This is a question I grapple with every day when I talk to patients. How do we accurately and reasonably set expectations so that people know what they are in for with explant procedures?
I have spoken (a lot) in the past about things like body image, and how explant procedures can screw around with that. And I have tried to build a picture of how we approach explant procedures so that patients understand our rationale for the techniques we use and what that means for their outcome. I've also discussed my concerns that plastic surgery (as a profession) seems to ignore the aesthetic outcomes of explant surgery in many regards, and why I find that troubling.
But that all comes across as a bit high-level and theoretical, when most people are just looking for an answer to "what will I look like?"
So, lets approach this from a couple of angles.
Firstly, we need to consider what procedure we're doing. Secondly, we need to think about what our "baseline" was (before implants). Thirdly, we need to consider what the implant has done to the breast. And finally, we need to consider what else has happened (to the body, and to the breast) between having breast implants and now.
What procedure?
What I mean is, are we doing an explant, an explant with fat transfer, an explant + mastopexy, or taking the maximalist approach and doing everything at once?
Obviously this is fundamental - if we are just doing explant, then logically we can consider our outcomes on the basis of what the breast looked like before implants, because the assumption is that if you don't need a mastopexy at the time of explant, then the breast must not have changed too much since the implants were put in. The conclusion then is that explant, if done well, may be able to restore the breast to something close to its original state (with a few caveats).
If however we are looking at an explant in conjunction with anything else, then we are going to be creating a new breast which may not have much relation to what a patient looked like pre-implants.
What is the baseline?
The "baseline" refers to how the breasts looked before implants. The relevance of this depends on a couple of things:
For many patients these days, they have an abundance of photos of themselves to refer to which can help to build a picture of what that baseline might be. For older patients and patients with implants from before around 2010, obviously it is much less common that we have these images.
Without images depicting a baseline, we are working with a patient's memory of what they used to look like, and we know from experience just how quickly our memory of past appearances and body image can change after surgery. In other words, a patient's baseline is only a useful reference point if we have standardised "before" images.
What changes have the implants caused?
Breast implants fundamentally change the breast over time.
The breast tissue is compressed and thinned, the breast stretches in response to the size and weight of the implant, the effect of capsular contracture can distort the overlying breast, and this all interacts with whatever was done in the original surgery. Oh, and gravity always wins.
The main thing we have to consider is the degree to which the breast has been thinned and stretched, because this will have a bearing on the need for, and outcome of a mastopexy.
Perhaps more common is the situation where a patient doesn't "need" a mastopexy, but there has been some stretching of the lower pole of the breast by the weight of the implant. In this case, we may choose to remove the implant and shorten the lower pole without a full mastopexy. This can be useful, and we can use internal sutures to re-establish the lateral boundary of the breast, but this technique can't actually narrow the breast the way a full mastopexy can.
So this will address the stretched lower pole, but obviously we are artificially creating a breast shape in the process which may not reflect the baseline.
What else has happened to the breast over time?
Both the divergence from the "baseline" and the changes the implant has wrought on the breast are dependent on time. Gravity does indeed always win, and its effect is magnified with the age of both the patient and the implant.
But of course, the breast itself changes with time as well. Not only do we need to contend with the effect of ageing on the breast, but we have to consider what other changes have taken place that may have altered the breast, and its relationship with a breast implant.
The most obvious example to use here is pregnancy and breastfeeding. For women who've had children after their breast implants, the breast characteristically "falls over the front" of the implant (when placed in a dual-plane pocket) as a consequence of breast enlargement and stretching - this is what we commonly refer to as a "waterfall" deformity. What this represents is a dissociation between the breast tissue and the breast implant. This is the number 1 reason that I recommend a mastopexy at the time of explant surgery.
One of the main aesthetic concepts behind using breast implants to enlarge the breast is the idea of the breast and the breast implant working together harmoniously for a desired effect. In other words, the breast should sit right on top of the implant, and the implant should sit right behind the breast.
Consider this from the perspective of both implant and/or breast malposition relative to the other. If the implant sits too low, then the nipple points upwards and the breast crease may be inappropriately lowered. If the implant sits too high, the breast looks odd, sometimes with a tight appearing lower pole and the nipple may point downwards. Similarly, if the breast falls over the front of the implant, the result is an odd upper pole fullness created by the implant with the natural breast tissue appearing to "hang" off the underside of the implant. Frequently, a co-existing breast malposition is magnified by an implant malposition, and vice versa. So the breast that appears to fall off the front of the implant is made worse by the capsular contracture and superior malposition of the implant.
So it is the development of an inappropriate relationship between the breast and the implant which will often guide us to the requirement for mastopexy to be performed at the time of explant surgery.
What can't we account for?
The one big thing to factor in, that we can't always account for, is scars. This is especially true for mastopexy procedures.
I often say to patients (who need a mastopexy) that the scars are necessary because they allow us to reset the breast shape and establish control.
The problem is that whilst scars are good the vast majority of the time, they can be unpredictable and (as our consent forms emphasise) patients don't always scar the same way. It is that unpredictable component that creates challenges for some patients, and we do our best to demonstrate the variation in scars to emphasise that this is an imperfect component of the surgery.
Where does that leave us?
Short answer: if you are lucky, have a modest breast implant that hasn't distorted the natural breast, and have a breast that hasn't substantially changed over time, then the appearance of the breast after implant removal may reflect your baseline.
For most women, this just isn't the case. We may "just be removing your implants", but when you factor in having to shorten the lower pole, or perform a full mastopexy, or if they choose to add fat transfer, then we are going to end up with a new breast, which may only have a rather tenuous relationship to that baseline.
This is why before & after photos are so important for most ladies to see. We need sufficient variety in our photos to offer our patients some chance of seeing a body/breast/implant like theirs, so they can understand what surgery may do for them. At the very least, we can offer our patients some idea of what to expect, even if just from the perspective of scars.
Explant surgery outcomes remain tricky to accurately describe for some women, and setting their expectations isn't easy. Which may account for why we spend so long with our patients ensuring that they understand the limits of what is possible.