Does a surgeon need to "believe" in breast implant illness to offer a patient an explant procedure? Does "believing" in BII make a surgeon better?
Let me be super clear about something right at the start: I think it is ideal if your surgeon understands, and maybe even agrees with your motivations for surgery, no matter the procedure. When it comes to BII, we don't have all the answers. I think that there seem to be some pretty substantial health issues associated with breast implants, and that is why I choose to do the procedures I do. That should be pretty obvious.
But loud professions of "believing" in BII are something else, something we are seeing with increasing frequency. It's an interesting phenomenon in a way, not least in what it says about the attitudes surgeons have towards explant surgery when compared to any other form of aesthetic procedure.
Does a surgeon's belief in BII have any role in whether or not that surgeon should be performing explant surgery? Or is it just virtue signalling?
This came up recently when I was writing a journal article, and it has come up more often in discussion with my patients. You see it commonly on social media from those chasing the explant market, but you also sometimes see it in slightly jarring contexts. For example, I saw an instagram post the other day from a very large volume breast augmentation surgeon, saying proudly "We believe in BII!" like some sort of badge of honor. So, these claims of "belief" seem to be made by those who seek moral superiority, whether they be explant surgeons or those who are aggressively pursuing the cosmetic breast augmentation market.
Don't worry, they say, we care. See! We believe in BII.
Anyway, here is what I wrote in that recent journal article:
Capsulectomy at the time of breast implant removal remains a contentious topic. A recent global poll suggests that nearly 1 in 4 surgeons disagree with the idea of performing capsulectomy at the time of explant...In arguments opposed to capsulectomy there may be conflation between the evidence for “breast implant illness” (BII), and the validity of total capsulectomy. There is developing evidence that symptomatic improvement for patients with self-diagnosed BII may be independent of whether capsulectomy is performed. In keeping with these findings, it is our opinion that capsulectomy should not be presented as a “cure” for BII. However, irrespective of the surgeon’s position on BII, we consider capsulectomy a necessary step... which results in better aesthetic outcomes.
The idea that surgeons are "opposed" to a particular operation on some sort of moral/ethical level is not necessarily new but the vehemence of that feeling certainly seems different when we consider surgeons' attitudes towards explant surgery.
The introduction of a moral dimension, as with so many other points of contention in our public discourse, is both unnecessary and unhelpful. The question of whether a woman can choose to have an explant procedure has no moral dimension beyond the questions of competence of both patient and surgeon.
The question of whether a woman can choose to have an explant procedure has no moral dimension beyond the questions of competence of both patient and surgeon.
Here is the really important bit: BII and explant procedures, as I have said before, must be separated from each other. Breast implant illness might be managed for a proportion of women by having explant surgery. But that cannot ever be the only rationale for doing the surgery - to suggest as much would be wildly disingenuous. No guarantee can ever be made about whether someone's BII symptoms will be resolved by having explant surgery. The data we have suggests that BII symptoms are likely to resolve after explant, but I remain firmly opposed to any attempt to link a surgeon's willingness to perform explant with their belief or otherwise in BII. Having said that, it seems to me that if a surgeon is opposed to the idea of BII, then they are unlikely to be pursuing excellence in explant procedures, and the work is unlikely to head their way.
Explant surgery is (or at least, in my opinion it SHOULD be) a procedure that properly (and safely) removes a breast implant and capsule and aesthetically rebuilds the breast. It is a procedure done for women who want their implants removed, regardless of their reasons for wanting to do so. In my opinion, the capsulectomy offers greater reliability in ensuring the best aesthetic outcomes. If we manage to resolve their concerns about BII by doing an explant, then that is great, but in some ways it is simply a happy side-effect.
So we have a bit of a dilemma. We have surgeons claiming that they believe in BII, but all they really want to do is appease the concerns of women having cosmetic breast augmentation. Then we have surgeons claiming they don't believe in BII, and therefore refusing to offer patients explant surgery, or capsulectomy. And of course we have those surgeons who are out there "believing" for all they are worth, explanting patients at every turn, possibly making some unwise claims about that, and getting rather awful aesthetic outcomes.
It seems to me that "believing" (or not) is totally unrelated to anything meaningful.
Rather than a surgeon saying that they don't do capsulectomy or explant surgery because they don't "believe" in breast implant illness, why don't they just say that they choose not to do those operations? I guess the challenge there is that for a surgeon to choose not to do a certain procedure, that involves some acknowledgement that either they can't do it well (which could be impossible, if you believe in the "Dunning-Kruger" effect), or don't know how to get a good result. And for some surgeons, that acknowledgement may be a step too far.
It is far easier to make an excuse like "not believing" in a condition or procedure, than it is for some surgeons to accept that maybe they don't have the skill set required to do it well.
As for surgeons who do perform explant procedures: well, it seems very clear to me that the surgeon's "belief" will not ever guarantee a good outcome.
Hence, the value of "belief" seems remarkably limited, no matter which way you look at it. That is why I prefer to focus on outcomes, aesthetics, function, and patient satisfaction. Those things far outweigh the value of any "belief" I can offer a patient.
I think we should look at explant procedures as aesthetic procedures like any other. Treated with respect, these procedures offer myriad benefits to our patients.
I have said before that I choose not to do a range of procedures because I think others do them better. A surgeon choosing what procedures they will, or will not offer should be deliberate, based on skill or expertise or interest. Whilst the desire to do a certain procedure may have a basis in whether a surgeon agrees with a patient's motivations for surgery, it should have nothing to do with moral judgements of those motivations.