Removal of Breast Implants

When an inert (non-reactive) foreign body such as a silicone covered breast prosthesis is placed in the body, the body’s immune system is unable to remove it (like it might a bacteria). Thus, the body’s response is to enclose the prosthesis in a scar capsule that seals it off from the rest of the body. This scar capsule is produced by your body and is different to the silicone capsule (shell) of the prosthesis that has been inserted.

When a prosthesis is removed or replaced there are many options and indications for what is done to, or with, the scar capsule.

Removing a scar capsule is more surgery and carries with it additional potential complications, pain and prolonged recovery. What is done to the capsule needs to be based on a clear clinical goal with the potential benefits weighed against potential complications and undesirable effects.

The range of options to deal with the capsule associated with removing or replacing a breast prosthesis include:

1. Leaving it totally intact and in place if there is no benefit to the patient to remove it (it is from the patient’s own body)
2. Manipulating the scar capsule by either opening and incising the scar (capsulotomy) to make the pocket for the new prosthesis a better shape, or suturing and tightening the capsule to change the pocket shape to hold the prosthesis in a better position
3. Removing part of or the whole capsule (capsulectomy) due to a specific indication or to achieve a desired effect

There has been much confusion spread on social media (and by some clinicians) regarding terminology and benefits of different degrees of capsulectomy, not based on scientific evidence. For clarification, the following classification of terminology for capsulectomy is accepted by surgical expert consensus:

1. “En Bloc” capsulectomy: The removal of the scar capsule with a margin of normal breast tissue that is uninvolved with any disease process. This is a curative cancer operation and is only appropriate in the cancer setting, after appropriate investigations. This type of procedure has potentially significant risks, complications and downsides, including distortion of the breast, which would all be specifically discussed with a patient with a diagnosis such as BIA-ALCL and BIA-SCC
2. Total intact capsulectomy: This is the total removal of the scar capsule in one piece (not always technically possible). This is what a patient with BII usually wants when they ask for an “en bloc capsulectomy”
3. Total capsulectomy: The total removal of the scar capsule, but not necessarily in one piece
4. Partial capsulectomy: the removal of a varying amount of the scar capsule, knowingly leaving some behind. [Especially in the case of a prosthesis deep to the muscle, on the chest wall, the capsule can almost blend with the ribs. Removing the capsule in that setting can be very morbid, painful and risky (even causing lung collapse) and should only be done if there is a clear clinical benefit to the patient]

Breast implant illness has been described with silicone and saline prostheses, smooth and textured implants and with all manufacturer’s brands. BII is associated with a myriad of symptoms as outlined above. These are common and non-specific disease symptoms, and other organic disease causes must be excluded before prostheses can be implicated. It is a diagnosis arrived at after excluding other causes. However, studies have shown a significant proportion of patients with BII will have improvement or resolution of symptoms following removal of their breast prostheses.

The internet and social media have been a source of much confusion, perpetuated non-scientific statements and claims, and misinformation based on anecdotal logic. Thankfully, good prospective, controlled scientific studies are now being completed and published, and we have good “evidence based” information to educate patients and allow them to make informed decisions regarding what is in their best interests.

Multiple controlled studies have shown in patients with BII that rapid symptom improvement occurred after implant removal, which was sustained in the long term. This improvement was independent of whether all or part of the capsule was removed, i.e. the same improvement was achieved with removal of part of the capsule as was achieved with removal of all of the capsule.

One published series where no capsule was removed, only the prosthesis, showed similar symptomatic improvement. All this suggests that removal of the prosthesis is the critical factor, and not how much scar capsule is removed.

Remember, the scar capsule is produced by your body and not the prosthesis. Removing the scar capsule can add significantly to the surgery, complications and recovery, and needs to be based on published and reviewed scientific evidence, as discussed with your surgeon. This is the way to get the best outcome with the least risk and cost.

In a patient who wishes to have her current breast prostheses removed, for whatever reason, there are many options as to how to proceed forward. All of these options can be coupled with capsulectomy or capsulotomy, as outlined above, depending on clinical indications:

1. Do nothing. Following discussion regarding the scientific facts of the patient’s specific issues or circumstances, the patient may decide that although not “perfect” the potential benefits or improvements that would be achieved by surgery would not outweigh the potential risks, complications and cost
2. Simply remove the implants
3. Remove the implants and rearrange the natural breast tissue to improve the shape of the breast. This is usually via a mastopexy (breast lift). The patient of course needs to have sufficient remaining breast volume to make the lift technically possible and beneficial
4. Remove the implants and replace them with new implants. The new implants can be changed to a larger or smaller size, to a different shape (round or teardrop), or into a different pocket (e.g. from on top of the muscle to below the muscle), depending on patient preference or clinical goal. Careful consideration and detailed discussion are required
5. Removal and replacement of the implants combined with a breast lift to reposition sagging breast tissue over the prostheses

Surgery to remove and/or replace breast prostheses, coupled with any type of capsulectomy, as well as a breast lift as desired, can be performed as day surgery unless there is a medical indication to contraindicate.

The operation is performed under general anaesthetic. Once asleep, long acting local anaesthetic is injected for post-operative pain relief. The incision for access to remove a prosthesis and perform a capsulectomy is usually via the inframammary crease, based on previous incisions.

Depending on the degree of capsulectomy, and the amount of pocket manipulation required, the operation is usually longer and more involved than the original breast augmentation surgery.

Our preference, if the prosthesis is being replaced, is to complete this component before any breast lifting surgery is performed, to minimise the risk of prosthesis contamination and infection.

• Upon completion of the surgery patients are placed in a bespoke handmade compression bandage. The bandage is generally removed two days post-operatively when the patient is then placed in a crop top.
• Drains are placed as they are essential to prevent collections of blood and fluid, and subsequent complications. The drains remain until the output drops, usually 4 to 7 days, but may be longer.
• Once recovered and ready for discharge, post-operative instructions covering wound care, medications and follow up appointments will be given.
• It is essential that a responsible adult collect the patient and stay with them for the first 24 hours following the surgery. Patients will be able to care for themselves after the acute effects of the general anaesthetic wear off after the first day.
• Bruising and swelling are normal following the surgery and will subside over the first few weeks. 
• Pain and recovery from the surgery is in the same ballpark as the original augmentation, though this depends on the prosthesis being replaced, the degree of capsulectomy and any associated breast lifting. A degree of discomfort, particularly when moving or coughing, can be expected for the few first days after the surgery.
• Patients can shower after their compression bandage is removed on day 2. All sutures are dissolvable and internal, and covered by a waterproof dressing. If a breast lift has been performed, scar taping to optimise scars will be recommended and taught.
• Recovery to activities is similar to the primary breast augmentation. Patients will be able to carry out most normal non-strenuous activities around the house in 2 – 4 days, and many patients will return to work if they have a desk job after 1 or 2 weeks. Patients are usually able to drive a car a week or so after their surgery.
• Bouncing of the breasts is to be avoided for 6 weeks, i.e. no jogging, aerobics or similar. It is important that patients avoid strenuous upper body activities for about 5 – 6 weeks following the surgery.  Stationary bike and leg weights are ideal post-operative gym activities.

Even with the highest standards of practice, all surgical procedures carry a level of risk and the potential for complications. In addition, every individual will have a different risk profile depending on their general health, age and the complexity of the procedure.

During the consultation Dr Perkins will explain the possible complications and risks of the specific procedure to provide the necessary information to enable patients to weigh up the benefits, risks and limitations of the surgery.  The following are some of the risks associated with this procedure.

• Specific risks of breast implant removal include changes or loss in sensation of the nipple, asymmetry, skin discolouration and prolonged swelling around the operation site. Ffurther surgery may be required if an implant has ruptured and there is silicone outside of the scar capsule.
  
  
• Specific risks of breast implant replacement include capsular contracture, rupture of implant, rejection of implant, asymmetry, changes or loss in sensation of the nipple, later changes in breast shape, rotation or change in position of the implant, rippling appearance, possible link to autoimmune disorders. Breast-implant-associated anaplastic large cell lymphoma (BIA-ALCL) and breast-implant-associated SCC (BIA-SCC) are rare.
  
  
• General risks involved in any surgery include post-operative infection, excessive bleeding, pain/discomfort, haematoma (blood collection), seroma (fluid collection), scarring, adverse reaction to anaesthetic, unsatisfactory scarring. Read more about general risks and complications of surgery.