What happens to the capsules in explant surgery?
December 20, 2022
December 7, 2021
By Dr. Andrew Campbell-Lloyd

What happens to the capsules in explant surgery?

Interestingly, there have been articles in both Plastic & Reconstructive Surgery, and The Aesthetic Surgery Journal this month on the topic of managing the implant capsules in explant surgery.

Not sure what has prompted this. These are the two leading journals in plastic surgery worldwide, with extensive readership and influence on practice amongst plastic surgeons.

I would love to say that these articles have confirmed that plastic surgeons are dealing with requests for breast implant removal by patients with sensitivity and understanding. I would love to say that these articles don’t have a strong whiff of dismissal about the topic of BII or concerns regarding breast implant safety. I would love to say that these articles might offer patients some reassurance.

Unfortunately, I can’t say any of that.

These articles continue to be written in a way that suggests the authors don’t really believe their patients. What they do say is: breast implant illness cannot be proven; the capsules aren’t the problem (but sometimes they are) so it makes no difference whether the capsule is left behind in part or in total; and removing the implant and the capsule together (whatever terminology you choose to use for that – let’s call it an “en bloc” capsulectomy) has no role to play except in the presence of ALCL.

These articles come across as being dismissive of the concerns that patients are presenting with. Whether the concerns that patients have regarding their implants can currently be proven isn’t really the issue. Listening, and doing our best as an industry to understand those concerns is. I do agree that social media is strongly influencing how patients are presenting to us, and it is having a huge impact on how patients are engaging with their surgeons. I guess that is what happens when the “industry” has been so determined to ignore implant-related concerns….nature abhors a vacuum, right?

Anyway, the point of this is that I continue to see the issue of how to manage the implant capsule (among other aspects of the surgery) during explant being dealt with very poorly. Given that most surgeons seem to be telling their patients that they have performed a “capsulectomy”, it is scary/fascinating to find out just what surgeons mean by that. Unfortunately, what they mean by “capsulectomy” often involves taking a little bit of the anterior capsule out, but leaving most of the capsule behind. There remains a worryingly dogmatic position in practice and in the literature that somehow a total capsulectomy is a) difficult, b) dangerous and c) not worth it.

I would argue that provided our patients understand why we do things in a certain way, total capsulectomy (and indeed so-called “en-bloc” capsulectomy) can be relatively straightforward (although not without a little effort), safe and definitely worthwhile.

So let’s run through what I tell every one of my patients about the capsules during explant surgery:

  1. If there is a known rupture, I prefer to perform “en-bloc” capsulectomy (for the purists, it is worth understanding that the term “en-bloc” is an oncological term which has been mistakenly applied to the concept of removing the intact capsules with the implant contained within – whilst the terminology is incorrect, I will use it for the sake of simplicity).
  2. If there is no known rupture, I will attempt an en-bloc capsulectomy if that is the patient’s preference. The issue with the en-bloc approach is that a larger incision is required (this isn’t a problem if we have planned a mastopexy/breast lift as part of the surgery) and for patients who would preference a shorter scar, we discuss the fact that if I am concerned that the access is inadequate for safe visualisation right up the top of the chest, then I will often open the capsule, remove the implant, and then complete the capsulectomy. This is important given the risk of this surgery being performed with poor visibility – things like bleeding and excess trauma to the pec muscle are common in that situation.
  3. In every case of explant surgery for a patient who is concerned about BII, I perform a total capsulectomy. There are uncommon situations where the capsulectomy may not be possible in its entirety without creating substantial trauma to the tissues we need to preserve. It is important to understand this, because we are seeing more ladies with Motiva implants placed in the last few years and they are a distinct subset of patients for whom the capsulectomy can be uniquely challenging. The particular properties of Motiva "nanotextured" breast implants mean that the scar capsules the body forms are often extraordinarily thin. They are quite distinct from the capsules we encounter with any form of textured breast implants, and they are different to those encountered with classic smooth implants. Whilst rare, there are sometimes cases where the capsule associated with Motiva implants is so insubstantial as to almost be absent, especially on the posterior surface of the Pectoralis major muscle. In these cases, sub-total capsulectomy may have to be performed to avoid excessive damage to the muscle in particular.
  4. I don’t use drains.
  5. This is day surgery. #4 helps with that. And day surgery means lower costs.
  6. Sure, it can be a little painful, but it is entirely manageable.
  7. Most patients who report symptoms that they attribute to BII will experience some improvement. Many patients will experience complete resolution. Some patients experience no benefit. We can’t predict who will benefit and who won’t. I also tell all of my patients that logically, we would only expect to see resolution of symptoms from about 6-8 weeks after surgery. This is the time it takes the body to heal, and it follows that if any surgical inflammation will persist until at least that time, then inflammatory symptoms will likely persist until then too.
  8. Some patients report instant resolution of symptoms. That is wonderful, and I am really happy for these patients, but it is biologically implausible that patients with instant resolution had a problem related to their implants. Inflammation and healing don’t work that way.
It seems a little jarring that we continue to see articles written by a bunch of old guys telling the rest of the profession that what they have been doing (dogmatically) for the last 20 years is perfectly ok and we don’t need to change. I’m really not comfortable with that. Patients really shouldn’t be comfortable with that.

I should however point out that there are now multiple studies ongoing trying to determine exactly what underlies BII. It is something that we are only going to learn about gradually.

When a condition is variable, with a huge number of possible symptoms that are being attributed to it, with multiple possible contributing factors, trying to figure things out in the lab is difficult – there are many different variables to contend with. Suffice to say, and as I have said before, whilst the science will take time, we owe it to our patients to actually consider whether what we are doing is in their best interests.