Is explant surgery dangerous?
No. No it is not.
I wish I could end this article there. I should be able to. I consider the risk of explant surgery to be very (very) low. Not zero, but low.
However, I am sure that patients are just as aware as I am that there are women out there who do experience complications after explant surgery which can pose a health risk. If I am honest, I hear about these things happening in the hospitals I operate at: patients who have to be taken back for surgery at night after operations becuase of bleeding or whatever.
So this will be a quick article to explain what those serious risks are, and how I avoid them for my patients.
Seroma / fluid collection
I can probably best discuss seroma risk by referring back to a previous article I have written about surgical drains, and why I don't use them.
The brief version of seroma (if you don't want to read that longer article) and why it occurs is this: whenever we do an explant procedure, the result is something like making a whole lot of separate breast layers that we need to stick back together to allow reliable healing and good outcomes. Fluid collections can only occur if things don't stick down. So, preventing seroma involves creating the right conditions for those layers to stick together.
The techniques I use allow me to have greater control over those separate layers, so they don't come apart once we put things back together. The consequence of that is that we don't see fluid collections for our patients, and we don't need drains to achieve that outcome. Yay.
For other surgeons who do use drains however, they are relying on those drains to stick things back down. That is an unreliable process, and it leaves patients vulnerable to developing fluid collections after the drains are removed.
Haematoma / bleeding
Bleeding is the most common reason that patients return to the operating theatre in the short term after breast surgery. Bleeding is an avoidable risk in my experience. We can control it.
Maybe I have been lucky because I have never had an explant patient bleed after surgery. Maybe it isn't luck, maybe I am just careful. I dunno.
Preventing bleeding is something that requires patience and perseverance to be honest. The capsulectomy needs to be done carefully. If a surgeon is rushing, or a bit sloppy, then the risk of bleeding is going to go up. I stop and spend as long as I need to once the capsule is out, dealing with any evidence of bleeding before we close up. And I guess whatever I do works. So far, anyway.
Infection
Infection (in my opinion) generally starts as a fluid collection. I do believe that for many patients a fluid collection is the root cause of most evils after capsulectomy. So controlling the risk of seroma also controls the risk of infection.
We do routinely use preventative antibiotics. I know that there are quite a few ladies who prefer not to take antibiotics if they don't need them. The use of antibiotics doesn't have a strong evidence base (there are conflicting reports in the literature, with some studies showing no difference and other studies showing a benefit) however my experience (like that of other surgeons I suspect) is that antibiotics are a simple, low risk intervention that seem to also decrease the risk of things like suture granulomas (stitch spitting), which can also be reasons for wound healing delay.
Put it in these terms: if you developed an infection after surgery, and you hadn't been given antibiotics, would you be thinking "gee, why didn't my surgeon given me antibiotics to reduce my risk of infection"? Maybe.
Wound healing problems
Wound healing delay exists on a bit of a spectrum, from the minor (a few scabs or raw areas that take an extra week or two to resolve) to the more significant (wounds that separate and require dressings, or even surgery). Whilst uncommon, wound delays do happen. I have had a couple of ladies over the years with fairly minor wound issues and we normally can get them across the line with dressings and a bit of TLC. Wound delays also increase the risk of scars that need revising down the track.
There is discussion in the literature of things like necrosis of the nipple or breast skin associated with capsulectomy. I think that is absolute rubbish personally. There is a small risk of compromised blood supply to the nipple, but with good technique it should be avoidable. I think it is fair to say however that there is a slightly higher risk for those ladies who had a previous mastopexy when they got their breast implants, and who need a second mastopexy at the time the implants are removed. It is a manageable risk, but it is something I discuss during consent.
Pneumothorax
A pneumothorax is a collapsed lung. The Americans love to suggest that this is a risk of capsulectomy. I love to suggest that they're idiots.
The only way for a surgeon to cause a collapsed lung is by somehow managing to open up the chest cavity during an explant. That would involve them diving down between ribs, cutting through a few layers of muscle and membrane, and not realising what they were doing. If a surgeon did that, it would be....surprising, to say the least.
Fortunately, some sanity has come to the fore with a few studies effectively debunking pneumothorax as a risk of explant surgery. What a relief. I hope I can remove this point from my consent forms in the near future.
So those are the main issues that can pose a health risk to patients after explant. These are the things that might lead people to conclude that explant surgery or capsulectomy are dangerous operations if they happened regularly.