20 y/o saline implants submuscular - why does en bloc removal matter?

Question

Hi and thanks for your time. I have 20 y/o saline implants submuscular. I've had significant BII sx since implant age 37 but never connected the two and thought it was not "real". I have consults for explant and am trying to educate myself. I do not understand why en bloc removal matters (in the absence of rupture). I worry about surgery complications. Also is it important to biopsy anything once it all comes out if I've been symptomatic for 18 years? I want to know the best questions to ask MD

Robert M. Wald, Jr., MD · Answer

With a patient with BII, we try to remove as much of the capsule that is possible. The thought being the capsule, which has silicone in it, may continue to upset the patients immune system. This concern is only theoretical and no one knows whether this is true. An en bloc or total capsulectomy is our goal realizing that it is impossible to do in all cases. When the capsule is very thin or is attached to the chest wall, the capsule will not be remove as one piece. In these cases, we cauterize the remaining capsule.

Alan Gonzalez, MD, FACS · Answer

Hello @ivrn1, thank you for your question. It is important to completely remove the capsule. No matter whether the implants are removed en bloc or if the capsule is formed independently of the implant placement technique, due to the morphology of the breast and the findings from the surgery, a capsulectomy will be performed and all of the capsule will be removed. This requires knowledge and dexterity. Keep in mind that an en bloc explant surgery has two different varieties: one where you take out the prosthesis along with the capsule, and most people call that an en bloc explant surgery, but we also need to state that there is total capsulectomy when the prosthesis is taken out and the whole capsule is removed in pieces, the entire capsule is explanted. Here is a video that sheds more light on the subject. In my opinion it is important to carry out a preventive biopsy on each capsule and I do send the tissue for testing in all explants. To obtain more information and recommendations, it is best to consult one or more board-certified plastic surgeons. Best wishes! Alan Gonzalez MD, FACS.

Gary M. Horndeski, MD · Answer

If you do not have breast cancer, which it sounds like you do not, then you do not need en bloc.  En bloc is only used for cancer treatments such as textured implants associated with BIA-ALCL.

Best Wishes,

Gary Horndeski, M.D.

Shaher W. Khan, MD · Answer

En bloc or 100% total capsulectomy is the gold standard. A capsule grows around the breast implant. That capsule is what holds the silicone toxicity, therefore the entire capsule must be removed regardless of saline or silicone. Even if your implants are not ruptured, you must still have the capsules removed in it's entirety as well as all inflamed or abnormal tissue and sent off to pathology for further testing.

Daniel Barrett, MD · Answer

Dear ivrn1,
it is hard to tell for sure without an examination. If you are considering surgery, I would suggest you consult a board-certified plastic surgeon. Only after a thorough examination, you will get more information and recommendations.
Daniel Barrett, MD
Certified, American Board of Plastic Surgery
Member, American Society of Plastic Surgery
Member, American Society of Aesthetic Plastic Surgery

Ahmad H. Ahmadi, MD · Answer

Those are all very good questions but are best answered after thoroughly reviewing your medical and surgical history and examination.  During your consultation, your surgeon can answer your questions fully.

Leland Webb, MD · Answer

I think that what you will find is that there’s a significant amount of debate on this topic. Most importantly, I think it is a good idea to have be comfortable with your board-certified plastic surgeon and have a plan. When I have encountered this in the past, I typically provide the patient with a total capsulectomy, an implant removal. Sometimes, however, there is a small amount of capsule that is left behind on the chest wall and this is because it has essentially fused with the chest wall or represents the front surface of the chest while at that point. Therefore one has to balance, the safety of trying to peel off this capsule from the chest wall. Understand that the capsule is naturally occurring scar tissue, and will often either remodel or become unrecognizable from other scar tissue in the area in the future. While much debate remains around BII, it is our hope that you have improvement in your symptoms. Find a surgeon that you are comfortable with and a safe operative choice. Have a conversation about your goals with a board-certified plastic surgeon. We are happy to help in any way we can.

Connie Hiers, MD, FACS · Answer

The term "en bloc" is saved for cancer surgery only and not used (correctly) to talk about capsule and implant removal.  The capsules can be removed and sent to pathology to be examined if you wish. If you have textured implants, I would recommend removing the capsules. Otherwise, removing the anterior capsule if the capsules are very thin, usually works well and decreases the risk of seroma of fluid collection.  If you have thick capsules, I would remove as much as possible for comfort.

Camille Cash, MD · Answer

En bloc refers to removing the capsule and implant as one unit.  If you have been having BII symptoms for some time you will want both removed.  Your surgeon will examine both the implant and capsule upon removal and send anything to pathology that looks concerning.  Be sure to visit with a board certified plastic surgeon near you to learn more.

20 y/o saline implants submuscular - why does en bloc removal matter?

Answers (9)

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