Capsular Contracture in Breast Implants: Causes, Grades, and Treatment Options

Capsular contracture is the most frequent complication associated with breast implants and, at the same time, one of the greatest concerns for patients considering or who have already undergone breast augmentation surgery. A proper understanding of it—from pathophysiology to current therapeutic options—allows for informed decision-making and the establishment of realistic expectations. This guide, developed from the clinical perspective of Mallorca Medical Group, addresses the essential aspects that every patient should know before and after undergoing breast surgery with implants.

What is capsular contracture and why does it occur?

When any foreign material is implanted into the body, the immune system naturally generates an encapsulation response: a layer of fibrous tissue that surrounds the implant and isolates it from the surrounding environment. This process is physiological and expected. The problem arises when that fibrous capsule—instead of remaining thin and flexible—progressively contracts and hardens, compressing the implant and altering its appearance and texture.

The exact causes are not always identifiable, but scientific evidence points to several factors that increase the risk: the presence of low-virulence bacterial biofilm around the implant, postoperative hematoma or seroma, implant rupture, smooth implant surface and certain individual patient characteristics. The plane of placement – submuscular, subglandular or dual plane – also influences the incidence, with the submuscular plane showing statistically lower rates of contracture in most of the available studies.

Baker Classification: The Four Grades of Capsular Contracture

The Baker scale remains the reference classification system in clinical practice for staging capsular contracture. This scale distinguishes four grades with well-differentiated diagnostic and therapeutic implications:

• Grade I: The breast has a normal appearance and consistency. The implant is not noticeable to the touch. There are no symptoms or deformity. This grade does not require any intervention.
• Grade II: There is a slight hardening detectable to the touch, but without visible alteration of the shape or position of the implant. Generally asymptomatic. Periodic clinical follow-up is the standard procedure.
• Grade III: Moderate to evident hardening, with visible deformity of the implant—which may appear rounder, elevated, or displaced—although without significant pain at rest. Active therapeutic measures are usually indicated at this stage.
• Grade IV: Very hard implant, with marked esthetic distortion and pain on pressure or even at rest. It is the most advanced grade and the one that most frequently requires surgical reintervention.

“Capsular contracture does not always progress in a linear fashion, nor do all grades require the same therapeutic response. Each patient presents anatomical characteristics, an individual fibrotic response and specific expectations that must be evaluated in a personalized way before deciding on any treatment plan.”

– Dr. García Ceballos FCCP, Plastic Surgeon at Mallorca Medical Group

Symptoms that should prompt a medical assessment

A significant number of patients with grade I or II capsular contracture do not experience perceptible discomfort. However, the appearance of any of the following symptoms should prompt a consultation with the plastic surgeon responsible for follow-up:

• Progressive hardening of the operated breast, especially if it is asymmetrical compared to the other side.
• Change in the shape of the implant: increased roundness, elevation, or displacement.
• Sensation of tension, pressure, or tightness in the breast area.
• Continuous pain or pain upon pressure at rest or during physical activity.
• Visible deformity without an apparent cause, especially if it appears late, years after the initial surgery.

Early detection in the initial stages significantly expands the treatment options and reduces the complexity of an eventual reoperation. In the context of plastic surgery in Mallorca, systematic postoperative follow-up is a fundamental tool for the early identification of this complication.

Treatment options: capsulotomy, capsulectomy, and implant replacement

The treatment of capsular contracture depends on the diagnosed grade, the patient’s symptoms, the time elapsed since the initial surgery, and the aesthetic goals. The main surgical options are:

Capsulotomy: Consists of making controlled incisions in the fibrous capsule to reduce tension without removing it. It is an option reserved for selected grade II-III cases with not very thick capsules. Its recurrence rate is higher than capsulectomy, so its indication requires individualized assessment.

Capsulectomy: It involves the complete (total) or partial removal of the fibrous capsule. In grades III and IV it is the most effective procedure and the one that offers the best long-term results. When there is suspicion of BIA-ALCL(Breast Implant Disease: Fact or Myth? associated with breast implant), total en bloc capsulectomy is the standard indication. It is usually combined with replacement of the implant with a new one.

Implant exchange: In the context of capsulectomy, the exchange of the implant for one with different characteristics -different surface, profile or plane of placement- can contribute to reduce the risk of recurrence. The selection of the new implant should be individualized, considering the current breast anatomy, the patient’s preferences and the intraoperative findings.

Explantation without replacement: In patients who choose to remove the implants without replacing them, complete or partial capsulectomy is performed together, assessing the need for an associated mastopexy depending on the resulting breast volume and ptosis.

Risk factors and strategies to minimize them

Although no measure completely eliminates the risk of capsular contracture, current evidence allows for the identification of strategies that contribute to reducing it significantly:

• Placement plane: Submuscular or dual-plane positioning reduces the rate of contracture compared to the subglandular plane in most available prospective studies.
• Type of implant surface: Nanotextured or microtextured implants present different risk profiles than smooth or macrotextured implants, and the choice must be individualized based on the clinical context.
• Refined surgical technique: Minimizing bacterial contamination during surgery, through strict antisepsis protocols and atraumatic handling of the implant, is one of the modifiable factors with the greatest impact.
• Control of postoperative hematoma and seroma: The appearance of these complications significantly raises the risk of contracture, making their prevention and early treatment a priority.
• Continuous postoperative follow-up: Periodic clinical monitoring allows for the identification of incipient changes before the contracture reaches advanced stages.

Capsular contracture in the context of revision breast surgery

Capsular contracture is one of the most frequent indications for revision or secondary breast surgery. For the best plastic surgeons in Spain with experience in secondary breast surgery, the approach to these types of cases requires meticulous planning: analysis of previous surgical history, imaging assessment—especially breast ultrasound or MRI—and an exhaustive evaluation of the current state of the breast tissues.

At Mallorca Medical Group, the approach to revision surgery is based on an individualized preoperative assessment that considers not only the resolution of the complication, but also the optimization of the long-term aesthetic and functional outcome. Patient safety and realistic expectations guide every surgical decision in this type of procedure, which is often more technically complex than primary breast surgery.

Patients with Trusted Plastic Surgery Clinics in Spain who have undergone surgery by other hands can also come in for assessment, without any inconvenience. The aim is always to offer the best possible treatment plan for each specific clinical situation.

Frequently asked questions about capsular contracture

What are the symptoms of capsular contracture?

The most frequent symptoms include progressive hardening of the implant, a sensation of tension or pressure in the breast area, changes in the shape or position of the implant and, in advanced stages, continuous pain or discomfort. The appearance of symptoms should prompt a specialized medical assessment.

What are the grades of capsular contracture according to the Baker scale?

The Baker scale distinguishes four grades: grade I (soft implant and natural appearance), grade II (slight hardening without visible deformity), grade III (evident hardening with visible deformity), and grade IV (hard, painful implant with marked aesthetic distortion). Grades III and IV require surgical intervention in most cases.

What is the difference between capsulotomy and capsulectomy?

Capsulotomy consists of making incisions in the fibrous capsule to release tension without removing it, and is reserved for selected cases. Capsulectomy involves the complete or partial removal of the capsule; it is the procedure of choice in advanced grades or when BIA-ALCL is suspected. The indication for one option or the other depends on the surgeon’s individualized assessment.

Can capsular contracture be prevented?

There is no measure that guarantees absolute prevention, but various factors can reduce the risk: appropriate choice of the implant placement plane, use of implants with suitable surfaces for each case, refined surgical technique with minimal bacterial contamination, and rigorous postoperative follow-up. Individualized preoperative assessment is essential to minimize the risk for each patient.

Are you experiencing hardening, change of shape or discomfort in your breast implants?

Request a personalized medical assessment with Dr. García Ceballos FCCP at Mallorca Medical Group. Schedule your consultation at mallorcamedicalgroup.com or call us at 971 254 686.

Article written by Dr. García Ceballos FCCP – Plastic, Aesthetic and Reconstructive Surgeon – Mallorca Medical Group – Palma de Mallorca