Our new series, Closer Look, takes a deeper dive into the controversial, critical, and of-the-moment issues facing doctors and patients in aesthetic medicine.
Breast implant illness (BII) is the name for a constellation of symptoms, which thousands of women have come to attribute to their breast implants—silicone and saline, textured and smooth. Maladies range from brain fog, memory loss, anxiety, fatigue, and joint pain to autoimmune diseases, skin rashes, hair loss, and more. BII is unrelated to BIA-ALCL, the rare lymphoma associated with textured implants.
Because BII itself is controversial and enigmatic—it’s not an official medical diagnosis, and there are currently no laboratory tests to prove or disprove its existence—patients often turn to social media support groups and BII websites for guidance and understanding. Within these robust communities, women share their implant journeys and encourage explant surgery, or breast implant removal, as BII’s only cure. They serve as advocates and advisors, swapping recommendations not just for explant-savvy plastic surgeons but also specific surgical techniques, detox protocols, genetic testing, explant pathology.
The plastics community is divided on the validity and safety of many of the ideas promoted within BII groups. As part of our Closer Look series, we’ll be exploring various hot buttons, starting here with appropriate techniques for removing breast implants in cases of BII.
Breast implant safety, science-defying symptoms, a driving desire for disease validation—these have been among the most durable threads composing the breast implant illness (BII) narrative.
But over the past couple of years, the conversation has shifted to focus sharply on capsules—the body’s scar-tissue reaction to foreign objects, such as implants. While the role these collagen-comprised sacks play in the onset and development of BII is only now being investigated, many patients are convinced that capsules contribute to their infirmity every bit as much as the silicone or saline devices themselves. Cutting out the capsules—every last trace, they insist, and in a very particular manner—is as critical to BII recovery as ridding the body of breast implants.
When Bravo’s Botched cast a mainstream spotlight on BII during its season six premiere, this capsule preoccupation nearly eclipsed the momentousness of BII, a once under-the-radar condition, receiving primetime attention. On the episode, reality star Tiffany “New York” Pollard has her implants removed, in hopes of alleviating persistent bouts of diarrhea, dizziness, and panic attacks, which she believes—after seeing “a list going around the internet”—are directly related to her implants. Not long after the segment aired, BII activists took to social media with concerns about Dr. Terry Dubrow’s perceived explant technique.
A post on the Breast Implant Safety Alliance (BISA) Facebook page read: “Thoughts on the latest episode of #botchedtv? Last night they discussed #breastimplantillness with patient #tiffanypollard. We applaud @drdubrow and @drpaulnassif for acknowledging and discussing #bii. This will raise #awareness for sure. But did they #botch the issue of #capsule removal with her #explant of her #breastimplants? We want to hear from you!”
Giving voice to like-minded BII sufferers, one member commented, “The capsule—the next hurdle and great debate. I was disappointed that they didn’t talk about the capsules.” Another follower added, “Yes, they botched the removal of her implants and capsules! Did they even remove the capsules? They never showed that or discussed the importance. They started well, but need to master the art of explant.”
Pollard received similar notes on her personal Instagram, like this one from @bigang18: “I am one of the thousands of women in these support groups with BII. As I watched the show, I noticed something and I felt that I should ask…did they keep the capsule in? It is super important to be removed. You will continue to be ill. The capsule is just as bad if not worse than the implant itself! Plz check that. I hope I was not being intrusive. I’m just concerned.”
Pollard graciously replied, “Capsule is completely removed 🙌🏾 I haven’t felt this good in years!”
Related: 5 Procedures for Higher, Perkier Breasts—From Least to Most Invasive
Breast implant capsules: the new BII battleground
Removing breast implant capsules—via an operation called a capsulectomy—has come to be regarded as imperative in the BII era. But according to Nashville board-certified plastic surgeon Dr. Melinda Haws, “there’s no objective data to prove capsule removal improves the resolution of BII symptoms, nor is there data showing that capsule left behind in a BII patient is dangerous.”
For the record, implant removal itself isn’t a promised panacea either, and the science of explant outcomes is only in its infancy. Still, “many patients are so desperate to get well, they’ll choose to have surgery, even though there’s no scientific evidence supporting the treatment,” says Dr. Marisa Lawrence, a board-certified plastic surgeon in Atlanta.
The average BII patient not only demands a capsulectomy with explant but also insists that a controversial surgical technique, called an en bloc resection, be executed. Now, if a woman believes her implants to be a source of malice—“toxic bags,” as they’ve been dubbed by BII groups—it’s easy to see why she’d rule the surrounding capsules guilty by association. But how are tens of thousands of laywomen hearing about the specific maneuver that is en bloc?
Dr. Haws, who fielded her first en bloc ask about two years ago, says the trend is being “perpetuated [mostly] by well-meaning patient advocates as well as by some [doctors] who’ve used this as a marketing term [to attract patients].”
Oftentimes, women first learn of the procedure in patient-run Facebook groups or on affiliated websites like Healing Breast Implant Illness, which serves as a major BII resource center and information hub. Indeed, the site’s explant page, which many take as gospel, offers this strongly worded directive: “No matter what you read or are advised by a plastic surgeon about explant of breast implants, if you are symptomatic, all breast implants should be removed EN BLOC if possible and always with a TOTAL CAPSULECTOMY, no matter the type of implant.”
The problem is, “most patients don’t have a firm understanding of what these terms actually mean,” says Beverly Hills, California, board-certified plastic surgeon Dr. Kelly Killeen, adding that about half of her practice is dedicated to the treatment of BII patients. “I believe them; I care about them deeply,” she says. “But with these groups dictating how surgery needs to be done, women are being led to morbid procedures and terrible outcomes.”
Before we delve into the dark side of en bloc, let’s zoom in on the technique and how it differs from alternate methods of breast implant removal.
Breast implant removal procedures—and the allure of en bloc
En bloc capsulectomy
Breast implants resected en bloc leave the body with their scar tissue, as a single unit, and the capsules are whole and unscathed. “The capsule isn’t opened until the specimen is removed from the patient,” explains Dr. Lawrence. Therefore, its contents—the silicone or saline implant accused of tanking the patient’s health—do not come into contact with the breast tissue.
Interestingly, the phrase en bloc—from the French, with a literal meaning of “as a whole” or “in a mass”—has long been used in oncology circles to describe a means of removing tumors in their entirety, covered by an undisturbed sheath of healthy tissue, to prevent the spread or spillage of malignant cells. The term was adopted by BII activists and is now bandied about by doctors and patients on Facebook, YouTube, Reddit, Instagram, and RealSelf.
“I really think the en bloc has become something of a badge of honor in the BII community,” laments Seattle board-certified plastic surgeon Dr. Lisa Sowder, whose @breastimplantsanity page explores this and other implant-focused firestorms.
Borrowing from the cancer lexicon was perhaps no accident, as the majority of BII patients view breast implants as equally pathogenic. Though implants can’t metastasize like tumors, they can leak and rupture. Plastic surgeons and implant manufacturers acknowledge the reality of “gel bleed”—small amounts of silicone seeping through unbroken implant shells—which is part of the reason women are growing ever more insistent about having their implants taken out en bloc. “They’re concerned there are toxins in the surrounding capsules [that] need to stay contained and that the capsules need to be completely removed for healing [to occur],” says Dr. Lawrence.
BII patient advocates promote the en bloc technique by asserting that “keeping the implant within the capsule until it’s out of the body keeps all that toxic material wrapped up.”
For Kingwood, Texas, board-certified plastic surgeon Dr. Philip Straka, gel bleed and even less obvious forms of “leaching” are among the many reasons he encourages BII patients to seek en bloc removal. “It’s been shown that silicone as well as platinum can leak through even intact implant shells and enter the capsule,” he says, adding that en bloc explantation is “by far the most requested procedure” in his practice today.
Meanwhile, physicians like Dr. Sowder maintain that “in many cases, there’s nothing discernible between the implant and capsule,” and the en bloc procedure simply isn’t always warranted.
Everyone agrees, however, that “it’s far preferable to remove the implant and capsule as one unit when there’s a ruptured silicone implant, as it prevents gel spill into the [breast] pocket,” explains Dr. Haws. Silicone is sticky—and if it were to ooze out of the implant into the chest, extricating it from the tissue would be a chore. Plus any left behind could “lead to hard scar nodules, called silicone granulomas, or spread to local lymph nodes,” says Dr. Straka. So surgeons strive to keep ruptured gel implants contained during explant.
Total capsulectomy
A total or precise capsulectomy is a form of implant removal where the capsule is perforated while still inside the body, the implant is removed, and then all the scar tissue is dissected out through a short incision in the natural fold of the breast.
A key distinction between en bloc and total capsulectomy: with the latter technique, the integrity of the capsule is deliberately compromised, allowing surgeons to get the implant out of the way early so they can see all sides of the capsule clearly during dissection rather than cutting blindly around the vision-obstructing implant, potentially causing internal injuries.
While surgeons see this safety measure as an advantage, BII patients count it as a strike against the total capsulectomy. Breaks in the capsule, they argue, make neighboring tissues vulnerable to contamination.
Partial capsulectomy
With a partial capsulectomy, scar tissue is removed incompletely and, typically, in pieces. The BII crowd generally opposes the partial capsulectomy, presuming that any capsule left behind will continue to trigger symptoms.
Women who encounter this advice too late or have unresolved symptoms following explant, are reportedly signing up for second surgeries—sometimes of the exploratory variety—to ensure that every hint of capsule has been removed, even though “locating and removing trace portions of capsules left behind is much more difficult and risky than performing a primary capsulectomy [at the time of explant],” warns Dr. Straka. And, to reiterate, there are no studies showing that removal of the capsule helps alleviate BII symptoms. “I personally have patients who’ve had only their implants removed and not the capsules, and their symptom resolution was just as good as those who had an en bloc,” says Dr. Haws.
Many misinformed BII patients view doctors who leave in capsules as unscrupulous or unskilled.
Related: Not Knowing This Before Getting Breast Implants Turned the Procedure Into One of My Biggest Regrets
Dueling definitions and the confusion surrounding en bloc
Semantics, it seems, plays an integral part in the en bloc controversy. “Doctors are misusing the term,” says Dr. H. Jae Chun, a board-certified plastic surgeon in Newport Beach, California, who specializes in explant surgery exclusively, performing upwards of 10 a week (which he fastidiously documents on his Instagram). At first glance, Dr. Chun’s grid resembles a sort of an en bloc museum, with near-identical specimens all in a row—but his captions tell a different story. While he almost always delivers capsules and implants together, as a single entity, explants fit his strict definition of en bloc only if they “don’t have a single tear anywhere in the sack,” he notes.
But across social media, surgeons are interpreting the term more loosely. “They’re putting up pictures where, yes, the capsules are draped over the implants, but they’re all shredded—and they’re calling that en bloc, because their definition is capsule around implant. They don’t go one step further and ask, ‘Are there any holes in it?’” If everyone were speaking the same language, he adds, “patients wouldn’t be coming away with the wrong impression of what’s being done.”
But as things stand, “women are often told, incorrectly, that if an implant doesn’t come out en bloc, then something was left behind,” Dr. Chun says. Which is why patients are often quick to dismiss any surgeon who won’t flat out commit to an en bloc during consultation.
“En bloc has become this hyperfixation,” says Dr. Killeen. “Patients believe this one part of the operation means the difference between them getting better and not getting better—and that’s just not true.”
Through his photo series on Instagram, Dr. Chun aims to educate patients about what’s possible during explant surgery. “I want to make sure they understand—this is not something where you tell your doctor, ‘I want an en bloc, because that’s just what I want.’ A total capsulectomy—getting the entire capsule out—is what you can request,” he says. And it’s what he guarantees every BII patient, believing it vital to eliminate all foreign materials that the body might react against.
But for an en bloc to be feasible, the implants and capsules need to fit certain criteria. First, “it’s much easier to achieve an en bloc removal when the implants are placed above the muscle,” says Dr. David Rankin, a board-certified plastic surgeon in Jupiter, Florida, who’s on track to log more than 400 explants by the end of 2019. The condition of the capsules matters even more: while those that are thick, calcified, or contracted often lend themselves to en bloc—“they peel off easily, like the rind of an orange,” says Dr. Sowder—diaphanous capsules that are glued to the chest wall tend to shred during dissection, disqualifying them from true en bloc status.
The success of an en bloc primarily “depends on whether the tissues cooperate,” says Dr. Chun. Over the past 25 years, he’s performed close to 5,000 explant surgeries—about 25% in en bloc fashion. “If you have capsules that are like wet toilet paper and stuck to the rib cage, they’re not coming out without tearing,” he notes.
What’s more, “en bloc doesn’t always give more value,” he concedes. “If you have intact saline implants, I don’t think en bloc gives you a better result than a total capsulectomy. But if you have old, ruptured silicone implants—now, that’s where the en bloc is worth its weight in gold.”
Board-certified plastic surgeon Dr. Lu-Jean Feng, an in-demand explant specialist in Pepper Pike, Ohio, also considers a total capsulectomy essential for restoring the health of women with BII. “I tell patients, I will take out all the capsule, but if en bloc means total intactness of the capsule, that’s not always possible,” she says. “When capsules are thin, it can be very hard to maintain the en bloc—nobody can do that. I have probably the most experience in the world doing capsulectomy, and it’s just not possible to do an en bloc every time.”
Fulfilling her total-capsulectomy promise sometimes means rooting out scar tissue “extensions” that have grown beyond the original implant locale to invade adjacent structures. “You need to uncover the normal fat, breast tissue, and muscle by peeling off the scar tissue,” she explains. However, “the danger of en bloc comes from removing normal tissue—that’s how you can get inside the chest.” While she has never encountered this complication, she says, “you have to really respect the presence of the muscles that run between the ribs.”
En bloc or bust: when the risks outweigh the benefits
Since “there’s absolutely nothing in the literature supporting total or en bloc capsulectomy [in cancer-free patients],” says Dr. Sowder, most surgeons err on the side of conservatism, endeavoring to remove implants en bloc only when conditions are utterly ideal. But then there are those who are less selective and indiscriminately offer the en bloc, reputedly to appease BII patients who are set on the surgery. This is where things can get dicey.
“If a doctor is too aggressive in trying to achieve an en bloc when a total capsulectomy gives more visualization, then an exposure of the lung could be an unfortunate circumstance,” says Dr. Rankin.
A punctured or collapsed lung, the most dreaded complication of en bloc, can happen when implants are placed below the muscle and the capsule is thin and stuck between the ribs, explains Dr. Lawrence. Lung leaks are being reported more frequently, she notes, as inexperienced surgeons are trying to perform en bloc resection without good visualization.
Separating the implant from the capsule, as is standard with a total capsulectomy, “makes the dissection easier and more accurate, so we can get the capsule out without trashing the breast tissue, the pec muscle, or the rib cage,” adds Dr. Sowder.
While some surgeons approach every BII case intent on delivering an en bloc, prudent providers don’t hesitate to pivot when the desired en bloc suddenly seems untenable.
Dr. Straka is one who attempts to do an en bloc procedure in 100% of cases, he says, “treating every explant as if it were a ruptured silicone implant” and falling back on a total capsulectomy only when need be. That said, he fully admits that “there are times when even a total capsulectomy cannot be performed—like if a portion of the capsule has basically incorporated into a rib and just physically cannot be peeled.” In such cases, he’ll use electrocautery to disintegrate the remnants rather than pressing on with excision. “It’s better to leave a trace of capsule when you feel that being more aggressive could lead to a devastating complication, like lung puncture or nerve injury,” he says. He recognizes the diagnostic conundrum that results, however, when scar tissue is left behind and patients fail to improve: “it becomes unclear whether symptoms persist due to the retained capsule,” he says.
While some surgeons worry about extensive use of cautery and the internal wounds it may create, Santa Monica, California, board-certified plastic surgeon Dr. Steven Teitelbaum assures us “that if you can’t excise [all of the] capsule, destroying its remnants is an alternative, and [doing so] does not affect the function of anything whatsoever.”
Lesser risks of en bloc include delayed wound healing; changes in nipple sensation; and cosmetic issues, like breast contour irregularities and disfiguring scars. “An en bloc can require an 8–11 centimeter incision [along the breast fold], depending on the size of one’s implant,” says Dr. Teitelbaum. “I’ve seen explanted women maimed, with horrible scars across their lower breasts.” (The lengthy incision is needed to see around the implant during dissection.)
Some doctors argue that the en bloc may also prolong operating time, hiking anesthesia risks. “I’ve heard surgeons brag about spending nine hours doing an en bloc,” says Dr. Sowder, “when it’s been shown that the longer you’re on the table, the greater your risk of a whole bunch of complications.”
Compounding the en bloc controversy, there are explant surgeons who feel the risks are highly overblown. Like Dr. Feng, Dr. Chun claims to have a pristine record when it comes to serious en bloc complications. “I do a lot of explants, and I don’t see these complications. Are they possible? Absolutely. Every procedure has risk. But I have never, in my 25 years, punctured a lung,” he says. The only problem he’s encountered following explant surgery is late bleeding, which occasionally requires patients to revisit the OR. “It happens about 1% of the time—and only to those who are trying to do too much too soon.”
While he agrees the en bloc technique can incur quite a scar, he refutes allegations that it can jeopardize patient safety by extending time on the table, noting that his average capsulectomy takes 1.5–2 hours, “depending on how tight the capsule is,” he says.
To address the purported dangers of attempting an en bloc, Dr. Chun is currently collecting data from one year’s worth of his explant surgeries. “I’ll present consecutive cases, so I’m not cherry-picking, and I’ll show you can do this surgery consistently without problems,” he says. He hopes to share his findings at the next American Society of Plastic Surgeons (ASPS) meeting.
Related: The FDA Recommends New Warnings for Breast Implants
The science so far: Does en bloc removal make a difference?
Is implant removal a definitive cure? Must the capsule come out? Should en bloc be the goal?
While, to date, there are no published studies exploring these questions, plastic surgeons are now initiating explant trials to delve into BII’s origin, targets, and ideal treatment options.
Dr. Lawrence has tracked more than 300 BII patients in her practice and found that 86% report partial relief of symptoms at three months post-explant and 95% at 12 months. “The symptoms most likely to improve include fatigue, cognitive dysfunction, hair loss, visual disturbances, muscle and joint pain, and anxiety/depression,” she says.
With her first 100 explants, she was able to do an en bloc capsulectomy in 69 patients and a total capsulectomy in 31 patients. When she tracked the resolution of symptoms at three months and 12 months, there was no difference in relief between the two groups. “I’m currently looking at my second batch of 100 patients, and the results are similar,” she notes. “An en bloc capsulectomy does not appear to be necessary for improvement of BII symptoms.”
This past September, at the annual ASPS conference, Dr. Feng presented research charting the 11 most common complaints reported by 742 of her BII patients. The severity of each symptom was graded on a scale of 0 (least) to 5 (most), for a max total of 55. In Dr. Feng’s pre-explant patient group, the average symptom score was 27. Following total capsulectomy, the average score dropped to 7—and “held there for the first and more distant follow-ups, up to 200 days after surgery,” she says.
Probing capsules for clues
The Aesthetic Surgery Education and Research Foundation (ASERF), an offshoot of The Aesthetic Society, is presently funding a study that will examine the capsules of women with BII as well as those of asymptomatic women. “All patients and their samples will be de-identified so we can objectively compare the two groups and really look at the pathology, the microbiology, and the heavy metal contents of the capsules, as these are some of the biggest areas of concern for both patients and surgeons,” explains Dr. Haws.
Indeed, explant pathology has become such a hot topic, experts say, because many BII patients fear the presence of microbes in and around their implants.
Which is why, even when women aren’t formal study participants, their capsules are routinely sent to pathology for analysis. Some surgeons also swab breast pockets for stray microorganisms after the chest has been vacated and flushed out with antibacterial solution. Other doctors send only suspicious capsules for testing, unless the patient requests otherwise. Most vigilant surgeons now systematically test all capsules from textured implants, to definitively rule out ALCL.
Dr. Killeen forwards “all specimens removed from the breast” to pathology. For BII patients, especially, she orders a test that looks for about 30,000 different strains of bacteria and 14,000 types of fungi. “While I have never seen fungus in the breast ever, the majority of women I see get better [after explant] do have bacterial contamination around their implants,” she says. “The significance of that we don’t truly understand yet, but this biofilm may be contributing to some women’s symptoms.”
Once implants and capsules are out, the body tends to clear any lingering bacteria (and consequential infections) on its own, and “most patients do feel better in the immediate post-op period,” Dr. Killeen adds. The need for antibiotic therapy after surgery is yet another topic of debate among doctors who care for BII patients.
Dr. Lawrence also sends every BII capsule to a lab “for DNA sequencing, to identify the current or past existence of bacteria or fungi in the capsule,” she says, noting that 31% have tested positive for bacteria, and fungi were identified in three patients’ capsules.
Dr. Straka has also had cultures come back positive for fungi and says that such findings underscore the importance of the en bloc technique for BII patients.
“I have never seen mold in implants and think finding a fungal infection is highly unusual,” asserts Dr. Feng. “We’ve studied many black specks inside of implants, and most of the time, they’re iron deposits from degenerated blood that perhaps found its way inside the implant during the instillation of saline, which sometimes introduces blood into the implant valve.”
In her experience, capsule pathology generally reveals “not an infectious picture but a foreign-body reaction”—the presence of silicone particles plus various types of immune cells. Since Dr. Feng has found that “some patients who are symptomatic may have weak detoxification genes,” she often prescribes various supplements and dietary changes to “optimize detox” and help quell inflammation. This practice, we should note, is also incredibly controversial.
While the presence of silicone in capsules is, no doubt, alarming for patients, the potential health implications of this fact are still unknown, says Dr. Killeen.
The bottom line on the benefits of en bloc
“Since the etiology of BII is not known at this time, it’s impossible to say for sure what role the capsules play in the disease process,” Dr. Lawrence reiterates. “We need controlled studies to determine whether all capsule tissue needs to be removed with the implants in our BII patients.”
In the absence of definitive data, plastic surgeons remain divided on the value and potential perils of the still unproven en bloc procedure.
In Dr. Chun’s estimation, the risks are exaggerated and largely theoretical. He believes surgeons who bemoan the dangers of en bloc either “don’t feel comfortable doing it, don’t like doing it, or don’t believe in BII and [therefore] don’t see the point in removing capsules.” There are other explant specialists who share his assumption. Yet the en bloc–wary surgeons interviewed here vehemently deny those charges and emphasize that aiming for an en bloc in every case, when there’s no proven benefit, is essentially a fool’s errand.
This is the crux of the matter: while doctors overwhelmingly report improvements in patients following implant removal and capsulectomy, even surgeons who unequivocally encourage en bloc cannot say with complete certainty that the technique positively influences patient outcomes. Drs. Straka and Rankin, for example, estimate that at least 90% of their BII patients experience significant relief in the majority of their symptoms. Yet both admit they don’t see a difference in those who resolve via en bloc versus total capsulectomy. However, notes Dr. Straka, “patients who don’t have an en bloc tend to experience more anxiety after surgery.”
And rightly so—they’re being told, after all, that recovery is improbable when en bloc proves impossible, which is clearly not the case. The BII community’s illusions about en bloc are hurting women, contends Dr. Killeen. “A patient will go into one of these so-called support groups after surgery and say she had a total capsulectomy, and she’ll be immediately attacked by 10 people telling her she’s made bad decisions and she’s never going to get better—and that puts her in a very negative headspace, where she’s going to have a more difficult recovery from surgery.”
What exactly happens to women who invest thousands of dollars and untold emotions into explanting “properly,” only to discover … they still feel sick? “We’re not really sure,” says Dr. Killeen. “They’re often shunned by BII groups and told they’ve done something wrong—but maybe they didn’t get better because there was something else going on with their health.” (We hope to investigate the fate of these patients further in a future column.)
Determined to quash fears and misconceptions, “many of us have made it our mission to inform women with BII that no doctor should ever guarantee an en bloc,” says Dr. Haws. “If a doctor says it may be unsafe to perform the procedure, that doesn’t mean they’re less qualified to take care of you. It means just the opposite—your health and safety are their top priorities.”
