Breast Implant Removal
If you have had breast augmentation and want to remove it, what are the methods? What are the differences between capsulotomy, capsulectomy, and en-bloc removal? What are the pros and cons of each?
Reasons for Removal
If you have had breast augmentation, there may be a need to remove the implants due to health or aesthetic issues. Health issues that necessitate removal include capsular contracture, implant rupture, seroma, infection, or cancer at the enclosing fibrous capsule. Aesthetic issues include size being too large or too small, implants placed too high or too low, too close or too far apart, or implants placed asymmetrically. If there are no problems, there is no need to remove the implants.
It is not true that breast implants need to be replaced every 5 or 10 years.
Regardless of the reason, breast implant removal requires another surgery and a surgical wound. There is no method in the world that can remove breast implants without surgery. Current breast implants use silicone as the main material for the shell, with either silicone gel or saline inside. Saline-filled implants can be deflated with a needle to remove the saline, making the implants flat. It sounds like surgery may not be necessary to reduce the size of the breasts.
Is Surgery Necessary?
In reality, deflating saline-filled implants with a needle is not straightforward. The implants are several hundred cc's in size and require a large needle (at least 20 gauge or larger) to deflate quickly. Blood drawing needles are 22-24 gauge, and some people still find them painful. Diabetics use 29-30 gauge needles for insulin injections, which are much smaller. This means that to deflate the implants, local anesthesia is needed at the puncture site to avoid significant pain. As the saline is gradually removed, it becomes increasingly difficult because the needle tip may not always be submerged in saline. Continuously moving a large, sharp needle deeper into the breast to remove as much saline as possible is dangerous and can puncture the lung or heart. Using ultrasound guidance may make it safer but is still challenging. The left and right sides may deflate unevenly, leaving asymmetrical breast sizes. Importantly, the remaining implant shell is not soft and may feel like a wrinkled plastic bag inside the breast. Silicone gel-filled implants cannot be deflated, and those who want to remove implants to eliminate foreign materials like silicone from their bodies will not prefer this aspiration method. Hence, surgically removing the entire implant is safer and more reliable. The next question is how difficult is it to remove the implant surgically?
Capsule Around the Implants
The body considers silicone a foreign material and does not readily accept it. When silicone is placed in the body for chin, nose, cheek, buttock, or breast augmentation, the body's response is to form a fibrous capsule around it, isolating the silicone from surrounding tissues. This capsule may tighten and harden the implants, making the breasts firm and misshapen. The capsule can also calcify over time, leading to hard, stone-like deposits. Even after implant removal, the breasts may remain firm due to the capsule. Some patients may experience pain from severe capsular contracture, while others may develop breast implant-associated anaplastic large cell lymphoma (BIA-ALCL) in the capsule. This raises the question of whether the capsule should be removed during implant removal. This is a topic of debate.
Breast Implant Removal Methods
There are 5 methods for breast implant removal:
This is the simplest method. An incision is made in the skin, and the tissue is dissected until the capsule around the implant is reached. The capsule is opened to remove the implant. This can be completed in less than 15-30 minutes, with the time mostly depending on closing the incision and whether any scar revision is needed. However, the implant pocket will remain in the breast. Additionally, when the capsule is opened to remove the implant, residual substances like silicone gel, bacteria, or other contaminants in the implant pocket can contact the surrounding tissue, and washing it out may not be completely effective.
After removing the implant, the capsule is scored with multiple incisions (scoring) throughout the implant pocket. The goal is for the incised surfaces to adhere, leading to the closure of the implant pocket. The incisions also allow blood, immune cells, and antibiotics to enter the pocket.
In this method, instead of just scoring the capsule, parts of the capsule are excised. Some thin areas of the capsule may be left if deemed less problematic to avoid damaging surrounding healthy tissue. The resulting wound is larger than with scoring alone, aiding in pocket closure and allowing better immune response and antibiotic penetration. However, there is a higher risk of blood accumulation, so drains are often placed.
The entire capsule is excised, leaving no capsular tissue in the body. Drains are placed to prevent blood accumulation. This method requires more surgical time and effort.
Instead of opening the implant pocket, this method involves dissecting around the capsule that encases the entire implant, enabling the simultaneous removal of both the capsule and implant. The goal is to prevent any contaminants from the implant pocket, like silicone gel or bacteria, from contacting body tissues. This is the most challenging method, requiring skill to keep the capsule intact. The incision must be as wide as the surgeon's hand and takes 3-4 hours. Drains are always placed.
Comparison of Breast Implant Removal Methods
| Removal of breast implants only | Removal of breast implant with capsulotomy | Removal of breast implant with subtotal capsulectomy | Removal of breast implant with total capsulectomy | En-bloc removal of breast implant | |
|---|---|---|---|---|---|
| Estimated Surgical Time | < 1 hr | 1 hr | 2 hrs | 3 hrs | 4 hrs |
| Residual Capsule | All remains | All remains | Some remains | None remains | None remains |
| Risk of Contamination | Very low, only at the incision site when removing the implant | Very low, only at the incision site when removing the implant and at the scored incisions | Moderate, at the incision site when removing the implant and at all areas where the capsule is excised | High, at the incision site when removing the implant and at all areas where the capsule is excised | Very low, only at small tears during dissection |
| Tissue Trauma | None | Very low | At excised areas | High, at all excised areas | High, at all excised areas |
| Implant Pocket | Remains, can be found in future surgeries | Remains, but may be closed | Does not remain if enough capsule is excised | Does not remain | Does not remain |
Summary
There are multiple methods for breast implant removal. The nature of the capsule around the implant is a crucial factor in choosing the surgical method. This decision also depends on the beliefs of the patient and the surgeon regarding the need to remove the capsule and whether contamination from the implant pocket is a concern.