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The ABCs of Breast Implant Removal Surgery

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The ABCs of Breast Implant Removal Surgery featured image
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This article first appeared in the Winter 2022 issue of New Beauty. Click here to subscribe

Knowing what a major life decision it is to get a breast augmentation, why are so many women now changing their minds?

While it’s not a new practice—breast implant removal has been happening for as long as women have been getting implants—today’s explant trend has been fueled by several factors: an increased focus on a mysterious illness that patients correlate with their implants; to avoid the risk of a rare cancer caused by textured implants; and more commonly, because we’re moving away from the Pamela Anderson–style breasts of the past. Whatever the reason may be, the options for recreating the breasts after implants have also improved drastically. Here, we explore the different ways plastic surgeons are taking unwanted implants out and the innovative new ways they’re rebuilding the bust.

Reasons Why

When the headlines talk about explant surgery, the story tends to focus on the removal of the implant due to increased reports of women experiencing Breast Implant Illness (BII), but that’s not the only reason women are reconsidering their implants. “The number of explants has certainly increased in recent years,” says Tucson, AZ plastic surgeon Raman C. Mahabir, MD. “A recall of textured implants and the increased awareness of BII are the most significant contributing factors. Another reason is a change in fashion as reflected in the media. There is a clear trend towards more natural-appearing breasts.”

In 2020, The American Society of Plastic Surgeons estimates there were about 110K breast implant removal surgeries performed, more than double the amount reported two years prior.

Reason 01. Changing Styles

“One of the most common reasons to have implant removal surgery is to downsize, especially as the breasts enlarge with aging, menopause and weight gain,” notes Louisville, KY plastic surgeon M. Bradley Calobrace, MD.

“There is also a segment of individuals who have them removed and replaced because they’ve lost volume and they want to be a little fuller,” adds La Jolla, CA plastic surgeon Robert Singer, MD.

“Someone who gets implants at 23 years old, has kids, breastfeeds or whose weight has fluctuated will often need some kind of revision surgery which may come with replacing the implants,” New York plastic surgeon B. Aviva Preminger, MD says. There’s also the longevity factor. “Implants are not meant to last forever. It’s like buying a car. You’re going to enjoy it, it’s going to get you to where you need to go, but eventually it is going to require some kind of maintenance.”

Reason 02. Irregularities

Another common reason to have implants removed is to correct implant irregularities that can occur over time. “Many patients struggle with recurrent capsular contracture, chronic fluid collections, and implant rupture,” says Campbell, CA plastic surgeon Kamakshi R. Zeidler, MD. “This can lead patients to feel frustrated and want options that won’t reintroduce these complications.”

New FDA Regulations

Recently, the FDA announced a stronger set of regulations for breast implants which fall under the device category. “Among the new guidelines is a requirement that each implant manufacturer provide a ‘patient decision checklist’ that the physician will review with each patient, as well as a boxed warning describing some of the risks of implants, including BIA-ALCL, and systemic illnesses that may be associated with implants,” explains Dr. Calobrace.

Also required now are updated silicone gel-filled breast implant rupture screening recommendations and a patient device card with a description of their implants and a list of the specific materials used in the device.

Reason 03. Threat of Illness

A worldwide recall of certain textured implants has also prompted many implant removals. Breast implant-associated anaplastic large cell lymphoma (BIA-ALCL) is an extremely rare type of lymphoma linked to certain types of textured implants. “To put it in perspective, there are 20 to 25 million people worldwide with implants. There are only 733 unique cases of BIA-ALCL,” says Dr. Singer “We don’t quite understand the mechanism,” explains Austin, TX plastic surgeon Ashley Gordon, MD. “In a small subset of genetically susceptible people, within eight to 12 years of being in the breast pocket, the implant’s aggressive texturing aggravates the immune system leading to a lymphoproliferative state and, ultimately, a lymphoma. It is a cancer of the immune system, not a breast cancer.”

Reason 04. Breast Implant Illness

“There’s also a subset of patients who feel strongly that their implants are causing what’s called Breast Implant Illness, which encompasses a huge assortment of complaints like joint pains, general aches and pains, fatigue, ‘brain fog,’ gastrointestinal symptoms, and a wide variety of things,” explains Dr. Preminger. “Those patients often decide that they shouldn’t have ever had their implants to begin with, and that the implants are the source of their ailments. There is a lot we don’t know, and we are still collecting data to make these determinations.”

“These patients may also be undergoing different lifestyle changes and factors that may cause more stress unrelated to their implants,” Dr. Singer says. “The Aesthetic Surgery Education and Research Foundation is doing a lot of research to find additional information for patients.”

Breast Implant Illness (BII) is currently not recognized as a diagnosable medical condition and the exact cause is still being studied, but some doctors say that explant surgery may not be the answer. “It is a really tough topic,” says Dr. Preminger. “Some surgeons will say, ‘Take these implants out and your symptoms will be gone.’ I think that the same way that some people develop capsular contracture, which is an immune response, it’s also possible some individuals have a real sensitivity to the implant. But I hesitate to promise that the symptoms will be gone with the implants or that they are necessarily attributable to them.”

Explant Surgery

Explantation surgery can vary greatly depending on the placement of the implants, a patient’s anatomy, and their specific wishes. “What they all have in common, is the removal of implants,” says Dr. Zeidler.

Implant Removal Techniques

Currently, surgeons say there is a lot of conflicting information about implant removal surgery circulated online and it concerns how much scar tissue surrounding the implant should be taken out and how. “Sometimes a capsulectomy is done. A capsule is the lining the body makes around an implant, it’s a simple thin layer of scar tissue much like the lining of a cyst,” Dr. Zeidler explains. “There are times this capsule can be problematic, and we recommend removal, like in cases of capsular contracture where it can be hard and calcified, or contain a ruptured implant or chronic inflammatory fluid known as a seroma. In these cases, every attempt is made at removing the entire capsule.”

A typical capsulectomy involves creating an incision in the capsule and first removing the implant separately from the scar tissue. An en bloc capsulectomy removes the breast implant and the scar tissue without cutting into or opening the capsule—but not everyone needs en bloc surgery. “There has been a lot of misinformation concerning the need for an ‘en bloc’ and an increase in surgeons promoting themselves as an ‘expert en bloc surgeon’,” says Dr. Calobrace. “The truth is, only patients with BIA-ALCL, or other tumors need this type of aggressive and often deforming surgery. There is no evidence that this helps anything. In patients with BII or textured implants who desire removal, a precise capsulectomy should be done, which can be dangerous.”

Reconstruction Options

“For women with some of their own breast tissue and very little droop or ptosis, removal alone may be enough to produce a nice, natural-looking result, ” says Dr. Mahabir.

Going Flat

Some women will opt to “go flat,” which involves an aesthetic flat closure, a technique used in post-mastectomy chest wall reconstruction. Once the breast tissue is removed, additional work is required to smooth out any lumps and trim any excess skin to restore an optimal chest wall contour.

Internal Scaffolding

If there are concerns about the patient’s own tissue being able to support the implant, surgeons may employ the use of an acellular dermal matrix or an allograft tissue that acts as a surgical mesh to reinforce the breast tissue and create an internal bra. “There’s also another scaffold that allows the patient’s own tissue to be used to help support the breast fold situation,” notes Dr. Preminger.

Lifting + Filling

To recreate the breasts without replacing the implant, many patients will undergo a fat transfer, a breast lift or both. “For those who had bigger implants before they had children and now have some sagginess, sometimes we will do a breast lift or fat grafting, but there are instances where we don’t want to introduce an inflammatory component to the picture,” Dr. Gordon explains. “We first let everything heal and then go back again about six to 12 months later when there’s better blood supply to do the fat grafting.”

Replacing Implants

Another option for patients who are not suffering from a symptomatic illness is to have the implants replaced. “When performing textured implant removal and capsulectomy, smooth implants are often replaced with or without a breast lift,” explains Dr. Calobrace.

“Newer implants have a better safety profile than implants from 20 years ago, so I also do a lot of cases where I’m putting in a new implant,” Dr. Preminger adds. “I often add fat grafting to the implant which is called a composite breast augmentation to help better cover the implant, reduce rippling, and provide a more natural-looking result.”

First Steps

For those considering breast implant removal surgery, the first step is to have a thorough discussion with your board-certified plastic surgeon about expectations, recovery period, and any potential complications. “We want to ensure each patient understands the anticipated outcome, both for her breasts as well as her overall health,” says Dr. Calobrace. “There are some very good studies underway. Hopefully in the future we will know more, which may help us provide even better counseling to our patients to assist in helping them make the best decision.”

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