As a plastic surgeon whose practice is largely focused on revision of prior breast surgeries, I have seen increased interest in breast implant explantation. This increased interest is driven in large part by both a lack of good science-based education for patients and growth of misinformation, including peer-to-peer spread. The reality is that we, as surgeons, also face a lack of definitive agreement on several emerging patient concerns.
Importantly, I continue to believe that silicone breast implants are generally safe and that patients receiving implants are at low risk for dangerous side effects. Nonetheless, surgeons must begin to address emerging concerns about implant safety and be prepared to respond to patients’ valid reasons for seeking explantation.
Informed consent for silicone breast implants has long included discussion of the risk for implant rupture, movement, and development of deformities, such as capsular contracture. Most are manageable risks that have been known for many years. As the as yet unproven breast implant illness (BII) continues to gain prominence, there are calls to at least re-assess the informed consent.
Some argue that patients with unrelated autoimmune illnesses could be wrongly associating their symptoms with breast implants. Although we lack reliable data, anecdotal reports abound from surgeons who see women recover from symptoms once their implants are removed. Though it is just one example, I often point to a woman who came to me from Spain. She indicated that she experienced a range of systems, most notably exhaustion, that would resolve with a course of penicillin and then re-emerge after a few weeks. She linked the symptoms to her breast implants and, concerned about the potential risks of continuous antibiotic use, sought me out for explantation. She has been symptom-free since the implants were removed. Of note, I cultured her implants and grew C. acnes (formerly P. acnes), which is known to produce numerous inflammatory mediators. We culture all explanted implants, and one-third of our patients have positive cultures and positive PCR.
Perhaps this bacterial presence is benign. Perhaps some patients are susceptible to an inflammatory state induced by bacterially generated inflammatory mediators. We cannot make a determination yet, but I believe we should maintain an open mind. It may be reasonable to update informed consent for breast implant candidates to at least indicate there is a possibility that biofilms can live on the surface of implants, and we don’t know the potential effects at this moment.
Another aspect of breast implant health is the identification of silicone in other locations in the body, even when implants have not ruptured. I recently removed an intact 410 implant from a patient who had had a recurrent cancer. A biopsy of her lymph node identified free silicone in the node.
A cohesive silicone gel is not expected to leak, and we would not intuitively anticipate finding silicone outside of an unruptured implant. Yet, we do have evidence of spread of microscopic silicone outside of intact implants. We believe this spread is benign, and we predict hundreds of women may have such spread with no negative impact. Nonetheless, it may be reasonable to address this possibility with patients before surgery so that they can fully trust us as surgeons.
The reality is that most patients who present for breast implant surgery are highly motivated and are unlikely to be dissuaded by updates to the informed consent, so why not be as thorough as possible?
There is a tendency, it seems, when we introduce any sort of aesthetic augmentation, for some individuals to tend toward an extreme. We have witnessed demand for large breast implants and are seeing a continuing interest in rather large, round buttocks. With time, the pendulum seems to eventually swing the other direction, as patients trend toward a more “natural” look with more subtle enhancement that eschews a “fake” or “inflated” appearance. (I predict patients will one day be looking at buttock reductions again!)
Trends toward a more “natural” aesthetic appearance may reflect overall health trends. Currently, Americans show substantial interest in health and wellness, as we see a surge in “clean eating,” juicing, yoga, and meditation, etc. Such a natural focus may lead patients to reconsider the use of artificial materials, such as silicone, for body enhancement.
The desire for more “natural” augmentation may also explain the increased demand for fat grafting as a method for breast augmentation. The “Mommy Makeover” patient is particularly well suited to fat grafting of the breast. Many women note a loss in breast fat and deflation of the breast after breastfeeding. They appreciate the ability to replace that lost volume with fat that is removed from elsewhere on the body, such as the love handles.
Patients may perceive “natural” fat grafting as a “simpler” alternative to implants. Patients require education on the procedure, and surgeons must be well trained on the technique. Optimal aesthetic outcome and reduced risk for fat necrosis each depends on the placement of hundreds of tiny strips of fat throughout the breast.
Whereas a surgical implant can take about 45 minutes to an hour, a fat grafting procedure will take a minimum of two hours for each hundred CCs, in my practice.
Fat grafting has limitations. My standard is that you can double the size of a native breast. If a patient is an A, I can get them to small B. Once the graft is established, we can do a second fat grafting procedure for further augmentation, assuming there is a sufficient harvest site. Nonetheless, that A-cup patient will not get to a C or D in one surgery.
Controversies remain in the field of breast augmentation. Lacking solid scientific evidence, we should at least acknowledge that there is theoretical support for some emerging concerns. Additionally, we must be receptive to patients’ health preferences. We must be willing to listen to patients and talk to them about their concerns and share our knowledge in order to determine whether or not permanent explantation is appropriate. Some cases are straightforward; a woman in her 50s who had an initial implant 15 to 20 years ago may want an explantation with no new implant placed because she wishes to avoid yet another surgery in 15 to 20 years. This is reasonable.
Decisions can become more complex, for example, for a patient who has had a mastectomy and will be left with a deformity if the implant is removed. Some patients who had rather large implants have very little natural breast tissue. The volume can’t possibly be replaced with fat. Such patients need to fully understand the consequences of the decision to explant and must understand what they’ll look like afterwards. 3D imaging has emerged as a useful tool to help patients visualize their post-explantation appearance, using the subtraction tool.
When patients present for explantation, a few key considerations are essential.
What is the patient’s rationale for seeking explantation? Is she being reactive? Does she need reassurance?
If the patient has completely normal breasts, no capsular contracture, and is very implant dependent, then I explain that this decision will have major consequences for her that are going to make her feel deformed and be affected by the surgery in a negative way.
Is explantation medically indicated? Does a capsule need to be removed?
A medical basis for explantation makes the decision easier, although patients still require education about anticipated outcomes as well as options for repair/replacement of volume.
What is the right surgery for repair? Must the silicone implant be replaced with fat grafting? Is a mastopexy in order?
First, do the right surgery to deal with the implant, then determine how to provide a repair that is aesthetically appealing. Put somebody back together again, so that when they wake up every morning and put their bra on, and go work out, they feel good about themselves. Removal and restoration/repair go hand-in-hand, but each element deserves careful consideration.
DON’T FORGET PECTORAL REPAIRS
If you and the patient decide to pursue explantation, be sure to repair the pectoral muscle with subpectoral augmentation. If you do not, the patient will have window shading deformities or pec flex deformities. I benefit from surgeons’ failure to do these repairs, because patients come to me to fix the bad looking removals. Why not put the pectoral together like it anatomically was, prior to the implant? I suggest that you take the free edge of the pectoral muscle and sew it down where it used to lie. This simple step brings the whole breast together, looks good aesthetically, and it restores function and balance.
Patients Not Cases
As surgeons, we may tend to view “cases” from a clinical perspective. If a patient expresses concern about an implant absent any deformity/defect or symptoms that may be directly linked to the implant, a surgeon may assess the aesthetic of the breast and dismiss the patient’s concern. However, we should make an effort to focus on the patient, so as not to appear negative or patronizing. Listen to the patient. If you believe she is being reactive, then have an honest conversation based on facts and science. Explain what you perceive as her individual level of risk and leave open the possibility to revisit her concerns in the future. If the patient is adamant, consider providing the desired surgery, assuming there is no significant risk.