I treated a patient recently who had had an explant (after multiple sets of implants) about 5 years prior to seeing me. She is one of our international patients; in this case she was previously living in Australia at the time of her explant. So her initial consults with me were over video, with photo submissions.
This lady presented to me in a way that I am becoming familiar with: she had her explant, her surgeon told her that he had done a capsulectomy, he even claimed to have "repaired" the pec muscle (which is in itself is very unusual) when she followed up and was asking questions. The reason she was asking questions was because she neither looked, nor felt right.
Typically, dissatisfaction with explant outcomes relates to the shape of the breast, although patients often can't quite describe what it is they don't like. Frequently, these ladies will be requesting fat transfer to "fix" their concerns. Unfortunately, there is a lot more required, and it is important to understand what is going on and why these things happen.
I've talked before about "explant related harm" and that touches on some similar topics to what I am going to talk about here, but I wanted to explore this a little further, and outline the process of undoing the harm that can be caused by a poorly performed explant procedure.
What explant should be:
In many ways, explant should be an opportunity to offer a patient both aesthetic and functional improvement. Many ladies seeking explant either have sub-optimal aesthetic outcomes with their implants, or their aesthetic appearance has changed over time. In either case, explant is an opportunity to correct various aspects of breast position or shape.
Not all women approach explant though from a position of aesthetic dissatisfaction. I have seen quite a few ladies who remain very happy with their breast appearance, but are struggling with functional concerns. In these cases, explant should be an operation that does not result in aesthetic deterioration, whilst allowing the patient the opportunity for functional improvement.
Some ladies have neither functional nor aesthetic concerns, but have a known rupture or some other implant complication. These ladies might choose explant over implant revision because they have reached a point where they no longer wish to consider ongoing revision procedures over time. I caution these ladies, because the risk of dissatisfaction with their appearance after surgery is real and "explant regret" has to be considered.
I view explant as an opportunity. For most women, explant offers a chance to reset and restore the breast to an ideal natural shape and position. For those ladies who are satisfied with their augmented appearance but wish to explant, then explant should offer the chance to revert to an equally satisfactory un-augmented appearance, and often we can achieve an appearance that they are happier with than they were with their natural breast size/shape before implants.
I have said many times before that my greatest concern with explant surgery is that surgeons are not treating the procedure with the same degree of cosmetic respect as they would for a breast augmentation. That is only reinforced when I see ladies with poor explant outcomes, because I consider these outcomes entirely avoidable.
What explant shouldn't be:
Explant is not a quick operation. Explant should not be a lazy operation. Explant should definitely not be a spiteful operation.
The problem is that many surgeons view explant as just something as quick and simple as shoving an implant in. A breast augmentation is a 45 minute procedure (for which surgeons charge a hell of a lot of money given the time involved), and the financial metrics for those surgeons tells them that they should be doing explant in about the same time. A quick explant is a bad explant. A quick explant can't possibly involve a proper capsulectomy; a quick explant can't involve correcting the muscle or the breast tissue position; a quick explant doesn't fix the breast crease. A quick explant is very likely to result in poor outcome. Whether a patient is satisfied with their outcome from a quick explant is variable. Some people just seem willing to accept it, and fair enough.
But for those ladies who aren't satisfied, when they then ask their surgeon why they look the way they do, they are met with something like what I described above - the surgeon will claim to have done a bunch of stuff (which they didn't) as a way of saying: it isn't my fault, this is just what happens with explant, so suck it up.
How does "bad" explant surgery present?
Bad explants present with a few common issues.
Typically I will see some combination (if not all) of the following:
Underlying these issues (in my opinion) is lazy surgery. None of the problems above can happen as easily if a surgeon takes the time to do the explant properly. I won't say that some of those issues are totally avoidable however. Even with a well done explant, and depending on what was done during the augmentation surgery, total correction of things like crease level, scar position, and breast shape can be very (very!) difficult to get right. But it is always true that by doing the explant properly, the outcome will be better than if the explant is done lazily.
So now that I have put the blame for shitty outcomes on the way the surgery is done, let's talk about the 4 fundamental concepts of explant surgery, and how that is applied for a patient who needs their bad explant outcomes fixed.
The 4 fundamental concepts of explant surgery
The basic elements of any well done explant (in my opinion) are: 1) total capsulectomy, 2) muscle repair (where needed), 3) appropriate repositioning of the breast tissue (regardless of whether we need to do a lift), and 4) fixation of the breast crease.
So when we see bad outcomes after explant, these 4 elements have either been done poorly or (more commonly) not at all. Therefore, the steps required to fix the situation involve going back and addressing each of these in turn.
Consider the list of problems above. A low scar (in point 1) relates to a lack of fixation of the breast crease, as well as a lack of correct positioning of the breast tissue into the lower pole. This further relates to the tendency of an unrepaired pec major muscle to pull the breast tissue up and away from the breast crease, resulting in the concavity of the lower pole that we may see in point 3. The lack of definition (point 2) of the breast boundaries is due to a failure to put the breast back where it started. The shift of breast tissue under the influence of an implant is up and out. Therefore, once the implant is removed, the breast tissue needs to be brought down and in. Again, this partly relates to muscle repair, but partly it relates to how the breast tissue itself is repositioned. The final point of animation is a big problem for active women, and honestly, any woman who doesn't want to feel as though their breast is distorted after explant.
You can see that in this list of problems, there is a fundamental role played by the Pec major muscle, its repair, and the associated repositioning of the breast tissue. So in many respects, when I see a botched explant, most of my focus is on the muscle.
Given that I have been banging on about the muscle here, what about when ladies who have implants on top of the muscle? Good question. For what it's worth, I haven't seen ladies with terribly botched explants who originally had implants on top of the muscle. How interesting, yes? There are a bunch of other things that need doing for ladies with prepectoral implants, and the breast tissue still has to be carefully repositioned, but there seems to be a far less significant risk of very poor outcomes when the muscle is not in play. Oh, and also, looking at my own data, it is far more common that a prepectoral explant will also involve a mastopexy, which ensures that we can properly reposition the breast tissue. I plan to write more about that in the near future.
The operation that needs doing
So, this brings us back to the operation that should have been done but wasn't, and therefore the operation that I end up doing for these ladies (albeit in more difficult circumstances).
Firstly, we define our goals. Normally that will entail correcting the crease level, situating the scar correctly, preventing ongoing animation, and then often adding some volume back into the breast.
So we go back in there, we deal with the scar capsule that was often left behind (a "completion" capsulectomy), we fix the muscle, we use an "internal bra" construct to set the crease, we reposition the breast tissue quite aggressively, and we add fat transfer in most cases.
When we do the operation that should have been done, we can correct most of the problems I see after poorly performed explant surgery. It isn't easy, and it just seems a pity that a patient would have to go through two operations, when it could all have simply been done in one.
I don't want to tar all surgeons with the same brush here. I am sure there are surgeons out there getting excellent results after explant surgery. But the challenge for patients is finding those surgeons, and understanding what needs to be done in order to avoid problematic results.
I see a lot of women who have consulted with other surgeons first. Increasingly these days they are asking more probing questions about capsulectomy, and about muscle repair, and still they are being told that capsulectomy is dangerous, and that muscle repair isn't possible. Fortunately, there seems to be enough information available to ladies that they are appropriately doubtful of that advice.
Collectively, I think plastic surgeons should be trying a lot harder to do explant surgery better.
Time will tell.
As always, if there are questions about any of this, please get in touch.