What is En-Bloc Capsulectomy or Total Capsulectomy?
When a silicone implant fails capsular contraction may begin. The scar around the implant (the capsule) tightens and squeezes around the implant. It may also gradually thicken. The rupture is often contained within the capsule and we call this intra-capsular rupture. Removal of the implant with the entire thickened capsule is called en-bloc capsulectomy. This is a significantly more lengthy operation, it costs more, and involves a longer scar in the infra-mammary area (usually using the old scar that is there but extending it further). This also enables a new implant to be placed if that is the plan, although the space that is present after en-bloc capsulectomy is often significantly greater than the space before. So the breast shape changes, becoming less firm, less full, and the breasts may seem smaller and lower. But the capsulectomy should be done when the capsule is clearly abnormal and it should be sent to histo-pathology. I like to orientate the capsules too. It can be difficult for patients to get used to the different feel of the replacement implants, and they will need reminding that the tight feeling from the thickened capsule was not normal.
What is Partial Capsulectomy or Capsulotomy?
Sometimes the capsular contraction is minimal, and the capsule is still thin, and in this circumstance it may be reasonable to simply incise (cut into) the capsule to release it. Placing radial and circumferential incisions through the capsule in this manner, would allow the remaining capsule to expand again over a replacement implant. I reserve this approach predominantly for minimal changes only or where capsular excision carries unacceptable risk. If there is just a localised area of abnormal capsule, such as thickening on the back wall, I would perform a partial capsulectomy of that area for histopathology. This analysis is then done by the consultant breast pathologists who are very experienced in these assessments. These localised thickenings are usually fairly innocuous and caused by a low grade localised chronic inflammation causing more collagen to be deposited, often around small microscopic fragments of silicone material that are derived from the implant surface or possibly tiny amounts of silicone bleed. But we must always be on the lookout for possible lymphoma change, although in 15-years of sending these samples this has never yielded a sinister result and the reports have always been benign.
Where Can I Find Someone To Perform My Removal Of Silicone Implants Possibly With Capsule Removal?
If you would like to remove your silicone implants or to replace silicone implant either alone of with the capsules I would suggest seeing you in person. So please simply book a formal consultation for this. It is helpful although not essential if you can bring information about your previous operations and any record regarding your current implants. One advantage with a specialist doing this type of surgery is the breadth and depth of experience they have in dealing with different scenarios, and understanding the optimal approach. However, there are always potential unforeseen changes and this type of surgery, predominantly in the patient who has had multiple revisions over the years can have a less predictable cosmetic outcome.
Common Indications For Capsulectomy At The Time Of Implant Removal
Baker Grade 3 or 4 capsular contraction. The breast has become hard due the contracted scar around the implant, there may be distortion and it may be uncomfortable.
If the capsule is found to be calcified or looks abnormally thickened.
Problems with a possible infection around the implant
Known or suspected immediately adjacent carcinoma
Known or suspected breast implant associated anaplastic large cell lymphoma (BIA-ALCL)
(The removed tissue should be always analysed by histopathology.)
It may also be considered in these circumstances: replacement to a larger size, change of tissue plane, to deal with a recurrent benign seroma, to remove a ruptured implant where the capsule is thick, removal of a polyurethane coated implant that is adherent, renewal of an implant with a macro-textured or MPU-coated device where adherence is extremely important to reduce movement of the new implant and outweighs negative factors.
Why Might Complete Capsulectomy Not Be Possible?
Implants that are behind the muscle, sub-pectoral or dual plane, will have capsules that are adherent to the ribs and the intercostal muscles. Aggressive attempts to excise capsules here, unless strongly indicated because of cancer or lymphoma, can cause pneumothorax or injure the muscle. It is therefore reasonable to leave capsule where there is no confirmed or high suspicion of malignancy, and perform a partial capsulectomy of the safer anterior and outer aspects of the capsule if indicated. It is also important to note that thin flimsy capsules are very difficult to remove from intercostal spaces and usually do not need to be removed. Occasionally if a patient has had very large implants there can be capsule that extends into the axilla (the underarm area) where there are large blood vessels and nerves. Risking an injury to these structures and the associated complications is not warranted simply to achieve complete removal because of patient driven fear that all implant capsule be removed. This dissection should therefore only be performed where clinically necessary and of course by an experienced breast surgeon, typically and oncoplastic breast surgeon, and may require a separate axillary incision.
“The overriding guideline for deciding whether a total capsulectomy should be performed or not is that the potential benefit must outweigh the risk” (V L Young PRS 1998)
What Is The Additional Cost For Capsulectomy?
Full capsulectomy will often take approximately an additional hour of operating time of an explantation. The additional time and expertise, and the sending of a tissue sample to histopathology involves additional resources and a consultant pathologist report, means the cost of the surgery will be a lot higher, usually in the region of £1000-£2000 extra according to what is required.