Performing explant surgery combined with a breast lift offers a multitude of advantages for the patient. The lift not only enhances the aesthetic outcome but also provides better capsule exposure and visibility during the procedure, allowing for more precise capsule removal compared to traditional techniques. I meticulously mark and measure for the breast lift prior to surgery, ensuring that I preserve as much breast tissue as possible while effectively lifting the breast into its natural position. This careful planning is vital for removing not just the implants and capsules but also any excess stretched, deflated, or damaged skin.
There are various types of breast lifts, each serving a distinct purpose, and I often find myself discussing these options with my patients. Generally, I categorize lifts into three main types: the periareolar lift (or “donut” lift), the vertical lift (or “lollipop” lift), and the wise-pattern (or “anchor”) lift. Each has its own indications and benefits, and I approach these choices based on the unique needs of each patient.
In my practice, I find limited use for the periareolar lift unless a patient is seeking a very modest lift and is open to having a bunched incision around the nipple that requires a great deal of time for the bunching to flatten. One way to understand this is to imagine the drawstring on a laundry bag. With a periareolar lift I make an incision around the nipple then a larger circular incision depending on how much lift I am trying to achieve. I then suture the smaller nipple-areolar complex into the larger circle using a purse-string style, or drawstring suture. As I pull the suture lines closed it has a drawstring effect on the outer rim of skin creating a bunched appearance as is seen when one pulls a laundry bag closed. In truth, I can’t recall the last time I did a peri-areolar lift. I don’t see much utility for this procedure in my practice, especially when trying to account for the excess skin laxity after explant.
Some surgeons advocate for a vertical or lollipop lift over the anchor style lift, but I believe there is no definitive right or wrong method; rather, it comes down to personal preference and the specific circumstances of each case. After an explant, patients often have excess skin in both the horizontal and vertical directions, and this skin can be very lax and stretched. This excess skin must be addressed in multiple directions to prevent ptosis, or drooping, post-surgery. While the vertical lift seeks to minimize the horizontal incision beneath the breast, it may not always adequately account for all of the excess skin that needs removal after an explant. The horizontal incision along the inframammary fold is often less visible and tends to heal beautifully, especially since many patients have already had an inframammary fold incision from their previous breast implant placement.
In contrast, I find the anchor style lift to be more effective for achieving superior support and long-term results in a patient with lax, excess skin, especially without the weight and volume of an implant. This approach allows for the removal of excess skin in both directions—horizontal and vertical—providing an aesthetically pleasing outcome while addressing the unique challenges posed by explant surgery. I am continually refining these techniques to improve support/lift and minimize the visibility of incisions and scars. Ultimately, my goal is to provide each patient with a natural, youthful appearance that they can feel confident about.
On this same subject, it is important for patients to understand that an explant and lift can be very safely performed simultaneously. I rarely encounter a situation where I feel the need to perform the explant and lift at different times. But one must remember that when an implant has been in the breast pocket for years, there are changes to the entire breast that a lift may not completely address. There are cases in which a second procedure may be needed to pinch excess skin or correct an implant-related abnormality with the breast fold.
I work very hard to minimize or erase the appearance of dogears, or excess skin along the lateral edge of the breast lift incision. I have developed techniques to remove or transpose the underlying fat and breast tissue along this lateral edge. I have adjusted my incision techniques to minimize uneven or excess skin folds along this edge. But many patients have naturally occurring excesses of lateral breast skin and fat that were less apparent with an implant and ptotic breast in place. After the explant and lift, these excesses become more visible.
Let me write that differently and more clearly. When a patient has large, heavy implants and the breasts have drooped down over the years, this often masks the presence of the “bra roll,” or that extra fat and skin on the lateral chest. With an explant and a lift the breast is now smaller and lifted and in some cases this bra roll is suddenly much more obvious. There are a number of secondary techniques that can be used to remove this excess skin or fat but during the initial lift procedure I want to limit how long the lateral breast incision extends. I don’t want the incision to extend far lateral to the breast fold if it doesn’t need to be. Therefore in certain cases I can transpose this lateral fat medially to enhance the breast projection and limit the lateral chest fullness.
Expertise
I saw my first patient for breast explant many years ago, and at her request, I agreed to remove her implants. At the time, I was not familiar with breast implant illness as a condition, but the patient was very concerned about her implants. She surprised me when she asked that I also remove the capsules. At the time, breast capsules were generally only removed for capsular contracture, and many of those cases involved only a partial capsulectomy. I informed this patient that I would remove her entire capsule, assuming I could do so safely and reasonably.
She had been told by other doctors that they would only remove her implant and not the capsule. Again, I assured her that, with safety as my top priority, I would be happy to remove her capsules as well. Removing a capsule is significantly more complicated than simply removing the implant which explains why many physicians were reluctant to perform this procedure. But in this case, the patient did fantastic after her surgery, and many of her autoimmune and inflammatory symptoms improved. She shared her experience with others, leading to a groundswell in my practice of diagnosing and treating breast implant illness patients.
As I continued within this very specialized pursuit, I became more educated and familiar with breast implant illness, diving deeply into the subject. Patients return after explant saying they feel like a new person, rejuvenated and revived. We have observed a significant reduction in inflammatory conditions and an increase in peace of mind and an improved sense of wellbeing among our explant patients. Indeed, the causes of autoimmune and inflammatory conditions are multifactorial. While there are medicines that relieve some symptoms and lifestyle modifications can lessen severity, there is rarely a singular cure to these serious inflammatory and autoimmune conditions.
I have been on a personal journey to evaluate, critique, and perfect the en bloc explant procedure and to focus on the intricate details that ensure it is performed correctly and consistently each time. Each step is critical to preserving and entirely removing the capsule. No matter how many enbloc explant cases I perform per day or per week, each case is unique and significantly different from the others. Every patient is treated as a unique individual, with her own set of concerns, conditions, and requirements for the procedure. I have seen patients who have had implants for as little as six weeks or as long as 45 years. Some have ruptured implants, capsular contracture, calcified thick capsules, double capsules, late seromas, and various other significant implant complications. Each patient’s concerns must be addressed and acknowledged to ensure they are taken seriously. Interestingly, most breast implant illness patients that I encounter have normal appearing implants and capsules.
I’ve included a step by step description of my typical enbloc explant procedure. These steps may be different with each case but this is the general cadence for the operation. Certain features of my technique are unique and have evolved with time. Examples of these unique steps include hydro-dissection of the capsule and surrounding tissue, and the auto-augmentation of lateral breast tissue. I am also developed unique capsule retractors to facilitate capsule removal without damaging the capsule or implant.
Expertise isn’t earned overnight or at a clinical meeting or in a weekend course. Expertise is the result of days, weeks, months, and years of repetition, practice, and evaluation of breast implant illness and explant patients. I have seen every type, shape, and thickness of capsule and I have developed my own techniques for removing ruptured implants without contaminating the breast pocket. It requires work and practice and there is no shortcut for that level of experience.
Another example of lessons I’ve learned through experience involves the use of drains during enbloc explants. From my experience a drain is always necessary when performing a total capsulectomy, complete capsulectomy, or enbloc explant (these 3 terms are synonymous with one another). About once per month a patient will say she wants the full capsulectomy but she wants to know why I use drains and some other doctor does not. I use drains because of the work it takes to separate the capsule from the pectoral muscle and chest wall. Carefully peeling this capsule away takes time and the tissues will produce fluid in response to this injury. If enough fluid collects within the breast pocket it cannot be adequately absorbed and a seroma will form. We prevent seromas with good drainage and compression garments. Other physicians and practices may have their own methods and protocols but I find that a short course with a drain in place and a good compression garment is the most consistent way to prevent seroma formation. Likewise I have not seen a good argument to avoid using a drain. The drain allows inflammatory markers to be flushed out after the explant and the drain provides an early warning system in case there is any bleeding afterward. The prudent surgeon uses drains after total capsulectomy, complete capsulectomy, or enbloc explant.
In my opinion the only way to safely perform an explant without a drain is to not remove the capsule. If a patient undergoes a total capsulectomy without a drain then it is just a matter of luck and good fortune if that patient avoids a seroma. Full disclosure, a few years ago at the request of some patients, I tried different techniques to avoid drains when performing enbloc explants and my seroma rate was 50% (N=4, two patients developed a seroma and two did not). A 50% seroma rate is far too high. Placing a drain for one week drops the seroma rate to a very acceptable 1-5%, meaning 1-5 patients in 100 may develop a small seroma regardless of the drain, but up to 99% of the patients will not have a seroma.
Being Seen and Heard
Each patient deserves to be seen, heard, and informed about the potential benefits of breast implant removal and en bloc explant. Many of these patients have gone to great lengths to feel better, making significant lifestyle and dietary changes, and often consulting multiple doctors or medical providers in search of relief. Many also come from a place of mistrust, feeling as though they have been misled by the medical community and that some providers do not take their concerns seriously.
This is why the consultation is so important for patients dealing with breast illness. A patient’s history and story reveal a great deal; excellent surgery is not simply about removing the implant and immediately feeling better. This is not akin to a patient with appendicitis, who can be cured with an appendectomy. Each explant surgery is a journey; the patient typically has experienced a lot before arriving at a consultation with me. I understand that it can be overwhelming to remove something that has been a part of them for so long, often linked to their identity and sense of femininity.
Some patients have excellent support from family and friends, which is crucial for healing and recovery, but others may not have the best support system. We need to understand this during the consultation to cater to each patient’s needs. Many of our patients have complex medical and surgical histories, and these details must be understood prior to surgery. Some of my consultation notes for breast illness patients are several pages long.
Ultimately, I want to ensure that patients feel seen and heard. I take detailed notes and strive to know as much about the patient as possible, allowing me to develop the best treatment plan. As I mentioned, this has been a journey not only for the patients but for me as well. It has been incredibly fulfilling to see so many individuals return happy, vivacious, healthier, and ready to embrace a better chapter in their lives.