Capsulocutaneous Fistula in the Setting of Capsular Contracture Following Nipple-Sparing Mastectomies

Document Type

Conference Proceeding

Publication Date

9-2026

Publication Title

Plastic and Reconstructive Surgery. Global Open

Abstract

Objective: Capsular contracture is a challenging and frustrating complication associated with breast prostheses, often requiring implant exchange and capsulectomy. When a capsular contracture is accompanied by delayed drainage, effusion, or nipple discharge in the reconstructed breast, a thorough systematic evaluation is crucial to exclude serious underlying pathology and should prompt consideration of an underlying anatomic cause. We report a case of a capsulocutaneous fistula identified in the setting of Baker Grade IV capsular contracture after nipple-sparing mastectomy (NSM) and immediate implant-based reconstruction.

Case Presentation: A 43-year-old female, active smoker with right breast ductal carcinoma in situ underwent a right NSM via an inframammary-fold incision followed by immediate placement of a tissue expander (TE) with an overlying sling of acellular dermal matrix. The TE was exchanged with a permanent implant and fat grafting at 4.5 months. By one year of permanent implant placement, she developed a Baker grade IV capsular contracture and then one month later, experienced a new white and milky nipple discharge. Oncologic workup was negative for recurrence. Examination confirmed serous fluid discharge from the right nipple-areolar complex (NAC) without signs of infection, raising suspicion for a capsulocutaneous fistula. The patient was taken to the operating room 15 months post-exchange for a right capsulectomy and implant exchange. Intraoperatively, a thickened capsule was encountered and a clear fistulous connection was identified between the capsule and the undersurface of the NAC. Capsule pathology was benign. The retroareolar fistulous opening was cauterized and oversewn, the pocket was irrigated with antibiotic solution, and a new implant was placed. At six-month follow-up, the patient has had no recurrence of contracture or discharge.

Discussion: This case report contributes to the limited literature regarding capsulocutaneous fistulae. Prior cases of mammillary fistulae after NSM highlighted patients with inverted nipples who initally presented with early postoperative infection and ADM erosion. The present case is distinct in that the capsulocutanous fistula was identified in the setting of a capsular contracture without any signs of infection, suggesting a different clinical trajectory than previously reported. The fistula likely arose from a retained duct remnant within the preserved NAC, establishing a communication between the implant capsule and the skin surface that may have contributed to both nipple discharge and capsular contracture. Smoking may have been a predisposing factor.

Conclusion: For patients with unexplained or refractory capsular contracture after NSM, particularly in smokers, should be considered as a potential contributor thus careful examination of the NAC is warranted. This case emphasizes the need to recognize a mammillary fistula as a potential underlying etiology of capsular contracture.

Volume

14

Issue

Suppl 4

First Page

8

Last Page

9

Comments

Michigan Academy of Plastic Surgeons 34th Biennial Scientific Meeting, July 12-15, 2026, Mackinac Island, MI

DOI

10.1097/01.GOX.0001276700.85544.6f

ISSN

2169-7574

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