More and more women with breast implants are asking for them to be removed without replacement, according to the authors of a new guide, but the field lacks formal guidance on how to present surgical options methodically and scientifically to patients.
Neil Tanna, MD, MBA, associate director of the plastic surgery program at Northwell Health in Great Neck, New York, working with thought leaders in the field nationwide, wrote advice on options for explant depending on the reason for the woman’s request.
These tips are likely to be helpful not only for plastic surgeons, but also in primary care, which is often the first place women question the risk balances surrounding breast implants versus the risks of explantation. .
The guide was published online in the April issue of Plastic and reconstructive surgery.
“An implant removal, just like an implant placement, must be tailored to the patient,” Tanna said Medscape Medical News.
The choice comes down to what to do with the scar tissue or capsule surrounding the implant and the necessary or acceptable level of risk, Tanna said. Patients should know the risks and benefits of capsulotomy, partial capsulectomy or total capsulectomy, he said.
The risks can be extreme, Tanna explained. For example, a total capsulectomy with incomplete resection of a mass can accelerate anaplastic large cell lymphoma associated with a rare breast implant (BIA-ALCL) and lead to death, the authors write.
Women request explantation for several reasons, Tanna said, including implant rupture; hardening of the capsule; fear that the implant will make them sick; desire to have textured implants removed (in particular the recalled Allergan textured implants); or personal preference. The article includes advice on each of these indications.
There is a broad consensus that rupture should result in removal of the implant, with or without replacement, the authors say.
“While the capsule does not generally need to be removed for isolated rupture, a significant rupture with a thickened capsule or silicone embedded in the capsule (preventing complete removal with washes) may warrant a capsulectomy,” write -they.
The risk of BIA-ACLC is of growing concern.
This rare but very treatable lymphoma has been linked to textured breast implants. According to the United States Food and Drug Administration, as of January 2020, 733 cases had been reported.
The most common symptoms are seroma, breast pain and / or swelling, capsular contracture, overlying rash, and a lump or lump around the implant.
It is important for patients to realize that BIA-ACLC is not breast cancer, the authors stress.
The authors write that although leaving part of the capsule when performing a capsulectomy may be appropriate for capsular contracture or breast implant disease, “when treating BIA-ALCL, a complete and total capsulectomy surrounded a contiguous edge of healthy margin (en bloc capsulectomy) is guaranteed. “
They point out, however, that deciding on en bloc resection for a patient diagnosed with BIA-ALCL is very different from deciding on a prophylactic procedure to treat cancer risk in a healthy patient who has a textured breast implant.
“Currently, there is no evidence whether a partial or total capsulectomy has an effect on risk mitigation in patients who have textured implants but no disease,” the authors write.
This lack of data presents a challenge for every surgeon in deciding the best choices regarding textured implants.
In the absence of available data, each surgeon should advise patients that a prophylactic capsulectomy may not reduce the risk of BIA-ALCL in the future. In addition, the surgeon should inform the patient that the complex and expensive operation carries an increased risk of death and a risk of cosmetic damage.
In asymptomatic patients, this explant alone or switching to a smooth implant may be appropriate and entail less cost and risk, the authors write.
Breast implant disease
“There is a growing group of women who believe their implants are causing them disease, especially autoimmune disease,” Tanna says.
No test for breast implant disease exists because symptoms are diverse and lab results are inconsistent, but complaints should be taken seriously, say the authors.
Those with symptoms should be given the option of removing the implant with or without capsulectomy, they write.
However, “[T]there is no indication for en bloc capsulectomy, and the use of this term and this type of treatment should be discouraged and reserved only for confirmed cancers, ”write the authors.
Christopher Reid, MD, director of plastic surgery education for medical students at the University of California at San Diego Health, who did not co-author the advice, said Medscape Medical News that it can also serve as a guide for physicians likely to receive questions from their patients with implants. Reid said that these tips “put everything in one place” in an area of the field where there is little and scattered advice.
Particularly important, he said, is the discouragement of en bloc capsulectomy outside of a confirmed malignant tumor.
Reid said that over the past year and a half, his practice has seen an increase in the number of women requesting implant removal, a trend he says is linked to the 2019 recall.
This advice can also be helpful for physicians in other specialties, he said, and can avoid unnecessary referrals to a plastic surgeon if the questions can be answered in primary care, for example.
Reid pointed out that insurance typically only covers two scenarios: documented rupture or grade 4 capsular contracture, the more severe form, which includes pain and disfigurement.
Having these discussions with women, he said, can avoid unnecessary costs as well as unnecessary risks.
Tanna and Reid did not disclose any relevant financial relationships, but several of Tanna’s co-authors report financial relationships with Allergan and other relevant entities. The full list can be found with the original article.
Plast Reconstr Surg. Published online, April 2021 edition. Full text
Marcia Frellick is a freelance journalist based in Chicago. She has previously written for the Chicago Tribune, Science News, and Nurse.com, and was an editor for the Chicago Sun-Times, the Cincinnati Enquirer, and the St. Cloud (Minnesota) Times. Follow her on Twitter at @mfrellick
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