Breast Implant Removal/En Bloc Capsulectomy
There are several reasons – some more urgent than others – as to why women undergo breast implant removal. These include: having an aesthetic desire for a change of size and shape, implant leakage or rupture, and capsular contracture. Some of the other potential problems that may have developed after the initial augmentation, creating the need for saline or silicone gel implant removal include: shifting, wrinkling, sagging, asymmetry, bleeding, and/or infection.
If you have breast implants and are considering removal, you have options and you do not have to live with implants that make you unhappy or uncomfortable. You may be concerned about how your breasts will look after the implants are removed. Dr. Samson is an experienced board certified plastic surgeon and will take extra steps to ensure a natural look and a safe removal.
Dr. Samson offers breast implant removal, also known as an explant procedure, including “en bloc” removal of all implant material, and removal of breast capsules with muscle reattachment. Dr. Samson also performs breast implant revision procedures for women seeking a new look. There are varying reasons that women decide to get breast implants removed.
Why Get Breast Implants Removed
Cosmesis: As trends change, some women are no longer pleased with the look of their breast implants and they seek removal for a return to their original look. Breast implants may need to be replaced over time, but some women opt for removal rather than revision or replacement.
Comfort: Bodies and lifestyles change as we age. Natural breast tissue can grow larger in a way that changes the position of breast implants. Some women find that their day to day lives are drastically different than when they initially underwent breast augmentation and for varied reasons they wish to return to their natural breast size
Capsular Contracture: Capsular contracture occurs when the body’s natural scar tissue becomes too tight or rigid around the implant. This condition is not harmful to your health, but it can cause pain and discomfort as well as hard or asymmetrical breasts that may appear unpleasing
Rupture: Breast implant complications are rare, especially with the current advances in technology. However, implant rupture can occur, especially with older model implants. It is important that women have regular physical examinations to check for implant rupture.
General Health Concerns: Extensive studies conducted in the past and currently taking place by the FDA and others, show that breast implants are safe. A growing number of women with breast implants believe that a disorder called breast implant illness may be causing them fatigue, joint pain, brain fog and other symptoms related to autoimmune disorders, and they are seeking breast implant removal surgery to help alleviate their symptoms. Although studies conducted by the FDA and others do not recognize breast implant illness, post breast implant approval studies should continue and possibly expand to explore the risk of genetic susceptibility to these symptoms. Dr. Samson is committed to women’s health and well being and performs en bloc breast implant explant surgery for women seeking to have their implants and the capsule surrounding those implants removed.
If you do not choose to have new implants inserted upon the removal of the initial implants, or further cosmetic surgery, it is important to note that your breasts will never look the same as they did before breast augmentation (especially if large implants are removed). Your breasts may appear smaller than before the implants, which could possibly be attributed to hormone changes or weight loss. Sagging, tissue atrophy, and chest wall deformity may also result from complete breast implant removal without an exchange. Some imporvement in appearance will occur during the first six months after explant surgery. To get an idea of the results you can achieve with breast implant removal, view Dr. Samson’s Breast implant removal before and after photos.
During the consultation with Dr Samson will discuss with you the steps and details of your breast procedure with you. The surgical plan will be individualized to your specific needs and desires. The breast implant removal procedure will typically take place at our surgery center, The Surgery Center of Volusia. If Samson determines that certain medical conditions necessitate that the procedure take place in a hospital, this will be discussed prior to scheduling your procedure.
Patients will usually be placed under general anesthesia. For the breast implant removal surgery, anesthesia may be either local or general anesthesia. The incisions made during this procedure are typically created in the scar from the patient’s initial augmentation surgery. Dr. Samson generally uses an inframammary incision to access the breast implant; however, other incisions may be used. The entire explant procedure typically takes between 1 and 3 hours.
Capsulectomy and “En Bloc” Removal
When breasts are augmented with implants, the body responds within weeks of the breast implant surgery by surrounding the implant pocket with scar tissue. This scar tissue is called the capsule and ideally it is a soft sheet of scar tissue that helps hold the implants in place. Removal of the breast capsule is called a capsulectomy. Whenever possible, Dr. Samson will perform the breast implant removal as an “en bloc” capsulectomy which means that the entire capsule is removed intact with the implant inside, as opposed to incising the capsule to remove the implant separately. In some cases the capsule may have become malformed, repositioned or adhered to the chest wall in a way that makes it impossible or unsafe to perform an “en bloc” removal. In those cases, any remaining capsule tissue will be cauterized, but whenever it is safe to do so Dr. Samson will remove the entire capsule.
One extra step that may be recommended for explant patients that have had their implants placed under the muscle is surgical reattachment of the pectoralis major muscles to the chest wall. After breast implants are removed, there is potential for animation deformity in which the detached muscle is visible through the skin. If so, Dr. Samson reattaches the muscle to minimize the risk of this deformity. Reattachment of the muscle may also improve blood flow for improved recovery and healthier breast tissue.
Breast Lift (Mastopexy) or Fat Grafting
It is normal to be concerned about how your body will look after implants are removed. There are a number of factors, including the size and condition of the implants, and how long they were in place, as well as the age and body type of the patient, that will determine the end result. Some patients inquire about breast lift surgery or fat grafting procedures in conjunction with the explant surgery. Dr. Samson believes that, in most cases, proper surgical technique during removal will result in a favorable aesthetic result without further surgical intervention. In cases with severe sagging or breast deformation after implant removal surgery, Dr. Samson may advise explant patients to wait approximately 6 months after their explant surgery to consider any additional procedures. The breast tissue will settle as it heals and blood flow improves and many patients are very happy with their appearance once they are fully healed. In some patients breast lift and/or fat grafting procedures may be appropriate at the time of explantation, and Dr. Samson will discuss this with you at the time of your consultation.
In general, for the first few days after breast implant removal, there may be mild discomfort, swelling and bruising. There may be suction drains placed for a day or two. You should plan to devote the first week after surgery to complete rest and recovery. Patients may experience some discomfort, but pain medication will be prescribed. There will be restrictions on physical activity and strenuous exercise and manual labor should be avoided for 3-4 weeks.
A post-operative appointment with Dr. Samson will be scheduled on the day after surgery, 5-7 days after surgery and at 5 weeks after surgery. The entire recovery period usually stretches over a few months.
These appointments are important to assess your recovery; a follow up appointment 6 months after surgery will be scheduled.
The cost of breast implant removal varies depending on the exact surgery planned, e.g. simple explantation, explantation with capsulectomy, “en bloc” removal, and mastopexy or fat grafting procedures will have varying costs. Also, anesthesia cost, cost of the surgical facility, and the cost of any medical tests and prescriptions you may need will vary. We have flat fee pricing for all breast implant removal procedures, including an all-inclusive “en bloc” removal with pathology for capsules, fungal/ bacterial cultures, Gram stain, and intraoperative implant photographs as well. Dr. Samson can give you an accurate cost estimate for your specific needs during a one-on-one consultation.
We are available to answer any questions about breast implant removal.
If you are living with breast implants that cause you physical discomfort or emotional distress, please contact us to take the first step toward feeling comfortable in your body.
If you are interested in these or other cosmetic surgeries in the Daytona Beach, FL area, schedule a consultation by calling 386-756-9400 or fill out our contact form.
BII (BREAST IMPLANT ASSOCIATED ILLNESS) – FAQS
Q: What is Breast Implant Illness (BII)?
There are women with breast implants who self-identify and present with various systemic symptoms and believe that these are related to their breast implants. They refer to these symptoms as Breast Implant Illness (BII). Breast Implant Illness (BII) is a term used by women who have breast implants and who self-identify and describe a variety of symptoms including (but not limited to) fatigue, chest pain, hair loss, headaches, chills, photosensitivity, chronic pain, rash, body odor, anxiety, brain fog, sleep disturbance, depression, neurologic issues and hormonal issues that they feel are directly connected to their saline or silicone, textured or smooth breast implants.
The recent increase in patients reporting Breast Implant Illness (BII) symptoms appears to be related to social media. There is one Facebook group alone with more than 70,000 members, all of whom report Breast Implant Illness (BII) symptoms. This is not to say that social media is the cause of Breast Implant Illness (BII) however, it may account for the rapid increases in patient reporting. BII is not an official medical diagnosis.
Q: Is there a link between medical grade silicone implants and any disease?
Silicone is an element that exists in nature as crystalline silica, which has been shown to activate the immune system in conditions such as systemic sclerosis which has been seen in stone masons. Silicone used in breast implants is different and to date has not been proven to cause any disease. This silicone does not exist is nature, it is created by hydroxylating silica to form polydimethylsiloxane. Medical grade silicone has had antioxidants, dyes, and plasticizers removed during processing.
Q: Are there any tests that would indicate a connection between breast implants and symptoms that are being labelled Breast Implant Illness (BII)?
There is no diagnostic testing specifically for Breast Implant Illness (BII). This is one of the current areas of focus for the Aesthetic Surgery Education and Research Foundation, the research arm of the American Society for Aesthetic Plastic Surgery. There are tests for autoimmune diseases that can be performed to evaluate for potential causes of a patient’s symptoms. There are patients who have symptoms they attribute to Breast Implant Illness (BII) with positive immune testing and others with all laboratory tests which show no abnormalities.
Q: Is there any scientific data showing causation between implants and these symptoms or any disease entity?
In 1999, The Institute of Medicine Committee on the Safety of Silicone conducted an extensive review of the available literature and concluded there was no demonstrated clear link between silicone implants and any systemic illness. There have been studies of many different sizes and design to look at the safety of breast implants themselves. These have looked at specific autoimmune disorders and diseases. In aggregate, these studies show little to no links between breast implants and any disease. Studies of patients who have symptoms that they have related to their breast implants have not shown consistent laboratory abnormalities to define a distinct syndrome. To-date, there has been very little in the way of research into this entity that has been labelled Breast Implant Illness (BII) by women with breast implants.
Q: Does implant removal improve patient’s symptoms or cure a patient who has a medically diagnosed disease entity like an autoimmune disease?
Various studies show different degrees of improvement in patient symptoms after removal of their breast implants, some of which are temporary, and some showing permanent resolution of symptoms. There are no studies which specifically show which symptoms may or may not improve with implant removal with or without capsulectomy.
There is no current definitive epidemiological evidence to support a direct link between breast implants and any specific disease process. However, this does not mean further research is not indicated. In rare and unusual disease processes, it can take years to come to a scientific conclusion. There are many factors that can affect the interaction between a patient and her breast implants. Further study is required to determine the best way to potentially screen patients prior to breast implant surgery and to determine which of the multitude of reported symptoms might improve with implant and capsule removal.
A lack of a direct, proven scientific link does not mean that the symptoms experienced by these patients are not real. Some patients have legitimate concerns about a potential link between breast implants and symptoms, so it deserves our attention and further scientific research to better determine what symptoms may improve with explanation of implants.
Q: What are plastic surgery societies such as ASAPS and ASERF doing to better understand this group of systemic symptoms being called Breast Implant Illness (BII)?
Because there are many women that self-identify as having Breast Implant Illness (BII), we are listening. ASAPS and ASERF are developing a new scientific study to examine this entity. They are also providing plastic surgeon members with a questionnaire to use to collect a record of complaints from patients with implants, as well as one to utilize for post-explantation. We cannot yet define BII and therefore cannot say with any certainty that it exists, because we do not have any tests we can run to prove or disprove its existence. However, we can listen to and partner with our patients to determine what is the best course of action to address their complaints, be it explantation or otherwise.
Q: What will we do when a patient complains of Breast Implant Illness (BII) symptoms?
We will not ignore our patient’s concerns. Their symptoms are real and whether or not they can or cannot be attributed to their implants isn’t relevant since there is simply no existing way to prove nor disprove causation or association.
Options can include: further medical work up with or without the consultation of a rheumatologist, observation without medical work up, implant removal without capsulectomy, exchange with or without capsulectomy, removal with total capsulectomy, or removal with en bloc capsulectomy.
Patients who present with concerns of Breast Implant Illness (BII) have real symptoms that often cannot be categorized into any specific known disease entity. This does not mean their symptoms are not real and they deserve a full evaluation. The various options need to be discussed and hopefully, with further research, we may be able to determine which patients may see symptom improvement or resolution with removal of their implants and which may not see any change.
Q: What is the risk of developing Breast Implant Illness (BII)?
As there is no definitive link between the often subjective and divergent list of symptoms, and no means for testing, there is no ‘known’ risk. Many of the symptoms described by breast implant patients are experienced by the general public on a regular basis with or without implants. That isn’t to write-off a potential connection, but no connection has been established to-date.
Patients should however be informed of the risks that can be associated with breast implants, including (but not limited to) BIA-ALCL, a rare spectrum of disorders that can range from a benign accumulation of fluids around the breast (seroma) to an extremely rare lymphoma. They should know that BIA-ALCL is not a cancer of the breast tissue itself and that when caught early, it is readily curable. If the disease is advanced, chemotherapy or radiation may be required.
Q: What do we offer when a patient asks for an en bloc (total removal of capsule and implant)?
There are many medical inaccuracies perpetuated by the internet. Some patients believe that a total capsulectomy is necessary to remove all causative agents and they prefer it be en bloc, often times without having a full understanding of what size incision is necessary for en bloc. We like to discuss the reasons why we would perform a total capsulectomy with any patient. Not all plastic surgeons routinely perform a capsulectomy with explant, but some do.
It is important to explain that it is not always possible to remove all of the capsule. Sometimes a portion of the capsule must be left behind or is disintegrated with the use of electrocautery to prevent significant damage to muscle, rib or lung. A larger incision is needed for an en bloc capsulectomy. If axillary approach or periareolar approach was used for breast implant placement, it must be noted that patients cannot have the procedure done through those incisions. There are increased surgical risks associated with en bloc capsulectomy which requires a complete dissection of all the tissues surrounding the breast implant. We do not have enough collective data to guarantee any improvement in symptoms labelled Breast Implant Illness (BII).
BIA-ALCL (BREAST IMPLANT ASSOCIATED ANAPLASTIC LARGE CELL LYMPHOMA) – FAQS
Q: What is BIA-ALCL?
BIA-ALCL (Breast Implant-Associated Anaplastic Large Cell Lymphoma) is a rare spectrum of disease that can range from an indolent accumulation of fluids around the breast (seroma) to a potentially metastatic lymphoma especially when there are delays in diagnosis. It is a disease that ranges from indolent to full-blown metastatic disease when not caught early. BIA-ALCL is not a cancer of the breast tissue itself. When diagnosed early, it is readily curable. If the disease is advanced, chemotherapy or radiation may be required.
BIA-ALCL is currently classified as a lymphoma. Many experts believe that it behaves clinically as a lymphoproliferative disorder (LPD) that encompasses the spectrum of disease from benign CD30+ seromas, to CD30+ malignant seromas, to invasive capsular disease, and finally metastatic disease. Current research is underway to further understand the proper classification of this disorder. Similar to other lymphomas, BIA-ALCL is a highly treatable disease with high cure rates.
Q: Have there been any deaths due to BIA-ALCL?
There have been 17 confirmed deaths globally, (9 in the United States), attributed to BIA-ALCL since the disease was first reported nearly 20 years ago.
Q: What are the symptoms of BIA-ALCL?
The first symptom of BIA-ALCL is usually a swelling of the breast between 2 to 28 years after the insertion of breast implants, with an average of about 8 years after implantation. The swelling is due to a collection of fluid surrounding the implant. This fluid can cause the breast to enlarge significantly over a period of days or weeks. It can also present as a lump in the breast or armpit, firmness of the breast, or pain. It is usually easily and completely treated if patients see their doctor at the first symptom.
Q: What is the risk of developing BIA-ALCL?
The FDA reports that it is 1:3,817 to 1:30,000 in their latest statement. These risk assessments are changing on an ongoing basis, but this is the most accurate information currently available (February 2019).
Based on current data, the risk can be further explained by the texture grade of the implants as follows:
Grade 1 (Smooth only) – In global databases, there has not been a confirmed case of smooth only. In the Feb 2019 FDA statement, it was reported that “there have been reports of BIA-ALCL in patients with smooth-surfaced implants and many reports do not include the surface texture of the implant at the time of diagnosis.” At the time of this publication it is known that a single case of smooth only BIA-ALCL was originally reported to the FDA; however, it was later determined that this was not accurate, and the case was a mixed implant case, and the report to the FDA was amended.
Grade 2 (e.g. Microtexture, Siltex and similar) – 1:82,000
Grade 3 (e.g. Macrotexture, Biocell and similar) – 1:3,200
Grade 4 (e.g. Polyurethane) – 1:2,800
So, in conclusion as of February 2019 no cases of smooth have ever been definitively described.
Q: If a breast implant patient comes to see us when she develops a first symptom, will she be cured?
That answer is not known and is a very important piece of information for patients and plastic surgeons. Most of the time patients see their plastic surgeon right away when they develop significant swelling of the breast. In these cases, the disease is almost always caught early and cured with a straightforward operation. Some women with advanced disease ignored earlier symptoms or saw a doctor who did not properly diagnose them. There are a few patients who presented with advanced disease who said that they never had earlier symptoms.
Q: Differences in implant texture and what role that factor plays in the research?
Although it is rare, BIA-ALCL appears to currently develop exclusively in women with textured implants. To date there has not been a case of BIA-ALCL in a patient with only smooth implants. There are several theories which attempt to explain the higher rate for textured implant patients: many believe that the increased surface area of textured implants allows a higher number of bacteria around the implant, which forms a biofilm in some patients, and can result in chronic inflammation, ultimately leading to a proliferation of lymphocytes. Less accepted theories are that textured implants create greater inflammation because of chronic mechanical irritation, and another postulates that microscopic shedding of silicone from the textured wall induces inflammation.
Q: Is it a problem with Saline or Silicone implants?
Of the 457 unique cases of BIA-ALCL (FDA 2-2019) implants are both silicone and saline. It appears to purely be related to the surface of the implant and not to what the implant is filled with.
Q: How does this impact those with breast implants?
The plastic surgery societies ASAPS and ASERF emphasize that the most important issue for women with breast implants is to screen for breast cancer with self-exam, a regular physician exam, and mammography/ultrasound/MRI as recommended by their physician. Regardless of BIA-ALCL, all women should see their plastic surgeon immediately if they note a change to the size, feel, or shape of their breasts.
Q: What about those considering breast implants?
Patients considering textured breast implants should discuss this issue with their plastic surgeon. As of this publication, there are no true contraindications of having textured implants. There are patients who are candidates for shaped textured implants. In them, science must precede fear.
Q: Do we recommend textured implants to a patient?
The choice of implant type is ultimately a decision between an educated patient and her board certified plastic surgeon. There may be certain circumstances where a textured implant is recommended for particular patients.
All patients should have a detailed conversation with their surgeon about the risks associated with textured implants, beyond what is published online or in pamphlets. Ultimately, there are instances where textured implants are the best choice for them.
Q: How is BIA-ALCL diagnosed?
If a woman develops swelling in an augmented breast, she should undergo an ultrasound scan. If fluid is detected, it should be drained and tested for:
CD30 immunohistochemistry is not diagnostic for BIA-ALCL; however, it is a marker for activated T-Cells. If a patient’s seroma is CD30 positive, and the cytology is negative, this likely represents a precursor to BIA-ALCL, and should be treated with total capsulectomy.
If the seroma test is CD30 negative with negative cytology, then it should be treated as a benign seroma using the idividual surgeon’s protocol.
The majority of seromas seen clinically are benign seromas and not BIA-ALCL.
Management of all seromas should be by a board-certified plastic surgeon. Mammograms are not useful in diagnosing BIA-ALCL. In confirmed cases PET or MRI/CT scans may be used to help stage the disease.
If a patient wants to have their textured implants removed and replaced, the options are:
Exchange to smooth implants
Exchange to smooth implants with a capsulectomy
Q: How is BIA-ALCL treated and what is the prognosis?
Current recommendations for the treatment of BIA-ALCL call for bilateral capsulectomy (removing all the scar tissue) and removal of the old breast implants. This is a very common procedure performed by plastic surgeons, identical to what is done when an implant has ruptured, or capsular contracture has developed. Smooth implants can be put back in or the patient can choose not to have implants. In all early stage cases, the disease has been fully resolved by this surgery alone. The majority of patients require no additional treatment. However, if the disease has spread to lymph nodes or grown into the adjacent tissues, chemotherapy and radiation may be necessary. These are very serious treatments with significant side effects.
Q: Are some patients at greater risk than others?
The rates of BIA-ALCL seem different throughout the world. This may be due to different reporting and registries, but there may be a genetic predisposition that is not yet fully understood. For instance, as of this time there are very few cases in Asian patients. The risk is only with textured implants and not smooth implants; the rate is no different between silicone and saline; it occurs in both cosmetic and reconstructive patients. There is no test to determine whether one textured implant patient is at any more risk of developing this disorder than any other patients.
Q: Should patients have their implants removed because of BIA-ALCL?
For textured implant patients, neither the FDA nor any plastic surgery society currently recommends that women should preventatively remove textured breast implants to prevent BIA-ALCL. However, there are women who have been concerned enough about BIA-ALCL and have chosen to have their implants removed. There are some women who were already considering a breast implant revision, and the BIA-ALCL issue gave them one more reason to decide to proceed.
Breast implant patients should have ongoing follow up.
Current FDA recommendations and ASAPS recommendations indicate that patients with textured implants with no issues should not do anything and implant removal is not recommended.
Q: Should women with breast implants be screened for BIA-ALCL?
There is no blood test to specifically screen for BIA-ALCL. The expert opinion is that asymptomatic women without breast changes do not require more than routine mammograms and breast exams. But if a patient experiences a change in her breasts – especially if there is swelling or a lump – she should undergo immediate examination, imaging, and consultation with a plastic surgeon. If there is fluid around the implant the fluid should be aspirated under ultrasound guidance and sent for analysis.
Q: What causes BIA-ALCL?
Major plastic surgery societies and research wings such as ASAPS, ASERF, and the FDA, along with the implant manufacturers are intensely studying BIA-ALCL. To date, no specific causal factors have been identified. Implant texturing, bacteriologic contamination, and genetic factors have been implicated and are undergoing further study.
The best theory today is that a combination of four factors are required for the development of BIA-ALCL:
Textured implants (surface area to sequester bacteria)
The source of the chronic inflammation is thought to be bacteria that have been identified around the implants in affected breasts. Evidence is accumulating that a long-term inflammatory response to the presence of these bacteria is one of the factors that may cause BIA-ALCL. Research is ongoing and cases are being monitored.
Genetic factors may play a role. Some geographic areas have reported very few cases. Ongoing data collection worldwide will help to determine whether or not there are any genetic propensities for this disease.
Q: Do we recommend against the use of textured implants?
The available data does not support discontinuance of textured implants. The best practice is always for the physician to discuss with each patient the known risks and potential complications associated with any procedure. It is important for the patient and her doctor to frankly discuss all options available, and the risks involved.
Every plastic surgeon offers patients options regarding breast implants in terms of sizing, shape, and surface. Depending on a particular patient’s needs, a textured implant may be preferable. The plastic surgeon must provide a frank and transparent discussion regarding the benefits and risks of implants, both smooth and textured. The patient must then make an informed decision, based upon her own assessment of her needs and the risks involved.
Every plastic surgeon needs to help each individual patient make her own decision about which implant she prefers in a fully transparent manner. This involves weighing any possible increased risks against the advantages offered by a particular type of implant. It is critical that the patient makes a fully informed decision following a full discussion of the risks and benefits.
Q: What is the recommended clinical response to a patient presenting with symptoms that could be attributable to ALCL?
Detailed information can be found on the ASAPS website at: http://www.surgery.org/professionals
Q: Where can I find more information on BIA-ALCL?
Additional information and resources on BIA-ALCL are available online at https://www.surgery.org/media/resources
Q: What research is being conducted?
ASERF is currently funding two BIA-ALCL studies on the Pathogenesis of BIA-ALCL and Genomic Profiling to Understand the Pathogenesis of BIA-ALCL.
ASERF is sponsoring leading, cutting edge research on BIA-ALCL to better define the disease and improve diagnosis and outcome. More information can be found on the ASERF website: www.aserf.org