Caitlin Gallagher
April 10, 2019 11:14 am

Breast implants have been in the news a lot lately—and not just because Khloé Kardashian’s plunging dress at Diana Ross’s 75th birthday party had her considering getting her “boobs done.”  The Food and Drug Administration (FDA) is looking into the safety of breast implants, and in March, the federal agency had a two-day public meeting about it. The main reason for the meeting was to look into how breast implants could potentially be causing cancer. So if you have implants, this FDA investigation might have you wondering—understandably—about breast implant removal.

The potential cancer risk is one reason you might be thinking about having your implants removed. You may just want a smaller or larger size, though, or perhaps it’s time to get them out since they don’t last forever. Whatever the reason, arming yourself with knowledge is always a good idea.

A brief note on the cancer the FDA is looking into: First of all, it’s not breast cancer. It’s actually a type of lymphoma called breast implant-associated anaplastic large cell lymphoma (BIA-ALCL). Not every type of breast implant is linked to this cancer—only textured implants are connected to BIA-ALCL, and NBC reports that only 12% of women with implants in the U.S. have the textured kind.

To help women learn more about breast implant removal—whether you have textured implants or not—we spoke with two board-certified plastic surgeons: Dr. Constance Chen and Dr. Katerina Gallus. These two surgeons have different perspectives on the breast implant removal process, but they both agree that anyone with breast implants should be aware of the potential health risks.

So here’s what you need to know about the safety of breast implants and what the whole breast implant removal process entails:

What are the different types of breast implants?

Dr. Chen: Breast implants can be separated into many different types. The outer shell of the implant may be textured or smooth. The inner filling can be saline [salt water], silicone, or cohesive gel. And the shape can be round or teardrop shaped.

What’s going on with textured implants?

Dr. Gallus: Textured implants are being highlighted because of the risk of BIA-ALCL. In the United States, most implants placed are smooth. This means the shell of the implant is just that: smooth. Textured implants have a rough surface that helps them stick to the surrounding tissue. They can be either silicone or saline, round or anatomic-shaped implants. Textured implants are FDA-approved in the U.S. but are more commonly used globally. There are also some types of textured implants that are not available in the U.S.

Why would someone get textured-surface implants rather than smooth-surface ones?

Dr. Chen: Textured-surface implants adhere more securely to the breast tissue. Thus, if someone has very thin breast tissue and would like breast reconstruction or breast augmentation in a teardrop shape—instead of a round cantaloupe shape—then they may look better with a textured-surface shaped breast implant. A smooth-surface shaped implant does not adhere as well to the breast tissue, and a smooth-surfaced implant is more likely to flip and move. If a shaped implant flips upside down, then the thick portion of the implant may be at the top of the breast while the thin portion of the implant is at the bottom, which would make the breast look like it is upside down. Thus, most shaped implants are going to be textured.

What do we know about BIA-ALCL?

Dr. Chen: It is an indolent T-cell lymphoma that is associated with breast implant capsules [the capsule is the scar tissue around the breast implant]. It usually presents with a late-forming seroma, or fluid around the breast implant, or a mass attached to the implant capsule. The only deaths in women who have had BIA-ALCL have been women who had residual capsule from their breast implant.

Dr. Gallus: The ALCL associated with breast implants is a rare and slow-developing disease and largely curable. It is unknown what specifically causes BIA-ALCL, but the association between textured implants and possible low level of chronic bacterial inflammation has been made. There is a theory that there may be a genetic predisposition, but we do not have a marker to test for that at this time. There have been no known cases of BIA-ALCL in women who have only had smooth implants. BIA-ALCL often presents as a fluid collection around a breast implant that accumulates suddenly over days to weeks. It is diagnosed when that fluid is sent for cytology and is positive for certain markers. If the cytology confirms the diagnosis, then the implant, the fluid, and the capsule should be removed. When diagnosed early, this is a curative treatment.

Are there other types of breast implants that the FDA is looking into?

Dr. Chen: The FDA is looking into all types of breast implants, including tissue expanders, but they are most concerned with textured implants.

What does the breast implant removal procedure entail? You have different standards of care, so please tell us about your process.

Dr. Gallus: The surgery, at its most basic, involves making an incision through the original incision where the implant was placed and removing the implant. Patients who have had their implants placed via an axillary (underarm) incision will need a new incision—usually under the breast. The capsule is present because of the implant. Once the implant is removed, the capsule will disappear on its own over time. I generally remove at least the anterior (front) of the capsule so that it disappears faster. Some women choose to have their implants removed under local anesthesia. That can be done, but in general, the surgeon will remove the implant only and leave the capsule in that case. I prefer to perform the surgery under general anesthesia to ensure patient comfort and safety.

You can have the implants removed, the implants and part of the capsule removed, or the implants and all the capsule removed [called “en bloc” removal]. En bloc removal is not always an option as the capsule is normally very thin. Removing a thin capsule is somewhat like working with wet tissue paper. In patients with submuscular implants, the posterior (back) of the capsule can be stuck to the ribs and chest wall making it impossible to take off without creating more damage. This is like taking the sticker off the bottom of a drinking glass—sometimes it peels off super easy and other times you are cursing Ikea. There is no medical evidence to support removing the implant capsule, so discussing what your options are and the pros/cons of variations of implant removal with your surgeon are important before proceeding.

With that being said, if there is a diagnosis of BIA-ALCL, the entire capsule should be removed en bloc. That is a basic principle for sound oncological (cancer) surgery—even if it incurs damage to surrounding structures. That is why proper assessment and diagnosis is so important.

Dr. Chen: The breast implant removal procedure involves making an incision through the skin, usually through the scar that the patient already had for placing the implants, and then identifying the breast capsule. Once the breast capsule is identified, it is dissected all the way around the implant and removed in an en bloc fashion with the implant inside and intact. The patient then needs a drain since the body does not like empty spaces, and will try to fill up the space with fluid where the implant used to be.

I do en bloc capsulectomy for all breast implant removal procedures. A patient may not be diagnosed until after the operation, and, as previously mentioned, all of the people who have died from BIA-ALCL only had partial or no capsulectomy. Thus, I feel it is safer to do en bloc capsulectomy for all breast implant removal procedures.

If a person has textured-surface implants, what do you suggest they do?

Dr. Gallus: The important thing is to stay informed. If you have a fluid collection or lump around your breast implant, then it is important to have it assessed by a physician who knows how to assess you for BIA-ALCL. Finding the implant card that was issued at the time of the original surgery is helpful for the physician evaluating you. The risks appear to be related to the manufacturing of the textured implant, so the more information you have about the type of implant, the better you can understand your risk and the options. Although don’t worry if you don’t have that information—most patients don’t remember what kind of implant they had placed.

It is not currently recommended that you have textured implants removed unless you have symptoms of a fluid collection or a mass. Some women are electing to change their implants for smooth implants if they are undergoing breast surgery for a different reason.

Dr. Chen: If they have textured silicone implants, they should get breast MRIs every two to three years to monitor for implant rupture and changes around their breast implant and capsule.

What are some other risks associated with getting breast implants?

Dr. Gallus: The most common risks of breast implants are rupture and capsular contracture (when the scar capsule around the implant becomes hard). Implant rupture is obvious when a saline implant is in place. With gel implants, this may be a “silent” rupture that is noticed on MRI or ultrasound. Capsular contracture can occur with any type of implant and presents as thickening of the capsule that forms around the implant. The capsule, or scar tissue, can harden and distort the breast and the implant.

Dr. Chen: All breast implants have health risks—including smooth, textured, saline, silicone, cohesive gel, round, and teardrop-shaped. The known health risks include capsular contracture, infection, and rupture. Many women also report a more amorphous entity called breast implant illness, which is a loose collection of symptoms and autoimmune illnesses that have a higher prevalence in women who have breast implants. Many women also associate their breast implants with autoimmune diseases and non-specific complaints, such as fatigue, joint pain, hair loss, inflammation, food and drug intolerance, infections, brain fog, etc.

What are some other reasons people may want/would need to get their implants removed?

Dr. Chen: People may want to get their breast implants removed because they have painful capsular contracture, ruptured implant, asymmetry, rippling, cold breasts, infection, and other known issues related to breast implants. Breast implants usually do not last forever, even in the best of circumstances. Over time, the scar tissue around the breast implant may become hard and painful, and can disfigure the breast and lead the patient to want to remove the implants. The outer shell can also leak or rupture, at which point the breast implant needs to be removed. Finally, since the breast implant is a foreign object without a blood supply, if the breast implant becomes infected, it may need to be removed.

Dr. Gallus: Some patients decide over time that the size of the implants they have are too large or heavy. With time, health, or weight changes, women may feel that their breast implants may no longer fit their lifestyle. Women who have had recurrent capsular contracture may elect to remove their implants instead of continuing with more surgery. Some women have associated their implants with health issues—they have self-identified as having breast implant illness.

What should women know before getting their breast implants removed?

Dr. Gallus: It is your decision to remove the implants. But it is an elective surgical procedure that has its own risks and benefits. Ensure that you have considered the reasons and motivation for implant removal. Many insurance companies will not cover elective implant removal unless specific criteria are met. Consider the cost of the surgery as well as the time for recovery. Understand that your breast tissue will have changed over time with the implants and that removal may result in flat or sagging tissue. Some women then elect to have a breast lift or fat grafting. There are multiple options and it is important to discuss your goals and expectations with your surgeon.

Dr. Chen: Before getting their breast implants removed, women should know that they should have their breast implants removed with complete en bloc capsulectomies to make sure that the biofilm associated with their breast implants and capsule is removed. In addition, when the volume is removed from their breast implants, their breasts may look deflated, deformed, and even mutilated without further procedures. If they have very little breast tissue, it may be difficult to create a breast mound. Over time, however, their breast skin will contract and their breast tissue will re-expand, so their breasts may improve in appearance even without further procedures.

With all this in mind, what do you think is important for women to know before getting breast implants?

Dr. Chen: Breast implants are a foreign body, and they are easier to put in than they are to remove. Some women who have breast implants will have them for decades without problems. Other women start having problems as soon as their breast implants go in. Sometimes, it is hard to know who is going to do well with breast implants and whose body will not tolerate implants well. It is like an allergy— some people are allergic to penicillin, while for other people penicillin is a life-saving antibiotic. Unfortunately, you often don’t know which category you fall in until you are exposed to it.

Dr. Gallus: It is important to understand that implants are not lifetime devices—most women will undergo a second breast surgery at some point. The most common reasons for this in the past have been a size change or treatment of capsular contracture. The current implants on the market are safe and continue to be approved by the FDA, but I recommend a smooth implant over textured implants for my patients in the hopes of ensuring the risk of BIA-ALCL is as close to zero as possible. It is important to remember that you should still be aware of the greater risk of developing breast cancer and that any lump or mass should be evaluated by a physician.

What else do you think is important to address regarding breast implants?

Dr. Chen: When it comes to breast reconstruction, women can undergo natural tissue breast reconstruction, in which the patient’s own tissue is used to reconstruct the breast. Advanced microsurgical techniques use the lower abdomen or upper inner thigh to reconstruct the breasts. In addition, with natural tissue breast reconstruction, it is possible to reconnect the nerves to restore sensation to breasts after mastectomy. The aesthetic result is usually superior to breast implants, but it may require a little more work and research on the part of the patient to find a microsurgeon with the skill set to perform these innovative types of breast reconstruction.

Dr. Gallus: As both a plastic surgeon and as a woman who has breast implants, I understand that it is important for patients to make informed choices about their health. In my experience in treating women with breast cancer, I have come to appreciate that there is not a one-size-fits-all plan. When facing breast cancer, some women will elect breast-conserving procedures, others will remove both breasts, and many are treated with a plan that is somewhere in between. Every medical treatment has risks and benefits. It is critical that we respect that women will have different opinions about breast implants and should be afforded the opportunity to make decisions regarding surgery that are informed.

These interviews have been edited and condensed for clarity.

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