Theoretically, could ALCL develop if posterior capsule can't be removed from ribs?

Question

I'm having my 1 year old subpectoral Allergan 410 implants removed. I'm sure I want them out and not replaced. While it is rare, the ALCL cases so far have mostly involved Allergan's textured implants. MD Anderson recommends complete capsulectomy for adequate treatment. Could ALCL (theoretically) develop if the part of the capsule on my ribs is left behind? I understand ALCL is extremely rare, but I am not comfortable with this risk. Is there any way to get the capsule completely removed?

Stacey Folk, MD · Answer

Dear jemaf,We are really just learning about ALCL, and in the decades to come we will likely have a much clearer understanding of this disease. It was first recognized in 1997 and patients that present with a mass rather than just fluid or seroma tend to have a worse outcome. People can also get ALCL who have never had breast implants, and those too present with a mass and tend to have the same poor prognosis. Patients with implants who present with a seroma and have a complete capsulectomy (like you are describing) have an excellent prognosis, so there may be 2 different things going on here. They have also found an association with a specific bacteria named rostonia picidii in bacterial biofilms that might be significant. If you had been diagnosed with ALCL removal of the complete capsule is indicated. If you have only had your implants for a year, and are not having implants replaced, I believe most plastic surgeons would not feel it is important to remove the capsule against the chest wall. If you feel strongly about having this done I am sure your surgeon would oblige, but it can increase the surgical time a little, increase the risk of bleeding, and also of collapsing a lung (pneumothorax), which is why we don't always do it if not needed.It is interesting that overseas they use textured implants the majority of time (around 80-90%), while in the US we only use them 10-20% of the time, yet we have found the majority of the cases (around 250 to date) here. It may be that we are better at identifying the cases.I completely understand your fears, and you should do what makes you the most comfortable. Traditional breast cancer effects nearly one in eight women so routine breast cancer screening and avoiding known risk factors is certainly wise.Best of luck,

Gary L. Ross, MBChB, FRCS · Answer

This is a very difficult question to answer as the number of cases of ALCL are low. The link of my personal guidance to patients is attached below.It is worth chatting through with your PS as this is extremely rare.If you did decide to proceed with removal  - a total capsulectomy would be recommended with the capsule sent for evaluation along with any fluid if present. This will likely give you the ultimate reassurance. It is possible that part of the capsule could be so adherent to the chest wall that it is difficult to remove and you need to run through the pros and cons with your PS should this be apparent during the op.  Usually one is able to remove all the capsule although there may be some scar tissue on the chest wall and it is this scar tissue that is the most difficult to remove. One needs to weigh up the pros and cons of trying to remove every last bit of scar tissue.

Peter A. Aldea, MD · Answer

With a total of 256 cases of real or suspected ALCL cases among the millions of women with breast implants worldwide the likelihood of developing it are extremely low. The disease is thought to be a reaction to the textured surface of some breast implants and can be diagnosed by checking the fluid which suddenly forms months to years after the surgery around the implant for CD30 markers and the cells in the fluid need to be viewed by a specialized pathologist. To my knowledge, there are no reported cases of ALCL related or caused by capsule left behind. ALCL appears to be caused by the implant just as the scar tissue around the implants is caused by the implant. Therefore in attempting to remove a scar which is densely attaches to the rib to prevent an event which is highly unlikely the surgeon is far more likely to damage the spaces between the ribs and penetrate the chest resulting in bleeding and or a dropped lung. I would discuss it with your surgeon. Dr. Peter A. Aldea

Ronald V. DeMars, MD (Retired) · Answer

Good question, and sometimes pieces of the capsule stuck to the ribs behind the implant are not easy to remove. If you are worried, have your surgeon destroy any remaining fragments by burning them with the electrocautery.

Theoretically, could ALCL develop if posterior capsule can't be removed from ribs?

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Answer: Theoretically, could ALCL develop if posterior capsule can't be removed from ribs?

Answer: Theoretically, could ALCL develop if posterior capsule can't be removed from ribs?

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Theoretically, could ALCL develop if posterior capsule can't be removed from ribs?

Answers (4)

Answer: Theoretically, could ALCL develop if posterior capsule can't be removed from ribs?

Answer: Theoretically, could ALCL develop if posterior capsule can't be removed from ribs?

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