Capsulectomy
- Approximate duration: 1h30 to 2 hours
- General anesthesia
- Recovery: one month
What is a capsulectomy or explantation?
Capsulectomy involves removing not only the implant, but also the capsule surrounding it. This capsule is scar tissue that the body forms around any foreign object to insulate it. For example, a splinter left in a finger will cause a capsule to form. The longer it remains, the thicker it becomes, eventually becoming permanent.
The exact importance of the capsule, and therefore of capsulectomy, is not yet well understood. While there are good reasons to remove it (see following sections), this procedure is clearly more complex than simple implant removal. It is essential that patients understand both the benefits and the potential risks. This is a priority for Dr. Nicolaidis, who presented this topic for the first time to the world at the American Society of Plastic Surgery in 2022.
What are the technical details of explantation?
Explantation requires a long incision in the crease under the breast to properly expose and safely remove the implant and its capsule. The capsule often adheres to the surrounding muscles, sometimes causing minor muscle damage. Fortunately, these injuries are usually minor and require only simple fiber realignment. In cases of implants placed under the muscle, the procedure is even more complex, as the capsule may be stuck to the ribs. This requires delicate dissection to avoid entering the lung cavity (risk of pneumothorax).
It should be emphasized that there is no guarantee that BII-related symptoms will improve after explantation.
Is this procedure covered by the RAMQ?
The RAMQ covers the removal of implants and en bloc capsulectomy in the following three situations:
- Polyurethane implants
- Ruptured gel implants, with proof before surgery
- Grade 4 capsular contracture, documented before surgery
Dr. Nicolaidis believes that Allergan textured implants should be added to this list, but this point remains controversial.
What are the possible complications?
Dr. Nicolaidis is the first Plastic Surgeon world-wide to report prospectively on the complications of capsulectomy with simultaneous breast lift, presented at the American Society of Plastic Surgeons Meeting in October 2022. Here, Dr. Nicolaidis was pleased to win the “outstanding paper presentation” award. The following are the complications in his first 500 explant cases; it is important to keep in mind that these complication rates are in experienced hands and are likely higher in the hands of someone who does not do these surgeries regularly:
Pneumothorax: Risk of pneumothorax is probably the main reason that many Plastic Surgeons hesitate to perform complete capsulectomies. Pneumothorax involves penetration of the covering around the lung (NOT the lung itself), typically as the capsule is being peeled off the rib cage. This occurred in 8 out of 500 patients (1.6%), all of whom had submuscular implants. The pneumothorax was recognized immediately and a small tube was placed in the hole. The tube was removed the following day with no further consequences.
Bleeding: Bleeding is the most common complication of capsulectomies, requiring return to the operating room to stop bleeding in 4 patients and simple drainage in clinic in 5 cases. So a total of 9 cases in 500 explantations for a rate of 1.8%.
For these reasons, Dr. Nicolaidis now places drains for all patients and asks them to keep their elbows on the sides for 2 weeks following surgery.
Skin laceration: This occurred in the two out of 500 patients, both of whom had implants above the muscle. One patient had severe contracture with the capsule stuck on the skin. The other patient was extremely muscular. An incidence of 0.4%. It is important to note that these two complications occurred in the first 50 explantation cases. Since then, Dr. Nicolaidis has had no further cases of skin laceration. Obviously, experience helps to diminish these complications.
Seroma: Seroma is a collection of non-bloody fluid that typically develops in the explant pocket. This occurs in small amounts in many patients, such that the liquid gets absorbed by the body over a period of weeks. Dr. Nicolaidis has had 3 cases of more significant collections which required drainage under ultrasound. So, a rate of 0.6%.
For seromas, drains may be effective. But Dr. Nicolaidis does not feel they are necessary given the low incidence of seromas. Nevertheless, if a patient really desires drains, Dr. Nicolaidis will be happy to comply.
Reaction to Anesthesia: While some patients may develop a sore throat following anesthesia, no patients had a major reaction to anesthesia, requiring transfer to the hospital or anything of that nature. So, a rate of 0%.
Total complication rate: 4.8%. For comparative purposes, the estimated revision rate for breast augmentations is 10%.
Types of capsulectomy
En bloc capsulectomy
This term is used in oncology, particularly for the treatment of BIA-ALCL. It involves the complete removal of the implant and its capsule, as a single specimen, with a margin of healthy tissue around it. This method is not controversial in cases of cancer.
Some patients with BII also request an en bloc capsulectomy, even though they do not have cancer. They simply want the implant and capsule removed together, without a margin of healthy tissue. Dr. Nicolaidis considers this request reasonable, especially if the implant is ruptured or if silicone or fluid is suspected in the capsule. This type of procedure requires an incision longer than the diameter of the implant; however, the removal of the breast implant with its surrounding capsule as one specimen can never be guaranteed, especially if the capsule is very thin.
Complete capsulectomy
It involves removing the entire capsule, even if the implant is removed first. This may be necessary when the capsule is too thin or the implant is too large. While no one can guarantee removal of the breast implant with its capsule as one specimen, Dr. Nicolaidis does guarantee complete capsulectomy for all of his patients. No portion of the capsule is left behind in the patient.
Exploratory capsulectomy
In some cases, patients suspect that the capsule was partially left behind after implant removal. If symptoms persist, exploration may allow for the removal of a residual capsule. Although some patients have experienced improvement in their symptoms after such a procedure, no results can be guaranteed.
Partial capsulectomy
Some surgeons will not remove the posterior wall of the capsule, which is often very adherent to the ribs, fearing the complication of pneumothorax. A study conducted by Diana Zuckerman showed that the best improvement of BII symptoms occurred after a complete capsulectomy. Dr. Nicolaidis therefore never recommends partial capsulectomy, especially for patients with Allergan textured implants, who have a 1:400 risk of developing BIA-ALCL.
Drainage before capsulectomy
This approach involves first emptying a saline implant and then removing the capsule later. Dr. Nicolaidis does not recommend this because it poses a risk of potential leakage of chemicals contained within the implant. He prefers to remove the implant intact.
Surgical details and post-operative
Implant removal with or without breast lift
After explantation, a breast lift is usually necessary to improve the shape of the breast. Only about 5% of patients do not require some form of a breast lift after explantation; these patients tend to be young, with significant breast tissue and with small breast implants. A lift removes excess skin and restores a more aesthetically pleasing shape. Dr. Nicolaidis adapts his techniques to preserve nipple vascularity and achieve harmonious results.
Important: Breast lifts are never covered by RAMQ, even if the criteria for capsulectomy are met. Dr. Nicolaidis performs these procedures in a private clinic in Montreal.
Anesthesia
Removal of implants with en bloc capsulectomy is always performed under general anesthesia by Dr. Nicolaidis.
Surgical technique
The incision is made in the inframammary fold. Surgery can be difficult, especially when the capsule is stuck to the muscles or ribs. Simple stitches are usually sufficient to correct minor muscle damage. If the implants are under the muscle, careful dissection is necessary to avoid entering the chest cavity.
Convalescence
Drains are placed in all cases of explantation. The dressings are left in place for one week. Patients are advised to keep their elbows on their sides for the first two weeks after surgery. Following that, they can gradually raise their arms such that their arms can rise above their head by four weeks. There are no restrictions following six weeks postop.
Back to work
Depending on the nature of your job, two to four weeks of leave is recommended. No manual activity is permitted for one month.
Important notice
Although Dr. Nicolaidis is a member of the Department of Plastic Surgery at the University of Montreal, the opinions expressed on this page are his own and do not represent those of the institution.
Post-surgery advice
The first week
• Keep your bandages dry and clean.
• Do not force your arms; keep your arms at your sides and use only your forearms without forcing.
• Wash with a sponge.
• Sleep on your back only (IMPORTANT: never on your side).
• Walk at least 5 minutes every hour of the day (avoid staying in bed constantly).
After the first week
• Continue to keep your arms alongside your body using only your forearms without forcing for a 2nd week (2 weeks in total after surgery).
• Continue to keep your dressings dry and clean until further notice by Dr. Nicolaidis.
• You can wash your back against the shower jets, with a sponge or with a hand-held shower.
• Avoid exposing your scars to the sun for a period of 6 months.
• Avoid lifting heavy objects until Dr. Nicolaidis gives you express permission to do so. • Before taking a bath again, you should ask Dr. Nicolaidis if you can.
• Keep moving to avoid complications due to inactivity, such as blood clots (walk regularly during the day).
• Wear a (comfortable) sports bra without cups.
• Do not wear an underwire bra for at least 2 to 3 months to avoid friction on the scar.
Please note
• It is normal to have some swelling and bruising around the breasts during the first few weeks after surgery. However, it is not normal for one breast to become significantly larger than the other; in this case, please call us.
• For your comfort, be sure to take your pain relievers as prescribed.
