Capsular Contracture Grades 1 to 4 Explained
Capsular contracture can cause a breast implant to feel increasingly firm and, in more advanced cases, change the appearance of the breast or cause pain. The capsular contracture grades most commonly used by medical professionals are Baker Grades I to IV, with each grade describing how the breast looks and feels.
If you are currently experiencing changes such as increasing firmness, tightness, asymmetry, discomfort or a change in breast shape, you may be trying to understand whether these could be signs of capsular contracture. You may also already have a diagnosis and want to know what your Baker grade means, how severe it is and what treatment options may be available.
Capsular contracture is a recognised complication of breast augmentation surgery and other procedures involving breast implants. Importantly, capsular contracture is not usually a sign of negligence. Its presence, severity or Baker grade does not indicate that a surgeon has provided negligent treatment.
Understanding the Baker grading system can, however, help you make sense of the changes you have noticed and the terminology used during a medical assessment. In this guide, we explain what each capsular contracture grade typically looks and feels like, how Grades I to IV differ, when medical treatment may be recommended and the main treatment options.
What are the four grades of capsular contracture?
The Baker scale provides a simple clinical way of describing capsular contracture grades according to firmness, appearance and pain.
Baker grade | What the breast typically feels like | What the breast typically looks like |
Grade I | Soft | Natural and normal |
Grade II | Slightly firm | Normal |
Grade III | Firm | Visibly abnormal or distorted |
Grade IV | Hard and painful | Visibly abnormal or distorted |
The Baker classification is useful for describing the severity of capsular contracture, but it is not a perfectly objective measurement. A plastic surgeon will consider the appearance and feel of the breast alongside your symptoms, implant history, the position of the patient's breast implants and other clinical findings.
They may also consider factors such as implant placement, the condition of the surrounding breast tissue and whether there are any changes within the implant pocket that need further investigation. This wider assessment is important because firmness, pain or changes in breast shape can sometimes have causes other than capsular contracture.
As part of the consent process before plastic surgery, your surgeon should also explain the risk of capsular contracture and how it could affect the appearance, feel or comfort of the breast after implant surgery. This should form part of a broader discussion about the material risks and possible complications of the procedure, as well as any treatment that may be required if complications develop.
You should therefore avoid assuming your own Baker grade purely from photographs or descriptions online. If you notice increasing firmness, pain, asymmetry or changes in the position or appearance of your breast implant, seek an assessment from an appropriately qualified medical professional.
Baker Grade 1 capsular contracture
Baker Grade I describes a breast that feels soft and looks natural. Although it is included within the grading system,Grade I describes the normal capsule the body forms following breast implant surgery.
There is no significant tightening of the tissue capsule and there should be no obvious cosmetic symptoms caused by capsular contraction.
For a breast augmentation patient with Grade I findings, treatment for capsular contracture would not normally be required simply because scar tissue has formed around the implant.
Baker Grade 2 capsular contracture
With Grade 2 capsular contracture, the breast feels somewhat firmer than normal but retains a normal appearance. You might notice that one implant feels less soft than it previously did even though there is no obvious change in breast shape.
Grade II can therefore be less visually noticeable than higher grades. Some people experience only minor cosmetic symptoms, while others become aware of increasing firmness when touching the breast.
Treatment is not automatically required. A plastic surgeon may recommend observation where the breast remains comfortable and there is no significant distortion.
If the firmness is new, increasing or concerning you, arranging a medical assessment can help determine whether capsular contracture or another implant-related issue is responsible.
Baker Grade 3 capsular contracture
Grade 3 capsular contracture is characterised by a breast that is firm and looks abnormal. The tightening scar tissue can begin to noticeably affect the position and shape of the implant.
With grade three capsular contracture, the affected breast may look higher, rounder or more distorted than the other breast. Asymmetry can become more apparent, and the implant may feel much harder than it did after the initial healing process.
The classic Baker classification describes Grade III as firm and visibly abnormal without the pain used to define Grade IV. Individual experiences can nevertheless vary, so any discomfort should be discussed during your assessment.
Grade III is generally considered clinically significant. A plastic surgeon may discuss revision surgery where the firmness and visible change are causing problems.
Baker Grade 4 capsular contracture
Grade 4 capsular contracture, or Baker Grade IV, is the most severe grade on the Baker scale. The breast is hard, painful and visibly abnormal.
With grade four capsular contracture, thick scar tissue contracts tightly around the implant. The breast may look unusually rounded, elevated or distorted, and the difference between the two breasts can become pronounced.
The tissue can feel very hard and the tightening can cause persistent discomfort or pain. Grade IV should be assessed by an appropriately qualified medical professional, who can determine suitable treatment options and investigate whether any other breast implant complication is present.
When should I worry about capsular contracture?
Arrange a medical assessment if a breast with an implant is becoming progressively firmer, changing shape, becoming noticeably asymmetrical or causing new pain.
Breast swelling, redness, a new lump or a significant late change should also be assessed rather than assumed to be capsular contracture. Breast implants can be associated with several different complications, and symptoms can overlap.
BAPRAS advises people with breast implants who experience problems such as swelling, lumps or changes in breast shape to seek medical advice.
Can you live with capsular contracture?
It may be possible to live with mild capsular contracture if it is not causing discomfort or a problematic change in appearance. Grade 2 capsular contracture, for example, does not automatically mean that a surgical procedure is required.
The decision to treat capsular contracture depends on its severity, your symptoms and your individual circumstances.
More advanced capsular contracture can lead to increasing firmness, visible distortion and pain. If these symptoms are present, a plastic surgeon may recommend further treatment rather than simply leaving the contracture untreated.
Can capsular contracture get worse over time?
It can. Capsular contracture does not necessarily progress steadily from Grade I through every subsequent grade, and not everyone who develops a firmer capsule will go on to develop severe contracture.
However, some people experience increasing capsular contraction over time. This may cause the breast to progress from slight firmness to a more obvious change in appearance.
Capsular contracture can also occur after the initial recovery from breast augmentation surgery. A new change that develops months or years later therefore deserves medical assessment. Other complications, including implant rupture, can also cause changes to a breast containing an implant.
How is capsular contracture treated?
How doctors treat capsular contracture depends on the Baker grade, the symptoms present, the type and condition of the implant, and the person's previous surgical history.
Mild capsular contracture may simply be monitored if it is not causing significant discomfort or changes to the appearance of the breast. More severe Grade III or Grade IV capsular contracture may require surgical intervention, particularly where the tissue capsule is causing substantial firmness, visible distortion or pain.
Treatment options may include:
- Monitoring: Mild capsular contracture may be monitored where symptoms are limited and the breast is not significantly affected.
- Capsulotomy: The contracted capsule is surgically released or opened to reduce tightness around the implant.
- Capsulectomy: Part or all of the capsule surrounding the implant is removed.
- Implant removal: The implant may be removed where this is considered the most appropriate option.
- Implant exchange: The existing implant may be removed and replaced with a new implant as part of revision surgery.
- Aspen therapy: Aspen therapy is a non-surgical therapeutic treatment that uses ultrasound to improve breast tissue elasticity. However, the evidence remains limited, and it should not be presented as an established alternative to surgery for everyone with capsular contracture.
BAPRAS notes that capsular contracture is a common reason for further breast implant surgery and that it can recur even after revision treatment.
The appropriate surgical approach will depend on the individual circumstances and should be discussed with a suitably qualified plastic surgeon. The most suitable treatment will usually depend on the severity of the capsular contracture, the symptoms present, the condition of the implant and the effect the condition is having on the breast.
Capsulotomy vs capsulectomy: what is the difference?
An open capsulotomy and a capsulectomy are different surgical techniques.
During an open capsulotomy, the surgeon makes an incision and releases or divides the tight scar tissue around the implant. The aim is to allow the capsule to open and relieve the constriction without necessarily removing it completely.
A capsulectomy involves removing part or all of the breast implant capsule. Depending on the circumstances, the surgeon may also remove or replace the implant. Capsular contracture is listed as a possible indication for capsulectomy.
Is en-bloc capsulectomy used for capsular contracture?
An en-bloc capsulectomy is not simply another term for removing an implant and its capsule.
Current specialist consensus defines en-bloc capsulectomy as removal of the implant capsule with a margin of unaffected tissue for the treatment of suspected or established breast implant-associated cancer following appropriate investigation. The consensus states that this is the only absolute indication for an en-bloc capsulectomy.
Capsular contracture may be a reason to consider a capsulectomy, but having capsular contracture does not mean an en-bloc procedure is required.
A plastic surgeon should discuss which procedure is clinically appropriate, along with its potential benefits and risks.
Can you fix capsular contracture without surgery?
Not every person who develops capsular contracture needs surgery. Mild cases may simply be monitored where the breast is comfortable and the appearance remains acceptable.
Various non-surgical approaches have been proposed, but the evidence and suitability vary. Treatment should therefore be discussed with an appropriately qualified medical professional rather than attempting to manipulate the implant or scar tissue yourself.
For more advanced Grade III and Grade IV contracture, revision surgery may be recommended because of significant firmness, visible distortion or pain.
How soon after breast augmentation can capsular contracture develop?
There is no single point after breast augmentation surgery at which capsular contracture must appear. It can become noticeable during the months after surgery or develop later.
For that reason, changes occurring well after your initial breast augmentation should still be assessed. Your doctor may need to consider capsular contracture alongside other causes of changes to the breast or implant.
What are the signs of negligent breast implant surgery?
Capsular contracture itself is not usually a sign of negligence. It is a recognised complication of breast implant surgery and can develop even where the procedure and aftercare were provided to an appropriate standard.
However, there are other signs and circumstances that may indicate that the care you received before, during or after breast implant surgery fell below the standard expected of a competent surgeon. These should be considered separately from the fact that capsular contracture developed.
Examples can include:
- Lack of informed consent: before surgery, your surgeon should explain the material risks associated with the procedure, including the risk of capsular contracture, infection and implant rupture, as well as suitable alternatives. If important risks were not explained and you would not have proceeded had you been properly informed, there may be grounds to investigate the consent process.
- Incorrect implant placement: an implant positioned incorrectly can lead to problems such as asymmetry, displacement or an unnatural appearance. Poor placement may indicate an issue with surgical planning or technique, depending on the circumstances.
- Using an unsuitable implant: choosing an inappropriate implant size, shape or type for a person's anatomy may result in avoidable complications or an unsatisfactory outcome.
- Poor surgical planning or technique: a surgeon should tailor the procedure to the person's anatomy, medical history and intended outcome. Problems arising because the procedure was not appropriately planned or carried out may warrant further investigation.
- Failure to recognise or properly treat an infection: infection is a recognised risk of surgery and does not itself establish negligence. However, negligence may arise if signs of infection were missed during follow-up, appropriate aftercare advice was not provided, or treatment was unreasonably delayed once infection was identified.
- Implant displacement or movement caused by poor care: implants that move upwards, downwards or sideways can cause asymmetry and discomfort. Where displacement results from inappropriate implant placement, poor surgical technique or inadequate planning, the circumstances may need to be investigated.
- Inadequate aftercare: your surgeon should provide clear recovery advice and appropriate follow-up. Failing to investigate significant swelling, persistent pain, discharge, implant movement or other concerning changes may amount to a failure in the duty of care if it causes avoidable harm.
- Problems with revision surgery: negligence can also occur during breast implant revision treatment, for example where implants are incorrectly positioned, an inappropriate procedure is selected or post-operative complications are not appropriately managed.
Not every complication or disappointing result means that negligence has occurred. A successful claim generally depends on establishing that the treatment fell below an acceptable standard and that this caused avoidable injury.
Read this guide to the early signs of capsular contracture.
How can Cosmetic Surgery Solicitors help?
Cosmetic Surgery Solicitors has specialist expertise in breast surgery negligence claims and other cosmetic surgery claims. Established in 2005, we were the first law firm in England and Wales to create a department dedicated exclusively to cosmetic surgery negligence, giving our team more than 20 years of experience in this highly specialised area of law.
Our solicitors can assess what happened during your breast surgery, obtain and review your medical records, and arrange independent medical evidence where appropriate. If there are grounds to make a claim, we can guide you through the process and work to secure the compensation you are entitled to.
When you choose Cosmetic Surgery Solicitors, you benefit from:
- More than 20 years of specialist experience in cosmetic surgery negligence.
- Pioneering expertise: we were the first law firm in England and Wales to establish a department focused exclusively on cosmetic surgery negligence.
- A 95% success rate for claims pursued after obtaining medical evidence.
- More than £10 million in compensation secured for people we have represented across our cosmetic surgery claims work.
- No win, no fee representation, meaning you will not be required to pay our legal fees if your claim is unsuccessful.
- A dedicated solicitor who can support you throughout your claim and provide clear, straightforward advice.
If you are concerned that negligent breast surgery has caused you avoidable harm, call Cosmetic Surgery Solicitors on 0161 877 1066 or complete our to speak to our specialist team about your circumstances.
