Types of Breast Explant Surgery

Sara Shunkwiler Breast Implants, Capsular Contracture, En Bloc, Explant
Types of Breast Explant Surgery En Bloc Capsulectomy

Know your EXPLANT TERMS!  Your recovery depends upon choosing the correct type of explant surgery and a skilled, licensed surgeon with experience. If you have any symptoms of Breast Implant Illness (BII), your health could actually get worse if you choose the wrong surgeon and wrong type of surgery. 

For Breast Implant Illness sufferers, the ONLY safe option is En Bloc, a specific type of total capsulectomy.  Keep reading to learn the terms you need to memorize!

Explant Terminology to Know

There are three terms typically used in the language of explant surgery. It is extremely important to understand the differences, particularly in the case of Breast Implant Illness (BII).

Capsule refers to the scar tissue your own body makes surrounding the breast implant. 

Capsulotomy, Capsulectomy, and En Bloc implant removal all have important distinctions.

CapsulOTomy

The word ending -otomy means “to make an incision or cut into”.  Therefore, capsulotomy refers to removing part of the capsule of scar tissue surrounding a breast implant in order to make more space for the implant.  This is NOT the proper technique for explant surgery!

This surgical technique is typically used to modify the scar capsule when capsular contracture has caused the capsule to shrink and harden around the implant.  See the separate post on capsular contracture for more information on causes and treatments. This technique is NOT appropriate for removal of implants in anyone, but particularly in the case of BII.

Total CapsulECTomy

Capsule refers to the scar tissue surrounding the breast implant.  In this case, however, -ectomy means “removal of an anatomical structure”.  TOTAL Capsulectomy is the removal of the entire capsule of scar tissue that surrounds the implant. 

Beware: Total CapsulECTomy may not mean that the capsule is removed INTACT, which exposes your body to toxins!

En Bloc implant removal is a particular type of total capsulectomy where the entire capsule is removed with the capsule intact! En Bloc is the only acceptable type of explant surgery for women with Breast Implant Illness.

En Bloc Capsulectomy

En Bloc is a French term (think ‘in’ ‘block’).  This specific surgery means the surgeon will remove the scar tissue surrounding the implant WITH THE IMPLANT STILL INTACT AND UNDISTURBED.  The scar tissue capsule should NOT be punctured during surgery. 

En Bloc is the gold standard for any breast implants, either saline or silicone.  Removing the intact implant WITH the surrounding scar tissue prevents any chemicals, silicone, and bacteria from being released into your body.  If you have silicone implants, your implants are ruptured or leaking, or if your implants are very old, it is extremely important to contain the toxins within the capsule during removal.

What’s the difference?

Total capsulectomy can refer to removing the implant from the capsule FIRST, and then removing the remaining scar tissue that had surrounded the implant.  This will release any of the toxins in the capsule into your body. 

It is extremely important to remove the scar tissue capsule completely. However, it is equally as important not to allow the toxins within the capsule surrounding the implant to be released into the body during surgery. 

If you have had Breast Implant Illness (BII), you should be more specific than total capsulectomy and choose En Bloc if possible.

Do NOT let your surgeon drain the implant or capsule before removal.  Yes, this is easier for the surgeon, but YOU will pay the health consequences. Not only would you be exposed to toxins surrounding the implant, but your surgeon should be aware of the possibility of BIA-ALCL.

BIA-ALCL

Breast Implant Associated Anaplastic Large Cell Lymphoma (BIA-ALCL) is a type of lymphoma (cancer) associated with textured breast implants. BIA-ALCL is often accompanied by fluid surrounding the implant. See the Consensus Guidelines on the Diagnosis of BIA-ALCL, linked below.

2019-NCCN-Consensus-Guidelines-on-the-Diagnosis-of-BIA-ALCLDownload

What about adhesions?

If you have had your implants for more than a few weeks, your capsule may be adhered to the chest wall and your rib cage. Surgeons who are trained in the En Bloc procedures and experienced in performing the surgery know how to gently separate the intact capsule from ribs and muscles.  Understanding what your doctor plans to do if your capsule is adhered is crucial BEFORE you have surgery.

Be sure to communicate your preferences before surgery, because your surgeon will need to make decisions while you are under anesthesia.  It is possible that your surgeon will find that your capsule is very thin or potentially adhered to the chest wall.  Even in these cases, with the understanding that en bloc removal is a high priority, your surgeon can work to remove the capsule without rupture (Feng, 2019; Chen, 2017).

For more information refer to the video from Midwest Breast and Aesthetic Surgery on the importance of removing the entire capsule.

Communicate BEFORE Surgery

Be informed about explant options BEFORE having surgery. Educate yourself before meeting with a surgeon and take a list of questions to your appointment. Have a written plan that includes what might happen in case the surgeon has difficulty removing the entire breast implant capsule. Review the post on choosing a board-certified surgeon who believes in Breast Implant Illness. These doctors will be more careful about protecting your future health from the toxins inside capsules during explant surgery!

If you have textured breast implants, which are part of the Allergan (and McGhan Medical) recall, ensure that your surgeons are aware BEFORE surgery. If you are not sure, be clear that you expect your implants to be analyzed and proper BIA-ALCL testing done if they are part of the recall.

Request the legal chain of custody for your capsules and implants from the surgeon IN WRITING BEFORE surgery. Keep copies for your records. Be vocal and clear about your expectations.

Be Your Own Advocate!

I requested the legal chain of custody for my implants in writing before surgery. My surgeons did NOT request this information when the samples were sent to the pathology lab. My surgeon excuse was his opinion that there would never be a viable lawsuit related to breast implants.

My surgeons also knew in advance that my textured McGhan breast implants and tissue expanders were both recalled, and I had significant clinical symptoms of BIA-ALCL. They still failed to follow the consensus guidelines for BIA-ALCL diagnosis.

The visual inspection report on my capsules and implants had been sent to the surgeon’s office 3 days after surgery. The Physician’s Assistant finally read the report after my fifth request, a full month later. She declared that the report was “fine” and even then did not give me a copy.

She failed to mention that proper BIA-ALCL testing had not been done, in spite of recalled implants and significant symptoms. Although my surgeon wrote in the surgical record that they sent my capsules to the pathology laboratory for CD-30 staining, they did NOT.

When I asked yet again for the chain of custody on my implants, my surgeon admitted that he did not know where my implants and capsules were located or who did pathology testing on his patients. He was completely unaware that the pathology lab routinely destroys implants two weeks after release of the visual examination pathology report. I requested the legal chain of custody from the manager of the pathology laboratory. She could not provide the document, because the surgeon had failed to request it when sending the implants. It would be illegal to make it up later. In fact, my implants were found in the medical waste bin awaiting destruction. They should have been destroyed 5 weeks earlier, while the surgeon’s office was completely unaware and unconcerned.

You MUST be your own advocate and follow up. I assumed that because my surgeon had glowing reviews about himself and his staff on their website that they were attending to details. I was disappointed to find that both he and his office staff belittled me as “an explanter” and harassed me about asking questions. In fact, my surgeon gathered the entire office staff together to make fun of me at my final appointment. His parting shot was that they “only ridicule some patients”. I am eternally grateful for both surgeons’ medical skills. I’d like to think that at some point he’ll realize that encouraging his staff to make fun of cancer patients recovering from yet another grueling surgery (who also pay their salary) is rude at best. And maybe they will all start paying attention to important details of patient care.

If you are planning explant surgery, you may wish to speak to an attorney BEFORE surgery to ensure that all proper procedures are followed. And be your own advocate, even if the surgeon and his staff make fun of you. You owe it to yourself and your loved ones!

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