Treatment and Recovery

My Explant Technique

Every single explant case is different, but these are the steps I employ in almost every case. Variations on these techniques include a submuscular vs sub glandular explant, an explant with or without a lift, unilateral or bilateral implant rupture, etcetera.

Step One: 

Step Two:  

• Transfer the patient to the procedure room.
• Place sequential compression devices on the legs to reduce the risk of blood clots (DVTs).
• Start an IV and administer either IV sedation or general anesthesia (typically TIVA).

Step Three:  

• Sterile preparation
• Prep the patient’s chest in a sterile.manner.
• Drape in a sterile fashion.
• Infiltrate the incisions with dilute 1% lidocaine with epinephrine.

Step Four:  

• Make the incisions: For non-lift patients, make the incision in the inframammary fold, ideally using the previous implant incision if possible.  In some cases the previous incision is too low on the chest and the natural fold of the breast is well above this scar.  In those cases I willl make the new incision at the level of the natural fold so that the new incision will hide better in the natural fold and be less visible.
• Carry the incision down to the breast implant capsule.
• For mastopexy, mark a perfect circle around the nipple-areolar complex using a 38 or 40 mm steel donut.
• Make additional incisions along the mastopexy markings.
• De-Epithelialization:  Dissect away the epidermis and upper dermis, leaving a thin layer of deep dermis. This preserves a transdermal plexus of capillaries for blood supply to the nipple-areolar complex.
• Continue dissection through the subcutaneous tissue to the breast implant capsule.

Step Five:  

Enbloc Explant

• Upon encountering the breast capsule I use a larger syringe with a blunt cannula filled with dilute 1% lidocaine to infiltrate along the edge of the implant capsule.
• I perform hydro dissection to create natural separation between the capsule and surrounding breast tissue, aiding in hemostasis and providing local anesthesia.
• I fully dissect the capsule free from surrounding tissues:  I use a combination of sharp dissection (knife or scissors), blunt dissection (non-sharp instruments), and electrocautery for hemostasis.
• I remove the capsule with the implant EN BLOC or as a single unit.
• I always aim to remove the implant enboloc, unless limitations arise (e.g., capsule diving between ribs or thin intercostal muscles). If remnants of the capsule remain, I will cauterize and obliterate them to ensure they resorb on their own.

Step 5A:

Pathology Specimen

Upon removing the capsule and implant I will examine the surrounding breast tissue and muscle for any visible abnormalities.  I will also examine the breast implant capsule for any abnormalities, masses, or fluid.  If any masses, fluid, or other abnormalities are found I will take a sample and send it for pathology evaluation.  

If the patient has textured implants I can send a sample for a CD30 marker test to determine the presence of Anaplastic Large Cell Lymphoma (ALCL).  It is important to note that ALCL typically presents with other symptoms such as late seroma, so the finding of textured implants in a patient with no symptoms is not technically an indication to send a CD30 test.  

Step 6:  

Hemostasis

• After the capsule and implant are completely removed, place them on the back table for further examination.
• Use electrocautery to obtain hemostasis.

Step 7:  

Nerve Block

• Administer Exparel by injecting it around the pectoral nerve and along the medial and lateral chest wall.  Many patients refer to this step as a nerve block.

Step 8:  

Irrigation with saline solution

I Irrigate the pocket with a dilute Betadine solution and examine the pocket for additional bleeding points.  If necessary, use electrocautery to stop bleeding from any small blood vessels.

Step 9:  

Auto Augmentation and/or Lateral Chest Liposuction

• For patients with excess volume in the lateral breast, undermine the skin edges of the lateral aspect of the breast incision.
• Once this lateral fat pad is freed I can either remove it entirely or rotate the lateral fat pad medially and secure it with dissolvable sutures to enhance the visible appearance of breast volume.
• The purpose of this maneuver is to minimize lateral fullness and volume and auto-augment the breast by rotating fat into the breast mound to maximize volume.
• In some cases I will also perform liposuction of the lateral chest and axillary (underarm) fat pads.  

Step 10:  

Muscle Repair

I examine the pectoral muscle closely for any areas of muscle separation.  This may occur when implants were initially placed or when the capsule was adherent to the muscle and the muscle had to be divided to free the capsule.  If muscle repair is necessary, I use dissolvable sutures to repair the muscle and restore it to its natural anatomic position.  Every single case is different when it comes to muscle separation and repair.  In some cases minimal to no repair is necessary.  In other cases an extensive repair is needed.  I will not know the extent of repair until the capsule is removed.

Step 11:  

Drain Placement 

• I make a small incision beneath the inframammary fold and place a Jackson Pratt drain in the breast pocket.   Drain may be flat or round depending on a number of factors.  Drain placement and the type of drain used is a matter of necessity, not patient request.  The drain is placed to decompress and close down the large empty space left from removing the implant and capsule.  The drain, combined with a compression garment provide the best opportunity to close the pocket and prevent seroma formation.  At this time there is no other method that I am aware of to properly close the pocket after enbloc or total capsulectomy without a drain.  One cannot safely place quilting or progressive tension sutures into the chest wall and rib cage to close this pocket, and a suturing technique like that on the chest wall would be extremely painful and risk tearing of the intercostal muscles.  The drain is typically in place for one week at the end of which, drain output is low enough to safety remove the drain.

Step 12:  

Closure

• I close the skin in 2 to 3 layers, depending on the thickness and volume of breast tissue, using dissolvable sutures. 

Step 13:  

Photography

Photographs are taken of the implant capsules on the back table.  I remove the capsules, typically using scissors, and take another photo of the capsules next to the implants.  If the patient wants the implants returned to her we will wash and return them.  Otherwise they are immediately discarded as a biohazard.  

Step 14:

• With the skin closed and the nipple-areolar complex inset, we place the drains to bulb suction and then wash the skin and apply Steri-Strips and gauze over the incisions.

We place a compression wrap around the patient’s chest and transfer the patient to the recovery area for further monitoring before discharge.  

Post op care and recovery

1. Mobility After Surgery

• Importance of Movement: Encouraging patients to move regularly is vital for circulation, reducing the risk of blood clots, and promoting healing. Light activities such as walking can help maintain flexibility and strength.
• Avoiding Restrictions: The idea of limiting arm movement (like the “T-Rex position”) can be counterproductive. Instead, guiding patients to engage in gentle movements can facilitate better recovery.

2. Drain Management

• Purpose of Drains: Drains are placed to remove excess fluid and reduce swelling. It’s important to monitor the amount of fluid output.
• Extended Duration: In cases where drains produce more fluid than expected, keeping them in for an additional week can help prevent complications such as seromas (fluid collections).

3. Compression Wrap

• Function: The compression wrap helps minimize swelling and provides support to the surgical area. It’s crucial for maintaining the results of the surgery.
• Showering: The first shower after surgery feels like heaven.  We want our patients to shower the day after surgery.  With drains in place just turn your back to the shower and let the water run down.  The drains will be removed in one week and this process will get much simpler.  In the meantime, a daily shower is important after surgery.  Remove gauze dressings, shower, and replace any necessary dressings after the shower.

4. Follow-Up Appointment

• Transitioning from Compression Garments: At the one-month mark, patients can transition to more comfortable undergarments like sports bras, which offer support without the constraints of a compression wrap.