Capsular contracture is the most common reason women seek breast implant revision surgery. The scar tissue capsule that naturally forms around every breast implant thickens and tightens, causing the breast to feel firm, change shape, and sometimes become painful.
For women who specifically chose a transaxillary approach to avoid breast scars, a capsular contracture diagnosis carries a double burden: the contracture itself, and the expectation that fixing it will mean a new incision on the breast they worked to keep scar-free.
That expectation is not always correct.
Understanding the Grading System
Capsular contracture is graded on the Baker scale from I to IV:
- Grade I — The breast looks and feels normal. The capsule is present but soft and pliable. No treatment needed.
- Grade II — The breast feels slightly firm but appears normal. Mild tightening of the capsule is palpable.
- Grade III — The breast feels firm and appears abnormal. Visible shape distortion from the tightening capsule. The implant position may have shifted.
- Grade IV — The breast is hard, visibly distorted, and often painful. The capsule is severely thickened and may be calcified.
The grade of your contracture directly affects which revision approaches are appropriate.
The Standard Treatment and Its Tradeoff
The conventional approach to capsular contracture is an open capsulectomy through an inframammary fold incision. The surgeon opens the breast crease, removes the thickened capsule partially or completely, creates a new or modified pocket, and places a new implant.
This is an effective and well-established technique. The tradeoff is a new scar on the breast — typically 4 to 5 centimeters in the inframammary crease. For many women this is acceptable. For women who chose axillary augmentation specifically to avoid breast scars, it represents a loss of one of the primary benefits of their original procedure.
What Endoscopic Revision Offers
For Grade II, III and IV capsular contracture, endoscopic revision through the original armpit incision is a viable alternative for many patients.
The procedure begins the same way as the original augmentation: I enter through the armpit scar and insert the endoscope. The camera provides a direct view of the capsule’s interior surface. I can see where the capsule has thickened, where it is constricting the implant, and where the tightening is most severe.
Endoscopic Capsulotomy
For capsules that are tight but relatively thin, I perform a capsulotomy — strategically scoring or releasing the capsule at specific points to relieve the constriction. Under endoscopic visualization, I can identify the areas of greatest tension and release them with electrocautery in a controlled pattern. The capsule opens, the implant can expand back toward its natural shape, and I confirm the result visually before closing.
This is fundamentally different from attempting to release a capsule blindly through a remote incision. The endoscope converts what would be a blind maneuver into a precision procedure.
Endoscopic Capsulorrhaphy
When capsular contracture has also caused the implant to shift position — which is common, as an asymmetrically tight capsule pushes the implant in one direction — capsulotomy alone may not be sufficient. In these cases, I combine the capsule release with a capsulorrhaphy: placing sutures inside the pocket to redefine its boundaries and stabilize the implant in the corrected position.
Endoscopic capsulorrhaphy requires visualization of the capsule interior to place sutures accurately. Published techniques using barbed sutures (V-Loc) for endoscopic capsulorrhaphy have demonstrated reliable results for correction of implant bottoming out after transaxillary augmentation.
Endoscopic Capsulectomy
In the majority of contracture cases treated endoscopically, I am removing the entire capsule. Few surgeons in the world do this. I have felt a need to devise how to do this effectively as I believe it is the best treatment for advanced capsular contracture. The entire capsule is removed, a sheet of Strattice acellular dermal matrix is placed and a new implant is inserted. A drain is necessary for this procedure. My case series of hundreds of patients show a greater than 98% success rate with this approach.
When Endoscopic Contracture Repair Is Not Appropriate
Patients with contracture accompanied by significant implant malposition that requires complete pocket restructuring may benefit from the broader access an inframammary incision provides.
These are not failures of the endoscopic approach. They are appropriate limits. The goal is to match the technique to the clinical situation, not to force every case through one incision.
Reducing the Risk of Recurrence
Capsular contracture has a recurrence rate regardless of the revision approach used. Several strategies reduce this risk during any revision:
- Implant exchange at the time of contracture repair — a new implant in a modified pocket has a lower recurrence rate than the same implant in the same pocket.
- Keller Funnel no-touch insertion technique — reducing bacterial contamination of the implant surface, which is implicated in contracture pathogenesis.
- Pocket irrigation with antibiotic solution — further reducing bacterial burden.
- Consideration of implant plane change when appropriate — switching from subglandular to submuscular, or vice versa, may reduce recurrence in selected patients.
- Placement of Strattice acellular dermal matrix seems to greatly reduce risk of capsular contracture recurrence.
These strategies can be implemented through the armpit incision just as effectively as through a breast incision.
Getting Evaluated
If you have been diagnosed with capsular contracture and told that an inframammary incision is your only option, a second opinion from a surgeon experienced in endoscopic revision is warranted. The grade of your contracture, the condition of your capsule, and your specific anatomy will determine whether the armpit approach is appropriate for you.
Virtual consultations are available for patients outside Hawaii. A thorough review of your history, imaging, and physical presentation is the starting point for determining the best approach to your specific case.