I do a lot of implant removal surgery, called explants. When I do an explant, I am always removing the capsule, the scar tissue your body formed around the breast implant. Every person who had a breast augmentation – saline or gel, in front of the muscle or behind, done 20 years ago or last year- you ALL have capsules.
There has been fear mongering over capsules that has occurred on the internet, with some surgeons preying on this, discussing how en bloc capsulectomy needs to be done on everyone, whether you have a thick capsule or thin, whether you have breast implant illness symptoms or not. Our national society came out with a position paper on it (HERE). Studies have shown you do not need to do a total capsule removal even if you are symptomatic- the studies do not show more capsule removal helps symptoms more.
This study in the September 2024 issue of Aesthetic Surgery Journal is looking at “Complications of Aesthetic and Reconstructive Breast Implant Capsulectomy: An Analysis of 7486 Patients Using Nationwide Outcome Data.” They specifically are trying to do a scientific review of the data presented by plastic surgeons through the Tracking Database TOPS. They looked at all surgeries where total or partial capsulectomies were done. Simple implant exchange surgeries were used as a control.
Study:
- 10,703 breasts were operated on
- Total capsulectomy showed higher overall complication rates- more than partial capsulectomy and controls.
- Partial capsulectomy did not have increased risk relative to controls.
- There were higher rates of seroma (fluid collection) than control
- Reconstructive patients had higher risks of complications, seroma, wound dehiscence, surgical site infections, and implant loss
They conclude that surgeries on the breast capsule are safe overall, though complete capsulectomies and reconstructive patients are associated with significantly increased operative risks.
In their analysis, they found total capsulectomies required more OR time. The surgeries were performed in equivalent settings (hospital, outpatient centers). Rates of issues overall were low, BUT
Things of note to me:
- Total capsulectomies had significantly more complications than partial capsulectomy
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- DVT (zero in partial capsulectomy)
- Pneumothorax (dropped lung) (zero in partial capsulectomy group)
- Serious bleeding was seen in 3 patients (vs one in partial capsulectomy group) which required transfusion
- More unplanned ER visits after surgery
- More rates of seroma, wound breakdown, superficial surgical site infection, and deep surgical site infection– these were not statistically significant
- Hematoma rates were significantly worse in capsulectomy group.
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- Both total and partial capsulectomy surgeries had higher rates of seroma, etal than control.
They conclude their study supports that capsulectomy has higher rates of complications that partial capsulectomy.
What do I think?
I try to get out the whole capsule every time. BUT. There are parts of the capsule that are easy and not dangerous, and there are parts which are in tiger territory, particularly if you have a thin capsule. Time and time again our scientific literature shows total capsulectomy 1. does not need to be done to improve symptoms and outcome and 2. has a higher risk.
Do I do total capsulectomy? Yes. But I do it usually with thickened capsules, which are technically much easier to remove safely. I know that is hard to understand. In my office I have a slide show of capsules I share with my patients during consultation, so they can see what I see. I have found it super helpful for them to understand the nuances.