Breast Implant Removal
WHY DO WOMEN ELECT TO HAVE IMPLANTS REMOVED
Women elect to have their breast implants removed for many reasons. In some cases, hormones or weight fluctuation can change the size and shape of the breasts and women choose to remove implants that feel heavy or uncomfortable. Other women have never really felt completely comfortable with their breast implants and just want to go back to where they started. Occasionally, women may have repeated issues with breast implants like capsular contracture or bottoming out. Although these problems can typically be corrected with a breast augmentation revision, some women simply wish to have their implants removed. There is also a small but growing population of women who believe their implants are responsible for health problems and elect to have their implants removed to improve their well-being.
WHAT IS BREAST IMPLANT ILLNESS BII?
There are some women who feel unwell months or years after placement of breast implants and believe that their implants may be the reason why. This phenomenon, which affects only a small subset of women with implants, has been termed “Breast Implant illness” or BII. The truth is, we know very little about BII, but it is presumed to be an autoimmune disorder that affects some people after placement of silicone breast implants. There is a wide range of associated symptoms that patients have reported, including fatigue, chronic pain, headaches, brain fog, depression, and skin/hair changes. Due to a lack of available scientific data, some plastic surgeons and others may be dismissive of a woman who feels like her breast implants may be contributing to her ill health. While I practice evidence-based medicine, I value a woman’s intuition and believe that we still have much to learn about BII. Anecdotally, I have observed that many patients who undergo explant surgery feel better and experience some resolution of their symptoms.
WHAT IS BIA-ALCL?
BIA-ALCL is a very rare lymphoma associated with textured implants that presents with breast swelling and a fluid collection around the implant. Left untreated, this disease can be fatal, but most cases of BIA-ALCL can be completely cured by removal of the implant and surrounding capsule. For patients with a BIA-ALCL diagnosis, radiological imaging and consultation with a medical oncologist are also recommended. The implant type responsible for most of the reported cases was recently removed from the market. The FDA is not currently recommending implant removal in the absence of symptoms. However, some patients feel more comfortable undergoing explant regardless of symptoms.
When a patient chooses to undergo breast implant removal or “explant” there are several surgical options to consider. The simplest option is to remove the implant alone. This is a fast and easy procedure that can even be performed under local anesthesia in the clinic. The implant is removed through a small incision and the capsule is left in place. The capsule is fibrous tissue formed by the body to wall off a foreign object. While it is made from a woman’s own natural tissue, some people believe that the capsule contains contaminates or inflammatory cells, contributing to the symptoms of BII, and prefer to have it removed. Removal of the capsule is a more involved and lengthy procedure that requires general anesthesia and a larger incision, typically located in the inframammary fold. A drain is usually necessary after capsulectomy and the recovery is longer. For patients who are interested, I provide photographs from the operating room of the implant, capsule, and breast pocket. For patients with a diagnosis of ALCL, complete capsulectomy is necessary to cure the disease.
“EN BLOC” CAPSULECTOMY
“En bloc” capsulectomy refers to the removal of the implant and capsule as one piece. Dissection is performed all the way around the capsule to separate it from the breast tissue and underlying chest wall, then the intact capsule containing the implant is removed from the breast. Many patients are interested in having an en bloc capsulectomy because the surrounding tissues are not exposed to the contents of the capsule. Unfortunately, en bloc capsulectomy cannot be safely performed in every patient. In women with submuscular implants, the capsule is often thin and very adherent to the rib cage and pectoralis muscle, like tissue paper that is superglued to the bone/muscle. When en bloc capsulectomy is attempted in these patients, there is a significant risk of collapsing the lung (pneumothorax) or damaging the pectoralis muscle. In this case, “complete capsulectomy” can typically still be performed. The capsule is opened (“capsulotomy”), the implant is removed, then the majority of the capsule is removed and any remnants of capsule are ablated with cautery.
Some women choose to undergo laboratory testing associated with an explant procedure. Common concerns include bacterial or fungal contamination of the implants, exposure to toxins and heavy metals used in the production of silicone breast implants, and MTHFR genetic variants. Some of these can be tested by blood and urine samples and some require a specimen from the operating room which is sent to a laboratory. If there is any concern for ALCL, specimens from the operating room are sent for CD30 and ALK gene testing.
WHAT HAPPENS AFTER EXPLANTATION OF BREAST IMPLANTS?
After explantation, some women are dissatisfied with the appearance of their breasts and are interested in procedures to lift or provide more fullness to the breasts. It is often advisable to wait several months after explantation before deciding to undergo a revision procedure because the skin retracts and the breast tissue “fluffs” meaning that fullness and appearance improves over time. In some cases, women are perfectly happy with the result and do not express a desire for future surgery. For women who choose to have an additional procedure to improve their aesthetic outcome there are many options including breast lift (mastopexy), fat grafting, and implant replacement. Fat grafting involves removing fat from another part of the body with liposuction then purifying and injecting the fat into the breast tissue to add volume. In some select patients, a lift or fat grafting can be combined with explantation.
BREAST RECONSTRUCTION AFTER IMPLANT REMOVAL
After removal of long-standing breast implants, many patients are left with sagging skin and very little breast tissue. There are multiple options for improving the shape of the breast. Sometimes reconstruction is performed at the time of explant and other times it is best to perform staged procedures. While some patients may wish to have smooth implants replaced in the breast pocket, others prefer to enhance the breast shape with their own natural tissues. This may involve a combination of fat grafting and/or breast lift.
Fat grafting is a way to add breast volume without an implant. It involves liposuction to remove fat from an area of excess, like the abdomen or thighs, then the fat is purified and placed into the breast tissue. Generally, about half of the fat that is placed survives and adds permanent volume. While we try to overcorrect to compensate for this, there is a limit to how much fat can be placed at one time. Occasionally, women choose to undergo multiple rounds of fat grafting, especially when they had very little breast tissue to start with.
Breast lift procedures remove excess skin, reposition the breast tissue, and raise the nipple areolar complex to create a more youthful perky breast. This creates incision lines around the nipple areolar complex and below it but these usually heal very well and fade away to thin barely visible lines. Often, the upper pole (cleavage area) still lacks fullness after a breast lift so fat grafting is performed simultaneously to add volume.