I put a thing on instagram the other day, which generated quite a bit of engagement.
Let me start by saying that I have a big issue with surgeons who just post endless photos on instagram of the capsulectomies they have performed, without ever showing their actual outcomes. And let's be honest, outcomes have very little to do with whether a surgeon can perform a capsulectomy. The capsulectomy is the easy part. But it is seemingly a bit of a thing for a bunch of surgeons about the place to just post these grizzly looking photos, and little dinky reels of them playing with ruptured breast implants as though "ooh, look at me, I must be a good surgeon because I saved this poor person from a ruptured implant". Hardly.
The capsulectomy photos are click bait. They seem to generate high engagement from patients because it feeds the fears that many patients have once they get to the stage of considering explant surgery. Which seems problematic, because I then end up seeing the poor patient on the receiving end of that capsulectomy once they realise what a shitty cosmetic outcome they have.
So, that all being said, I did chuck a grizzly photo of some very old, very unpleasant looking capsules, on instagram the other day, and I figured I should explain myself.
The point that I really wanted to make was this: have some sort of plan to ensure you are keeping any eye on your implants over time. I don't think it matters when you had a breast augmentation, or what sort of implants you have, all implants require surveillance, and that requirement increases over time. The grizzly pictures I posted the other day were of 35 year old implants and the associated capsules, which had never been assessed since the day they were put in in the 80's.
I see a lot of ladies who are thinking about explant, but aren't ready to make the leap.
That makes plenty of sense. The decision to explant is a complex one, which affects many aspects of a person, but particularly it affects things like body image, confidence, femininity and sexuality. The point being that for many ladies, they feel that explant is the right thing for them to do, but they feel nervous about that decision, and they want to feel safe in perhaps putting things off for a while as they come to terms with that.
I think it is super important that these ladies aren't rushed, and they can be reassured that it is entirely safe to defer the decision to explant until they are good a ready.
The notion that explant is a health priority in all cases just isn't true. I know that for some ladies, their implants can't come out soon enough. They are deeply concerned about the health effects of those implants and they are comfortable making that decision without delay. But for many ladies, the decision to explant has nothing to do with health concerns. Both surgeons (and so-called "advocates" in online groups and on social media) need to accept this point. There are many ladies who choose to explant for functional or aesthetic reasons and not because they feel that they have BII.
I spend a lot of time and energy reassuring ladies that it is safe to put off having explant surgery. The most frequent question I get relates to implant rupture. Normally a lady will present to me having been told but her GP or another surgeon that because she has a rupture, it is URGENT that she has her implants removed.
This is absolute rubbish.
I am happy to argue about this all day.
No, rupture is not ideal. No, rupture should not be ignored. Yes, rupture does need to be managed and this will require removal of the ruptured device and (in my hands) a total capsulectomy.
But no, rupture is not an emergency health concern in the vast majority of cases.
The ruptured implant, just like an unruptured implant, is contained by the scar capsule. With the exception of rare cases (which normally involve direct trauma to the breast such as a car accident or falling off a horse), the silicone contained within the scar capsule doesn't suddenly start leaking out and randomly moving around through the tissues.
Actually, most women wouldn't even know they have a rupture. Most ruptures are "silent". The reason women find out that they have a rupture is because something else was being investigated. Women present with pain, shape changes, capsular contracture and hardening, or some combination of all 3, and this prompts someone to arrange an ultrasound or an MRI. And then the rupture is identified. No one "feels" their implant rupturing.
But that all being said, most women think they are having breast implant surveillance recommended to them to detect rupture. Most surgeons probably think the same thing. But that is wrong.
Breast implant surveillance is about ensuring women have a frequent point of contact with a specialist so that they can act on the things that actually cause them trouble. Implant surveillance may detect a rupture, but in my experience, the main reasons for revision surgery (including explant) are pain, shape changes and implant hardening due to contracture. Whether there is a rupture or not should be immaterial.
Why: you should have implant surveillance to ensure that any problems with your breast implants are detected early. Those problems include capsular contracture, pain, shape changes, changes in the breast tissue, and yes, rupture. But don't get hung up on the whole rupture thing.
What I would want any patient to understand is when you need to act promptly.
The main reason for any woman with breast implants to seek immediate review with their surgeon (or whoever is doing their surveillance) is when there is a sudden change in one breast, but not the other.
A sudden swelling and enlargement of one breast can indicate a fluid collection (seroma), a sudden bleed (yes, this can happen years after surgery, and is more common for ladies who have very old implants and calcified capsules), or even BIA-ALCL (which we do need to consider in any case of sudden breast changes). Some ladies will present to me with unilateral capsular contracture, which doesn't happen overnight, but for whatever reason, some patients will suddenly notice a thing that has actually been happening for ages....I'm sure the psychologists could offer us some insight into our ability to ignore things until we don't. Anyway, any unilateral change should always be promptly assessed and investigated. The first investigation (after clinical review) is an ultrasound, to assess for fluid. If there is fluid, it must be sampled an tested to rule out BIA-ALCL. If there is no fluid, or it can't be drained, then we may need to consider MRI (see below for further comment about MRI).
When: I recommend surveillance for most ladies every 12-24 months.
How: Surveillance may be little more than a chat, and an opportunity to tell your surgeon how things are going from your perspective. Be honest, tell them how things feel, and whether you think there have been any changes. I strongly recommend clinical photography at each appointment as this is the single best way to demonstrate progressive changes in the breast over time that may lead to a woman choosing to have revision surgery. Importantly, photographs will reveal the subtle changes that patients themselves aren't aware of. I also use ultrasound in my rooms to examine implants and assess for folds in the implant shell, fluid around the implant, and rupture. Ultrasound isn't perfect but it is a useful tool.
Let me be very clear though in saying that women with breast implants who don't have any change in their breasts DO NOT NEED AN MRI every 12-24 months. I keep hearing about ladies being subjected to this sort of wasteful, expensive and pointless investigation.
More importantly, for women considering explant, only a very select few actually need an MRI. MRI has its place, and it may be a necessary investigation when a lady has a sudden change in her breast. But again, I am hearing about too many surgeons applying a blanket rule to any woman considering explant, telling them all to have an MRI. Hard disagree on that one.
In general, I recommend that ladies should have surveillance with whichever surgeon put their implants in. The surgeon bears ongoing responsibility to their patient for the long-term outcome of that patient's breast implants. Follow-up with the original surgeon isn't always possible, or desirable, which is why I do offer surveillance for ladies who are considering their options for explant or revision but may not be ready to make a decision, or who don't wish to see their original surgeon.
Hope that helps clear up a few things. If anyone has questions, or if you're concerned about your implants, please get in touch or send in an appointment request
Have a lovely day people.
ACL