Breast Implant Removal - Explant

I have long counseled my patients who are considering breast implants that extensive research performed over many years appears to provide a high confidence level that implants are systemically safe. I also acknowledge, however, that I am open-minded to the possibility that over time, our knowledge regarding potential issues associated with breast implants may change. Experience leads to evolution in our understanding of many things. This is certainly true of Breast Implant Associated Large Cell Lymphoma, and may eventually extend to Breast Implant Illness as well.

Breast-Implant-Associated ALCL and Breast Implant Illness

Today, we are dealing with two relatively new issues relative to breast implants: Breast Implant-Associated ALCL (BIA-ALCL) and “Breast Implant Illness” (BII). BIA-ALCL is NOT breast cancer; rather, it is a rare form of lymphoma that is predominately associated with “textured surface” breast implants. This condition is an accepted diagnosis that is definitively established with pathologic study of implant pocket fluid or capsular tissue.

BII, on the other hand, is not an accepted diagnosis. It is controversial, as it has no specific or uniform clinical, laboratory or pathology correlations. There are no diagnostic criteria or tests for BII. This does not mean that it does not exist; it simply means that we do not have enough scientifically verified information to establish its existence. Therefore, I currently describe “Breast Implant Illness” as a symptom complex rather than a disease. In my experience, this label is associated with a broad range of non-specific symptoms that vary by patient in terms of presence and severity. Many patients have symptoms in multiple categories and do not seem to fit any observable pattern in terms of outward appearance or lifestyle. BII can affect patients with any type of implant, saline or gel, smooth or textured. .

Some patients experience “mechanical” issues with their implant such as tension, pressure, excess weight, stiffness and immobility. They often have chronic pain in the breast or chest area. These symptoms are often associated with oversized implants and implants positioned below the pectoral muscle, and often occur in the absence of capsular contracture (excessive scar tissue). Burning or stinging in the lateral breast area is commonly reported even if the implants are otherwise comfortable. These patients consistently improve following removal of their implants.

Most patients have some type of systemic symptomatology. These issues can occur in conjunction with the physical complaints, or independent of those problems. The most commonly described symptoms are fatigue, difficulty concentrating, joint and muscle pain, irritable bowel type issues, changes in the skin and hair and restlessness or anxiety. Many other symptoms are also reported. I have tried to categorize the symptoms, and I believe they have characteristics of allergy and autoimmune sensitization, neurotoxicity, hormone disruption and possibly chronic low-grade infection. Interestingly, a significant majority of these patients also improve with implant removal. Currently, the underlying reason for these symptoms, and the apparent improvement following explant, is unknown. However, I have had the experience of meeting many of these women each week, and it is clear to me that their symptoms are real. I appreciate their frustrations with physicians who often refuse to acknowledge their implant concerns, or who try to help but are unable to provide diagnosis or effective treatment. What is not clear is why these women are suffering. I am concerned that these problems may be due to something that we have failed to recognize and investigate with adequate broad-mindedness and diligence.

Breast Explant Surgery

Initially, I had some discomfort with the concept of removing breast implants for a controversial condition. I can’t test for BII, and I couldn’t provide reasonable assurance of symptom improvement. I offered alternate explanations such as diet, stress and Lyme disease. Most patients, however, had already explored those possibilities without success. Ultimately, I believe that patients have the right of self-determination. Just as they decided to have the implants placed, they have the right to request removal.

To date, I have removed breast implants from nearly 200 patients. Reassuringly, my patients have consistently indicated high levels of appreciation and satisfaction with their outcomes. Gratifyingly, nearly all have indicated symptoms resolution or significant improvement within weeks to months of explant. Some were on disability and were able to return to work. Other plastic surgeons throughout the country are reporting similar experiences.

On the other hand, many other plastic surgeons, general practitioners and specialists remain skeptical and say these women are experiencing severe anxiety and/or are fabricating medical symptoms that have no cause. Others accept the symptoms as real but believe they are unrelated to the implants, and any improvement is a psychosomatic or self-fulfilling outcome. In my experience, however, most of my patients were completely unaware that their implants might be making them sick until they exhausted attempts at medical diagnosis and failed multiple management approaches including conventional medication, integrative medicine treatments and lifestyle changes such as dietary restrictions. They present as rational, reasonable people who are not angry, accusatory or panicked. They are aware that the stories online are anecdotal. Many describe unease with the overly dramatic online posts they read. They realize mainstream scientific studies contradict their claims. Yet, they recognize similarities to their own experience, and they feel that implant removal is an option they must explore. Individually, each patient realizes she might not improve with the explant surgery and that esthetically, she is going to look very different. They accept the cosmetic consequences in the hope of regaining health.

Where Do We Go From Here?

Am I still using breast implants? The answer is “yes”. I still perform augmentation procedures and I still perform breast reconstruction with implants. Breast implants remain useful devices for many situations. I do educate and inform my patients of the known possibility of BI-ALCL and the potential for symptom complexes referred to as BII. Unfortunately, we do not have consistent statistics regarding the true incidence of BI-ALCL, and we have no definition of BII to even begin to establish a possible incidence for that condition. Most likely, however, BII affects only a small percentage of implant patients, or we would have become aware of the possibility before now. Social media, while criticized for being a potential driver of this “factitious” phenomenon, may actually be helping to connect affected patients and bring our attention to a real problem. My own experience working with these women suggests to me that more research is needed. There is so much we don’t know and much to learn about this complex of symptoms.

Because I have become a “go-to” plastic surgeon for explant surgery due to this condition, I have many thoughts and questions. First, I would like to determine the most common and suggestive symptoms. With a consensus definition of the symptoms, we can try to establish the incidence of this complex in the implanted population. Additionally, for patient education and consent, it would be helpful to know if there are certain patient specific factors, such as certain genetic types, that seem to be more at risk. For diagnosis, are there any laboratory studies that are commonly abnormal, such as elevated inflammatory markers, or is there a way to test for possible sensitivities to specific chemical components of the implant? Is there a more effective way to evaluate the implant pocket or implant surface for microbial populations such as biofilm? Can we be more specific in our histopathologic analysis of the implant capsules?

The Food and Drug Administration (FDA) is actively reviewing these questions and will make recommendations as Committee hearings continue.

I will keep patients updated on my website as well as my Facebook page as developments occur.