This is a bit of a long read - go and make a cup of coffee or something then come on back and dive in.
I've been meaning to write something about this for a while. Every day, when I am doing an explant procedure, I find something different to the day before. Some days are easy, some days are hard; often the thing that makes all the difference is the way the previous surgeon (or non-surgeon, depending on the case) shoved the breast implant in, and in particular their surgical technique (or lack thereof).
The interesting thing here is that I am not even referring to ideas like under vs. over the muscle, or the type of implant being used. I'm talking about the way the surgeon opens things up, makes space for the implant, or tries to force certain changes in the breast.
So, let's have a look at how some breast augmentations can allow an easier explant procedure, and some make me want to throw my instruments on the floor and walk out of the operating room.
This is probably the one that makes me curse more than any other. If the capsulectomy is especially challenging (and there are a few reasons it can be), I offer the folks in the operating theatre a taste of my potty mouth.
Whilst capsulectomy can be very challenging due to things unrelated to the surgeon - very inflamed, fragile capsules are a particular pain in the ass - the role of the surgeon is front and centre here.
For ladies whose implants are under the muscle: the capsule is stuck to the back of the muscle and to the front of the ribs (and the muscles in the spaces between the ribs). The previous surgeon's actions can make the capsule much harder to remove from the ribs in particular.
When the breast augmentation is being done, once the surgeon has made the skin incision, the first steps in a dual-plane/under-the-muscle breast augmentation is to go down to the muscle, release the muscle from the rib (typically the 5th or 6th rib) and then lift up the muscle with a retractor and create a pocket under the Pec major. There is a very important layer of loose, spongy tissue (referred to as loose areolar tissue) between the muscle and the rib which, if preserved, makes the capsule much easier to peel off the rib at the time of explant. There is also a natural soft tissue covering over the rib (periosteum and perichondrium, depending which part of the rib we are talking about) which must equally be protected and preserved.
Most surgeons these days use "diathermy" to perform the operation. Diathermy uses electrical currents to cut tissue, but also to stop bleeding and seal off blood vessels. When diathermy is used a little too enthusiastically, or at too high a setting, the result is tissue that is "burnt" - quite literally, the tissue is charred, and depending on the severity, this can result in the destruction of the tissue layers that are found between the rib and the muscle.
So, if the previous doctor takes some kind of "scorched earth" approach to creating the implant pocket, and burns away all of that loose tissue, and then cooks the ribs, we end up with ribs that lack their normal covering, and once an implant is put in, the capsule that forms is aggressively stuck to the rib and becomes incredibly hard to remove.
It is interesting that in textbook descriptions of breast augmentation, most expert authors do suggest that the augmenting surgeon avoid damage to the "periosteum and perichondrium". Implicit in such instruction is the imperative to avoid denuding the ribs of their coverings. For the augmenting surgeon, this minimises bleeding. For the explanting surgeon, this allows easier capsulectomy.
The other thing that has an impact here is the way the surgeon has treated the smaller Pectoralis minor muscle. This little muscle sits higher up on the chest wall, under the Pec major. Technically, a dual-plane breast augmentation should place the implant BETWEEN the two Pectoral muscles. The issue I run into sometimes (but still way more than I should) is of the augmenting surgeon inadvertently lifting the edge of the Pec minor, and placing the imlant under the Pec minor as well. Now, this is almost always the outcome of a non-surgeon doing the operation.
For ladies whose implants are over the muscle: the capsule is stuck to the front of the muscle and to the underside of the breast tissue overlying that. Typically these are easier capsules to remove, but not always.
There is a variant of the over-the-muscle technique called "subfascial" which some surgeons claim offers the some of the benefits of dual-plane techniques. This technique relies on the implant pocket being made on top of the muscle, but under a tough layer of "fascia". In different parts of the body, the fascia is a distinct sheet that can be elevated easily (the abdomen and the thigh are examples of that) but it is definitely not the case over the Pec major. On the one hand, this is why I am not especially enamoured of the "subfascial" technique. On the other hand, surgeons who try to elevate the fascia over the Pec major muscle often end up causing a lot of damage to the muscle, with the plane of their dissection diving in and out of the muscle fibres. And the resulting capsule can then be very difficult to peel off the muscle without causing even more damage.
If I had to choose the best implants to remove, I would say that the classical over-the-muscle or sub glandular implants are easiest, provided the surgeon hasn't tried something dumb like raising the fascia and found themselves in and out of the muscle fibres. A close second would be small-ish dual-plane implants where the surgeon has carefully preserved that loose tissue and coverings over the rib, which allows the capsule to subsequently be removed off the rib more easily.
And before some naysayer gets themselves all worked up and starts foaming at the mouth because "there is a higher incidence of capsular contracture with subglandular implants compared to dual plane" blah blah...my response to that is: show me the evidence. This remains a pervasive myth that I have touched on before, but in current practice, with modern implants and modern techniques, there is no evidence that dual-plane augmentation is protective. In fact, I would contend that dual-plane augmentation is associated with more complications. We need to step away from historical perspectives and critically appraise the data we have currently - and that data does not support the idea that dual-plane is safe/better/more natural than any other technique.
I mentioned above that one of the first steps (in a dual-plane augmentation) is to release the muscle from the rib to get under it and create the implant pocket.
The way the muscle is released can make a big difference to me, because of my obsession with repairing the Pec major as part of my explant technique.
So, if the breast augmentation surgeon peels that muscle up from the very edge and leaves nothing behind, then proceeds to take that scorched earth approach I was moaning about above, it makes the muscle repair much harder simply becuase there is nothing to stitch the muscle back on to. We can find alternative purchase points but that requires more effort, more time, and more swearing.
Other things that breast augmentation surgeons can do to really annoy me include over-releasing the attachment of Pec major to the sternum.
With dual-plane techniques, one of the rather perverse consequences of that technique - whilst claiming to offer "more natural" results - is that the surgeon must be more destructive to achieve that more natural outcome. Basically, if the attachment of the muscle is maintained to the sternum, there is a much greater tendency to animation deformity and superior implant malposition. So, the breast augmentation surgeon will deliberately weaken or release the attachments to the sternum, to minimise this tendency. The problem then arises when some banana head misunderstands what they're meant to be doing and ends up releasing the muscle most of the way up the sternum. I see this more than I should (I seem to say that a lot).
That muscle repair onto the sternum is more annoying than difficult, but it still gives me reason to wonder if whoever did the breast augmentation was an idiot.
The last thing worth commenting on when it comes to muscles, is that situation where a surgeon has (deliberately or inadvertently, it makes no difference) involved muscles other than the Pec major.
Now, there is a bloke on instagram who loves to do this rubbish and it breaks my brain every time I see it. But what he will do (in revision cases it seems) is he will destroy another perfecly good muscle (this time the Serratus anterior muscle) and use that to fashion a sling for an enormous implant. I mean, he could just use a smaller implant, he could use a dissolving mesh, he could do a plane change, he could do a bunch of far less destructive things, but this seems to be his schtick. And he isn't alone it seems. I find myself peeling Serratus off capsules more that I would have expected, and trying to restore some sort of normal anatomy.
I mean, it's pretty simple.
The inframammary fold/breast crease
One of the most frustrating actions that MANY surgeons perform when putting in cosmetic breast implants is the attempt to lower the breast crease/ inframammary fold (IMF), and in doing so, the total loss of control of the lower pole.
It's worth revisiting this to understand why they think it is necessary.
The basic idea is this: the breast "footprint" - the boundaries of the breast, anatomically speaking - is significantly influenced by the level of the breast crease. If a surgeon wants to use a breast implant (and particularly a round implant), then they need the implant to "fit" both the WIDTH, and the vertical HEIGHT of the breast.
The height of the breast is the tricky one. Whilst a surgeon can easily modifiy the upper breast boundary by simply dissecting further upwards, this isn't necessarily helpful because for a surgeon using a breast implant, they need the volume of the implant to be centred behind the nipple, so that the nipple sits right at the most projected part of the breast. If the implant sits too high relative to the nipple, then this results in the nipple facing downwards. If the implant sits too low relative to the nipple, then the nipple will face upwards. The classic ideas around breast augmentation suggest that the volume distribution of the implant should be 45% above the nipple and 55% below (so the nipple has a slight up-tilt), or otherwise it should be 50/50 above and below the nipple with the nipple facing straight ahead.
Now, the most common scenario that these surgeons encounter is one where the width of the breast is greater than the height. Given that the height of the breast is determined largely by the inframammary fold, if the height of the breast needs to be modified, the most common way to attempt this (without ending up with the implant sitting too high, as I described above) is by LOWERING the inframammary fold.
Common wisdom in breast augmentation would suggest that this MIGHT be safe in certain women, especially those with relatively "soft" breast creases, provided the surgeon then correctly reconstructs that breast fold once it has been lowered.
The issue is that many surgeons lower the fold, fail to rebuild the fold properly, and then we end up with those classic issues of double-bubble and bottomming out.
When I then encounter these sorts of issues my job is to think about what the surgeon before me has done, and reverse those actions by elevating and reconstructing the breast crease. This is fundamental to explant surgery, and these days is typically encapsulated in the idea of so-called "internal bra" techniques (which I have discussed before).
Lateral "overdissection"
The other really common way in which breast augmentation surgeons try to modify the breast footprint to fit a great big implant is by expanding the outer/lateral aspect of the breast implant pocket.
Many ladies will recognise this issue. A significant proportion of my patients complain of their implants "falling into their armpits" when they lie down, and this is a direct consequence of that lateral pocket over-dissection.
As with so many other things when discussing the problems that breast augmentation can create, if the surgeon simply works within the patient's anatomical restraints, things don't become such a problem.
Interestingly, whilst most surgeons these days recognise that the inframammary crease is a distinct anatomical structure, there is still a rather (wilful) ignorance of the fact that there is a distinct set of structures forming the outer restraints of the breast (and thus establishing the outer edge of the breast footprint).
Given that I prefer the prepectoral position for an implant, I see these structures far more clearly than a surgeon who uses the dual-plane pocket, becuase the lateral restraints of the breast footprint extend around the outer edge of the Pec major muscle. So as I approach the outer edge of the muscle, i can appreciate the denser fibrous elements that I need to protect to support an implant. A surgeon working under the muscle however is going to miss those structures (they don't run under the muscle) and hence, the tendency for dual-plane implants to lose control and fall out laterally in my experience. This is then exacerbated by the constant animation forces of the Pec muscle which really pushes that implant outwards with much greater force.
This is the situation where some surgeons then try to create more lateral support using other muscles like the Serratus muscle - which is just chasing one bad idea with another.
Periareolar incisions for breast augmentation
This last point relates to breast shape, rather than the breast footprint.
Fortunately most surgeons have moved away from this, but in the early 2000s, periareolar approaches were very common for breast augmentation. It was a pretty easy sell at the time - the scar was very nicely hidden on the lower border of the areola, and there was no scar under the breast (the classic give-away of a breast augmentation).
Unfortunately, this incision is responsible in some cases for signficant contour issues after a few years due to the scar tissue running through the centre of the breast which is then anchored on the implant capsule. As that capsule hardens and tightens (which is appears is a higher risk with this approach), the distortion of the breast becomes much more significant.
At the time of explant, this distortion can be a little tricky to fix given that the scar runs through the breast tissue. If we are dong a mastopexy, this isn't a problem, but for those ladies who don't need a mastpexy, it means I have to get into the breast tissue itself (from the inside), which is something we would otherwise try to avoid.
The obvious answer is the one that still seems to escape so many surgeons shoving great big implants in - leave the IMF alone, use smaller implants and don't go beyond the lateral breast "ligaments".
Oh, and the IMF incision for breast augmentation remains the better option in the vast majority of cases.
This one gets a special section all to itself.
An increasing number of surgeons are deciding to use dangerously large implants (like, 700-800cc in cosmetic patients). The issue is that the patients they are placing these implants into simply have no natural way of supporting the weight of these devices, so the surgeons use a product called "Ti-Loop" to create the additional support. I have discussed this before - read that here - and I think it is a really stupid idea given the incidence of complications associated with these sorts of permanent mesh products, but when it comes to explant, this is an especially frustrating thing to manage.
So, in summary, here is my wish-list for breast augmentation surgeons. These points, in my opinion, would mean their patients get better results from the breast augmentation, and they would also mean that when these ladies come to have their implants removed, it isn't a complete shitshow.
As a general rule, the best breast augmentation procedures (those that look best and last longest) are those that work within the constraints of the patient's anatomy. Once that anatomy is disrespected, everything goes wrong very quickly.
So if you want a breast augmentation, go for it. But do it properly, with a degree of restraint, and you'll hopefully get a good 15-20 years of satisfaction. Do it badly, and you'll be seeing someone like me in pretty short order.