Whether for cosmetic breast augmentation or breast reconstruction, it is known that breast implants are not lifetime devices. Common reasons for breast implant removal include rupture and capsular contracture; however, recent discussions pertaining to the safety of silicone breast implants are fueling increasing demand for explantation. Rates of explantation have increased from 19,857 procedures in 2009 to 30,000 in 2018, making explantation one of the top ten most commonly performed plastic surgery procedure performed in the United States.
With any breast implant, your body creates a layer of protective scar tissue around the implant, called a capsule. In some women, this capsule can abnormally harden and tighten, causing pain and distortion of the implant. Studies report rates of capsular contracture ranging from 2.8% to 18.9% for augmentation patients. In the setting of capsular contracture, implant removal or implant exchange can be considered.
All types of breast implants can develop a tear or whole, leading to rupture. Rupture of a silicone implant is an indication for implant removal. Implant rupture rates can vary based on surgeon and manufacturer. Diagnosis of silicone implant rupture is usually achieved using MRI or ultrasound.
“Breast Implant Illness” or silicone implant illness is characterized by a non-specific and generalized constellation of symptoms. These can include malaise, fatigue, fibromyalgia, headache or other autoimmune like complaints potentially caused by a breast implant. No diagnostic test for BII currently exists.
Breast implant-associated anaplastic large cell lymphoma (BIA-ALCL) is associated with textured breast implants. Patients most commonly present with seroma (fluid collection around the implant), pain and/or swelling in the breast, capsular contracture, and a mass or lump around the implant. In patients with BIA-ALCL, the capsule, fluid surrounding the implant, and any associated masses should be completely removed with the implants (en bloc resection). In asymptomatic patients with textured implants (without BIA-ALCL), there is no evidence that whether implant removal with partial or total capsulectomy has any effect on reducing risk of developing BIA-ALCL in the future. Lack of data creates a challenge for patients and surgeons to determine the best course of action with textured implants.
Women who are unhappy with their breast appearance due to age-related changes, pregnancy, weight gain or loss, or changes in public opinion concerning breast implants, may desire to remove previously placed implants.
Breast implant removal is a safe, reliable, and outpatient procedure. Prior to breast explantation surgery, there are two important considerations. Breast explantation will change the appearance of the breast, and procedures such as mastopexy (breast lift) and/or fat grafting can be performed at the same time as breast implant removal. Secondly, it is important to determine how the breast capsule will be managed during surgery. With any breast implant, your body creates a layer of protective scar tissue around the implant, called a capsule. The appropriateness as to whether capsule removal is indicated is not always clear and can be quite controversial based on the indication for breast implant removal.
Capsulotomy is the simplest, and safest, of the procedures used to manage the capsule in explant patients. During an open capsulotomy, the capsule is cut open, allowing exposure to remove the implant. The capsule remains in the patient and the implant is removed. Capsulotomies are not adequate in patients with BIA-ALCL or when the capsule has calcium deposits, masses, or silicone embedded in the capsule.
During a partial capsulectomy, a portion of the capsule is removed with the underlying implant. In contrast, with a total capsulectomy the entire capsule is removed with the implant. Total capsulectomy is a more invasive procedure that carries a higher risk of bleeding and other complications compared to partial capsulectomy or capsulotomy. The decision to proceed with a total capsulectomy should be considered carefully, taking into account the specific reason for explantation.
En Bloc capsulectomy is defined as an oncologic procedure in which a margin of normal-appearing tissue around the capsule is removed with the implant and an intact implant capsule. Currently available evidence indicates that an en bloc capsulectomy should only be performed in those who have BIA-ALCL. Although some in the lay press and on social media have referred to an en bloc capsulectomy as removal of the capsule and implant as a single unit, this is an inaccurate use of this oncologic term. Whereas an en bloc resection is appropriate for the treatment of the established diagnosis of BIA-ALCL, it is not indicated in non-cancer breast implant removal surgeries.