The necessity of en bloc explant surgery, and what happens if your surgeon leaves parts of the capsule behind?
The available medical literature around the controversial subject of en bloc capsulectomy is limited, and doesn’t include scientific evidence to support total capsule removal unless you have capsular contracture, or BIA-ALCL. Yet the largest group of patients who do not fall into these two categories is electing to remove their breast implants for health reasons despite the absence of specific medical evaluations and guidelines. Opinions regarding en bloc explant necessity are confusing and contradictory, even among the medical community.
Breast implant illness group’s choice
Researchers are still investigating breast implant illness symptoms to better understand their origins and connection to breast implants; however, this doesn’t stop many women from removing their implants and capsules entirely and in one piece (en bloc explant) based on information shared in social media.
Statistics you should know
Have you ever asked yourself how often women are exposed to breast implant conditions that warrant an immediate explant surgery? And what are your statistical chances of being part of one of these groups?
- Implant rupture rates are initially very low and begin to increase after six to eight years of implantation. According to the National Library of Medicine, for silicone implants, the mean duration of implantation until rupture is 12 years, while for saline implants it is only 5.6 years.
- Capsular contracture: Approximately 18% of women with implants will develop some type of capsular contacture.
- ALCL is a rare form of cancer. Experts estimate that one out of every 50,000 women with implants will get the disease.
- Breast implant illness: We have no statistics on the number of women who suffer from BII symptoms, but most women with breast implants experience some symptoms, and as many as 50 have symptoms that increase progressively with time.
MRI scans, mammograms and ultrasound scans often fail to detect ruptured implants.
Making the decision to explant: en bloc or partial capsulectomy?
Women in the breast implant illness group often elect to undergo breast removal surgery of their own free will, unlike the previous two groups who are provided with medical monitoring and treatment.
When removing the breast implants (regardless of the medical reason for the capsulectomy) their main concern is that the remains of the capsules may continue to cause breast implant illness or ALCL, especially in the case of textured implants.
The capsules may hold silicone residues, bacteria, mold, fungus, and be a source of inflammation. To date, there is no scientific evidence to confirm or deny this except for testimonials, and clinical evidence shared in social media by women and their plastic surgeons.
Why are we so confused?
While many women’s testimonies point out that total capsulectomy is crucial and necessary for their healing, the general medical community still recommends leaving capsular tissue behind in the absence of symptoms. En bloc resection is often recommended only for women with a diagnosis of BIA-ALCL.
Jennifer’s story
Jennifer had her explant surgery in 2016. Her first plastic surgeon told her that he had removed the capsules entirely but failed to provide her with a photo documentation of her en bloc explant.
Two years later she continued to experience severe breast implant illness symptoms until she decided to undergo an exploratory surgery in 2018. Her second surgery revealed a set of old capsules that were hiding behind her muscles and were not detected by a recent MRI scan. Once the capsules were removed she progressively became better.
“I was so sick and so desperate that I had nothing to lose. Based on my BII symptoms my new doctor agreed to perform an exploratory surgery. He found my old capsules behind my muscles; they were still intact after 2 years. He removed them, and this time I asked him to provide me with photo documentation of my capsules.
Since my second surgery in 2020 my health has progressively improved and I have my life back.”
Asking the experts’ opinions
Dr. Randall Feingold, MD FACS from New York has a long waiting list of women who are seeking breast implant removal knowing that he is one of the few plastic surgeons in the US with expertise in microsurgery and en bloc explant techniques. He believes that it is essential to remove all the capsules entirely and in one piece without leaving behind remnants which may be contaminated with pathogens.
”Thirty to forty percent of pathology evaluation of the capsules come back positive for either mold, fungus or other bacteria; it’s obvious that these capsules can’t stay in the body. Capsules do not magically dissolve. I have performed en bloc capsulectomies on women who have had multiple implant exchanges over the years and you can see the layers of different colored and textured capsules embedded in my specimen. If you want them out, just find someone who will accommodate.
The take-home message is just that capsules will remain until removed, and all capsules from a lifetime of surgeries can be removed in one effort.”
Dr. David Rankin FACS, also leads a busy practice in Miami, Florida focusing mainly on breast implant removal and breast reconstructions:
“I often do capsule exploration surgery for patients who potentially have residual capsules. In my experience, many of those patients feel much better post op. Several of my patients have shared their stories post removal of residual capsule; Angie Everhart and Talia Corrine are just two examples.”
“In my experience, capsules do not dissolve over time. They may be extremely thin, but are still present In my practice, I am 100% committed to removing the entire capsule during breast explant surgery. An en bloc capsulectomy (removing the entire capsule in one piece) is the goal when safe and appropriate. However, a total capsulectomy is an equivalent option.”
Final Note
We see a trend of women who are actively involved not only in the diagnostic part of BII but also in the selection of the type of surgery they want. En bloc surgery appeals to many women because it makes sense. Dr. Randall Feingold says:
“In reality, breast implant-associated anaplastic large cell lymphoma occurs rarely, while inflammation, fungus, and bacteria in the capsules are common. Approximately 30% of the capsules return positive with some kind of pathogens, for which I recommend further treatment. The pathology evaluation is essential to rule out malignancy, inflammation, colonies of bacteria, fungus, and mold.
“Additionally, when these cultures are positive, long term antibiotic or antifungal therapy is necessary for these patients to heal”.