The Smart Patient Questions
Here are the key questions to ask your surgeon before having breast implant removal. These are the questions that the most savvy patients ask. I wanted to share them with you – so you too can be super savvy and find the right doctor for you. A little tip: if your doctor gets defensive in response to your questions, then they are likely the wrong doctor.
OK, you want your implant removed. You are worried it may be affecting your health. You have images of green slime in there… mold…and you heard that the plastic surgeon MUST remove the capsule, and cannot leave it behind! You saw photos online! So, what is really going on here, and is the patient right who wants the capsule out, or the doctor who says it doesn’t matter?
What we have here is really a consumer trust issue. I’ll first give you a grasp on the problem, and then figure out how to solve it.
Most implants are just sitting under the breast, surrounded by natural scar tissue that is called the capsule. The implant looks fine. The capsule is normal. The implant can be removed. The capsule will shrink down and may leave old residual scar tissue. But what if the implant isn’t normal? What if it leaked silicone, and microscopic silicone is in the capsule? What if it the capsule is inflamed, calcified, or contracted? Then, the capsule should be removed.
Here’s the consumer trust issue. For years, lots of doctors just left the capsule behind. Some doctors took only the front part of the capsule. I‘ve had patients tell me their capsule was removed, but more surgery reveals that it was not removed. I’ve also had patients tell me that a surgeon told them that they could not have the capsule removed. That they could “perforate their lung”. This is ridiculous. After inappropriately laughing out loud, I realized that those surgeons should really never perform a capsulectomy if they really think that. They are either dangerous surgeons, or lazy, or they lied. What is a patient to think? So, patients want their capsules out, and they aren’t sure that they trust their surgeon anymore.
My first advice here is to find a surgeon you can trust. The surgeon should not peddle in breast implant illness cure, and should be honest, and realistic. Removing implants may not change your health. Removing capsules may not change your health. And do you really even need your capsule removed?
My personal algorithm is that any patient with an abnormal capsule should have the capsule completely removed. We don’t want an empty pocket with silicone in the lining, or fluid in it, or calcifications and chronic inflammation. Just remove it. For patients with normal capsules, especially from saline implants, and very thin capsules, the capsules are actually more difficult to remove completely. Imagine a thin, gossamer like see through lining. It tears easily, doesn’t hold together, and is so fine that a complete removal of the entire structure weighs only 3-5 grams. These are not the complete capsules you see on Instagram; these are see-through and rarely come out in one piece. They also have no inflammatory component, so the chance that they have pathology is also highly unlikely. When the implant is removed, and the pectoral muscle is repaired, and the breast is brought together, no sign of it remains. SO how do you know if you need the capsulectomy or not? I personally have a conversation with the patient, and if it’s abnormal, the capsule is removed. If it is normal, but the patient insists on removal, it can still be done. My preference is to leave normal structures intact and remove the abnormal only.
Finally, a note on the “en bloc” capsulectomy. En bloc can mean removing the implant and capsule all together as one specimen, or it can mean removing the capsule as a single piece. I think en bloc became popular as a concept because the surgeon would remove the whole capsule, leaving nothing behind, which distrusting patients like. Also, the idea of contamination of the tissue from the capsule being opened bothers people, even though in reality little nicks occur in many capsulectomies that expose the implant. The en bloc also can require a larger incision, all for supposed peace of mind. For me, the larger incision is a pretty big trade off. I like to do as much work as possible through a small incision, and we can decide ahead of time whether to enlarge the incision or take the implant out separately if it comes to that. If we decide the capsule is coming out, it will come out completely either way.
Have your surgeon check your capsule for PCR, microbiology, and pathology. I’ve been fascinated by the interesting bacteria we find. More on this later!
Lisa Cassileth MD, FACS
