Capsular contracture remains one of the most difficult problems associated with augmentation mammaplasty and is a leading cause of reoperation and patient dissatisfaction. This article outlines several variables that may contribute to development of grades III and IV contractures. Preventing capsular contractures is essential, and different approaches taken through the years are explored. If prevention is not possible, options for treatment are limited. Because treatments such as open or closed capsulotomy are generally ineffective over the long term, implant exchange is often required. Implant removal, total capsulectomy, and re-implantation usually comprise the most effective treatment for grades III and IV capsular contracture. However, for implant replacement to have the best chance for reducing the risk of recurrence, surgeons should change at least one variable (eg, implant position, filler material, and/or surface type) so the replacement surgery differs from the original. Unless something in the biological environment of the implant is altered, another grade III/IV capsular contracture is likely to develop.