Breast implant removal. Capsulectomy with Mastopexy? (Photo)

Question

I had 410cc textured cohesive silicone gel implants placed above the muscle 5 years ago. I had grade 1 ptosis and was a 34c pre op. My surgeon said I had enough breast tissue to go over the muscle and correct the slight sagging to avoid a lift.I am now looking to explant and remove the capsule. - Am I likely to need a breast lift after? If so, what type of lift would be best for my breast? - Is it safe to remove the implant and do a lift in the one surgery? Many Thanks for any feedback.

Raffy Karamanoukian, MD, FACS · Answer

Removal of breast implants, intact or ruptured, may have positive implications if patients are symptomatic. A constellation of symptoms associated with breast implant illness, and autoimmune disease are considered when treating patients who have breast implants and are concerned about foreign body reaction. In our office, we begin this journey with a consideration of symptoms and exclusion of obvious autoimmune problems. In many of our patients, en bloc removal of breast implants with capsulectomy is important and beneficial. Further clinical evidence about breast implant illness is evolving and will continue to guide treatment. I would suggest removal if there is a possibility of foreign body reaction.

Best,
Dr. Karamanoukian
Realself100 Surgeon

Best, 
Dr. Karamanoukian
Realself100 Surgeon

Camille Cash, MD · Answer

When you remove the implants the skin will retract to some degree.  That is enough for some patients and they do not want to undergo a lift. If you were borderline for a lift prior to your augmentation you will be the same as before at best, but likely have more ptosis now.  If you are wanting to raise the position of the nipples then a lift would be needed.  The lift can be performed in the same surgical day as the explant.

Scott L. Replogle, MD (retired) · Answer

The following is a response to a different patient asking this question. Your breasts have more ptosis but in general, the issues are the same and I would agree with another response that it is best to remove the implants first and then see if a lift or other surgery is indicated. I would add that there is no medical reason to remove the capsule around the implant if it is normal. The capsule is essentially a scar tissue layer and if removed, a new one forms (but wouldn't be spherical if there is no longer an implant). Removing the capsule requires a much bigger procedure, more risk, and more cost with a less predictable outcome. Several thoughts on explanting silicone gel implants that are apparently not causing any problems: The choice to remove implants is a cosmetic decision just like having them put in. In should be up to you but you need to know what's involved, the expected result, and the costs, risks, and consequences.Since there is no simple test to verify the integrity of silicone gel implants, removal is best done through an inframammary crease incision regardless of how they were put in. This can be done under local anesthesia with IV sedation but most plastic surgeons are going to insist on general anesthesia.If the implants are found to be intact once exposed, they can be removed with what is called a simple removal and the incision closed. If they are not intact then it is much harder to clear the silicone gel inside the capsule and if the implant is too firmly incorporated into the capsule then the capsule may need to be removed around the implant which is a much bigger procedure and involves more risk, potential for bleeding, and possibly a drain.The capsule surrounding the implants does not need to be removed unless it is heavily calcified, causing problems, or is abnormal in some way that at least a partial removal and biopsy is needed.Breast implants are merely pillow volume behind the breast and do not lift the breast when put in and don't cause sagging when taken out. The lift effect is an illusion caused by filling out the lower pole of the breast and filling in the upper pole. The sagging effect is also an illusion and is the reverse of this. A lift is only needed if the nipple-areola is significantly below the level of the inframammary crease behind it when upright and with arms down. Experienced plastic surgeons should have examples to show you of other patients who have had simple removal/explant of their implants.One other option to consider is to downsize without complete removal of implants particularly if there are no apparent problems with the current implants and capsule. You can't downsize the diameter (and height in a round implant) from what it is without significant capsule work, but you can downsize the forward profile of the implant if it is not already the lowest profile. Changing from a high profile to the lowest profile could drop you a cup size and from a middle profile to the lowest profile could drop you about a half cup size. If the current implants prove to be intact, this can be as simple a procedure as exposing the implants, taking the old ones out, and putting the new ones in and closing the inframammary crease incisions. Although obviously not recommended, it is possible to remove implants, find you made the wrong decision, and then have them replaced later on.

Denis L. Gonyon, Jr., MD (account suspended) · Answer

In general, I try to encourage patients to remove the implants and capsule at a first surgery and then consider a mastopexy 6 to 9 months later.   Your breast skin will contract and shrink during that time.  You obviously have some asymmetry, for example, the left nipple points much more to the side.  By allowing everything to heal first, when you do the mastopexy at the second surgery the amount of skin to remove, nipple position, and scar quality are better.  Sometimes you can use a smaller scar pattern because the skin has shrunk, such as a lollipop scar instead on a full inverted T scar.  Sometimes the skin will shrink enough that patients elect NOT to have the mastopexy at all.Also, you may want to add some fat transfer to your breasts to help add some natural volume back to your breasts if you are unhappy with the size, shape or asymmetry after your implants are removed and everything is healed.  By separating the surgeries, you are maximizing the positives of what is often a very difficult decision.  In a perfect world, your skin would shrink nicely after the first surgery and at the second surgery you perform a minor lift with some fat transfer to get a reasonable result with your own tissue and minimize scars as much as possible.This is my personal philosophy.  It's OK to do them at the same time but I always inform patients that revision surgery may be necessary to provide the best symmetry in size and shape, scar quality and nipple position.  A lot of patients do not like the thought or the cost of having two surgeries but the cost may not as much as you think and you should also budget for the higher possibility of needing some touch up surgery when you do them at the same time.Good luck.

Melek Kayser, MD (retired) · Answer

Thank you for your question Pisces. Implant removal is actually not that uncommon. An implant is a volume device which necessarily makes your breasts larger. Unfortunately, it is not a substitute for a breast lift. Many surgeons will use an implant in an attempt to increase upper pole fullness, however, long-term results often result in a larger breast that is droopy, especially if the original breast was droopy in the first place. This occurs because the implant eventually falls right back into the breast over time.In your situation, removal of the implant would result in volume depletion and, since your skin envelope was stretched from the implant, this may be more obvious than if you never had the implant placed at all. You certainly have the opportunity to simply have the implant removed and see if that would be a satisfactory appearance to you. This would avoid the scars of a breast lift. However, if for minimizing surgery and cost, you desire to have a breast lift performed at the same time, restoration and improvement of your breast to a more youthful position would likely occur from a breast lift.One concern to keep in mind is, that because the implant was placed above the muscle, there is a higher potential for vascular injury if a breast lift is performed as well since the blood supply to the breast and nipple were possibly compromised to some degree,during the original surgery.Removal of the implants in a single stage without any further surgery would allow observation to determine whether or not the results would be satisfactory to you. If you felt that there were deficiencies and contouring irregularities, you could come back and have a lift and even fat grafting. Fat transfer allows the removal of fat from one part of your body to be transferred into the breast. This would allow volume restoration and fill any contour irregularities that may exist. Finally, unlike an implant which must occupy a fixed pockets, fat is placed as millions of seeds which can be distributed throughout the entire soft tissue envelope, even in a breast that is droopy. Fat is natural, yours, and has the potential to last a lifetime. Of course I would recommend a consultation with a board certified plastic surgeon who is experienced in all these techniques. I hope this helps and have a wonderful day. Dr Kayser - Detroit. PS I suspect that a happy birthday wish is an order too!

Susan Kolb, MD - Account Suspended · Answer

I would recommend a total capsulectomy, and internal lift and if there is deformity from excess skin after the internal lift, a donut or lower pole skin resection.  It can be difficult to determine if the skin resection is needed prior to the explant.

Breast implant removal. Capsulectomy with Mastopexy? (Photo)

Answers (6)

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