Know Your Options with Breast Explant Surgery
Breast explant surgery, also referred to as breast implant removal surgery, refers to the surgical removal of silicone or saline breast implants. The procedure is typically performed in a hospital, ambulatory surgery center or office-based surgery center under the careful administration of general anesthesia. During breast explant surgery, the plastic surgeon may also perform a capsulectomy, removal of the capsule or fibrous lining that forms around the implants following their placement. According to the American Society of Plastic Surgeons, 36,367 women in the United States had their breast implants removed during 2020, marking a growth of 8 percent from the previous year.
There are many reasons why women will choose explant surgery. These include systemic symptoms that fall under the category of Breast Implant Illness (BII), ruptured or leaked implants, capsular contracture (a reactive scar tissue that forms around the implants affecting the shape and appearance of the breast), and textured implants that carry the risk of a rare lymphoma of the capsule. These particular complications are not merely aesthetic—they can cause pain, discomfort, and/or distortion. In addition age, breastfeeding, pregnancy, and weight changes are factors that may also alter the shape of the breast. Some patients will have more than one of these concerns.
Who is a Good Candidate for Breast Explant Surgery?
- Women who are suffering from BII symptoms.
- Women who have calcium build-up surrounding their implants.
- Women with recalled implants, including textured implants such as Allergan’s BIOCELL® implants, which have been withdrawn from the market at the request of the United States Food and Drug Administration (FDA).
- Women with textured breast implants who exhibit symptoms such as pain, lumps, swelling, or asymmetry of the breasts.
- Women who have leaking silicone implants, known as ruptured implants. The FDA has indicated that ruptured implants should be explanted. There are two degrees of implant rupture. Intracapsular rupture occurs when the silicone gel remains contained within the capsule’s wall. Extracapsular rupture means that silicone gel has escaped through the capsule’s wall; this can occasionally migrate to the axillary lymph nodes and cause lymphadenopathy. Ruptures can usually be identified by ultrasound or MRI.
- Women who experience undesired movement or shifting of the implants.
- Women who have been diagnosed with Breast Implant Associated- Anaplastic Large Cell Lymphoma (to date, at least 949 cases have been reported worldwide)
- Women with breast cancer in the implanted breast where implant removal is necessary to excise the breast cancer.
- Women who experience an extrusion of the implant through skin.
- Women afflicted with implants that are complicated by recurrent infections.
- Women who have implants with severe contracture, which is associated with pain.
Impact of Social Media, Plus Words of Caution
BII is a controversial topic that, until recently, was deemed a psychosomatic illness. A combination of women’s activists, doctors, and patients are increasingly fueling the spread of awareness and information on social media platforms such as Facebook and Instagram in order to help women with breast implants across the world communicate and exchange pertinent information related to their BII symptoms. Despite the concerning fact that misinformation spreads as fast as beneficial information through social media, crowdsourcing is ultimately transforming into a powerful, positive tool for women to become aware of and identify their unwanted, harmful symptoms and independently plan and manage their future breast implant removal. Notably, these women reflect on similar symptoms, further disputing the notion that BII is a mere coincidence or psychosomatic illness. Nevertheless, the lack of conclusive evidence and ability to diagnose BII makes it a challenging road for both women and their medical practitioners. Despite this, patients and doctors agree that the first step to healing is removing breast implants and the tissues surrounding them.
Best Practices for Breast Explant Surgery, Plus How Best to Prepare For Surgery
The goal of this section is to clarify and explain the explant procedure. Details have been checked for accuracy by our Medical Advisor Dr. Randall Feingold. He is a board-certified plastic surgeon with more than twenty years’ experience with en bloc, total capsulotomies for ruptured implants, capsular contracture, textured implants, and symptoms of BII. He is also a renowned expert in breast reconstruction and microsurgery and has been one of the early leaders in offering and refining natural tissue techniques in addition to fat grafting.
Consultation: You will meet with your plastic surgeon, which will include an initial examination and further discussion. During your private consultation, your doctor should thoroughly explain the breast implant removal procedure and provide you with ample time and opportunity to ask any questions and voice any concerns you may have. You should explain your motivation for explant, and whether you have had medical evaluations to rule out other conditions that can cause symptoms. Your surgeon will also discuss with you additional options you may choose to have done during your surgery: A breast lift and/or fat grafting. During fat grafting, your surgeon will take fat from chosen donor areas, such as the abdomen or inner thighs, and then use that fat to reshape the breast after explant.
Your consultation should never be rushed; patients should be given appropriate preoperative counseling in regards to the indications for breast explant surgery including its associated risks, financial implications, and expected postoperative appearance. These risks include long scars, flat chest, asymmetry, deformity and the need for additional surgery. It is encouraged to ask for pictures of patients in your age group both before and after their breast explant surgery so you can know what to expect aesthetically.
Setting up a date for surgery: You will schedule a surgery date and be given requirements for pre-surgical lab testing and possibly a medical evaluation well prior to that date. You may be asked to stop smoking; and avoid taking aspirin, anti-inflammatory drugs, and herbal supplements due to their likelihood of increasing bleeding. You will receive the test results of your medical exams prior to your surgery date. Plan for a week of downtime after surgery. This is the time to reflect on your decision to remove the implants, the psychological impact of downsizing your breasts and accepting that reality. A separate preop office visit may be arranged to review the operative plan, take preoperative photographs and to prescribe postoperative antibiotics and pain medication. You should pay attention to your symptoms and write them down for future comparison.
Day of surgery: General anesthesia will put you into a sleep-like state. During the operation, your surgeon will make an incision under the lower fold of your breasts (the inframammary fold), and then proceed to remove the implants and related scar tissue. The best technique for this process is en bloc, as it allows for the removal of the entire capsule (or prior capsules) and implant in one piece while ensuring that any ruptured silicone contents do not escape the capsule and leak into the body. A skilled doctor with years of relevant experience should be able to execute this process though it is not always possible.
If the implants were placed under the pectoralis muscle, the muscle should be reattached to the chest wall to maximize its function after surgery. A long acting anesthetic can also be injected into the chest wall to minimize pain associated with removing implants whose capsules were attached to the ribcage. Draining tubes will be inserted under the breast tissue for 3–7 days to drain excess fluids and blood. Capsules will be sent to a pathology laboratory for evaluation, and samples of capsule sent for bacterial and fungal cultures.
If you choose to also have a breast lift or fat grafting done, this will also be performed. Breast lift may involve repositioning the nipple and areola with scars limited to the perimeter of the areola, or it may involve tightening and lifting the breast with vertical scars. Fat transfer involves harvesting fat from another body area (abdomen, thighs) and injecting that liquid fat into the fatty layer under the breast skin to relieve depressions, hollows or indentations that may be revealed by explant surgery. Further volume augmentation with fat grafting may require additional stages of surgery several months later.
Explant surgery is tedious and time consuming. Seventy women who underwent this surgery (with the majority having undergone a breast lift as well) reported operative times averaging approximately three or more hours. Not one woman reported surgery time of under two hours. You will rest in a recovery room for 1-2 hours until you are fully awake. At that point, a friend or family member will accompany you home that same day. You will be instructed in how to empty and record drain outputs. You will be given a specific bra and a donor site compression garment.
The First Week: The first week after surgery is for rest. Diet is up to you but drink plenty of liquids. Changing position and walking is encouraged, even outdoors. Lying in bed only increases mucous in the lungs and increases the risks of blood clots in the legs. Showering is permissible but check with your doctor for the best day to start showering. Empty and record the drains twice each day. Wear the bra (and donor site garment) as prescribed. It is too soon to exercise. Raising your heart rate and blood pressure in the first week could cause bleeding in the surgical site.
The post-op visit with your doctor will be 5–7 days after surgery. You will be examined by your doctor and your drain tubes will be removed along with any stitches. A new bra may be required. Pathology reports from the surgery will be reviewed. Recommendations for increasing activity for the second week will be reviewed. An additional follow-up doctor visit will be scheduled after six weeks.
Your plastic surgeon should provide you with images of your en bloc explant, similar to the images below. The first image should show you that your implants were removed with the entire capsule (illustrating the results of the en bloc technique). The second picture should show the implants after they were removed from the capsules, as this will give you an opportunity to view the condition of your implants and see if they were intact or ruptured, had calcifications, discolorations or mold.
The First Month: You will receive more specific “do’s and don’ts”to follow during the first weeks following your surgery. This is a time for increasing your range of motion, but not aggressive exercise. There may be bruising, swelling and distortion of the breasts (and fat graft donor sites) that will resolve over the next several weeks. A support bra and continued use of the compression garments will be useful. You should pay attention to your symptoms from before surgery to see if any changes occur after surgery. Write them down. Final culture reports from your capsules should become available at four weeks.
Women need clear and precise information regarding the entire explant procedure prior to deciding on a doctor to help them make better choices. Furthermore, knowing precisely >what questions to ask is paramount so that you can make the right decisions for yourself. At the present time, no best practice guidelines exist for breast explant surgery. Social media platforms and dedicated groups, such as those on Facebook, hold both valuable information and inaccurate information—the latter of which certainly warrants clarification. Additionally, it is not clear whether women who have undergone explant surgery have experienced a cure of some or all of their BII conditions. We should not be under the assumption that breast implants are the sole cause of our current health conditions.
One thing, however, is certain: Careful removal of breast implants by means of the en bloc technique is a safe method of ensuring that all inflamed, calcified or silicone-exposed tissue is removed to initiate your recovery. When it comes to the healing and recovery process, you should be aware that it is a different, personalized experience for each woman for a myriad of reasons. However, what should be the same within the experience is that doctors should be transparent about the explant procedure; this includes providing their patients with images following the (en bloc) breast explant surgery as well as pathology and microbiology reports.
Explant Terms You Need to Know
- Breast reconstruction: the surgical process of rebuilding the shape and appearance of a breast. This is most commonly performed in women who have undergone surgery to treat breast cancer, and it involves using autologous tissue, prosthetic implants, or a combination of both with the goal of reconstructing a natural-looking breast.
- Capsulectomy: generally, this involves creating an incision in the capsule and first removing the implant separately from the scar tissue.
- Total capsulectomy: the removal of the implants and the entire capsule of scar tissue that surrounds them, though this may not indicate that the capsule was removed intact.
- En bloc: a surgical procedure in which the implants are removed along with the capsules intact without leaving behind any tissues, including those that may be glued to the rib cage. This technique is designed to guard against silicone leakage from a ruptured implant, as removing the capsule and implant in one piece prevents spilled silicone from contaminating the body and helps reduce further inflammation. Your surgeons should have at least ten years’ experience in en bloc technique, as this is a delicate surgery that requires years of training in microsurgery in order to successfully separate the intact capsule from the muscles and rib cage. This technique is more difficult and results in a longer scar as well as additional healing time.
- Hydrodissection: a technique your plastic surgeon may use when the capsule is adhered to the rib cage in order to carefully remove the tissues in individual pieces.
- Microsurgery: an intricate surgery performed using miniaturized instruments and a microscope.
- Capsule: reactive fibrous capsules that form around the implants after they are placed.
- Flap reconstruction (autologous tissue reconstruction; tissue-based reconstruction): a method to rebuild the shape of your breast after surgery.
- ASPS: American Society of Plastic Surgeons.
- Explant: surgical removal of breast implants with or without the capsule.
- Pain blocker: medicine that inhibits pain; administered during surgery and several days after surgery.
- Silicone implant, textured: breast implants that have a rough surface similar to sandpaper; unlike smooth-surfaced implants, their textured surface adheres to the tissue that surrounds them, preventing them from moving around within the implant pocket created by the surgeon.
- Silicone implant, smooth: breast implants that are covered by a smooth outer shell; they are softer than textured implants, allowing for a more natural look and feel.
- Recall: occurs when the FDA removes medication or a medical device from the market because it has been deemed unsafe for use.
- Breast Implant Associated-Anaplastic Large Cell Lymphoma (BIA-ALCL): a type of lymphoma (cancer) associated with textured breast implants and is often accompanied by fluid surrounding the implant; see the Consensus Guidelines on the Diagnosis of BIA-ALCL linked below.
- Capsular contracture: a condition that occurs when the capsules surrounding the implants hardens and contracts over time, affecting the shape of the breasts as well as creating pain and asymmetry of the breasts; up to 10 percent of the women suffer from this condition.
- Seroma: a clear fluid that can accumulate in the cavity that exists within the breast following surgery for a small proportion of patients even 2–3 weeks later; seroma can be drained by a needle aspiration or during the same time as an ultrasound scan.
- Fat grafting (fat transfer): a surgical procedure in which fat is transferred from one donor area of the body to another area, such as the breast. It is a procedure that is divided into three techniques: harvesting, processing, and injection. The surgical goal of this procedure is to improve or naturally augment the area where the fat is injected. Because fat transfer for breast augmentation is not yet standardized, outcomes may vary depending on the surgeon’s level of expertise. There is no evidence to suggest that fat grafting increases breast malignancy risk, though long-term follow-up is required.
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