Bay Area & Oakland California (CA) Capsular Contracture Surgeon
Breast explantation refers to the removal of a breast implant with or without the immediate or later replantation. Reasons for explantation are many, the most commonly sited in my office is the unfavorable complication of a painful capsular contracture.
The incidence of capsular contracture in the United States approximates 12% per patient. It appears that this incidence is lower for saline over jel, textured over smooth and under the muscle over over the pectoral muscle re. implant placement. Not to be forgotten, there is the significantly higher incidence of capsular contractures in women who have breast fed within 6 months of implant placement. Often, patients do not know whether or not they they have a capsular contracture. Some believe it is normal that the implant feels hard and the breast and chest feels tight with shoulder extension. In fact, this is quite abnormal after the first few days following surgery. The American Society of Plastic and Reconstructive Surgery and the two US FDA approved implant companies: Mentor and Allergan both do not endorse attempts to break a capsular contracture using mechanical force across the chest wall. However, early and educated massage of the pocket following augmentation appears to be at least partially preventive in the development of a symptomatic capsular contracture.
The concept of implant replacement because of the age of the implant is controversial. Clearly, most silicone jel implants which were placed in the 70’s and 80’s at some point will rupture and the removal thereafter may be difficult without performing a near-total capsulectomy. Ideally a capsulectomy should not include that portion directly beneath the nipple areola complex for fear of loss of blood supply and sensation to the nipple areola area. Further, once an implant has ruptured there is a higher incidence of capsular contracture. Once a capsular contracture has formed even after capsulectomy the incidence of recurrent capsular contracture has been reported in excess of 30%. If this is true, then the question arises, why wait for this difficult situation. Perhaps, it would be better to replace a jel implant before it ruptures and then place a new implant in the same pocket, providing the pocket is soft, thus avoiding the added surgery, pain, recovery time and cost of a capsulectomy.
Breast Explants, Surgery, Photos, Breast Explantation, Breast Explant Surgeons
However, it is my opinion the same is not true for saline implants. At worse a saline implant might partially deflate. The contents, a salt water solution isotonic to blood, is resorbed without consequence. So, periodic exchange of saline implants, unless there is an unfavorable result, or a specific desire to replace for cosmetic purposes, does not make sense to me.
Chronic pain following augmentation is an important complaint not to be disregarded by the surgeon. A few years ago it was advocated to partially elevate the muscle called the Serratus Anterior at the time of the augmentation or breast reconstruction in order to provide some lateral support to the implant. It has since been discovered that this may lead to pain in the lateral chest wall, which will not subside until the implant is removed.
Insurance company criteria for payment of breast explantation, as a covered benefit, may vary. As a rule, most US insurance carriers will pay for the removal of a cosmetic surgery – related breast implant, providing that the implant is associated with documented chronic pain and suffering. However, replacement of the implant is not a covered benefit except in cases of breast reconstruction for either breast cancer or a congenital malformation of the chest wall.
Aesthetic explantation refers to the removal of an implant with minimizing disfigurement. Typically explantation leads to a flattening and hollow above the nipple and a laxity, sagging narrowing of the breast and skin below the nipple and areola. I have found that by simply performing a breast lift, termed mastopexy, the breast is restored to a better shape and albeit a smaller breast. Then, at a later date, should the patients desire change, a reaugmentation can be performed safely and in a staged fashion.
The author is aware of the recent concern regarding the possible formation of a rare form of lymphoma within the capsule of breast implants. To date, there are a total of 60 reported cases of anaplastic large cell lymphoma in the 5-10 million women world wide who have breast implants. All cases were contained by the implant capsule and did not invade surrounding tissue. The median time from implantation to clinical diagnosis is 8 years. The implants involved are both silicone and saline. Four of the 34 case reports world wide, since 1997, specifically described the implant surface and all 4 implants were noted to textured, suggesting that texturing may have a role in the causation of this rare tumor. Further studies are underway to confirm whether or not texturing has a role in causing the disease process. The current recommendation by the FDA is not to remove textured, or for that matter, smooth breast implants at this time.” For additional information click here.
Important update about Poly Implant Prothese (PIP)
The recent concern over Poly Implant Prothese (PIP) implants from France has created a concern over whether or not the saline and silicone implants will leak (reported 11%) and also possibility of causing a non Hodgkin’s Lymphoma, called Anaplastic Large cell Lymphoma (ALCL), with one reported death in France.
MRI imaging provides 87% sensitivity, 91% specificity as to whether or not there is a silent rupture in the case of gel implants in general. The breast implant shell consists of a silicone elastomer with a high level of cross linking between the polymers, whereas the filling of the implants consists of silicone gel with a lower level of cross linking.
PIP silicone breast implants were made with three different types of shells (smooth, textured, and micro textured) and at least three different types of gels (NUSIL, PIP1, and 22 PIP2). PIP1 gel was used before 2008, and PIP2 gel was used after 2008. In addition the barrier layer was removed from the shell in 2007. The silicones used in PIP silicone breast implants were not the CE marketed Nusil (MED3-6300) that was indicated as a component in the files on PIP silicone breast implants.
The Nusil silicones were substituted by other types of (industrial) silicones. The PIP silicone gels contained significant levels of silicones with low molecular mass. In addition, thermographic analysis showed that the PIP gels were much less stable than the Nusil gel.
The European Commission Scientific Committee for Safety Hazards published a report on February 1st 2012 which indicates there may be an increased risk of ALCL for the PIP implants. The authors recommendation is that any patient who is plagued by uncertainty and anxiety should have the PIP implants removed.
For patients who want definitive information regarding the patency of the implant an MRI should be performed, and if this is normal and there are no problems associated with the implant it can be observed or replaced with a non PIP implant. The Mentor Corporation is currently offering a $250 gift certificate (until Dec 31st 2012) to patients requesting exchange from the PIp implants.
