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:
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.