I do a lot of breast surgery.
Not only am I a female plastic surgeon, I did an additional breast fellowship in addition to my plastic surgery residency. As an expert in breast, people refer a lot of secondary cases to me to do breast implant revision surgery. Yes, the tough cases.
Breast implant revision surgery can mean many things. It depends on your goals and what your issues are. Revision ranges from a simple implant exchange, to capsule removal and implant exchange, to capsule and implant removal. And many times this also involves doing a breast lift.
I keep getting inquiries about if I do “en bloc removal” of the breast implant. So I thought I should write a blog on it. Yes, I do en bloc removal of implants.
First lets get the terminology down.
- Implant– Breast implant, can be silicone or saline
- Capsule – This is the scar your body forms around the implant. It does not exist before your implant. Your body forms a capsule around any foreign object in your tissue. It doesn’t know if the foreign object is good or bad, so it walls it off from your body. It is protective to your body and to the implant. When a capsule is good, you cannot feel it.
- Capsular contracture – When the capsule thickens, tightens, or calcifies. When you have a ‘hard implant” the implant is never hard. It is always the capsule.
- Capsulectomy – This is when we remove the capsule around the implant. It is usually done for one of two reasons:
- Capsular contracture. We assume the capsule is infected with biofilm, thickened, calcified, and/or firm.
- You are permanently removing the implant. You need to make the tissue sticky again, so the space where the implant was can seal off.
- En bloc removal – This is when you remove the capsule and the implant in one piece, with the implant still within the balloon of capsule.
Imagine your capsule is like a balloon of scar around the implant. Many times, particularly when I see really old implants, the actual breast implant shell may not be intact, but your capsule (the scar your body made around the implant years ago) around the implant IS. In most implants, even leaking ones, the silicone is not flying around your body – it is caught by the capsule. This whole capsule thing can look like a round hard white ball of scar, with the implant inside. When I am dissecting this, I hug the side of the capsule, and gently dissect it free from the surrounding tissue. It is like a little round present. I do not see the implant at all. I like to keep the capsule intact, so I can see the extent of the capsule, and also if the implant has leaked, I want to keep the silicone from getting into the surrounding tissue.
- The most common reason I will not remove it fully en bloc doesn’t happen until the very end of my dissection. And it is simply I cannot fit the hard round large ball through the tiny incision I have made. Rather than making your visible scar which you will have for the rest of your life longer, I will open the capsule carefully with sterile towels nearby, remove the contents within the balloon of capsule onto the towel, clamp the capsule closed again, and then get it out through the incision.
- The second reason has to do with capsule variability. Sometimes the capsule is thin and adherent to the nearby tissue too tightly. To remove the capsule would involve risk. The most common example of this is in a subpectoral implant where the posterior capsule is thin and adherent to the underlying ribcage. The lung lies just below this. Another example would be when your skin is whisper thin, and to remove capsule would cause the overlying skin to die. Again, as with my example above, I dissect as much as I can with it en bloc, empty the contents within the balloon of capsule, and then finish my dissection of the capsule.
- If I am doing a capsulectomy and cannot remove the entire capsule, I will cauterize any capsule left in the body. I do this for a multitude of reasons, including to make it “rough” so the area can re-heal, and to “sterilize” it (see all my blogs on biofilm). I cannot repeat enough, my goal is always to remove the entire capsule if it is safe.
So, to remove en bloc or not en bloc? En bloc is almost always the goal, with the exceptions as outlined above.