Removal of Breast Implants

The following applies to patients with prostheses for both cosmetic and breast reconstruction reasons.

A patient may elect to have her prosthetic breast implants removed for a variety of reasons including:   

• Personal preference
• A complication of the prostheses such as pain, capsular contraction, infection, visible folds or malposition (abnormal change in shape of the breast from the prosthesis moving, leading to deformity)
• A change in an individual’s physical characteristics such that the prostheses are no longer required for their desirable breast shape and size. This is common after weight gain, children and advancing years
• A change or breast ptosis (drooping) of the breast tissue to produce an undesirable shape or symptoms
• Leaking or rupture of an implant
• As management associated with cancer of the breast gland
• Due to cancer associated with the breast prosthesis and capsule such as BIA-ALCL and BIA-SCC (see specific information)
• Due to the diagnosis of Breast Implant Illness (BII). This is associated with a myriad of symptoms that are not specific to BII but include (not only) fatigue, joint and muscle aches, tiredness, difficult concentrating (foggy brain), breast pain, headaches, flu-like symptoms, moodiness, anxiety, depression. Over 100 symptoms have been attributed to BII

  All these symptoms can be produced, or are similar to, other organic diseases and a diagnosis of BII should only be made after appropriate investigations to exclude other causes

No patient who has breast prostheses is obliged to keep them. It is the patient’s body and they have the right to choose for themselves. This choice should be made after appropriate investigations of symptoms to exclude another cause, and made after collecting evidence based scientific information so the patient can make a decision about what is best for themselves and their preference.

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Capsulectomy

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 (BII)

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 no 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.

Removal or Replacement of Breast Prosthesis

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 with your Plastic surgeon, 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 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 a 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 tear drop), 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

The Surgery

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.

My 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.

Recovery

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 appointment 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.

Risks

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.

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.

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, further 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) rare, breast-implant-associated SCC (BIA-SCC) rare.

Costs

Under the Medicare scheme in Australia, there are very specific criteria that need to be satisfied to have Medicare item numbers applied to this surgery.

An assessment of the criteria, including taking clinical photographs necessary to support a claim, will occur at the time of the consultation at our Sydney practice.

If these criteria are met, the operation is considered reconstructive surgery. If the patient is in a private health fund with appropriate cover, a proportion of the costs will then be rebated by Medicare and the health fund.

If the criteria are not met, the surgery is classified as cosmetic and as such no Medicare or private health fund rebates apply for the medical or day surgery fees. An estimate of costs will be provided following the consultation with Dr Perkins.