En Bloc Explantation
In experienced hands, it is entirely possible to do most cases of explantation with the en bloc procedure. Please see video.
"En bloc" implant removal may be a good idea on paper, but in practice it may not work out
The only time that I can think of that an en bloc removal of the breast implants confers a significant advantage is when we know we have a confirmed rupture of a silicone implant and wish to avoid any potential contamination of the tissues with the silicone gel. Bear in mind however, that from a technical standpoint this may make the operation significantly more challenging, it may require a much longer incision to allow adequate exposure - especially if done through an inframammary approach - and to remove the implant and capsule together and intact if there is any thickening or contracture of the capsule, as it will not be pliable and supple enough to deliver through a smaller incision, and worst of all, in the case of a ruptured implant, should you commit to this approach and get 80% of the way through the dissection and inadvertently make a hole in the capsule ( which can happen even to the MOST skilled of us out there, especially in a difficult to reach area, you may actually spill and spread more silicone across a larger open area of the breast which you can't control now that you've committed to this dissection. Thus, I can make a very strong argument, even in the case of a ruptured gel implant, or perhaps especially in the case of a ruptured gel implant, to first open the incision only enough to access the capsule, block off the immediate area of the exposed capsule with surgical towels or sponges, open the capsule in a controlled manner, and extract the implant - intact and whole or ruptured - in a controlled and clean manner, dispose of the implant and change any gloves or instruments that may have contacted any free gel, before proceeding with the removal of the capsule. This to me is a much more reliable way to do an explant with capsulectomy, limiting the possibility of gel spillage as much as possible, and I have done many of them both ways. Bear in mind that I use the word "contamination" when talking about free gel, not because the gel is necessarily toxic or infectious, but because we believe that if free gel (as opposed to gel contained in the intact rubber shell of an implant) may cause more of an inflammatory reaction in the tissues and lead to fibrosis, granuloma formation, and lumps (not cancerous) in the breasts. This is the major reason to avoid gel contact with the tissues if possible. Even if the gel does get on tissues it can be irrigated off; it's just easier and quicker to control it in the first place. In summary, while the idea of an "en bloc" removal of the implants is appealing, I'm here to tell you as someone who has done a lot of these both ways that from a technical and practical standpoint I'm not sure it's always possible to execute this plan without fail, and sometimes planning for possible hurdles up front and pre-empting them is a better way to go. In any event, be sure to schedule consultations with experienced board certified plastic surgeons who can give you their own perspective on this issue and advise you accordingly. Good luck.
En bloc removal of breast implant and capsule
When the plan is for capsulectomy and implant removal over the muscle, each surgeon will usually employ an en bloc capsule release so that everything comes out pretty much together. When it is under the muscle, it is not generally advised to perform a total capsulectomy since it can increase the chance of bleeding, and shred some thinned out muscle fibers. When a capsulectomy, implant change, and breast lift is contemplated, one has to tread carefully and not be overly aggressive in removing all the scar tissue as it can effect the circulation in the lifted zones. For the very slim patients with dense scarring over existing breast implants, some form of capsule removal is necessary, but once again, if you take too much capsule and scar, you can render the breast skin brassiere too thin, and rippling of any new saline or silicone implant may occur. For those who need a full capsulectomy, sometimes alloderm grafts can be used to replace scarred tissue that came out with the capsulectomy when there is a fear of thinning over the new implants. For implant removal alone, one can be more aggressive in capsular and scar removal. En bloc removal of the total capsule is neatand clean. It can freshen the breast but the judgment to do it, risk thinning, scalloping, and circulatory loss when changing the breast size, shape, and during a lift, must be weighed carefully.
All plastic surgeons should/can remove the entire capsule along with the implant. Sometimes the implant must be removed first in order to remove the rest of the capsule. If the implant is ruptured it is best to keep the silicone contained in the capsule upon removal.
Ruptured silicone implants require en-block removal of the implant and the capsule to avoid contamination of the rest of the breast tissue with free silicone. This requires an inframammary incision that is long enough to let the implant and capsule to come out. Surgery requires experienced surgeon and longer surgery to dissect the capsule with minimal injury to the breast tissue or muscle.
I found that using the harmonic scalpel to dissect the capsule is much better.If the implants are under the muscle and the posterior capsule leaflet is thin, it becomes more difficult surgery, and risks increase.
Replacing the implants is possible, and changing the plane of the implant should be entertained and discussed.
The condition of the muscle should be evaluated if the implant is under the muscle.
There are a lot of decisions to be made, and a lot of options you have .
Searching for PS who performs en bloc explant surgery
Thank you for the question.
I would suggest starting with the American Society of Plastic Surgery and/or the Aesthetic Society of Plastic Surgery to obtain a list of well experienced board-certified plastic surgeons.
Then, I would suggest you visit a few surgeons whose practices concentrate on aesthetic surgery.
***Ask to see lots of examples of their work and preferably speak/see patients who have had similar procedures done.
Be very careful with your decision-making. You will find, while doing your due diligence, that there are many different “specialties” who will offer their services to you; again, I strongly recommend you concentrate on surgeons certified by the American Board of Plastic Surgery.
Generally speaking (in my opinion), unless the breast implant capsules have thickened (and/or are otherwise symptomatic), are associated with the ruptured silicone gel breast implants, or if the patient has concerns about "medical conditions" related to the breast implants, capsulectomy is not universally necessary. For these patients, en block removal of breast implants is a good procedure.
On the contrary, capsulectomy can expose patients to additional risks, such as bleeding, size loss, contour irregularities and other serious complications. In other words, any maneuver performed during surgery exposes patients to additional risk (morbidity). For example, attempting to remove very thin capsule densely adherent to the patient's rib cage may expose the patient to significant bleeding and/or entrance into the thoracic cavity.
I hope this, and the attached link, helps. Best wishes.
Searching for PS who performs en bloc explant surgery?
Hello! Thank you for your question! It is a matter of surgeon
preference as well as what is seen during your procedure that will
determine whether or not a complete capsulectomy is performed. If
significant capsule formation is seen intraoperatively, a full capsule
removal may be warranted with a drain in order to completely remove all
of the tissue and allow better adherence of your breast back to its
normal anatomic position down on your chest wall. If minimal contracture
is seen, it may be possible to leave the capsule, or place cuts within
the capsule to allow better adherence. It truly is dependent on what is
seen with your capsule and the issues that may be causing you to have
such a procedure (e.g., contracture from rutptured implant vs pain vs
simple pocket adjustment, etc).
Without knowing your issues and
without an examination, it is difficult to tell you what may be the
best thing for you. I tend to favor performing capsulectomies (in an en bloc fashion) in order
to create a fresh pocket, reshape the pocket, allow better shape and
adherence of the overlying breast. I would discuss your issues with your
plastic surgeon who will assist you in determining the right modality
for you. Hope that this helps! Best wishes!
#Explant #BreastImplantRemoval - en bloc explant surgery
This refers to removing the entire capsule along with the implant and it can (normally) be done by any board-certified plastic surgeon. It may require a larger incision that removing the components at the same procedure but not necessarily "en bloc" which refers, specifically, to removing the combination of implant and capsule as a single large specimen.
That can be a challenging procedure and not always accomplished even when that's the intent. For example, the capsule may tear or be adherent to one or more portions of the surrounding tissue (en bloc removal is generally easier for implants that are above the muscle than below).
And, finally, even when the intent in doing en bloc removal is to assure that ALL of the silicone is removed - it is not actually possible to guarantee that, as microscopic bits of silicone (or anything else) may have extended beyond the apparent physical limit of the capsule.
None of which is to suggest that, even if that were to happen, there is any medical or physical consequence to that. That issue has been debated for decades, without clear scientific conclusions - but that's an entirely different (and long) discussion.
I hope that this helps and good luck,
Dr. Alan Engler
Member of RealSelf100