How to fix breast Herniation

The Food and Drug Administration lists rupture and capsular contracture among the risks of breast implants. Capsular contracture is the thickened form of that scar. It is laid down when further contaminants reach the pocket. A herniation is not the same event as contracture. Contracture is a thick capsule. Herniation is a break in the capsule that lets the implant bulge through.

Extra scar is the difference between a normal capsule and a contracture. The normal capsule walls the implant off from the rest of the body. When more contaminants reach that pocket, more scar is laid down and the wall thickens. That thickened wall is the contracture. A herniation starts when the wall, thick or not, develops a rent, and the implant bulges through it. A bulge is not only a size change. A hard capsule is not automatically a rent. Both have to be named before a repair is chosen.

The photograph above the diagrams is a 26-year-old woman who had high profile silicone implants. That caption records an augmentation. It does not record a herniation repair, and it is not a claim that those implants later bulged. The diagrams are the herniation discussion. The implant in a herniation is a silicone or saline implant that has found a rent in its capsule.

The bulge typically sits on the outer, lateral side of the breast mound. It is more likely when a supportive bra is not worn at night. Sleeping on the back lets the breasts hang laterally and drop toward the mattress. Sleeping on the stomach pushes the implants out to the side. Either position, without a supportive bra, feeds that lateral drift.

A normally formed capsule can still allow a lateral bulge. The tendency is higher when capsular contracture is present, because a thickened capsule becomes brittle and is prone to tearing. A rent or a break in the capsule is what lets the implant herniate. The thickened capsule cracks under the pressure and tension inside it, and the implant then pouts through as an outpouching.

Capsular contracture can show up right after surgery or years later. Early contracture is tied to the time of the operation. One root is contamination, such as talc powder on gloves. The other is bacteria that seed the implant. That seeding is not described as gross contamination in the operating room. It is translocation: bacteria that live on the body, or bacteria from an infection elsewhere, enter the bloodstream and reach the implant. The result can be a low-grade colonization and a capsule that thickens, even without a full-blown infection.

Blood products oozing around the implant are a further early cause. Some oozing happens during the operation, and that oozing is treated as a root of early thickening. Late contracture, years later, has two roots. One is silicone leaking from a ruptured silicone implant. The incidence of implant rupture is 1% per year. With two implants, that is a 20% risk over 10 years, or 1 in 5 women. The other late root is bleeding into the capsule. Blood products irritate the pocket and promote scar. People on aspirin products or fish oil, or who eat a high-fish diet, are the group named as more exposed to that bleeding.

Timing changes what is being looked for. It does not add a third repair. An early thick capsule points back to talc, to bacterial seeding by translocation, or to blood that oozed around the implant during the operation. A late thick capsule points to a ruptured silicone implant that is leaking, or to bleeding into a capsule that had already formed. The bulge can appear with either timing. The rent is still a rent. What the timing changes is whether the rest of the capsule is soft enough to sew, or thick enough that the whole capsule has to come out.

Surgery to fix breast herniation is twofold. If the capsule is soft and the problem is one isolated herniation, the rent is repaired. The repair sews the capsule deformity with sutures. That sewing is capsulorrhaphy. The herniation is often on the lateral or outer side. The correction sews the lateral pocket down and, at the same time, releases the medial pocket. That release is a capsulotomy.

Sewing the rent without the medial release would leave the repair under the same lateral tension that opened the bulge. The two moves belong together when the capsule itself is still soft and the rest of the pocket is not deformed. An implant exchange is not required when the capsule is soft and the only finding is the rent.

If the rest of the capsule is thickened and is causing further deformity, the entire capsule may have to come out. Removing that capsule can compromise the overlying skin. When it would, a breast lift is added so the breast mound can be moved to a higher area that has not already been operated. That move gives the implant a more stable place to sit. A lift with implants is a different operation from sewing a single rent, and it is used when the skin cannot cover the pocket after the capsule is removed.

Before either repair, the cause is sorted out. One question is whether a supportive bra was worn during sleep. Another is whether contracture is present, which may take breast imaging to settle. Another is whether the breasts and the nipples sag. Sagging changes whether a lift has to be part of moving the mound. Those three questions decide which of the two repairs is the one being planned.

The bra question asks whether the lateral drift had a nightly cause. The contracture question asks whether the capsule is the soft kind, with one rent, or the thick kind that is deforming the breast. Imaging is what may be required to settle the second question. The sag question asks whether the nipple and the mound have dropped. A dropped nipple matters because moving the mound up is what a lift does, and a lift is the addition used when removal would leave the skin short.

Hardness and a bulge are often described together, and they are not the same finding. Hardness points to contracture. A bulge points to a rent. Both can be present, because a brittle capsule is more likely to crack, and a capsule that is still soft can still pout on the outer side. The exam has to say which finding is there before the operation is chosen. Sewing one rent in a capsule that is hard everywhere does not match removal. Removing a whole capsule for one soft rent does not match a single seam.