En bloc & capsulotomy - confusion on types of implant removal procedures

Question

I recently visited my PS that performed my BI surgery to enquire about BI removal. I've had my gel breast implants for 6 years, under the muscle, and honestly, I've never felt comfortable with them - physically/emotionally. I asked him if he was going to do en bloc capsulectomy, he said no, as it's not safe. Instead would do a total capsulotomy. I'm totally confused about what's the right procedure. What are best options? I felt imitiated to push more about it w/him...

Richard Baxter, MD · Answer

There is a lot of conflicting advice about capsulectomy with implant removal but we now have very good data showing that total or even partial capsulectomy is equally effective for relieving symptoms of BII as en bloc. Your surgeon is correct that en bloc is a radical and riskier procedure and not usually needed.

Alan Gonzalez, MD, FACS · Answer

Hello @deedee44, thank you for your question. An en bloc explant surgery has two different variations: one where you remove the prosthesis along with the capsule, and most people call that an en bloc explant surgery, but we also need to state that an en bloc explant surgery is when the prosthesis is taken out and the whole capsule is removed in pieces. To put it in a simple example, when you go to a hairdresser and ask him to style your hair in a ponytail. Whether it is a side ponytail, braided ponytail, or a high ponytail, the key thing is that it is a ponytail. A complete capsulectomy is essential when removing breast implants, regardless of whether they are removed en bloc or with all of the parts. And it depends on the specific surgical technique and the patient's characteristics that the specialist can determine during surgery whether a complete capsulectomy is in bloc. However, the entire capsule must be removed. This requires knowledge and dexterity. Best wishes! Alan Gonzalez MD, FACS. American Society of Plastic Surgery Member (ASPS), International Federation for Adipose Therapeutics and Science” Member (IFATS), Colombian Society of Plastic Surgery member (SCCP)

Anna Steve, MD · Answer

Great question! The breast capsule is the scar tissue that forms around a breast implant. Just as you form scar tissue on the outside of your body, when an incision is made, your body also forms scar on the inside as well. This is a normal process. 
En bloc capsulectomy is the recommended treatment for BIA-ALCL (breast implant-associated large cell lymphoma). It includes removal of the breast implant and the entire capsule around the implant all in one piece. This usually involves removal of some of the normal tissue surrounding the capsule in order to remove the capsule and implant as one unit. 
Total capsulectomy refers to a process where all of the capsule is removed, but not necessarily as one piece with the breast implant inside the capsule. Some surgeons remove the implant before removing the capsule itself. 
Women who have not been diagnosed with BIA-ALCL, do not need an en-bloc capsulectomy, En bloc capsulectomy is not indicated for the treatment of breast implant illness. During any explant surgery, after implants are removed the capsule is inspected. Any abnormal portions of the capsule are removed and sent to pathology for further testing.

David J. Levens, MD · Answer

En bloc capsulectomy means complete removal of the "capsule" aka scar tissue surrounding your implants along with the implant inside as one unit and preferably all intact. The term has been misused and promoted by some patients and physicians that are inappropriately attaching it's necessity for women with all sorts of breast implant issues (Breast Implant Associated Illness "BIAI").

A total or subtotal capsulectomy is sufficient in the vast majority of women who are ready to have their implants removed for various reasons.

A total or subtotal capsulectomy is sufficient in the vast majority of women who are ready to have their implants removed for various reasons.

Karl William Schwarz, MD · Answer

Confusion arises because there is no data. BII is not well defined and it makes it very difficult to study something not well defined. It is easy to study a medication that is supposed to prevent heart attacks by measuring the number of heart attacks in a group who takes the medication and those that don't. But with BII it is difficult because there are so many symptoms. So there is no consensus if removing the implant will affect any symptoms let alone if all or most of the capsule will affect anything. And all of the data we have collected over the last 30 years doesn't indicate that there is a relationship between some or all of the symptoms and implants. So that's where the confusion arises. No good data.

So without any evidence, most plastic surgeons are reluctant to take the whole capsule as removing the posterior wall of the capsule can be quite risky in certain patients (depending on the capsule)--some capsules come off of the chest pretty easily and others are plastered to the chest and removing them is dangerous or certainly can lead to more bleeding at the very least.

So we feel if there is no known benefit to removing the back wall of the capsule why expose a patient to the added risk when we don't have data that it will change the outcome.

Garrett A. Wirth, MD, MS, FACS · Answer

en bloc generally refers to taking out the implant and the surrounding scar (capsule) tissue all together.  Sometimes people will take out the implant and then the capsule separately as a capsulectomy.  Try to ensure how much or if total amount of the capsule will be or was removed.

Shawna R. Kleban, MD · Answer

This terminology can definitely be confusing. An en bloc capsulectomy means that the surgeon will remove the implant and the capsule in one piece without removing the implant from the capsule. A total capsulectomy means that the surgeon will remove all of the capsule and the implant. The capsule may come out in more than one piece or the implant may be removed to safely get the remaining capsule out. An en bloc is a type of total capsulectomy.

Darryl J. Blinski, MD · Answer

Great questions! The terms are quite confusing. In the most recent Plastic Journal article the "en bloc" was seems as a deforming unnecessary operation. Sub total capsulectomies are now better options, less deforming of the chest/breasts. Virtual consult always better....

Camille Cash, MD · Answer

When you elect to have your implants removed there are several options.  The implants alone can be removed and leave the capsules behind.  This option is often selected by those with thin capsules who are not having issues with their capsules or implants.  Another option is to have both the implants and capsules removed.  It is recommended to have the capsules removed along with the implants when the capsules are thickened, causing issues, or if there is an implant rupture.  The third option is a version of the second where the implant and capsule are removed as one unit.  This option is often selected by those who have ruptured silicone implants to minimize potential leakage of the silicone to surrounding tissue.
A capsulotomy is different.  This refers to the capsule being cut into/opened.  This can be done for several reasons, including the removal an implant.
It is important that you feel comfortable and confident in your selection.  If you do not feel you can communicate openly with your surgeon you may want to seek the advice of another.

Connie Hiers, MD, FACS · Answer

En bloc is a term used for cancer surgery where the capsule plus surrounding breast tissue is removed. Removing normal breast tissue is not needed in removing implants and capsules.  Nonmedical people are using the term incorrectly, especially on the Internet. Your surgeon is correct.

En bloc & capsulotomy - confusion on types of implant removal procedures

Answers (10)

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