1) We are just starting to become aware of the problems with breast implants. So the importance of the capsule and its removal are not known.
2) BIA-ALCL has been shown to originate between the implant and its surrounding capsule.
3) BIA-SCC has also been shown to originate between the implant and its surrounding capsule and is associated with any type of implant, smooth or textured, saline or gel.
4) If capsule is left behind, it will never go away (as some Plastic Surgeons have been suggesting to their patients). Dr. Nicolaidis has explored patients years after implant removal and always finds capsule (as in the photos shown here).
5) Capsules will often thicken and calcify over time, especially with gel bleeds or older implants, as seen in these adjacent photos. Nobody wants to keep such a capsule in their body.
6) Improve breathing and restore normal anatomy. Wee et al in 2020 proved that breathing improves after complete capsulectomy. The thinking is that the posterior wall capsule (the very same capsule that is left behind by Plastic Surgeons who claim that it is too dangerous to remove for fear of pneumothorax) tethers the ribs so that they cannot fully open for deep breaths, sort of like if you glued something on the side of an accordion so that it can no longer be opened. When patients are able to breath easier, anxiety is decreased and patients can function better.
If enough capsule is left behind, a full pocket will remain. Because of the composition of the capsule, that pocket will never stick together and close, leading to loose soft tissues above. Fluid can also potentially collect in that pocket at a later time.
7) Removing capsule ensures that any residual silicone or infection is removed along with the implant. Residual silicone in the capsule is of particular concern with gel bleeds or rupture.
8) Patients want the “peace of mind“, knowing that both implant and capsule have been removed.
9) To date, only one VALID study has looked at improvement of symptoms with respect to degree of capsulectomy. Dr. Zuckerman sent questionnaires to 792 patients with a 57% response rate and found that the best improvement in symptoms occurred in those who had en-bloc or complete capsulectomies. As mentioned above, the 2020-21 study funded by ASERF tried to look at the importance of capsulectomies; however, the surgeons and patients decided who would get what kind of capsulectomy, instead of that being randomly decided. This is called SELECTION BIAS, which renders a study INVALID.
10. Unlike most of his colleagues in Plastic Surgery, Dr. Nicolaidis argues that capsulectomy is not a dangerous procedure in experienced hands. Dr. Nicolaidis presented “Prospective Study of Complications Following 500 Explantations with Simultaneous Breast Lift” for the first time in the world at the American Society of Plastic Surgeons meeting in October 2022. His total complication rate was 5%, compared to a 10% revision rate for breast augmentations.
“BII is far from understood. So I approach it very carefully. There are some issues that are very clear while others that are completely uncertain. Also, different patients have different priorities with respect to their health, scars, etc. In such cases of uncertainty, patients should be listened to and understand the risks and benefits of the various options so that they can make an informed decision themselves.”
— Dr. Nicolaidis
Explantation paid by the government
In Quebec, removal of breast implants and capsulectomy are covered by the government in three circumstances:
- Polyurethane implants
- Ruptured gel implants
- Grade 4 contracture (in which the capsule becomes hard and painful with visible changes in the breasts).
Authorization for capsulectomy requires documentation of the above with radiologic proof, if necessary, the operative protocol and a pathology report confirming the above. If anything is missing or cannot be found, the surgery is not reimbursed. Moreover, the government will never cover lifts, which are usually necessary at the time of explantation in order to minimize terrible skin folding. Lastly, Dr. Nicolaidis works at the CHUM super hospital, where his directive is complex reconstructions following cancer, etc. He does not have operating time to perform explantations. For all of these reasons, Dr. Nicolaidis does not perform explantations in the public system; rather, he performs explantations at a private surgery center.