I have a bit of a problem with the commentary and discussion within the plastic surgery community regarding the management of explant procedures, and particularly capsulectomy.
Strap in folks, this is a long one. This is a topic that I have wrestled with for quite some time now. I have touched on capsulectomy in the past, but I hope you’ll bear with me here - there are a bunch of issues that I think warrant deeper consideration.
I will stress at the outset that I am generalising in some regards in this piece. I will use the collective term “Plastic Surgeons” quite a bit, simply because it will make it a little easier to discuss the actual problems here. It is not to say that ALL plastic surgeons are at fault. There are plenty of capable, honest and ethical plastic surgeons out there who should not be tarred by the broad brush strokes of this article.
Anyway, on with the show.
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I often find myself wondering if Plastic Surgery as a profession is capable of managing the issue of breast implant removal in a mature way.
There is a worrying hostility in the language that is used when plastic surgeons discuss, write about and even when they offer breast implant removal to patients. There are multiple aspects to this, and I think they are worth exploring to understand why it is the case.
First and foremost, let me say that if Plastic Surgeons want to claim the mantle of being experts in cosmetic/aesthetic surgery, then at all times there must be a focus on excellence and a pursuit of perfection in our outcomes. Equally, if we want to maintain our position as experts in restorative and reconstructive work, then at all times there must be a rigorous approach to the restoration of natural form and function.
In the absence of the above, the I would argue that Plastic Surgery will cease to exist as a distinct and worthy specialty field. I have made my opinions on the necessity for specialisation and sub-specialisation very clear previously and I do not resile from those opinions.
So, lets break the issue of 'explant' down to consider why plastic surgeons behave the way they do, and consequently why patients struggle to access what could be considered “excellence” in explant procedures.
Conflict of interest or admission of guilt?
One of the issues that I see is the inevitable conflict between the well-established focus on breast augmentation as a plastic surgery business model, and the acceptance that breast implants are causing problems for many patients.
Plastic surgeons have been performing breast augmentation for well over 40 years in this country with relative impunity. We have one of the highest per-capita rates of breast augmentation in the world. Australia never went through a “silicone moratorium” as happened in the USA in the '90s. We have a body-centric culture that is long standing (and not necessarily a bad thing in and of itself) which has had a strong focus on beach lifestyles in many parts of the country. I guess it makes perfect sense that breast enlargement has reached wide acceptance in our community.
Generations of Plastic Surgeons in this country have become wealthy off the back of breast augmentation as a procedure and as a business model. We have seen the good and the bad as a consequence. The 'good' being that the profession has pursued excellence in breast augmentation surgery over a much longer period than the USA, and it could be argued that this has resulted in higher quality outcomes for patients in Australia. We have been ahead of the curve in pursuing breast implant registries, and certainly when it comes to research into breast implant-associated issues including ALCL, Australian surgeons can stand proud.
The 'bad' however includes the fact that an unregulated industry in untrained doctors performing cosmetic surgery (including breast augmentation in huge numbers) has been spawned (admittedly this is not a uniquely Australian problem). We see surgeons whose main consideration is their income, in some cases at the expense of outcomes or ethics. We have witnessed the rise of the “influencer-surgeon” which has in large part risen off the back of the breast augmentation boom of the last 15-20 years.
The 'bad' also undeniably includes the sclerotic response of Plastic Surgery as a profession to the fact that breast implants are causing an increasing number of women harm in some form or another. And this issue is more than just a case of a bunch of surgeons protecting their incomes. This seems to me to be something more. It strikes me as a profound resistance to an idea based on the fact that if plastic and cosmetic surgeons accept that breast implants could be causing a problem, then this would amount to an admission of guilt for a procedure that has been done in enormous numbers over a long period of time, and perhaps this would open the flood gates, drowning the profession in recriminations based on past practice.
Whilst I choose not to perform primary breast augmentation with implants in my own private practice, it is fundamentally important that Plastic Surgeons are able to facilitate safe breast augmentation whilst also accepting that breast implants can be problematic (if not downright dangerous).
Breast implant removal should be treated with the same diligence, care and thought as has been applied to breast augmentation over a long period of time.
Is it just too hard?
Over the last 20 years in particular, there has been an abundance of literature on the assessment, planning and execution of breast augmentation surgery. There have been countless “systems” with catchy acronyms or cute names devised to ensure predictable and safe results. Whilst many of the described techniques are complete rubbish (honestly, you should read some of the trash in our journals!), there are just as many thoughtful and well described concepts which have vastly improved patient outcomes.
The same is true for augmentation-mastopexy. Classically, an augmentation with a lift has been described as one of the most challenging procedures in plastic surgery. Many surgeons will still perform the two procedures separately due to concerns about the reliability of outcomes. But again, many excellent surgeons have thought their way through this difficult problem to ensure that they can achieve excellent outcomes.
So what about explant surgery? What about combining breast implant removal with a lift, or with fat transfer? How many papers have been written on these topics? How many surgeons have applied their considerable skill and intellect to creating systems to optimise outcomes for patients who choose to have their implants removed?
Pretty simple answer: almost none. And of the few papers written, none include both total capsulectomy and management of the Pec major muscle in their approach.
Compared to the litany of described techniques for shoving an implant in, it’s a bit of a tumbleweeds situation when looking for described techniques for assessment, planning and execution of explant procedures, despite them being typically far more complex than implant insertion procedures.
Surely this begs the question, why?
And the only conclusion to that question is: because there has been insufficient incentive to do so.
It is fair to say that there is an increasing amount of scientific literature considering the problem of explant surgery, but unfortunately much of it comes from an angle of trying to “debunk” the idea of breast implant illness, and “dismiss” the concerns that many patients have. I have written a bit about that in the past too if you want to get into it.
So let’s have a look at what IS being published.
Let’s look at the language
If we look at the literature currently on the topic of explant, and particularly if we focus our search on the term "capsulectomy", the vast majority of this literature can be (cynically) read as an attempt to demonise capsulectomy to an extent. It is also true that (like with most things) there is a polarisation of this issue, with a proliferation of a subset of surgeons trying to cash in on the rise in capsulectomy procedures being sought. You can normally recognise these surgeons by social media feeds full of images of explanted capsules and implants, but nary an actual outcome to be seen. These surgeons dangerously glorify the idea of "en-bloc" capsulectomy, and often post images and videos which actually demonstrate appalling surgical technique - we see overly aggressive dissection, the removal of totally healthy tissue, and concocted claims of benefit to their patients. If you are scrolling through instagram and see a feed that is nothing but images of capsules, be concerned. So we definitely have an issue at both ends of the spectrum.
Let's focus though on the language being used in mainstream literature, which is overwhelmingly ambivalent if not negative about the concept of capsulectomy. Even a brief perusal of the literature demonstrates that there is a sense of belligerence in the language being used.
Here are a few actual quotes from recent scientific papers in our major journals, all of which don't hold up to even a cursory fact-checking process:
“In patients with subpectoral implants, a complete capsulectomy is associated with an increased risk of chest wall injury and pneumothorax (collapsed lung)” (Tanna et al. PRS April 2021) So, this is a claim repeated over and over and over but there has never actually been a study performed which a) defines chest wall injury or more importantly, b) defines the risk of pneumothorax. In fact, there is no data anywhere (Adi-Rafeh et al. PRS July 2021) to support pneumothorax as being a substantial risk. Sure, it has been reported, but it has also been reported after breast augmentation. Hell, pneumothorax has been reported after liposuction. Don’t hear anyone using that as an excuse not to do those procedures do we? Besides, as I tell most of my patients, if a surgeon has managed to get through 3 layers of muscle between two ribs and find their way into the chest cavity without realising that they are in the wrong place, well, be a little scared. It isn’t to say that a pneumothorax can’t happen, but in a typical patient having implant removal with a capable surgeon, the risk should be vanishingly small.
“...the capsule generally does not need to be removed for a rupture” (Tanna et al. PRS April 2021). Err, ok. Given than any residual bit of silicone goo (in the case of a rupture) will probably stimulate further/ongoing foreign body responses with scar/neo-capsule formation, surely the motivation must be to ensure complete removal in the setting of rupture? I wonder how many of these surgeons simply close up a residual capsule containing a whole lot of silicone material? I wonder how they think that is going to result in a decreased scar burden or a better outcome? I wonder whether anyone has followed these patients up to really look at what is going on? It would certainly be enlightening to run a handful of women who have ruptured implants removed without capsulectomy through an MRI scanner to see what the consequences are.
“...total capsulectomy can be challenging and can have a significant impact on...ultimate aesthetic outcome” (Calobrace, Clin Plast Surg 48, 2021). This kind of intrigues me. Sure, capsulectomy can be challenging, but so can a lot of other plastic surgery procedures. More importantly, the claim that it compromises aesthetic outcome I absolutely refute. The capsulectomy should have no negative bearing on the cosmetic outcome. In fact, I would suggest that the opposite is true: by performing a careful and complete capsulectomy, I think I am able to achieve BETTER aesthetic outcomes as it creates more predictable conditions for healing, especially when it comes to managing the muscle (which is a fundamental predictor of aesthetic outcome, unlike the capsule!). I can (and do) show some of my revision patients images of other women who have had explant procedures without capsulectomy, to demonstrate the really awful outcomes that can follow if the surgeon just pulls out an implant without doing anything more.
“Patients who undergo explantation …often experience disappointment and sometimes even feel mutilated …. This is in contrast to implant exchange in which only 14% of patients reported feeling disappointed, and none felt mutilated” (Manahan, PRS May 2021) This one is key. It is the fundamental basis for the profound resistance expressed by many plastic surgeons for the idea of breast implant removal, let alone capsulectomy, and it is a totally false comparison. For 99% of the women I see for implant removal, implant replacement simply isn’t an option that they are prepared to accept. It just isn’t. Yes, it is undoubtedly true that for some women with tiny amounts of natural tissue, proportionately large implants, and sparse natural fat stores, achieving aesthetically satisfactory results is extremely hard. But that is just a good argument for finding a good surgeon. Surgeons must be honest and transparent when setting expectations for our patients. And surgeons must rigorously document and scrutinise their own results so that they can set patients’ expectations correctly.
Surgeons must rigorously document and scrutinise their own results so that they can set patients’ expectations correctly.
“For those patients who require post-explantation...fat grafting...this is accomplished best when the capsule still is present” (Calobrace, Clin Plast Surg 48, 2021). This is another statement that is made repeatedly in the literature with no basis in fact. First the author makes some claim about the capsule magically improving the blood supply to the breast (it doesn't), and then you read this! The capsule offers precisely NOTHING when fat grafting the breast after explant. A capsule can’t hold fat (I’ve seen the consequences of surgeons injecting fat into the old implant capsule after NOT doing a capsulectomy, and it isn’t pretty let me tell you), it can’t allow more fat to be added, and it doesn’t enhance the fat graft survival.
The obsession with the term “en-bloc”
The other aspect of these academic papers which is particularly striking, is the singular focus on criticising patients for requesting what is commonly referred to as “en-bloc” capsulectomy.
This is worth breaking down a little. It reveals much about the antagonism that surgeons feels toward explant procedures.
The request for an “en-bloc” capsulectomy has become increasingly popular. What this request encapsulates, and what the term actually means in a technical surgical sense though are two distinct things. Patients requesting en-bloc capsulectomy are using the term incorrectly, but any surgeon knows that what the patient means when they say “en-bloc” is actually what surgeons refer to as a "complete-intact" capsulectomy.
Now, the difference between the two terms is important and we’ll get to that. But the way that surgeons choose to respond to the use of the term en-bloc reveals far more about the surgeon than it does about the patient.
So, let’s start with some definitions.
En-bloc: a surgical term referring to the removal of (typically) a tumour with a cuff of surrounding healthy tissue. When used in the context of breast implants, the additional removal of a cuff of healthy breast tissue is only ever appropriate (and not always then) in the context of BIA-ALCL. This involves deliberately removing healthy breast tissue and muscle (which is obviously destructive), which any numpty can appreciate is not the goal in explant procedures.
Complete-intact (aka total-intact) capsulectomy: a surgical term referring to the removal of the breast implant contained within the totally intact capsule. This is what patients are asking for when they use the term en-bloc. The capsule is removed cleanly and precisely whilst avoiding the removal of any otherwise healthy, normal tissue. This is a key concept as the removal of healthy tissue should be the antithesis of precise total capsulectomy. The important idea here is that there is a distinct and clear plane of dissection around the implant capsule. This allows for precise capsule removal without causing damage to the breast, to blood vessels, to nerves or muscle. The tricky part is certainly taking the capsule off the ribs, but with patience it is possible.
Complete-intact capsulectomy is a form of total capsulectomy. Total capsulectomy can also be performed after the capsule is opened and the implant removed. A total capsulectomy may then be performed with removal of the capsule as a single intact piece of tissue, or the capsular tissue may be removed piecemeal, sometimes referred to as a “strip capsulectomy”.
Finally, partial capsulectomy implies the deliberate non-removal of portions of the implant capsule. This very commonly involves a failure to remove the capsule from the posterior surface of the pectoralis major muscle,and/or the capsule on the chest wall/ribs.
Ok, so now that we have some definitions, let’s look at the spurious arguments that it seems a lot of surgeons have decided to mount against “en-bloc” capsulectomy.
The first thing to say is that we (by which I mean plastic surgeons) are perfectly capable of understanding that when our patients ask about “en-bloc” capsulectomy, they don’t want some sort of cancer resection. Plastic surgeons understand all to well that “en-bloc” is a term innocently misused by patients trying to navigate their way through a challenging problem, and they are asking for something that should be well within the limits of what a surgeon performing explant procedures can offer.
The aggressive denouncement of “en-bloc” capsulectomy is a classic ‘straw man argument’. Rather than engaging with patients, perhaps offering some education regarding terminology, and trying to collaboratively work through what a patient wants and what is achievable, surgeons are choosing to throw up the use of the term “en-bloc” and then attack that misused term. As with any other example of a straw-man argument, this is a tactic designed to avoid engaging with an issue head on.
So sure, “en-bloc” is the incorrect term, but it is simply reflective of patients using the best words they have available to them to ask for what they want.
The fact that patients have picked up the term "en-bloc" from social media is not a reason to treat them with disdain. Let's help our patients to understand the words they are using. Let's be clear that a total precise capsulectomy should minimise trauma to the surrounding tissues. Let’s be clear that if a patient prefers a complete-intact capsulectomy that this may require a longer incision. Let’s put all of that on the table, and then let’s talk about a way forward. Let’s not attack the straw man whilst ignoring the real discussion to be had.
Why does any surgeon think it is acceptable to aim for anything less than the best possible outcome?
I guess the final point that I want to make is this:
Plastic surgeons claim to pursue aesthetic and functional excellence in every operation they do. As a specialty, Plastic Surgery aims to devise means of reconstructing, enhancing or restoring the human body in such a way as to leave the least evidence of surgery having taken place. We want our outcomes to look good and feel good!
If these are the core tenets of plastic surgery, then why don't we see the same pursuit of excellence when performing explant procedures?
The literature (what many surgeons like to call “evidence”) and my experience as both an explant surgeon and as a revision surgeon would suggest that plastic surgeons are guilty of viewing explant procedures as something less worthy than other plastic surgery procedures. Something not worthy of their time, their effort, or their intellect. Something where average or even sub-optimal results are not only to be expected, but are to be accepted.
I don’t find that acceptable. Patients don’t find that acceptable.
Plastic surgeons are the right people to be doing this surgery, but unless the speciality at large chooses to engage in a totally different way with patients seeking explant, then I fear there will be an increasing number of angry, disillusioned patients. Indeed, the specialty will be entirely responsible for the fact that “Patients who undergo explantation …often experience disappointment and sometimes even feel mutilated”.
Which is a bit shit really.