What happens if I don't like the outcome of explant surgery?
December 20, 2022
January 23, 2024
By Dr. Andrew Campbell-Lloyd

What happens if I don't like the outcome of explant surgery?

This can be a tricky topic, but I have to discuss it frankly with all of my patients.

Explant is a very complex operation with associated risks, and you need to understand how those risks might be managed before you decide to proceed.

We recently conducted a survey of our patients as part of research project. The main goal of that was to determine how satisfied our patients were after explant surgery. Fortunately, the overall satisfaction was high, but that isn't to say that everyone gets perfect outcomes. There can be aspects of explant surgery that lead to disappointment, and some ladies will require revision procedures.

What our study did reveal to us is that the techniques we use, including repair of the Pec major muscle, offers us greater predictability and control over our outcomes. We don't have any patients with the horrible distortion of the breast that is described with indentations behind the nipple or in the lower pole of the breast. But every now and then we do see a scar that isn't as fine as we'd like, or a scar that isn't quite positioned where we'd like, and sometimes we'll see a contour or shape that is just a little off. So this article is really to discuss how we approach those questions if they occur.

The information we receive in feedback from our patients has always helped guide changes to my practice over the years. I constantly revise and update the information we present, and that can only happen by listening to our patients and learning from what they tell us. If I see an outcome I consider less than expected, I work very hard to consider why that might be, and to integrate what I learn into what we subsequently do. Over the years, in the pursuit of the best outcomes I can achieve for my patients, I have made countless changes to my operative techniques, and just as many changes in the way I discuss the surgery I perform. I think that means we have seen continual improvements in our outcomes, but also we have seen our outcomes more closely match the expectations we set for our patients before surgery. That is probably the key theme of this article.

What happens if you don't like the outcome of explant surgery?

When we think about the outcomes of explant surgery, we have to consider the kind of surgery performed (and the steps the surgeon took to get the best possible outcome), and we also have to consider the patient's expectations. If your expectations are unrealistically high, chances are that even with the best possible surgical outcome, you'll be unhappy. It is the surgeon's job to set your expectations correctly.

So, what is possible with explant surgery, and therefore, what should you expect?

Different surgeons will have different abilities with regards to various procedures. The outcomes I can achieve with explant may be different to those of a surgeon who does an explant only twice a year. I'd like to think I could do a little better than Dr Twiceayear, but it is up to me to set my patient's expectations accurately, using things like before and after photos, along with the discussion I have during consultation and the information I present to patients during consent discussions, and in other areas such as in social medial posts, or on my website (in an article like this). All of these sources of information should be directed to ensuring that my patients understand what I consider the likely outcomes of their surgery.

Ok, so assuming that all makes sense, let's say you go ahead and have explant surgery and 3-4 months after surgery you have concerns.

What are the possible sources of concern and what can we do about it?

1. Scars. Especially if you've had a mastopexy at the same time as explant. Scars (even with the best efforts) can be unpredictable. Scars can stretch, they can thicken and become hypertrophic, they can remain discoloured, they can be pink and elevated, they can be itchy, they can feel uncomfortable. Scars can also create contours we don't like. In all of these cases, be honest with your surgeon (and if that happens to be me, I do what I can to make sure my patients feel comfortable to tell me if something isn't to their satisfaction). Most of the time something can be done to improve outcomes.

Possible approaches to managing scars include surgical revision, silicone therapy, steroid injections (I'm not a fan of this for a few reasons), and these days things like fractional ablative lasers are increasingly recommended. General advice here is to do NOTHING surgically for at least 6 (if not 12) months to avoid exacerbating an already active (or over-active) scar. In the waiting period, silicone therapy is a mainstay.

2. Shape. Not liking the shape of the breast after implant removal is a challenge. Obviously, you have to accept having a smaller breast, but ideally the smaller breast is well positioned and well shaped. Shape is to some extent within a surgeon's control in two scenarios: a) young women with small, firm natural breasts and implants that aren't too big - we expect the breast to be smaller but to maintain a good natural shape; and b) in cases requiring a mastopexy, we can directly reshape the breast in surgery, although the ability to reshape the breast depends on some unpredictable aspects of the procedure, like how much relaxation of the tissues we'll see and how much natural tissue we actually have to play with. For ladies with very large implants, and minimal natural tissue, shape is always a greater challenge.

If the shape causes you concern after surgery, one of the most common ways of resolving that is with a second stage fat transfer. Whilst fat transfer is often done at the same time as explant, doing further fat transfer at a second stage is especially useful. Keep this in mind when considering explant. Additionally, there may be rare cases where we actually need to go back in to reposition some part of the breast tissue to optimise the contour.

A related issue is the size and shape of the areola. This is something that only really matters for those ladies having a mastopexy. We warn all ladies that, if you require a mastopexy at the time of explant, the areola will be repositioned which implies that the size and shape will be a consequence of surgery. If you have a small areola before surgery, there is a risk of areolar stretching and an enlargement in the areolar diameter. If this occurs, it may require correction with an areolar reduction procedure subsequently, which would involve excising the scar around the areola with a "doughnut" of the outer portion of the areola itself. This normally allows the areola to be reduced in size, but recurrent stretching can occur.

3. Volume. This is similar to, but also distinct from shape. The volume question comes down to how much natural breast tissue you have, and what you do to augment that at the time of explant. Obviously we come back to fat transfer as the best solution here, but I guess the point to make is that there is a limit to what can be achieved in one operation, and for women who are seeking more volume, the best solution is often to plan for a 2nd operation with further fat transfer to improve this aspect.

These are all fixable things.

The last thing worth considering in terms of explant outcomes relates only to those ladies having fat transfer. Because fat transfer involves liposuction, we have to consider the possible complications of liposuction.

4. Liposuction issues. The main thing worth understanding is that liposuction may be associated with contour irregularities wherever it is done. This may mean indentations, dimpling or a dip in the general surface contour. I would suggest that these issues are heightened in slender ladies, with smaller fat deposits. Obviously, the harder we have to work to remove enough fat for transfer, the greater the chance of visible irregularities on the legs or abdomen or wherever else liposuction is done. This is a problem that is not totally unavoidable. Whilst we use a gentler form of liposuction when harvesting fat for transfer, and we often use smaller cannulas to decrease the risk of "over-harvesting", there is some degree of unpredictability with liposuction and it is important to understand that.

If contour issues do occur, they may not be the easiest thing to fix. Whilst there are suggested techniques including attempting to release possible scar bands which can cause contour irregularity, trying to smooth the adjacent areas with further lipo to decrease the perception of contour issues, fat transfer into the indentation, or event "fat freezing" adjacent areas, it is generally accepted that contour irregularities are better prevented than fixed. Having said that, even with careful, gentle technique, it may not be possible to prevent all contour irregularity if liposuction is done. So this is definitely worth keeping in mind. A bit like with scars, liposuction is one of those issues where there needs to be a certain tolerance for (minor) imperfection.

It is vital that patients understand that no operation, and no surgeon (including me!) can ever guarantee perfect outcomes. Ultimately the choice to have surgery is yours, and therefore you need to understand and accept the risks. What matters is that your surgeon can honestly explain the potential outcomes and offer you solutions to problems that could arise.

Like I said above, explant surgery is hard. Achieving outcomes that will lead to total satisfaction simply may not be possible in every case.

Ultimately, if in discussing explant the feeling I get from someone is that they won't tolerate the effect of that surgery (whether it be the loss of volume, or unpredictability of outcome), I may suggest implant revision instead. A new smaller implant, whilst still removing the old implants and performing a total capsulectomy, may be the right solution for a small number of ladies who I see. Often these ladies will also need a mastopexy.

In such cases, no matter what I do with an explant procedure, the expectations that some ladies have can never be met. Typically this might relate to ideas about fullness in the upper pole, or overall breast volume in a lady with very little naturally. But with an implant revision, we may be able to offer functional and aesthetic benefits in those cases that just aren't possible without using an implant.

I guess the point being that I have to try to get into my patients' heads to understand their hopes and expectations (which isn't always easy), and do what I can to ensure that whatever surgery I offer them provides the best chance at achieving their desired outcome.

This is obviously quite a complex topic. Let me know if you have any questions.

Have a lovely day.