CAPSULECTOMY-EN-BLOC: As mentioned earlier, capsulectomy-en-bloc is an oncologic term recommended for diagnosed BIA-ALCL, involving the removal of the implant and its entire capsule as one unit, with a cuff of surrounding normal tissue. There is no debate over this treatment. However, patients with BII have been requesting capsulectomy-en-bloc to treat their symptoms. Obviously, these patients do not desire removal of surrounding normal tissue, given that they do not have cancer. Rather, they want the implant and capsule to be removed together as one unit. Given that BII is not understood, Dr. Nicolaidis feels that such a capsulectomy is not unreasonable in order to remove any possible silicone, infection, liquid, etc that may exist within the capsule, particularly in the case of ruptured silicone implants. How about we call it a “single specimen capsulectomy”? However, it must be understood that such a capsulectomy requires an incision length longer than the diameter of the implant. Obviously, a breast implant with an average diameter of 11 cm cannot be removed with its capsule intact through a 5 cm (2 inch) incision. Furthermore, no surgeon can guarantee a capsulectomy-en-bloc, particularly when the capsule is thin and tears.
COMPLETE CAPSULECTOMY: Although Dr. Nicolaidis sees a certain logic in removing implants and capsule as a single unit, patients must understand that it cannot always be done, particularly in the case of thin capsules (which tear easily during dissection) or large implants (unless patients accept an even longer incision in the breast fold). In such cases, the implant is removed from the capsule in order to permit better visualization and removal of the entire capsule. Given our limited understanding of BII, Dr. Nicolaidis and most explant surgeons feel that removal of the entire capsule is necessary. No capsule is left behind.
EXPLORATORY CAPSULECTOMY: Many patients have reached out to Dr. Nicolaidis with the concern that capsule was left behind after their removal of implants. The removal of implants is very likely more important than that of the capsule. The important issue is symptom improvement in the patient. If the patient has complete resolution of symptoms, then further treatment might not be necessary. However, several patients have presented with persistence of symptoms after either simple removal of implants or incomplete capsulectomy. In these cases, Dr. Nicolaidis explored the submuscular or subglandular pockets and found residual capsule, which was then removed. Although there was symptom improvement in some patients, Dr. Nicolaidis cannot guarantee improvement of symptoms following exploratory capsulectomy.
PARTIAL CAPSULECTOMY: In an effort to minimize the risk of pneumothorax (discussed later), some Plastic Surgeons with less experience in explant surgery have proposed leaving behind the posterior wall of the capsule, which is often very adherent to the rib cage. The only UNBIASED study that has looked at the effect of different degrees of capsulectomy on BII symptom improvement is that of Diana Zuckerman, who found that BII symptom relief was best following COMPLETE capsulectomy. Given Zuckerman’s findings and Dr. Nicolaidis’ experience that the risks of pneumothorax are minimal, he NEVER recommends partial capsulectomy. Another reason to remove the posterior wall of the capsule are the 2020 findings by L-J Feng of improved pulmonary function after removal of breast implants and total capsulectomy, with the suggestion that a posterior wall capsule which is glued to the rib cage may limit expansion of the lungs during inspiration (as in an accordion that is taped closed).
IMPORTANT: Dr. Nicolaidis cautions that patients with textured Allergan implants should NEVER undergo partial capsulectomy as a prophylactic measure, given what has been observed to date. “You’re better off just following for the signs of BIA-ALCL then.”
DRAINAGE > CAPSULECTOMY: A fourth approach circulated in early 2021, specific to saline implants. Some Plastic Surgeons will empty saline implants first and then perform capsulectomy at a later time, the reasoning being to allow for a smaller skin incision for capsulectomy; however, the concern of patients is the inevitable spillage of saline (with whatever other chemicals may be present within the implant shell). Once again, given our limited understanding of BII, Dr. Nicolaidis feels that it is more prudent to remove everything as a single specimen without drainage. But that is his opinion.
