Commentary on: Breast Explantation With Simultaneous Mastopexy and Volume Restoration: An Analysis of Clinical Outcomes and Prospective Quality of Life

Requests for breast explantation surgery have been steadily increasing in recent years. Concerns secondary to risk of breast implant–associated anaplastic large cell lymphoma (BIA-ALCL; with textured devices) as well as breast implant illness along with the changing trends in breast aesthetics have led many patients to request implant removal without replacement. Due to the long-term effects of a breast implant on the breast tissue, implant removal can be a challenging procedure with variable aesthetic results. Capsulectomy can increase the complexity of this procedure and lead to an increased risk of complications. Therefore, when approaching these patients, it is important to have a reliable and safe approach to maximize outcomes while modifying potential risks. In this paper by Messa IV and Messa III entitled “Breast Explantation With Simultaneous Mastopexy and Volume Restoration: An Analysis of Clinical Outcomes and Prospective Quality of Life,” the authors present a thorough and thoughtful discussion that summarizes the literature with respect to implant safety and outcomes following explantation.1 They describe their approach for simultaneous mastopexy, explantation, and capsulectomy, utilizing autoaugmentation and/or autologous fat grafting to improve aesthetic outcomes. Their discussion includes important references relating to the improvement of symptoms following explantation along with possible etiologies for this improvement. They assess patient-reported outcomes, in terms of satisfaction (breast shape and size) and quality of life and in relation to the procedure and breast implant illness symptomatology, with an author-generated nonvalidated tool. The authors present 4 cases with very good postoperative aesthetic results; however, it is important to note that these cases all include patients with good quality and quantity of tissue, which is often not the case in this patient population. All patients in this study underwent capsulectomy for various indications, with 51.1% of patients undergoing this procedure because of concerns related to breast implant illness. The authors refer to their approach as a “precise total capsulectomy en masse,” and this was performed on all patients. Indications for this procedure included “textured breast implants, ruptured implants, a calcified capsule and patients with symptoms attributed to breast implant illness.” Currently, the literature does not support an absolute indication for total capsulectomy in the treatment of breast implant illness. In fact, an important recent paper demonstrated an improvement in patient symptoms following implant removal irrespective of the way in which the capsule was managed.2 As well, there is controversy regarding the management of capsules when removing textured breast implants due to concerns about the risk of BIA-ALCL. Currently, evidence is lacking to support the need for total capsulectomy.3,4 In our practice, absolute indications for total capsulectomy include a diagnosis of BIA-ALCL, an undiagnosed mass in the capsule, a thick and calcified capsule, and an extracapsular implant rupture with foreign body granuloma. Capsulectomy is not without its risks, and these are more likely when performing total or en-bloc procedures. Capsulectomy at the time of explantation has been found to have a significantly higher rate of complications, especially hematoma, when compared to patients undergoing explant with no capsulectomy.5 Total capsulectomy also increases operative time and incision size and may have a negative impact on aesthetic outcomes.2 This is particularly true with implants placed in a subglandular plane or in patients with minimal overlying breast tissue.2 Furthermore, when performing mastopexy in conjunction with prepectoral explant and capsulectomy, potential vascular compromise to the skin and/or nipple-areola complex may occur. To examine patient-reported outcomes, the authors utilized a simple practice-generated assessment tool in their patient population. The authors should be congratulated for trying to include this important outcome measure. As mentioned in the paper, the assessment tool was nonvalidated. It is also important to note that although the authors describe the questionnaire as being completed in an anonymous fashion, the fact that it was provided to the patients in the office by a nurse, where it was completed and returned, would at least lead many patients to question the true anonymity of their responses. This may very well impact scores due to patient reporting bias, because patients may not want to disappoint their surgeon. It should also be noted that the assessment tool displays the preoperative and postoperative scores adjacent to each other. Although it is not clear from the manuscript if patients were able to see their preoperative scores at the time of completing their postoperative scores, this might influence their range of responses. There is great variability in the presentation of patients in our practice with respect to their indication for implant removal and surgical options. Surgical management for explantation in patients who do not wish another implant may include explant alone, explant and capsulectomy (partial or total if indicated), as well as explant with or without capsulectomy in conjunction with mastopexy. Mastopexy is often combined with autoaugmentation and/or fat grafting when indicated to improve overall aesthetic results. Fat grafting is typically done to improve breast shape as opposed to adding significant volume. Before undergoing explantation, preoperative deflation is typically employed in all our patients with saline breast implants. This allows the mass effect of the implant to be removed and allows for gland hydration and re-expansion. Breast volumes have been found to increase, and the sternal notch to nipple length decreases following 3 weeks of preoperative deflation.6 This assists with surgical planning and may help a patient decide if she will be content without an implant replacement. In this study, 37% of patients were reported to have saline implants and might have benefited from preoperative deflation. This is especially helpful in those patients with very thin overlying breast tissue, who were excluded from this study. In patients with silicone gel implants, preoperative explantation under local anesthesia can also be considered. Figure 1 shows a patient with contracted implants for many years who was managed with in-office deflation and eventual capsulectomy, replacement, and mastopexy. Note the improvement in tissue quality between the time of immediate deflation and 2 weeks later. A 56-year-old female with (A) 520-cc subglandular contracted saline implants; (B) immediate deflation; (C) 2 weeks following deflation; (D) calcified capsules with deflated implants; and (E) 3 months post-explantation capsulectomy mastopexy and replacement with 345-cc smooth round gel implants. This study demonstrates that in a select population of implant patients with a variety of indications for explantation, the removal of their implants results in an improvement in quality of life. The select population in this study requested explantation either because of implant-related complications or concerns about implant safety and impact on health. Only 9.2% of the patients in this study were asymptomatic and requested implant removal without any specific indication. It is reasonable to assume that patients who have concerns about their breast implants are more likely to feel better following removal than patients having implants removed for reasons other than health-related concerns. As well, it would have been interesting to include an additional study arm to compare patients who underwent implant removal without additional aesthetic re-shaping. Patient-reported outcomes have been shown to improve in patients with breast implant illness symptoms following explant, irrespective of capsulectomy and secondary aesthetic procedure.7,8 Explantation following aesthetic augmentation can be challenging. Many options exist for managing these patients based on the unique goals and expectations of each person. The authors should be congratulated for presenting their experience with implant removal capsulectomy and aesthetic breast reshaping. As with any medical device, breast implants require maintenance and upkeep. The number of secondary procedures and requested implant removals is sure to increase with time. The authors declared no potential conflicts of interest with respect to the research, authorship, and publication of this article. The authors received no financial support for the research, authorship, and publication of this article.

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