BY LISA B. CASSILETH MD, FACS
Breast Implant Revision – Is Capsule Removal Necessary?
Most plastic surgeons say, “never”. A small group says, “always”. Why is this and what is the real answer? The truth is that there are situations where the capsules need to be removed. There are three good ones:
1. The presence of a biofilm. This is a low-grade bacteria that can cause capsular contracture. Capsular contracture is the presence of a higher, firmer, and often painful, implant. If your implants fell and look abnormal, you may have a biofilm. The biofilm usually entered with an implant on a previous surgery but wasn’t a strong enough bacteria to cause a true infection. The biofilm does cause chronic inflammation, however, which leads to the contracture. You are at higher risk if you have had multiple prior surgeries or an areolar incision.
2. Free silicone. Especially if you have had silicone implants for a while, I often find old silicone in the capsule from an old leaky implant, sometimes form a previous pair. Best to remove it and just “keep it clean”, especially if you are worried about sickness from old leaking implants, it takes out the doubt that something there may still be affecting you.
3. BIA-ALCL. This is rare cancer, called Breast Implant-Associated Ana-plastic Large Cell Lymphoma. It presents with fluid (seroma) around the implant and is cured by capsulectomy. Older implants with texture place you at higher risk, and any patient with an unexplained seroma around the implant should be tested.
These three situations are fairly rare, and if your implants are “normal” you may not choose to remove the capsule. From a surgical point of view, once I see the capsule that gives me additional information. Sometimes the capsule is fine, see-through, and would be difficult to remove as it so gossamer-thin (link to normal capsule video). At other times I am shocked by how thickened and calcified it is. In these cases, when the patient is healthy and we don’t know ahead of time if there will be a problem, I remove the capsule based on the appearance. A complete capsulectomy, if the capsule is abnormal, is certainly worth the increased recovery time; this will involve a drain for a few times and will be slightly sorer.
The disadvantage of removing the capsule is that it does make the surgery more extensive, and if you are fat grafting to replace some of the lost volumes, then it limits how much fat can be grafted. So, I do argue against the attitude of removing it no matter what; you should never electively do any surgery without a good reason. Finally, don’t forget to ask your surgeon to repair the pectoral muscle if your implants are sub-pectoral. Either way, go to a surgeon that doesn’t have a “never” or an “always” attitude; the right answer is in between.