EN BLOC BREAST EXPLANTATION: WHEN SHOULD IT BE CONSIDERED?

Part 1 of 2
Jed Horowitz MD
Newport Beach, CA.

What is En Bloc breast implant explantation?

En Bloc breast implant explantation is a specific type of breast implant removal with complete capsulectomy. Total Capsulectomy, although completely removing the implant capsule, may not be the same as En Bloc Implant Removal. En Bloc refers specifically to the complete removal of all of the capsule and implant with the capsule intact. The capsule is not opened during the surgery. This procedure can be performed for silicone gel implants or saline implants. It is more important for silicone implants to avoid spilling any gel content into the surrounding tissues, especially with an implant rupture or silicone implant leak.

A Total Capsulectomy refers to the complete removal of the capsule, often performed in patients with severe breast implant encapsulation but no other symptoms of Breast Implant Illness, BII, or Breast Implant-Associated Lymphoma, BIA-ALCL. Total Capsulectomy often involves removal of the breast implant capsule in pieces. A smaller incision is used and the surgeon may perform this procedure through the areola or inframammary incision. Because the incision is smaller, the capsule is frequently opened during the procedure to allow the implant or silicone gel to be removed following which the remaining capsule is taken out.

The posterior capsule against the patient’s chest (ribs) is sometimes left in place to minimize the extent of the operation. The total capsulectomy or anterior capsulectomy may be sufficient for the patient whose only complaints are encapsulation, firmness, discomfort and cosmetic deformity. However, there has been and continues to be a number of women of suffering from a variety and multiple symptoms that have been associated with Silicone Toxicity. The signs and symptoms can be diffuse, involving multiple organ systems and this creates diagnostic confusion, often mimicking a variety of other medical conditions. Although the majority of patients suffering from toxic symptoms have had silicone gel implants, there is a smaller number who have had saline implants as well.

In the United States alone 250,00- 300,000 patients have had cosmetic breast augmentation for decades. In addition, about 100,000 breast reconstructions with implants are performed annually. Worldwide the statistics for augmentation with Silicone Gel implants or Saline Breast Implants is over 1.5 million women per year in recent years. Whether used for augmentation, replacement, or reconstruction, the majority of breast implants used in the U.S. and worldwide are silicone gel implants. Most women with silicone gel breast implants are satisfied with their result and their decision to have this procedure and do not suffer from associated illness.

Who should consider En Bloc Explantation?

Patients with Breast Implant Illness often have complaints that may include:
  • Fatigue/low energy
  • Cognitive dysfunction (brain fog, memory loss)
  • Headaches
  • Joint and muscle pain
  • Hair loss
  • Recurring infections
  • Swollen lymph nodes and glands
  • Rashes
  • IBS

There are a number of theories as to why all implants and more often Silicone Gel implants initiate these symptoms. As genetic testing becomes less expensive and more widely available, we are identifying genes or genetic deficiencies which make us more susceptible to certain sensitivities. We all know people with sensitivities to certain foods, medications, environmental conditions, metals, plastics, and so forth. Our bodies have protective mechanisms to mount an immune response in the presence of a foreign body. We all have different capacities to do so, and when we have certain illnesses, take certain medications, or have specific genetic patterns, our ability to mount a proper and safe protective defense may be impaired. Auto-immune diseases are conditions in which a person’s immune system mistakenly attacks their own body. The immune system mistakes parts of your body, such as your bone joints or skin, as foreign objects, releasing proteins and antibodies in response. This ultimately may weaken the overall immune system, making you more susceptible to other illnesses.

Implantable medical devices are developed and chosen to be as compatible as possible with our bodies. Examples include Titanium, Surgical Stainless Steel, Gold, and Silicone. There are many examples of products, and devices that are no longer used as science, experience, and technology have evolved. None-the-less, if our bodies can mistake our own tissues as foreign objects, why wouldn’t some patients with Silicone Breast Implants experience signs and symptoms consistent with their body recognizing a large amount of foreign material and mounting some type of immune behavior in response. In the last three decades alone there are likely more than 20 million women worldwide who have had silicone breast implants for cosmetic reasons or breast reconstruction. Implants have been widely available since the 1970’s and more than 50 years since the first breast augmentation. Even if a very small percentage of these women demonstrate a systemic response to these foreign bodies (silicone-gel and saline implants), this amounts to a very large number of patients worldwide every year.

In performing an En Bloc Breast Implant Removal, the goal is to remove all or as much of the foreign body as possible. This is especially true in the case of a ruptured or leaking silicone implant.

Many of the Silicone Gel implants by different manufacturers have shown to have more gel-bleed than others. This is usually seen as a slick or sticky coating around the implant when it is removed, even though the shell is intact. An implant left on blotter paper will often show the bleed through from the implant. The newer cohesive gels seem to have less bleed, none-the-less, when I have re-operated on patients, the cohesive gel often behaves differently in the body and will often show signs of bleed and less cohesiveness on removal.

In Part ll of this article, I will discuss in detail the surgery, pre and post-operative preparation including laboratory studies. I will cover the general costs and options for creating the best cosmetic outcome after the implant is removed.

Jed Horowitz MD

References:

1. Immune functional impairment in patients with clinical abnormalities and silicone breast implants: https://www.ncbi.nlm.nih.gov/pubmed/7570622
3. Is explantation of silicone breast implants useful in patients with complaints: http://link.springer.com/article/10.1007/s12026-016-8813-y#Tab1
4. Balk EM, Earley A, Avendano EA, et al. Long-term health outcomes in women with silicone gel breast implants: a systematic review. Ann Intern Med. 2016;164:164–175.