Is "Half" en bloc feasible?

Question

I had a consultation with a plastic surgeon because the MRI shows that one of my implants is ruptured and I want to remove and not replace the implants. Instead of "en bloc", he suggested to make a 4cm scar, then, while the implant is still in, cut around the capsule as far as he can reach (leaving the difficult dorsal part where the ribs/lungs are), then take the implant only out, and then go and get the capsule that he cut before. Is this feasible? And does it give me enough safety im terms of silicne leftovers? Of course I like the idea as it would spare me two 10cm scars. Also he mentioned that something that he would (amongst others) use his fingers to separate the caspule from the implant which I find strange.

Don W. Griffin, MD · Answer

Thank you for your question. It sounds like your surgeon is recommending a partial capsulectomy with implant removal. From what you describe him saying, I assume that your implants are placed subpectorally or in a dual plane fashion. You did not say whether or not you have capsular contracture or not which plays a huge role in the decision process with implant removal. If no capsular contracture is present, your implants can be safely removed including all the leaked silicone without needing to address the capsule. If your capsule is thickened, calcified, or has fluid present around the implant, some sort of capsulectomy is usually required. In multiple peer reviewed studies, En Bloc capsule removal has been shown to not be necessary-this procedure removes normal tissue in addition to the capsule. Your surgeon seems to be recommending a partial capsulectomy which is appropriate if you have a thickened or calcified capsule. If the capsule is beneath the muscle, the posterior capsule is attached to the ribcage and this portion is sometimes left in place. Removing it has the potential for more complications and in the same studies discussed above, does not have any different outcomes compared to En Bloc or complete capsulectomy. If there is fluid present in the capsule and you have or previously had textured surface implants, the fluid should be aspirated and sent for cytology to rule out ALCL (SSBI) or other forms of cancer that are associated with these types of implants.

Jon Bradley Strawn, MD, MBA · Answer

When an MRI confirms silicone implant rupture, the surgical priorities (in my opinion) are:
1- remove the implant and 100% of the free silicone2- remove 100% of the surrounding capsule3- prevent further silicone contamination of your healthy tissues.
The technique you described of partially dissecting the capsule, removing the implant first, and then removing the capsule in pieces, is technically feasible, however, when an implant is ruptured, this approach allows additional silicone to escape into the surrounding healthy tissues during removal.
I believe it is much better to remove a ruptured implant "en bloc" or "total intact capsulectomy". This removes the Capsule surrounding the implant and all of the ruptured silicone in one piece and prevents the free silicone from contaminating your health tissues. 
Not all plastic surgeons are committed to removing all of the capsule and/or all of the silicone material from your body. I believe that if you leave that silicone, it will continue to irritate your immune system. In order to do this, the incision does usually need to be about twice as long. 
There are then reconstructive options you may want to consider so that you look good afterwards, including breast lifts and fat grafting. 
In my opinion, especially when rupture is confirmed, the goal should be complete removal of all implant, shell, silicone, and capsule, preferably with zero silicone leak in to the healthy tissues... this requires patience, skill, and commitment from the plastic surgeon. 
Ultimately, safety and completeness should probably take priority over scar length.

Jacob Carlson, MD · Answer

An "en bloc" resection of a ruptured implant with its capsule is ideal, but as you and your surgeon have noted, it is not always the easiest thing to do. If you and your surgeon are trying to limit the size of the incision that is made, the suggested approach of removing the capsule in pieces is reasonable. It's very hard to prevent the leaking silicone to touch the breast tissue somewhere in the dissection pocket, but there are techniques to minimize how much silicone is expose to the breast tissue (e.g. creating a barrier between the capsule and the skin incision, sucking the implant out using a large syringe and high-powered suction, rinsing the pocket out with a copious amount of saline solution). In this instance, I am sure your surgeon will make every effort possible to minimize how much silicone leaks out and remove as much as possible.
Depending on the size of the implant and how firm the capsular contracture has become, a larger incision is usually necessary to remove the capsule "en bloc" simply because the surgeon has to dissect circumferentially around the capsule. Anecdotally, it is easier to do an enblock resection through a periareolar incision than through an inframammary incision, just because of the angles and tissue manipulation that is required from those two approaches.
For patients in whom I am performing a capsulectomy, I always tell them that I will remove as much of the capsule as is safely possible. If your implants are 'under the muscle,' the the posterior (dorsal) portion of the capsule is adjacent to your ribs and intercostal muscles. Digging into the ribs can cause significant pain, and dissecting to deep through the intercostal muscles can cause bleeding that is very difficult to control and/or a pneumothorax - all of which are terribly complications for an elective surgery. Sometimes the posterior portion of the capsules peels off beautifully, but your surgeon won't really know that until they are performing the operation.
Assuming that you and your surgeon elect to proceed with the route of removing the capsule in pieces - obviously he will do his best to minimize how much silicone is left behind. If he employs the techniques similar to the ones described above, the amount of silicone left behind will likely be negligible. But, if some silicone is left behind, you body will react exactly how it reacted to the ruptured implant. Your body will form scar tissue around any remaining large pocket of silicone that is left behind in an attempt to 'wall it off' from your breast tissue.

Laura Roider, MD · Answer

Thank you for your question. The procedure described by your surgeon is more often called a partial capsulectomy and implant removal (Explant). It is common to only remove the anterior capsule to decrease the risk of complications. This does not limit the surgeons ability to remove the implant/silicone from the ruptured implant. 
The only reason the entire capsule MUST be removed is if there is concern for breast implant associated cancers.

Is "Half" en bloc feasible?

Answers (4)

More Breast Implant Removal Questions

Possible Results after Removal - will my breasts look deformed?

Necrosis never went away after removal and reduction - what can be done to treat this?

Breast Explant and lift w/cardiac issues and pacemaker - how do I find a provider that specializes in high risk patients?

Breast implant removal and reconstruction - can this be done under local anesthetic?

Popcorn capsulorrhaphy instead of capsule removal - is this a good method to use if BII is possible?

Will I need a lift with explant? (Photos)

WE SEND PRETTY
EMAILS