It's a fair question.
To me the answer is no. Absolutely not.
To most surgeons, the answer is yes. Why the difference?
I've seen recently the recycling of a certain (very flawed) argument as a way of justifying NOT performing a total capsulectomy at the time of explant surgery. I've seen it on reels, podcasts, and more recently, at a number of conferences.
The argument goes like this:
"... one of the basic tenets of medicine is to "first, do no harm". By that logic (they say), we should NOT remove the capsule (at the time of explant) because <<insert horrible complication here>> might happen (even though the evidence available in the literature doesn't support that assertion)."
The assertion here is that capsulectomy is RISKY, and therefore, it behoves us as responsible, ethical surgeons to NOT do capsulectomy. Right?
**Hint: The warning bells should be clanging away right about now.
What we have is a range of rather prominent surgeons (who choose not to do capsulectomy) essentially using a "moral" argument to suggest that a surgeon who does choose to do a capsulectomy is wrong.
Now, there are a heap of reasons why that argument is deeply flawed, and I'll get into that, but what I can't help but think is this:
If these surgeons truly believed in the idea of "first, do no harm", then they would not have put in the breast implants that they are now being asked to remove.
So, let's look at what is meant by harm, and let's consider how the risks of breast implant removal stack up against breast augmentation.
The potential for harm (from breast augmentation)
In a general sense, we can consider harm from breast augmentation in two ways.
Firstly, what are the possible complications that can arise from surgery. This is the easy stuff. Bleeding, infection, fluid collections, wound issues, swelling, scars and maybe stuff like altered sensation...and I would suggest that we can also throw in there things like poor aesthetic outcomes requiring revision.
And secondly, what are the possible consequences of surgery (in the longer term) which, whilst perhaps not typically what we would consider complications, are likely to create limitations in someone's potential or compromise their function in some fashion. Now this bag of issues is a bit trickier. This is where you'll find the typical surgeon will want to argue (a lot) and it's is where I think Plastic Surgery as an industry really lets patients down badly. So this would include issues like chronic pain, animation deformities, muscle weakness (from cutting the pec major muscle for example) and loss of function, and implant-related issues that can accumulate over time such as capsular contracture, inflammatory neuropathies, and the need (eventually) for revision or removal of any breast implant.
The potential for harm (from explant)
I've written a fair bit about this in the last year or two: as the volume of explant surgery has gone up, so has the volume of revision surgery I am required to do to correct the poor outcomes from some of those explant procedures.
If we consider a similar framework of complications and consequences, then we can start to make some comparisons.
The complications of explant are very similar (in quality) to breast augmentation - bleeding, infection blah blah - the same list that I wrote above is just as applicable here.
The consequences however are rather distinct. Because explant is a form of "revision" surgery (that is, we are trying to undo something that has previously been done), then we typically think about the consequences as relating to either a failure to resolve a concern, or some sort of residual problem. In that vein, we might then consider the issues following explant as broadly including things like cosmetic deformity/distortion, residual animation effects, and perhaps this is also where we might look at issues like chronic pain - from the explant, as compared to the pain from breast implants - if indeed that is an issue (imo: it's not - more below)...
Explant vs. Augmentation - a true comparison of risks
So if we consider the above, we can look at this in a few ways.
I think it very fair and reasonable to DIRECTLY compare the risks of true complications. I think it is far harder, and far less valid, to try to directly compare the various consequences of surgery however.
One of the really important findings I considered in my recent study looking at surgeons' opinions on explant and capsulectomy was the data on risk perceptions (as it applies to capsulectomy). What we found there was that most surgeons consider capsulectomy to be high risk, and the major perceived risks were: haematoma (bleeding), pneumothorax (collapsed lung), seroma (fluid collections) and damage to the chest wall or Pectoralis major muscle.
Complications
This is where we might go to the literature to really figure out what the risks are and make some comparisons. I don't think we can pull comparable data for every possible outcome, but there are some data points that seem to be more reliably captured.
The easiest one to compare is the risk of bleeding. As I wrote in my research:
"The risk of haematoma after cosmetic breast augmentation has been estimated at between 0.2-5.7%. The incidence of haematoma after capsulectomy has been estimated at between 1 and 1.6% (versus a 0.9% incidence in patients having implant removal or exchange without capsulectomy). Capsulectomy confers a (very slightly) higher risk of haematoma than no capsulectomy, but the absolute risk remains...possibly lower than routine cosmetic breast augmentation."
The problem however remains that nearly every publication that discusses capsulectomy (many of which have a dual purpose of refuting the existence of BII), we see a quote like this:
"Patients are entitled to remove their breast implants and request a capsulectomy. The discussion for this procedure must be done with fully informed consent, discussing the risks and benefits of implant removal with or without capsulectomy. Capsulectomy can be performed safely in most patients but is a more invasive procedure which carries a higher risk of complications, specifically for hematoma." (DOI: https://doi.org/10.1093/asj/sjaf205)
Even worse, this claim references a publication (https://doi.org/10.1093/asj/sjaa115) that was itself nothing more than a letter to the editor, and which did NOT even bother to provide a reference for its claim of increased haematoma risk!
In other words, this is total bullshit, and it is an example of so-called "evidence" in surgery which drives me crazy. This is junk research writing, from an author who is considered a world authority on BII (and therefore, by inference, capsulectomy), who should definitely be held to a higher standard, and whose latest "editorial" has been published in what passes for a top-tier aesthetic surgery journal!
Pneumothorax - a collapsed lung - is a little trickier to compare as there is likely a lack of reporting/data on the incidence with routine cosmetic breast augs, although it has been reported. The better data relates to the incidence of pneumothorax associated with breast implants used for reconstruction after mastectomy, which, whilst a similar technique, has a few differences.
In any case, a decent paper (doi: 10.1097/SAP.0b013e31827e2936) from The Memorial Sloan Kettering Hospital in New York looked at this question, and they determined that the incidence of pneumothorax after breast reconstruction with implants was between 0.04% and 0.55% per patient. They also quoted an older survey study which suggested that up to one third of plastic surgeons in California had experienced pneumothorax after breast augmentation at some point in their career! Now that sounds like a rather remarkable statistic, albeit one from 20 years ago.
If we then compare that risk to the risk in the literature associated with explant and capsulectomy, the estimated incidence of pneumothorax after capsulectomy is between 0.06-0.1%, although as I wrote in my research, that data includes both cosmetic and reconstructive patients and thus, the true incidence of pneumothorax after the removal of cosmetic implants is not entirely clear.
Buuuuuut...a direct comparison of those numbers again would suggest that the risk of pneumothorax after capsulectomy is no higher (and possibly it could be lower!) than after routine breast augmentation.
What about seroma? Well, this data is available for most breast implants available in the USA by looking at the publicly available FDA product safety sheets which are provided for all implants on the market. For example, if we look at Mentor breast implants, the risk of seroma is between 0.9-2.1% and the risk for the (now recalled) Allergan textured tear drop implants, the risk is between 1.3-3.3%. On the other hand, if we look at current generation Motiva implants, the data provided shows a 0% risk of seroma! So, the data here is variable, according the device characteristics.
Now, by comparison, the risk of seroma for explant surgery is rather heterogenous on the basis of technique - which matters - more than anything else. My own published data shows a risk of seroma which is extremely low (less than 0.5%) even thought I don't use drains. On the other hand, if we look at the broader literature, there is no good data on this point but it seems to be generally accepted that seroma is "common".
So, what makes me special? Well, plenty - but if you want to understand my rationale for not using drains, and why my seroma rates are so low, have a read of this article.
Consequences
I said up above that this one is a bit trickier, and it is. The problem being that these "outcomes" are typically ignored in the majority of breast augmentation literature, and are typically wildly overstated when the discussion turns to explant (you can see the problem there).
But I think we can look at the 3 most significant consequences after surgery (in the longer term) to see if we can make any sort of comparison.
Chronic pain/functional decreases:
This one is interesting. We actually have data on this that is a little bit unintentional when it comes to augmentation. Over the years that have been numerous studies looking at PROMs (patient rated outcome measures) for breast surgery, typically using a validate score called the BREAST-Q, which specifically looks at a couple of domains including self-image, sexuality, satisfaction, and one that specifically looks at function/pain. That last one is the one that we are going to look at here.
Breast augmentation is, in many ways, a very successful operation. We do see significant increases in the scores seen in self-image, sexuality, and overall satisfaction.
And we also see (almost uniformly) that these scores come at the expense of significant decreases in the scores for function/pain. But what normally happens is that the papers written go into great detail about the positives, and then make a brief comment about the decrease in function/pain scores and kinda brush it off.
Which, I will admit, irks me. It irks me enough that, to my eternal shame, I became one of those people who writes letters to the editor to point out a few important facts.
In my reply to that article (DOI: 10.1097/PRS.0000000000011722), I wrote:
"In any other context, a cosmetic procedure that significantly reduced physical function would be considered a failure. A rhinoplasty that results in reduced airway patency, no matter the aesthetic improvement, is a failure. A face lift that results in a dynamic asymmetry due to nerve injury is a failure, regardless of the rejuvenated appearance in repose. The question that must be asked is, are plastic surgeons accepting a lower standard for “success” in breast augmentation, compared with other cosmetic procedures?"
I went on to say:
"Breast augmentation is not without risk. Putting aside considerations such as hematoma, infection, implant loss, and cosmetic deformity, there are real (but often underreported) risks of nerve injury (approximately 15%), chronic pain (ranging from 13% to 38%), and physical dysfunction, including problematic animation deformity and weakness, most commonly relating to the placement of implants under the Pectoralis major muscle."
"...Explant procedures are increasing at double the rate of breast augmentation, and in many cases, the decision to explant is entirely or in part related to chronic discomfort and functional concerns after dual-plane breast augmentation. Whether explant procedures result in improved physical well-being has yet to be clearly answered."
What I would offer you (and this is what I tell my patients when consenting them for explant) is that whilst we currently do not have data on physical well-being after explant to allow direct comparison, in my own experience, I see two important things with explant procedures:
I think that second point really matters, not least because there are surgeons who will say (and this is a direct quote I received from a surgeon in response to my recent survey study) they consider one of the risks of capsulectomy is the possibility of "converting a patient who is concerned with BII to a chronic pain patient!".
Deformity:
When we consider breast augmentation, it is pretty uncommon that this will directly lead to a visible "deformity". Sure, there can be issues with symmetry, implants dropping out or shifting outward and so on, and those issues are actually very common, but I don't know that we would call those issues "deformities". There are two aspects in which I would say that breast augmentation can lead to a deformity: 1) animation effects can be considered "dynamic" deformities - that is, they are deformities that are only present when moving; and 2) we can see visible deformities of the lower pole when surgeons have attempted to lower the inframammary crease position.
The effects of animation deformity should not be underestimated. There is nothing natural about breasts moving about all over the place just because the muscle activates. We see this with otherwise innocuous movements - some ladies will notice it when thev wash their hands. use cutlery to eat their dinner, when they drive or when they pick up their kids. Animation deformity affects essentially EVERY patient with subpectoral or dual-plane implants, and it is can be associated with chronic pain. The animation deformity is a major driver of the reduction in physical quality of life that I was talking about above. The bigger question is whether women notice or are bothered by the animation effect, and this is a very individual perception. Whilst we might argue to 100% of women with implants under their muscle will have an animation deformity, my observation (of my explant patients) is that perhaps 30-40% will describe that in negative terms as being something that bothers them. For those women who do notice it, the animation deformity may be one of the major drivers to seek revision surgery or explant.
The deformity arising from attempts to lower the breast crease is certainly less common as it typically relates to an underlying anatomical difference like a tuberous breast. The incidence is hard to estimate, but I think it is fair to say that the risk of this problem is directly related to the experience of the operator. A research paper form some very experienced Australian surgeons a few years ago suggested that with careful planning the risk of "double-crease" deformities could be below 1:1000. On the other hand, when I see double-crease deformities (and, as a rough guess I would say I see that to some extent in about 5-10% of all explants), it is abundantly clear why and how that has formed: often a careless initial procedure, with either inadequate support of the breast crease or some attempt to lower a high crease, done by a surgeon who perhaps didn't know any better!
Now, by contrast deformity after explant is a completely different topic, and one I have spoken about extensively in previous articles. It is a problem that appears to be common, a problem that arises almost exclusively due to the surgery performed (and therefore, it is under the control of the surgeon doing the procedure), and in my opinion, it should be largely preventable.
In our recent study, it was interesting to note two points: the vast majority (92%!) of surgeons were satisfied with the aesthetic outcomes of their own procedures; on the other hand, 60% claimed that they had be asked to treat patients with aesthetic complications arising from explant surgery. Overwhelmingly, the issues that surgeons were being asked to address related to contour deformities, scar malposition, and persistent animation deformity after explant.
Now, that data raises the question of whether surgeons are able to objectively assess their own outcomes accurately. At the least, it would suggest that patients may not be in agreement with those surgeons about the quality of their outcomes. If almost every surgeon is satisfied with their explant work, but a majority have also seen patients who clearly are not satisfied after explant with other surgeons...something clearly doesn't add up.
So, without having actual numbers to offer here, I will offer instead a qualitative judgement: the risk and incidence of troublesome deformities (ie. deformities that cause patients concern or discomfort) after explant is indeed higher than after breast augmentation. Which really just serves to emphasise the importance of trying to get surgeons to accept that they aren't doing explant well enough, and I think it should be an argument that techniques for explant surgery require far more study. I like to think I am doing my part there.
Animation:
I think we can, in a sense, consider the most common deformity that arises from breast augmentation as being animation.
It is a particular issue related to all under-the-muscle techniques, and totally avoidable with over-the-muscle implant placement. Which certainly raises a few questions I think. I mean, especially in the current era, when patients seem to be prioritising subtle, "natural" results, it seems wildly incongruent for surgeons to still be pushing a technique (dual-plane) that will almost unavoidably create a particular deformity.
So, given that 100% of patients with dual-plane implants will have animation of some sort, can we better define the problem?
The reality is some animation is worse than other animation - we can think of it more in terms of severity. And the severity of the problem relates to the extent of muscle release, and how that muscle (which may be different for each patient) will then interact with their chosen implant.
It is also very important to acknowledge that whilst every patient will demonstrate an animation deformity, not every patient with be troubled by it. I am not sure how to best qualify that statement - I ask every patient if they are troubled by the movement of their implants when the Pec muscle contracts, and I actually get three different answers: 1) Yes (and that is typically a rather emphatic yes), 2) No, it doesn't really bother me or 3) What do you mean "animate"?. The last group confuses me a little I will admit - these are ladies who simply aren't even conscious of the implant movement, but I think most of the ladies in this group have what we might call a rather low "demand" of their Pec muscles, so perhaps that helps to account for it.
One of the major arguments that I would offer in favour of placing implants on-top-of the muscle is the avoidance of animation. However, most implants in Australia remain under-the-muscle or in a so-called "dual-plane". This means we see animation in the majority of our explant patients, and it is something that we have to address at the time of explant.
At risk of me sounding like I keep saying the same thing again and again, the muscle repair at the time of explant is a really vital step to avoid residual animation deformity after explant.
Which of course means that one of the problems I am seeing in patients looking for revision after they have had an explant is that residual animation.
There is no useful data available on how common this deformity is after explant. At least, not at scale.
What I can tell you is that 100% of the patients who present to me for explant revision still have animation deformity, and that is because 100% of the patients presenting for explant revision had implants under the muscle and the muscle wasn't repaired.
The question I asked at the start of this article is whether we are dealing with double standards in how surgeons discuss the risk of capsulectomy. The idea that we should NOT remove implant capsules becuase it is "risky" is clearly a demonstration of bias, and more importantly, it is totally unsupported by data. Indeed, it is clear that the risk of primary breast augmentation may well be higher than capsulectomy in some cases.
I would also argue that when capsulectomy is performed, and a patient goes on to develop a complication or negative consequence of the explant surgery, such outcomes are not becuase a capsulectomy was done, those outcomes are because the explant procedure itself was done poorly.
So yeah, I would say there is a double-standard. Clearly, surgeons are very prepared to accept a certain level of risk of complications after breast augmentation. The question then has to be asked: why do so many surgeons consider capsulectomy to be a higher risk procedure which therefore should not be done?
Implants are not inherently "bad". But nor is a capsulectomy.
Let's stop vilifying the explant process. The root cause of an explant remains the primary breast augmentation. For those surgeons who are seeking to create this moral dichotomy, I'd suggest that basic logic dictates that they need to look to the breast augmentation process itself - for that is where they'll find the true culprit.