Removal of breast implants & En Bloc Capsulectomy

Textured Implants

Around 2016, a definite association between textured implants and a rare lymphoma called Anaplastic Large Cell Lymphoma (ALCL) was established and became widely known. There has never been a reported case of ALCL associated with SMOOTH implants. At the time, the incidence of the lymphoma was estimated to be only one in 1 million (1:1,000,000). Nevertheless, Dr. Nicolaidis stopped using these types of implants, feeling that any risk of cancer was unacceptable. Unfortunately, the incidence has since been found to be as high as one in 2800 (1:2800) with Allergan textured implants and 1:36,000 with Mentor textured implants.

The normal reaction of the human body to any foreign object (Including breast implants) is to form a capsule around that object. That is completely normal for the human body. With textured implants, the rough surface between the implant and the capsule leads to chronic inflammation, which can ultimately lead to ALCL. The classic presentation of ALCL is the development of fluid around the implant–capsule or a mass about 7-8 years after breast augmentation. Current guidelines recommend biopsy of the mass and collection of the fluid to rule out ALCL, using the markers CD 30. Although the treatment for diagnosed BIA-ALCL is capsulectomy-en-bloc, the current American recommendation for patients with textured implants is to simply follow these patients and biopsy if a collection or mass develops. Understandably, patients with textured Allergan implants find that recommendation difficult to accept. Dr. Nicolaidis can discuss this further at the time of consultation.

Breast Implant Illness

Silicone breast implants were introduced in 1963. And there have been complaints of various symptoms from implanted patients ever since. Unfortunately, these complaints were not taken seriously by neither their Plastic Surgeons nor the implant companies, who both argued that breast implants were perfectly harmless. With the recognition of BIA-ALCL secondary to textured breast implants, it became apparent to everyone that breast implants were not so harmless after all. Following this, Breast Implant Illness (BII) has become acknowleged by the various Plastic Surgery associations, although it is yet to be proven.

BII is estimated to develop in between one and 10% of implanted patients. Symptoms are varied and span from head to toe: hair loss, skin rashes, brain fog, headaches, difficulty concentrating, dry eyes, dry mucosa, difficulty breathing, irritable bowel, muscle pain, bone pain, joint pain. Severe cases can progress to autoimmune diseases. Although the etiology of BII is unclear, it is felt to be the result of chronic reaction and inflammation to either silicone or other chemicals in the processing of breast implants. Moreover, BII symptoms have been seen to improve following removal of implants with the entire capsule as well (capsulectomy). For patients who develop established autoimmune disease, symptom improvement seems to require not only capsulectomy but additional medical treatment as well.

IMPORTANT:
Given all of the discussion around breast implant illness on the Internet now, many implanted patients are consulting Dr. Nicolaidis with the concern and even anxiety that they might have BII. Do not forget that 90% of implanted patients do not develop BII. Breast, neck, back and shoulder pain are mechanical problems due to the additional weight over the chest, not BII.  Also, breast implants cannot be blamed for every problem a patient has. The symptoms with BII are fairly consistent. Dr. Nicolaidis will assess at the time of consultation.


Objectives

Explantation involves not only the removal of the implant but its entire capsule, given that the capsule contains the inflammatory response to the breast implant. Capsulectomy en bloc implies removal of the entire capsule with the implant inside as one unit, particularly important in the case of ruptured silicone implants because it prevents the silicone from diffusing in the surgical site. With larger implants and thinner capsules, capsulectomy  En Bloc may not be possible, in which case a complete capsulectomy will be performed. Capsules are never left behind. It is important to clarify that although many patients feel much better right after their explantation, there is no guarantee that the BII symptoms will improve after explanation.

Removal of Breast Implants Cost :

Procedure sometimes paid by the RAMQ

Removal of breast implants and capsulectomy are covered by the RAMQ in three circumstances:

1) Polyurethane implants

2) Documented ruptured gel implants

3) Documented grade 4 contracture (in which the capsule becomes hard and painful)

Given the one in 2800 (1:2800) risk of ALCL with textured Allergan implants, Dr. Nicolaidis has asked that the Plastic Surgery Association of Quebec push for textured Allergan implants to be a fourth indication that would be covered by the RAMQ.

Removal of implants with or without breast lift (breast lift)

If you’ve had a breast explant, regardless of when, we invite you to complete a post-explant questionnaire to tell us about your experience. By doing this, you will help us to better understand the possible impact of implants and explants on health.

Regardless of whether or not the explantation is covered by the Regie, Dr. Nicolaidis works at the CHUM, where the primary objective is treatment of cancer cases and major reconstructions. Therefore he cannot do explantations at his hospital. He does these in a private setting when a simultaneous lift is necessary, whether it be a minimal or more significant lift. Given that the tissues can be thin and stretched by the breast implant, Dr. Nicolaidis modifies conventional lift techniques in order to ensure safety for the nipples.

In reality, after only a few weeks with breast implants, the breast skin tends to stretch. Therefore, after breast implants are removed, the breasts will tend to hang and lose their shape, requiring removal of excess skin to improve the breast shape (called a breast lift). While the removal of prostheses and capsulectomy are sometimes covered, the RAMQ does not cover the breast lift. If a breast lift is desired, removal of breast implants and capsulectomy can be done at the same time but these are done in a private center in Montreal, in which case there is a minimal to no wait.

It is important that patients have realistic expectations after explantation. The priority is to remove the implant with its entire capsule. The bigger the implant and the thinner the patient’s skin and tissues, the more the skin will tend to fold after explantation. Breast lifts after explantation are designed to minimize the folding and give a reasonable shape to the breasts. Dr. Nicolaidis will do his best to obtain the best result but you should not expect to have the same breasts as before your breast augmentation… Your skin was younger and wasn’t stretched (by an implant) at the time. If you had minimal breast tissue before your breast augmentation, you will have minimal tissue after explantation. But rest assured, there are other options that can be offered later on if you are not satisfied with your breasts, the main option being transfer of fat to the breasts. Dr. Nicolaidis prefers to transfer fat as a secondary procedure (NOT at the time of explant) in order to minimize risks and to retouch irregularities that often develop after explantation. Like all interventions, fat transfer is not without significant risks. Dr. Nicolaidis will discuss these risks at the time of consultation.

Anesthesia

Dr. Nicolaidis always performs explantation under general anesthesia.

Surgical techniques for En Bloc Capsulectomy

Capsulectomy en bloc is done through a long incision in the fold under the breast in order to allow for adequate exposure of the implant and its capsule. The surgery can be exceedingly difficult because the capsule is typically adherent to the surrounding muscles. Capsulectomy en bloc inevitably leads to some degree of damage to the surrounding muscle but the damage is usually minimal, requiring a few simple stitches to repair. In the case of implants under the muscle, surgery is that much more difficult because the capsule is stuck to the underlying ribs as well, requiring careful dissection without entering the lung cavity.

As already mentioned, Dr. Nicolaidis will only do these surgeries with a simultaneous breast lift. But the breast lifts are variable in their degree. An inferior lift does not move the nipple; therefore there is no risk to the blood supply of the nipple. When the nipples have to be raised, Dr. Nicolaidis uses more conservative lift approaches in order not to compromise the blood supply to the nipple.


Recovery after explantation

Following explantation, dressings are left in place for 1 to 2 weeks. Drains may be used if Dr. Nicolaidis is concerned about bleeding or collections. Patients are asked to keep the dressing dry and clean. Wounds are usually well healed by two to three weeks after surgery. Patients are asked to sleep only on their back and not to force with their arms for a period of one month.


Return to work after explantation

Time off work depends on the patient’s type of work. As already stated, patients cannot force with their arms for a period of one month. A conservative period of time off work is between two and four weeks.


Complications specific to En Bloc Capsulectomy with removal of breast implants

Dr. Nicolaidis is the first Plastic Surgeon to report on the complications of capsulectomy in a prospective study of his first 182 explant cases for Breast Implant Illness (The ASPS Meeting 2020).

Pneumothorax: Pneumothorax is a complication in which the covering around the lung (NOT the lung itself) is penetrated, typically as the capsule is being peeled off of the rib cage. This occurred in four out of 182 patients, all of whom had submuscular implants. The pneumothorax was recognized immediately, a small tube was placed and the hole repaired. The tube was removed the following day with no consequences.

Bleeding: Two out of the first 182 patients had to be brought back to the operating room to stop bleeding in the first week after surgery, following large movements with their arms. After Dr. Nicolaidis imposed movement restrictions of the arms, there were no further cases of bleeding.

Skin laceration: This occurred in the two out of the first 182 patients, both of which had implants above the muscle. One patient had severe contracture with the capsule stuck on the skin. The other patient was extremely muscular.

Nipple necrosis: Nipple necrosis involves death of the nipple tissue when the blood supply to the nipple is severely compromised and requires removal of the nipple with later reconstruction. Dr. Nicolaidis had no cases whatsoever of nipple necrosis, despite doing 103 round lifts and 65 complete lifts, some of which had already had previous lifts (which increases the risks to the nipples). It is important to note that many Plastic Surgeons will hesitate to do lifts at the time of explantation because of the danger of nipple necrosis.

Other complications are those seen with any surgeries under general anesthesia, that is infection, reaction to anesthesia, etc.