En Bloc Breast Explantation: When Should It Be Considered? (Part II )

Part 2 of 2 of a series relating to En Bloc Breast Implant Explantation. In Part l of this article, I described what an en bloc breast explantation is, as well as who are qualified candidates. To reference part one, click here.

What is En Bloc breast implant explantation? – Written by Dr. Jed Horowitz

In the first part of this article, I discussed what En Bloc implant removal is and how it is different than other types of explantation and complete or total capsulectomy. I also reviewed the conditions in which En Bloc Explantation should be performed by a Board Certified Plastic Surgeon.Examples include women suffering from symptoms consistent with Silicone Toxicity or Breast Implant Illness (BII). En Bloc Breast Implant removal should also be considered with BIA-ALCL or Breast Implant-Associated Lymphoma. In this part of the article, I will go over the preparation for surgery and a description of the procedure. I will also review the general costs for surgery and options for treating the breast after implant removal.

Preoperative Preparation

En bloc explantation and associated procedures are generally performed with a general anesthetic. The surgery is normally an outpatient operation and recovery can be done at home.Overnight care and a variety of after-stay facilities are available for our patients, many of who travel from out of town.The final preoperative preparations are performed two weeks before surgery to allow time for any additional laboratory or medical care that may be needed. This part of the surgery is the same for all of our patients having a general anesthetic and are based upon age and existing medical conditions. Medical problems such as hypertension, diabetes, the cardiac or pulmonary disease will require clearance by the appropriate specialists.

Laboratory testing specific to the breast surgery may include ultrasound, mammogram and MRI examination. There are no tests specific to BII however some lab tests may be abnormal and related to specific body systems and conditions. This may require enlisting an internist, endocrinologist, gynecologist, rheumatologist, and infectious disease consultant among other medical specialties.

Standard tests based on each patients signs and symptoms may include but not limited to:

Autoimmune markers (ANA antibodies, NK cells {Natural Killer white blood cells}), CBC, B12, folate, and iron metabolism. MTHFR and associated DNA markers. Chemistry panel with all electrolyte levels. Thyroid and parathyroid function, Sed rate, Crp-c, and other inflammation markers.Adrenal hormones, estrogen, testosterone, progesterone, and other hormone levels and function. Unusual infection disorders such as HIV, lymes, fungus, 1,3 beta-D–Glucan testing (fungitel) , immunoglobulins (IGG, IGM), Herpes, mold biotoxins, mycoplasma, and candida.

There are no blood tests that check for levels of silicone. Some laboratories test for sensitivities to by-products of silicone used through the manufacturing process but the conclusions of these studies may vary with the patient and type of implant. However, for a patient suffering from the signs and symptoms of Breast Implant Illness, this additional information, along with other allergy testing may provide some insight into chemicals and other environmental agents which can be contributing to their disorder. It may be useful for a woman, with such symptoms, to obtain much of this evaluation before surgery to monitor the effect of En bloc explantation.

En Bloc Total Capsulectomy: Procedure

The surgical procedure is generally performed using an inframammary incision which is about 9 cm. long. This is significantly longer than the 3.5-4.5 cm incision most often used in the breast fold. This incision must be longer to remove the capsule intact with the implant, which is often encapsulated and less compressible. The goal is to avoid opening the capsule and releasing any free silicone gel which may be present. Photos will be taken of the intact capsule with the implant inside and then opened to show the content of the capsule.

One problem that may arise occurs when the capsule has been broken at some point and gel allowed to move into the surrounding tissue.The silicone may be within the pectoralis muscle, the chest wall, the lymph nodes, breast tissue or surrounding fat. It is important to discuss with your surgeon how this situation will be handled in the operating room. Aggressive surgery to remove this additional silicone can carry much higher risks of bleeding, deformity, damage to surrounding structures including the chest wall, lymphatics, nerves, and even the lungs. Benefits of any surgery should always outweigh the risks. There will frequently be a drain for the early healing period. The removed capsule may be sent to pathology for examination and the implant to the manufacturer for evaluation. If you desire to keep the implants and send them to a private lab of your choosing, you must let your doctor be aware to provide you with these devices immediately after surgery. The surgery center will otherwise dispose of them.

The appearance of your breasts after capsulectomy will most likely change significantly. This will depend upon how much breast tissue you have, your age, number of pregnancies, amount of sagging, history of breastfeeding and the size of the implant removed. As noted above, the removal of any involved breast tissue and or muscle can create a significant deformity. You also may have a great deal of asymmetry between the two breasts in size and shape.

What options exist after implant removal?

It is often best to treat these changes in a second operation. There may be many options to consider. If the breasts are sagging but otherwise have enough volume then a mastopexy or breast lift is the best option. This may require an incision around the areola or a“lollipop” method that adds a vertical incision. On occasion, the surgeon may recommend an inverted T or anchor incision, however, we rarely perform this operation. Since you will likely already have the inframammary incision, part of this may be used to obtain the best shape.

If a larger breast is desired, the choices become more complex. If the concerns are about any silicone at all and any foreign body being re-implanted, consideration should be given to a Natural Breast Lift ( California Breast Lift®). This method uses your fat to enlarge your breasts in one or more stages. The fat must be removed by liposuction from your body, often the abdomen, flanks or thighs. This will be processed then placed into your breast tissue in multiple layers, like a honey-comb. Usually, about 60-70% will remain permanently as your living tissue. Additional amounts can be added over time as desired. This breast tissue will increase or decrease with changes in weight as do most women’s breasts.

Depending on the severity of your symptoms, some women have opted to switch to Saline Breast Implants. It is important to remember that the “bag” is still silicone and your breast implant illness may continue to be stimulated by this new implant. We prefer to use the Ideal Structured saline implant. This new design feels more natural and similar to breast tissue than the typical saline implants It is not advised for women who have severe symptoms.

There are more aggressive “flap” reconstructions that are used for breast cancer reconstruction and are possible for cosmetic treatments. These can be discussed with your surgeon when appropriate if desired.

What are the usual costs for En Bloc Breast Explantation?

The operation for both sides will generally take 2-3 hours and most patients require a general anesthetic (asleep).The surgery should be done in a certified outpatient surgery center. The surgeons’ fees, anesthesia, supplies, and the operating room will run 5000-10,000 in most major cities. This will depend upon the experience of the surgeon and the city and facility where the surgery is being performed.

Costs for the follow-up surgery will depend upon these same factors and then, of course, the type of procedure being done whether it’s a mastopexy or fat grafting: perhaps a combination of these procedures will be requested.

Conclusion

En Bloc explantation is a specific method of total capsulectomy and implant removal which should be performed by experienced Board Certified Plastic Surgeons. This surgery is generally reserved for women suffering from Breast Implant Illness or BIA-ALCL (which is still modified because of the typical seroma present).

The preparation for surgery is typical of other operations but some specialized tests should be considered. Lastly, costs for the surgery and the options for subsequent correction of the breast to improve the shape, size, and symmetry are reviewed.