Total Capsulectomy
Advised for smooth saline or as an alternative to cases that cannot be done en bloc.
En Bloc
advised for all silicone breast implants (smooth and textured) and textured saline breast implants.
Capsulectomy
only partial scar tissue removal.
Importance of Full Capsule (Scar Tissue) Removal:
What is explanting?
Almost all breast implants used in the United States have a 10-year warranty. While some implants can last for decades, many implants need to be changed in a much shorter period of time. Implants are not expected to last forever. According to data gathered by the implant manufacturers, about half of breast implants need to be changed within seven years. The most common reasons for implant problems include capsular contracture, rupture, infection, and breast implant illness symptoms.
Removal of breast implants and the capsules that grow around them is an essential step to healing and recovery. The body starts working to build capsules (scar tissue) immediately after implantation and continues to build capsules over the years. Capsules are the immune response to a foreign object and all breast implants develop them. In all cases they should be fully removed upon explant because they can cause several problems when left inside – can harbor microorganisms and biofilm, they can continue to grow and spread, they can calcify (causing pain and inflammation), can cause radiology interference, can stimulate autoimmune responses and ultimately further symptoms. Proper and timely explant is key. Choose a plastic surgeon who is experienced in full capsule removal and is committed to removing 100% of the capsule tissue.
Capsules do not dissolve. There have been many instances in the breast implant illness groups and in scientific literature where the capsules are not fully removed and women require a second surgery. Issues that may develop with capsules left behind are:
- TOXINS – Capsules surround the implants and hold some of the contaminate particulates that are released. In the area between the inside of the capsule and the surface of the implants there can be biofilm (bacteria), gel bleed (silicone, heavy metals, chemicals), textured shell fragments, inflammatory cells, mold, etc. These are contained and may be absorbed by the capsule, which over time may also result in capsule calcification.
- CAPSULES PERSIST – Capsules can persist and spread after removal of only the breast implants. If you are symptomatic it is critical that you have full removal of the capsules. There was a woman in the community whose capsules were left in and continued to spread upward towards her neck and into the sides of her armpit. She developed a heart condition from this excessive growth and proceeded with a second surgery. Upon full capsule removal her symptoms begin to improve and her heart condition resolved. There have been other cases of women who continued to be symptomatic and required second surgeries to fully remove the leftover capsules.
- FOREIGN BODY REACTION – Thick capsules can behave like foreign bodies and continue to provoke a foreign body reaction and possible autoimmune response. They can also calcify and harden, causing pain and inflammation. The body will continue to be symptomatic until full removal.
terminolgy importance
explanting terminology
*EN BLOC – is the gold standard for explant. It is a French word meaning “as a whole,” referring to the removal of the implant and the capsule altogether, intact as one unit. It comes out similar to a sac where the capsule encloses the implant.
This was first developed in France to protect from the spillage of the earlier versions of the implants, where the silicone was more fluid and would heavily bleed out of the implants. Dr. Urzola has a YouTube video illustrating the importance of en bloc removal.
It takes more time and experience to do an en bloc explant. The surgery should not be scheduled for less than two hours. This is a meticulous procedure that takes a lot of surgical skill and experience to be able to do, especially for cases of thin capsules, ruptures, and under the muscle implant placements where capsules are partially attached to the ribs and lungs. Expert explant surgeon, Dr. Jae Chun’s instagram showcases many complex cases (thin capsules, ruptured implants) and how they can be removed en bloc. Dr. Urzola has a video showing how it is possible to meticulously cauterize thin capsules adhered to the ribs and perform an en bloc. Ultimately, an experienced surgeon will know how to cauterize any bleeding and how to achieve the best outcome.
*TOTAL CAPSULECTOMY – all scar tissue is removed. This includes the scar tissue lining around the implant along the ribs and lungs. Usually with this procedure the surgeon will remove the implants and then go back in and remove any or all left over capsule tissue.
CAPSULECTOMY – generally refers to only partial scar tissue removal.
(Capsulotomy – This procedure is more in regard to releasing capsular contracture than to explanting, it is explained here and should not be confused with caspulectomy.)
Enbloc is advised for all silicone and textured implants. If en bloc is not possible, then total capsulectomy should always be done as an alternative. Silicone implants could be ruptured or have gel bleed, therefore removing en bloc is the best outcome to avoid spillage and contamination of silicone across the chest. Textured implants are very problematic. They were created for the dual purpose of stabilizing the implant in the breast pocket and to reduce capsular contracture (Efanov et al, 2017). Instead, they are the most confirmed with causing BIA-ALCL, a cancer of the immune system that in most cases develops in the capsules and fluid near the implant. En bloc removal of textured implants is the best outcome to keep the toxins and cancerous cells secured in the capsule as a sac until they are explanted out of the body, as a whole. According to the FDA, BIA-ALCL may develop in 1 in between 3,817 to 30,000 women with textured breast implants. If you have textured implants, please insist for your surgeon to request pathology to do the CD30 test for BIA-ALCL.
Total Capsulectomy is advised for smooth saline. It is also highly recommended for silicone and textured saline implants if en bloc can not be done. Full capsule removal correlates with recovery.
Capsulectomy requires less surgical skill and time, it is the preferred option by the many plastic surgeons who are not experienced in en bloc or total capsulectomy (proper explant). They will argue against those two procedures and will push for only partial removal. The surgeons may say the capsule is thin and unnecessary to remove. Primarily they will insist that an implant can be removed and the capsule can partially stay in. Reasons given are that the capsule is partially attached to the rib cage and lungs – they can’t scrape it all off and don’t want to puncture the lungs. There are techniques, such as cauterization, the explant surgeons who do en bloc and total capsulectomy know how to do to stop any bleeding and they will have the experience to understand how to do those explants. It is preferable not to leave any capsule in, especially if you are symptomatic.