Implant Removal & En Bloc Capsulectomy

Blog |  Dr Eddy Dona

Wed 4th Dec 2019

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As a specialist plastic surgeon, I have spent many years performing breast enhancement surgery with implants. During this time, I have also performed countless breast implant removal procedures, with or without replacing implants. However, in recent years I am receiving more and more requests to have implants removed.

The desire to have implants removed is being driven by many factors:

  • Breast Implant Illness
  • BIA-ALCL
  • Implant related complications – eg. rupture, capsular contracture
  • Change in aesthetic preference

What is the Implant Capsule?

When breast implants are initially placed, the body’s natural healing process means that it forms a scar sac around the entire implant. It is a normal process for the body to form a scar tissue layer (sac) around any foreign object. This normal scar tissue lining is the capsule. The capsule effectively seals off the implant from the rest of the body. A normal implant capsule is tissue paper thin and soft and can’t be felt.

In capsular contracture, a problem that occurs in over 5% of women with implants, this capsule layer becomes abnormally hard and thickened for reasons largely unknown. Basically, the capsule becomes thickened and tightens up around the implant, making the breast implant feel hard, become distorted and even painful. So, when a patient is being treated for capsular contracture, the surgeon needs to remove the entire capsule. This is referred to as a total capsulectomy.

A total capsulectomy, or at the very least a near total capsulectomy, also needs to be performed after a woman has decided that for aesthetic reasons, she no longer wants implants. Removing the capsule in this situation allows the breast tissue to “stick back down” to the chest wall and seal up the empty space left by the now absent implant.

 How is a Total Capsulectomy performed?

As previously stated, a total capsulectomy involves removing both the implant and the entire capsule. However, it often involves opening the capsule to do so. This can be done in two ways:

  • Method 1 – Due to the implant size and general technical difficulties, it is sometimes not possible to completely free the entire capsule from the breast tissue whilst the implant is still inside. This is especially the case along the upper part of the capsule which is effectively behind the implant that’s accessible via the small incision. In this situation, I’ll free up as much of the capsule as I can safely do so. Whilst I could make a much larger incision to get access to the top end of the implant, this is usually not an acceptable solution. Therefore, I’ll make a small incision in the capsule just big enough the remove the implant completely. With the capsule now fully deflated I can comfortably free up any remaining attachments it has to the normal breast tissue and then remove the capsule. All this is done via the original smaller incision.
  • Method 2 – If it is possible to free the entire capsule from the breast tissue via the initial small incision, I then need to remove it via that small incision. However, an implant with an intact surrounding capsule cannot be compressed and squeezed through the typically small scar that was used to originally insert the implant. I’ll therefore make a small incision in the capsule just big enough the partially remove the implant from the capsule. By partially removing the implant from the capsule allows the capsule sac to decompress and partially deflate and thus allow me to remove both the implant and capsule together from the small breast incision.

These two different methods of Total Capsulectomy results in both the implant and capsule being completely removed from your body in one operation.

What is “en bloc capsulectomy” and when did it become so important?

The actual term “en bloc” means “as one”, and when referred to breast implants and capsules, it means removing the implant and associated capsule as one whole, without opening the capsule and exposing the implant during the procedure.

As far as the end result is concerned, it is a form of total capsulectomy, but performed in a more complicated manner than a routine total capsulectomy.

This is typically an operation requested by those who have breast implant illness (BII), but it also necessary for those with ALCL.

Regarding those with BII, the actual origins of why an en bloc capsulectomy became necessary is hard to determine. However not exposing the body to the “contaminating” implant during the explantation surgery is considered to be one of the keys to success in the treatment of BII.

Unfortunately, it has become a somewhat “hot topic” amongst women wanting implants removed. Furthermore, it is being marketed by some surgeons who often don’t fully understand the precise nature of the surgery and the significant potential complications associated with it – or if they do understand it, they are not discussing these with there patients.

What are the DANGERS & PROBLEMS of en bloc capsulectomy?

A total capsulectomy is typically a far more complex and difficult operation than a routine breast augmentation operation. It involves removing the implant and capsule during the same operation, although often not removing them as one whole.

As stated, an en bloc capsulectomy is a Total Capsulectomy, but performed in a more complex manner. It involves removing the scar tissue and the breast implant in one piece without opening the capsule. In other words, the capsule is not opened at any stage and the capsule is removed completely intact with the implant still inside. However, this is often not even possible. Whilst I would always intend to remove implants en bloc, certain issues that you can only determine during surgery make it sometimes impossible to do.

Bigger scar – as stated previously, to do an en bloc capsulectomy typically requires a MUCH LARGER incision than the usual incision required for a breast augmentation or normal total capsulectomy. The larger the implant, the larger the incision. That is, an en bloc capsulectomy warrants a very large scar – 3 or more times longer than my usual scar! Of course, when performing a capsulectomy as part of say a breast reduction or breast lift, that’s not an issue because you have large wounds that you can use, but without that then it’s a little bit too much to expect a women to accept a very large scar.

It is often not technically possible to perform a total capsulectomy, let alone an en bloc capsulectomy – If a surgeon claims they ALWAYS performs en bloc capsulectomy, then that simply means they have never done one, or they are being dishonest!

  • The normal capsule is typically very thin and with an implant placed under the muscle, often the capsule attached to the chest wall is typically fused to the chest wall ribs and muscles. To remove the capsule here would involve serious risk. It would involve damaging the ribs, significant bleeding with a high risk of puncturing a lung which lies just beneath the capsule lining here. This issue is something that can only be determined during the surgery. These patients will end up having a Sub-Total Capsulectomy.
  • Another example where it would not be possible and safe to perform an en bloc capsulectomy would be when the breast tissue and skin is extremely thin. To remove capsule in this situation could cause a number of complications, including causing the overlying skin to die. These patients will also end up having a Sub-Total Capsulectomy.

If I am doing a capsulectomy and cannot remove the entire capsule, I will cauterize any remaining capsule left in the body. I do this for several reasons, including to make it “rough” so the area can seal and close up the empty space left by the now absent implant.

Does breast implant removal “cure” BII symptoms?

No scientific evidence exists to support that BII exists. Therefore, no scientific evidence exists to demonstrate that removing implants cures BII. However, for many women removing their implants have resolved symptoms. To complicate matters, zero scientific evidence exists to show that any difference exists in “curing BII” between:

  • Implant only removal
  • Implant removal with Sub-Total Capsulectomy
  • Implant removal with Total Capsulectomy
  • En Bloc Capsulectomy/implant removal

But even in the cases where symptoms persist, at the very least implant removal typically provides peace of mind, and this appears to be especially the case in those who have had an en bloc capsulectomy.

Ultimately, breast implant removal is performed to see if breast implants are a factor in your BII symptoms.

Your surgeon of choice very important!

As stated earlier, it is easier to do a routine breast augmentation then it is to do a total capsulectomy. So, if you think it’s difficult finding a good surgeon to do breast augmentation, then it will be far more difficult to find a quality surgeon who can remove them properly and safely. You need to choose a surgeon with extensive experience in implant removal.

If you have only one goal in mind – an en bloc capsulectomy – and you “go shopping” for a surgeon who performs and guarantees you en bloc capsulectomy, then you’re probably not going to find the right doctor!

As a Sydney Specialist Plastic Surgeon, I’ve treated many women over the years removing breast implants for all manner of reasons. Many of these cases we have recorded with our patients consent and some of these videos can be found on our YouTube Channel, so if you’re watching this on our YouTube channel check out the links below to some of those videos.

If you no longer want your breast implants or have health concerns related to them, contact my office to schedule a one on one consultation with myself, and let’s talk about it.