dr. Koehler (09:04): The Baker scale. So grade one is a normal healthy capsule. So there is a scar tissue there, but when you feel the breast, it feels soft, that's normal. So Baker grade one is normal. Baker grade two is firmer than normal. It's like when you feel it, it might feel different than the other side. It's a little bit firmer. That's something you can live with. There's some treatments, non-surgical treatments that your doctor could discuss with you, but anyhow, that's not terrible. Grade three is when it starts to become even tighter and it starts to distort the shape of the breast. So now there's a visible difference. So grade two, you could look at the breasts and they visibly may not look any different, but there's a difference in the feel. Grade three, it looks different. And grade four just means it's painful. So if it's hurting, then it's a grade four. Kirstin (09:57): At what point do you tell someone it's time to do something about it? Dr. Koehler (10:03): Well, grade four is definitely, if it's painful, you've got to do something. Nobody wants to live with chronic discomfort. Grade twos, like I said, you could probably live with. There are some treatments like you can use some of the leukotriene inhibitors like Singulair, which is FDA approved for asthma. It's not FDA approved for using it in capsule contracture, but there is scientific evidence now that suggests using that for a 90-day period when you develop a grade two contracture that it can help. So that's something that you might discuss with your doctor. Kirstin (10:41): Because it gets rid of the slime. Dr. Koehler (10:43): It doesn't get rid of the slime. It does decrease the inflammatory mediators though, and it can slow the process down. And in some cases it seems if it's early enough in the formation of your capsule, it may reverse it. So you can use it in a grade two because you could potentially be fine with a grade two. They look good, it's just it might feel a little different. Now you might opt to have surgery, but the point is grade two is not terrible. Grade three, once it's starting to distort the shape, most women are going to opt to have surgery to correct the shape. And so the surgical treatment involves either taking the entire capsule out or taking part of the capsule out or sometimes not taking the capsule out, but making little cuts in the capsule to stretch the capsule. But all of the treatments, most people would recommend replacing the implant because if we believe that potential bacteria is a problem, we don't want to put that same implant back in. (11:46): We'll take that out, we'll rinse everything out really good and we'll put a brand new implant in. However, we do know that when patients do develop capsular contracture and then we do whatever any of those treatments like a capsulectomy where we take all the scar tissue out and we put a new implant in, there's a 25% chance that it's going to happen again. So unfortunately, if you get a capsule contracture once, it can be a frustrating problem and it can tend to recur. Kirstin (12:18): Is there anything you can do to reduce the odds of recurrence? Dr. Koehler (12:23): Yeah. The biggest one that we can do is the placement of acellular dermal matrix. So one of the products that I use, it's called Strattice. It's pig skin, but all the cells have been removed. It's basically just dermis. So it's an acellular. There's no cells, dermis, dermal, and it's a matrix and it's basically collagen. But once you take out all the scar tissue, you suture this material in place. And what it does is it prevents those myofibroblasts from aligning in a certain way to cause that scar tissue to contract, and it's extremely effective. I think in the literature, it shows like a 85% relative risk reduction or something like that. But in my experience, I feel like I've had a hundred percent success rate with Strattice when it comes to capsule contracture, maybe not a hundred, but it's very high. I can't recall a time. (13:17): So the unfortunate thing is that material is expensive and a lot of people really wouldn't consider it first line therapy anyhow. So let's say you had surgery and now it's three years later and you got a grade three contracture and it's distorted. A lot of doctors would do a capsulectomy or one of the other treatments I mentioned and put a new implant in, but not put the dermal matrix in. However, if it recurred, most people would be leaning you towards trying out one of these dermal matrix products to try to prevent it from recurring. Kirstin (13:57): Recovery wise, is there a difference between primary augmentation capsulectomy or capsulectomy with Strattice? Dr. Koehler (14:05): Well, yeah. I mean, a capsulectomy is, I don't know, I'd say it's probably on par with a primary augmentation, maybe a little bit more uncomfortable. It just sort of depends on how the capsulectomy goes, but putting the dermal matrix in really is, I don't consider that to be really any added postoperative discomfort. But if the treatment was just like doing a capsulotomy where we're just making little cuts in the capsule and putting a new implant in, that would not be very uncomfortable, but sometimes that's not an effective treatment. So a lot of times I find a capsulectomy is a better choice. Kirstin (14:45): So beyond capsular contracture, let's just talk about a few other things that could go wrong potentially down the road. So maybe like rupture, either silicone or saline. How would someone know? And does silicone behave differently than saline when it ruptures? Dr. Koehler (15:02): Oh yeah, very different. So people with saline implants, they call the office in a panic going, "I need on your surgery schedule tomorrow because with a saline implant, it's just IV fluid saline that is in your implant. And if it leaks, usually you can occasionally have a slower leak, but usually it happens pretty quickly. And so they wake up the next morning and they're like one breast is half the size of the other and they're panicking because like, oh my God." So saline, it's not one of these where I think it might be leaking. Usually it's pretty obvious. Silicone on the other hand, because it is a gel and your body doesn't reabsorb that, you could go a long period of time and have no idea that your implant is even ruptured. In fact, I remember a patient that I didn't do her primary surgery, but I was going to do a revision surgery on her. (16:00): She was only like a year and a half out from her surgery and I was going to redo her lift and some other stuff. Anyhow, we planned on using her existing implants because they were only a year and a half old. When we got in there, found that both of her implants were ruptured. So it wasn't obvious on exam for her, but sometimes on the exam, it can feel even almost squishier than normal for a silicone because the shell's ruptured. And so sometimes you can have a contracted breast, but yet it still kind of feels soft and it's kind of hard to explain, but it's like the implant doesn't move, but yet the breast is soft. So anyhow, silicone, the only way you're really going to know if it's ruptured is you can do imaging. An ultrasound is what is a good screening tool and it'll pick up a lot of ruptures. (16:51): MRI is also a helpful tool, but a little bit more expensive to get the imaging done. But these things aren't even perfect. I remember one time with a patient that she swore her implant was ruptured. It had only been in for a short period of time, and I examined her and I said, "I really just don't think this is ruptured." And she said, "Well, what do I do?" I said, "Well, get an MRI." And the MRI said the implant was ruptured. And so I was like, "Well, I'm shocked anyhow." So I took her and she had no history of trauma or anything else. I took her to surgery and I videoed me taking the implant out and the implant was completely intact, not even a little bit ruptured. So the imaging's not perfect. We did replace the implant, put a new implant in, but the point is that sometimes ruptures can be a little difficult. (17:40): The bigger concern with silicone implants, and this was more true for the old liquid silicone implants that were taken off the market in the '80s, is that when they ruptured, it was a liquid silicone back in the '80s and it would not stay contained to the scar tissue, the capsule, and it could spread beyond the capsule and get into the breast tissue and form painful nodules and that sort of thing. And it could be really difficult to sometimes get in there and remove all of that. I've had to do that before and it's just a mess. But these newer implants are more cohesive. So most of the time on any of these implants that have been ruptured nowadays, it's all contained within the scar tissue and it's pretty easy to take care of. Kirstin (18:26): Okay. What about rippling or bottoming out or symastia? Are any of those not fixable? Dr. Koehler (18:34): No, they're all, you can do things. Some of them may not be completely fixable. Rippling unfortunately is a function of your tissue thickness. And sometimes if you just have extremely thin tissues, even with a small implant, you can have rippling. But usually most people that have rippling, visible rippling usually have saline implants and the treatment is to switch them to silicone because they ripple much less likely. But if you're super thin, you can still have visible ripples in your breasts. Also, another patient of mine, she was very fit. She was, I don't know, like a personal trainer and she had no body fat, none. And she also had no breast tissue and she had implants and I swapped her implants from saline to silicone and it was better, but she still had rippling. She ultimately ended up getting pregnant and put on some weight and all her rippling went away. (19:27): So it's kind of one of these things where tissue thickness plays a role. And yes, some of the newer, more cohesive implants ripple less, but they can be firmer feeling and you can palpate the shell a little bit more. So anyhow, some of these problems, you may just kind of get to a point where it's like, well, this is the best we can get to. Synmastia is generally correctable. Some of them are easy to correct and some of them can be more challenging, but basically that's when you end up with a Uniboob because the muscle gets lifted off or sometimes it can be above the muscle in the Uniboob because the implants are too close together. And so in those cases you have to tack all that down. It's sort of hard to explain in the podcast because each situation's a little different, but there are treatments for that. And then what was the other thing you mentioned? There was synmastia - Kirstin (20:17): Bottoming out. Dr. Koehler (20:18): Oh, bottoming out. Well, again, that's also, that can be a function of if your tissues are just not strong enough to support the size of implant you've chosen. And we see bottoming out much more commonly in these massive weight loss patients because their tissues are not as, they're thinner, their tissues tend not to support an implant as well. So in some of those patients, we'll use mesh or other things to kind of help support it. You may see stuff online about people calling it an internal bra. Well, it's a mesh. It's not FDA approved for breast surgery or reconstructive surgery, but it is FDA approved for tissue support. And so that's what's used in those cases. But yeah, bottoming out, the bigger the implant you have, the more likely you could bottom out because there's more weight and sometimes it can be a function of time. (21:08): It was good at first, but then five years later, again, your tissues aren't supporting it and that implant slowly drops. Kirstin (21:16): You had a really, really impressive synmastia repair. Is that what you would call it earlier this year? Dr. Koehler (21:24): Yeah. No, it was good. Yeah. Kirstin (21:26): She came from another surgeon. I'd love to show her before and afters in this podcast because she looks amazing. Dr. Koehler (21:32): Yeah. She had a synmastia and they're never easy to correct, but hers was one of the, I want to say easier ones, but it went really smoothly and turned out great. So it can be a frustrating problem for sure, but now she looks more like she has real breasts, not a uniboob. Kirstin (21:54): Have either one of you ever experienced a patient where you've tried and tried and tried and you're just like, "Girl, I think you just need to take these things out. I just think implants are not for you." Dr. Koehler (22:06): Yeah. I mean, and I think for some of those people, they come to that conclusion themselves. And sometimes it can be, if you've had a patient who's had multiple surgeries, like I just had a patient, she had multiple, multiple surgeries prior to seeing me. And anyhow, we were able to salvage it, but I did have to use Strattice and all of that to get her satisfactory. And it's not perfect, but it's a million times better. It's so much better. And she was kind of at the point where like, do I just take them out? But she didn't have any breast tissue just of her own. So taking them out was going to be pretty devastating and she really didn't want to do that. And I sort of said, "Well, this would be my one hurrah here. If this works," because she had just multiple, multiple recurrent capsular contractures, but nobody had ever used Strattice on her. (23:01): So that was something that we were able to do. But yeah, if somebody's just had problems, sometimes the best thing is take everything out and just give your body a rest. Give it a year, just let everything heal, reorganize and reevaluate, and then maybe consider doing it again, but with a plan in place. But when you get to that point where you're chasing this, this is a vicious cycle and it's like inflammation, contracture, inflammation, contracture, you got to stop the cycle and you got to remove it. And maybe it means removing it for good or maybe it just means removing it for a period of time, a year. Kirstin (23:43): Okay. Social media says, and we've talked about this before, that you have to replace your implants every 10 years no matter how they look or feel. Do y'all agree or is this like a get off my lawn, we're not talking about this? Dr. Koehler (23:56): Oh no. Well, I don't agree, but that sort of came about and had to do with the implant studies. The bottom line is that your risk of re-operation goes up over time, and that can be for capsule contracture, implant malposition, bottoming out, all these things. So statistically, probably it's going to be over 20% of people at 10 years are going to have had a surgery for some reason. So that 10-year thing was kind of like, well, they're not permanent devices. Your risk starts to go up over time, so maybe at 10 years you should replace them. But these newer implants are more cohesive, so we don't have to worry about the issue of the gel migrating and causing all those nodules and granulomas and stuff like that. So really, if it's soft and you're happy with the size and they look good, get it imaged, get an ultrasound, get an MRI, and if everything is good on imaging and it's not ruptured, then yeah, I think you can go longer. (25:02): But I do think when you get to that 10-year point, if you haven't replaced it, and maybe you don't need to replace it, but now would be the time to say, "I'm going to start a little fund to put away some money knowing that at some point," because they're not lifetime devices. So you may be able to go 15 years, you might even get lucky and go 20 years, but you do need to get them imaged. And I think you should always prepare for the fact that at some point you'll have to replace them. Kirstin (25:32): Okay. Do you have a burning question for Dr. Koehler or Dr. Gardner or me? You can leave us a voicemail on our podcast website at alabamathebeautifulpodcast.com. We'd love to hear from you. Thanks, Dr. Koehler and Dr. Gardner. Dr. Koehler (25:47): Thanks, Kirstin. Dr. Gardner (25:48): Thanks. Kirstin (25:49): Go back to making Alabama Beautiful. Announcer (25:53): Got a question? Leave us a voicemail at alabamathebeautifulpodcast.com. To learn more about Eastern Shore Cosmetic Surgery, go to easternshorecosmeticsurgery.com. The commentary in this podcast represents opinion and does not present medical advice, but general information that does not necessarily relate to the specific conditions of any individual patient. If you enjoyed this episode, please share it and subscribe to Alabama the Beautiful on YouTube, Apple Podcast, Spotify, or wherever you like to listen to podcasts. Follow us on Instagram @easternshorecosmeticsurgery. Alabama the Beautiful is a production of The Axis, T-H-E-A-X-I-S.io.