Do you need to remove the capsule when you remove a breast implant if you are trying to improve systemic symptoms? En bloc capsulectomy, total capsulectomy, partial capsulectomy, or implant removal without removing the capsule- what do you need to do? Breast implant illness is thought to be due to biofilm, a low grade inflammation and infection. Implant removal is known to help. But do you need to remove the capsule? And if so how aggressively?
This was in the Aesthetic Surgery Journal August 2024, “Symptom Improvement After Explanation With No Capsulectomy for Systemic Symptoms Associated with Breast Implants.” In English that means they removed the implant and did not remove ANY of the capsule.
Study:
- This was to look at symptomatic patients after implant removal.
- No capsulectomy was done. No new implants were placed.
- 5 study sites were used. Ages 25-64. They were evaluated at baseline, 3-6 weeks, 6 months, and 1 year.
- They looked at past medical history, allergies, menopausal status, 22 systemic symptoms, autoimmune history.
- Questionnaire looked at anxiety, fatigue, cognitive function, and sleep disturbance.
- Findings? Systemic symptom improvement without removal of capsule were seen. People reported 74% reduction in symptoms with no capsulectomy. This was not statistically different than partial or total capsulectomy.
In their discussion they talk about why we don’t remove the total capsule. They discuss that leaving the capsule makes the surgery less invasive, has less OR time, and has lower risks. Some think that capsules may reduce in size or dissolve with time.
But are there potential consequences to leaving behind capsule? People have discussed that they worry about pain, seroma, and interference with breast imaging. Patients with anxiety may be concerned with potential capsular malignancy or symptoms caused by retained capsule.
Social media has gone wild with these fears. They discuss a need for a “proper explant” and state en bloc capsulectomy is the only appropriate treatment. Some doctors have latched onto this and use it to market their practice.
They conclude, “STUDIES SHOW SYSTEMIC SYMPTOM IMPROVEMENT WAS INDEPENDENT OF WHETHER PART OR ALL OF THE CAPSULE WAS REMOVED.”
What do I think?
I think if you have an abnormal thickened or calcified capsule it is generally achievable to remove the total capsule, and that is my preference. I always try to remove the whole capsule if possible, when doing an explant. BUT. And the but for me is if the capsule is thin and densely adherent to the underlying ribcage, I may leave some behind to avoid complications like bleeding into your chest, deflating your lung, or chronic pain from removing the rib periosteum. Any capsule I leave behind I cauterize. A thin capsule is not an angry capsule. It is unlikely a source of symptoms. This study would support that.
Study after study shows BII (breast implant illness) and biofilm are improved without doing total en bloc capsulectomy. There are websites and doctors who breed fear in patients, despite studies showing you do not need en bloc. Such fear mongering has happened that our national society made a position paper on it. HERE
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