July 22, 2025
Capsulectomy Update
Thinking about removing your breast implants? Here is the latest information to know about capsulectomy, the surgery to remove the scar tissue that forms around implants.
The latest research and professional society consensus statements inform decisionmaking. Dr. Bass breaks down the four types of capsulectomy and when each one makes sense.. He also explains why the most aggressive option—en bloc capsulectomy—is only recommended when there’s a confirmed or suspected implant-associated cancer.
If you’re concerned about breast implant associated illness or just exploring your breast implant removal options, this conversation clears up the confusion with the latest expert guidance.
About Dr. Lawrence Bass
Innovator. Industry veteran. In-demand Park Avenue board certified plastic surgeon, Dr. Lawrence Bass is a true master of his craft, not only in the OR but as an industry pioneer in the development and evaluation of new aesthetic technologies. With locations in both Manhattan (on Park Avenue between 62nd and 63rd Streets) and in Great Neck, Long Island, Dr. Bass has earned his reputation as the plastic surgeon for the most discerning patients in NYC and beyond.
To learn more, visit the Bass Plastic Surgery website or follow the team on Instagram @drbassnyc
Subscribe to the Park Avenue Plastic Surgery Class newsletter to be notified of new episodes & receive exclusive invitations, offers, and information from Dr. Bass.
1
00:00:01,170 --> 00:00:03,720
Welcome to Park Avenue
Plastic Surgery Class,
2
00:00:03,780 --> 00:00:07,440
the podcast where we explore controversies
and breaking issues in plastic
3
00:00:07,440 --> 00:00:10,260
surgery. I'm your co-host, Summer Hardy,
4
00:00:10,320 --> 00:00:13,500
a clinical assistant at Bass
Plastic Surgery in New York City.
5
00:00:13,860 --> 00:00:17,670
I'm excited to be here with Dr. Lawrence
Bass, Park Avenue plastic surgeon,
6
00:00:17,700 --> 00:00:19,770
educator and technology innovator.
7
00:00:20,490 --> 00:00:23,880
The title of today's episode
is Capsulectomy Update.
8
00:00:24,780 --> 00:00:28,020
So I'm gathering this has something
to do with breast implants.
9
00:00:28,050 --> 00:00:30,090
What is the basic topic, Dr. Bass?
10
00:00:30,360 --> 00:00:33,810
Well, this episode is
about capsulectomy surgery.
11
00:00:34,440 --> 00:00:38,100
This is done to the capsules
that form around implants.
12
00:00:38,610 --> 00:00:43,050
It's about some guidance for patients
13
00:00:43,440 --> 00:00:47,640
who are thinking about removing their
breast implants because of health
14
00:00:47,640 --> 00:00:52,410
concerns, and there are some recent
new advisory recommendations.
15
00:00:52,920 --> 00:00:57,720
Okay. So let's start at the beginning.
What is a breast implant capsule?
16
00:00:58,200 --> 00:01:02,550
The breast implant capsule
is a white glistening
17
00:01:02,550 --> 00:01:07,080
membrane comprised of
rows of collagen fibers
18
00:01:07,500 --> 00:01:10,800
that the body forms
around the breast implant.
19
00:01:11,370 --> 00:01:16,230
The body recognizes that the implant
is not a natural part of the body,
20
00:01:16,680 --> 00:01:21,600
and it lays down some collagen
around the implant to wall it off.
21
00:01:22,080 --> 00:01:26,880
And the way this appears to the surgeon
when the capsule is healthy is as a
22
00:01:26,880 --> 00:01:30,300
thin pliable white glistening membrane.
23
00:01:30,600 --> 00:01:35,520
Okay, thanks for explaining Dr.
Bass. So why is this surgery done?
24
00:01:36,060 --> 00:01:40,890
Well, there are lots of reasons we do
surgery on the breast implant capsule.
25
00:01:41,430 --> 00:01:44,700
Sometimes we do this for
an implant malposition,
26
00:01:44,700 --> 00:01:49,320
an implant that either didn't settle
in the right position or that has
27
00:01:49,650 --> 00:01:51,570
distorted over time.
28
00:01:52,200 --> 00:01:56,040
One of the main reasons that an implant
distorts over time is because of
29
00:01:56,070 --> 00:01:57,870
capsular contracture.
30
00:01:58,350 --> 00:02:02,760
Basically a thickening and
tightening of the breast implant
31
00:02:02,790 --> 00:02:07,290
capsule that makes the breast feel firmer,
32
00:02:07,860 --> 00:02:12,210
but also can shift the implant
out of symmetric placement.
33
00:02:12,870 --> 00:02:13,950
So those are very,
34
00:02:13,950 --> 00:02:18,060
very common reasons that
capsule surgery is done,
35
00:02:18,570 --> 00:02:21,330
and there's not a lot of
controversy about that.
36
00:02:22,140 --> 00:02:27,030
But there are also newer
issues that are under a lot of
37
00:02:27,030 --> 00:02:30,750
discussion these days and
for the past several years.
38
00:02:31,440 --> 00:02:33,780
So one is something,
39
00:02:33,870 --> 00:02:38,370
and we've mentioned these on
the podcast before and again,
40
00:02:38,370 --> 00:02:40,590
brought updates about this before.
41
00:02:41,130 --> 00:02:43,800
One is breast implant associated illness,
42
00:02:44,400 --> 00:02:47,670
so that's one item.
43
00:02:48,270 --> 00:02:53,130
And another is breast
implant associated ALCL or
44
00:02:53,640 --> 00:02:57,090
a tumor that forms in the capsule,
45
00:02:57,600 --> 00:03:01,870
not in the implant, but in the
capsule around the implant.
46
00:03:02,470 --> 00:03:06,190
And that ALCL is anaplastic
large cell lymphoma.
47
00:03:06,190 --> 00:03:10,810
It's a very rare tumor
that can form around the
48
00:03:10,810 --> 00:03:13,060
capsule. And more recently,
49
00:03:13,810 --> 00:03:18,460
breast implant associated squamous
cell carcinoma has been demonstrated,
50
00:03:18,460 --> 00:03:22,390
which is even more rare than
51
00:03:22,420 --> 00:03:23,800
ALCL.
52
00:03:24,250 --> 00:03:28,660
And all of that seems to be
associated with textured implants,
53
00:03:28,660 --> 00:03:29,493
by the way.
54
00:03:29,860 --> 00:03:31,570
Okay, that makes sense.
55
00:03:31,720 --> 00:03:34,870
But could you provide some
definitions about these things?
56
00:03:35,230 --> 00:03:40,120
So let's go back and discuss in a little
more detail breast implant associated
57
00:03:40,120 --> 00:03:44,410
illness. So this is a
syndrome of symptoms,
58
00:03:44,920 --> 00:03:49,360
more than 90 different symptoms
that have been attributed
59
00:03:49,840 --> 00:03:53,320
to breast implants in one way or another.
60
00:03:53,830 --> 00:03:58,300
And it's controversial. We don't
understand exactly what causes it.
61
00:03:58,300 --> 00:04:02,680
We don't understand exactly what the
62
00:04:02,680 --> 00:04:04,840
spectrum of symptoms are,
63
00:04:05,500 --> 00:04:10,390
but a number of people
who have implants in place
64
00:04:10,450 --> 00:04:14,470
felt very strongly that the
implants were responsible
65
00:04:14,800 --> 00:04:17,740
for fatigue, weakness,
66
00:04:18,430 --> 00:04:21,250
all manner of illness symptoms,
67
00:04:21,760 --> 00:04:26,350
and that they got better when
the implants were removed.
68
00:04:26,830 --> 00:04:31,750
Okay, got it. So what are the
causes and what is the treatment?
69
00:04:32,260 --> 00:04:33,093
So again,
70
00:04:33,220 --> 00:04:38,080
this is controversial and I don't
think we fully understand this
71
00:04:38,080 --> 00:04:39,310
scientifically.
72
00:04:39,640 --> 00:04:44,320
It's immensely difficult
to study an illness that
73
00:04:44,740 --> 00:04:49,000
can have 90 different
diagnosable symptoms.
74
00:04:49,810 --> 00:04:54,430
So that's so broad and so many of those
75
00:04:54,430 --> 00:04:59,350
symptoms are things that all of us
experience from time to time that it
76
00:04:59,350 --> 00:05:03,640
makes it very difficult
to rigorously study this
77
00:05:03,640 --> 00:05:04,630
scientifically.
78
00:05:05,110 --> 00:05:10,090
But some of the possible reasons that
have been cited for causing breast
79
00:05:10,090 --> 00:05:14,230
implant illness are impurities
and heavy metals in the
80
00:05:14,230 --> 00:05:19,150
implants or mold that's associated
81
00:05:19,150 --> 00:05:24,130
with the implants or bacterial
colonies that live on the surface
82
00:05:24,130 --> 00:05:26,800
of the implants. And
these are called biofilms.
83
00:05:27,220 --> 00:05:31,540
And biofilms live on all medical
implants, not just breast implants.
84
00:05:31,540 --> 00:05:36,400
They live on our teeth and that's why
we brush our teeth all the time to try
85
00:05:36,400 --> 00:05:38,260
to keep those to a minimum.
86
00:05:38,860 --> 00:05:43,060
But they've been listed as possible
87
00:05:43,060 --> 00:05:48,010
causes for this problem.
In terms of treatment,
88
00:05:48,610 --> 00:05:53,440
the treatment relates to removing the
89
00:05:53,440 --> 00:05:58,400
implant and possibly to
removing the capsule.
90
00:05:59,090 --> 00:06:03,080
Okay. And overall, you mentioned
that this is controversial.
91
00:06:03,080 --> 00:06:05,750
What's the controversy
around these procedures?
92
00:06:06,080 --> 00:06:10,670
So the issue is how much
improvement or what percentage of
93
00:06:10,670 --> 00:06:15,350
patients we can expect to
improve if we remove the
94
00:06:15,350 --> 00:06:16,183
implant.
95
00:06:16,640 --> 00:06:21,290
And also there's a controversy
about whether there's a need to
96
00:06:21,290 --> 00:06:26,240
perform a capsulectomy and whether
that has a benefit in alleviating
97
00:06:26,240 --> 00:06:29,150
the symptoms. In particular,
98
00:06:29,720 --> 00:06:34,220
one of the procedures that's
sometimes done for breast implant
99
00:06:34,220 --> 00:06:37,970
associated illness includes what's
100
00:06:37,970 --> 00:06:40,550
called en bloc capsulectomy.
101
00:06:41,600 --> 00:06:46,310
So this is taking out the capsule in a
102
00:06:46,310 --> 00:06:51,230
single piece, including a rim of
normal tissue around the capsule.
103
00:06:51,680 --> 00:06:56,600
And that's traditionally used in cancer
surgery. We use that for example,
104
00:06:57,110 --> 00:07:01,310
for cases of breast implant associated
105
00:07:01,730 --> 00:07:05,180
ALCL or squamous cell carcinoma.
106
00:07:05,780 --> 00:07:08,060
Okay. Well, if that's the case,
107
00:07:08,060 --> 00:07:11,570
then why not perform the
biggest removal possible?
108
00:07:12,410 --> 00:07:13,610
The reason is this,
109
00:07:13,610 --> 00:07:18,050
everything we do has a cost
or a risk as well as an
110
00:07:18,050 --> 00:07:18,740
advantage.
111
00:07:18,740 --> 00:07:23,090
So it seems like a great idea to
take out the most tissue you can
112
00:07:23,540 --> 00:07:27,650
for the greatest chance of helping
patients with breast implant associated
113
00:07:27,650 --> 00:07:28,880
illness improve,
114
00:07:29,510 --> 00:07:33,980
but that won't necessarily provide more
115
00:07:33,980 --> 00:07:35,210
improvement,
116
00:07:35,420 --> 00:07:39,080
and there's definitely
increased risk to en bloc
117
00:07:39,650 --> 00:07:44,060
resection. So it's only worth
it if there's a proven benefit.
118
00:07:44,600 --> 00:07:48,770
And in many ways, this echoed the
experience with cancer therapy.
119
00:07:48,770 --> 00:07:52,370
If you went back to the
middle of the 20th century,
120
00:07:52,370 --> 00:07:55,130
there was this notion that
the more you take out,
121
00:07:55,130 --> 00:07:59,150
the greater your chance of cure.
And when it was carefully studying,
122
00:08:00,920 --> 00:08:05,780
it's more like Goldilocks and the three
bears, not too much, not too little,
123
00:08:05,780 --> 00:08:10,070
just right. So more
wasn't necessarily better,
124
00:08:10,070 --> 00:08:14,240
but it definitely has
more risk, more recovery,
125
00:08:14,780 --> 00:08:19,760
more potential for deformity
or medical complications.
126
00:08:20,330 --> 00:08:24,020
Okay. I'm starting to get an
understanding of the issues here.
127
00:08:24,440 --> 00:08:26,180
So what's the news?
128
00:08:26,870 --> 00:08:27,290
Well,
129
00:08:27,290 --> 00:08:32,270
there's been a consensus statement
on breast implant capsulectomy
130
00:08:32,270 --> 00:08:35,300
from the breast surgery
collaborative community.
131
00:08:35,960 --> 00:08:39,530
Can you explain what this group is
that's putting the statement out?
132
00:08:40,790 --> 00:08:44,750
FDA has developed a very strong
133
00:08:44,750 --> 00:08:49,130
priority to create these
collaborative communities,
134
00:08:50,270 --> 00:08:55,220
to bring together all the
stakeholders to help solve
135
00:08:56,340 --> 00:08:58,230
challenges, controversies,
136
00:08:58,230 --> 00:09:03,180
basically to get input from everybody
involved rather than saying, well,
137
00:09:03,180 --> 00:09:08,160
let's ask the manufacturer, or let's ask
the doctors, or let's ask the patients.
138
00:09:08,460 --> 00:09:11,730
Well, no, you really need
to ask all of those groups.
139
00:09:11,730 --> 00:09:16,260
All of those groups need to be
looking at the data, discussing it,
140
00:09:16,650 --> 00:09:20,220
providing input from their perspective,
141
00:09:20,550 --> 00:09:22,770
probably to get to the right answer,
142
00:09:23,190 --> 00:09:26,130
certainly rather than excluding anybody.
143
00:09:26,130 --> 00:09:31,020
So this breast surgery collaborative
community is a consortium
144
00:09:31,020 --> 00:09:34,680
of patient advocates, board
certified plastic surgeons,
145
00:09:35,430 --> 00:09:37,830
medical device manufacturers,
146
00:09:38,100 --> 00:09:42,420
and others with a vested interest
in enhancing breast surgery
147
00:09:42,420 --> 00:09:43,253
safety.
148
00:09:43,590 --> 00:09:48,030
So they were assembled to
clarify some of these issues and
149
00:09:48,030 --> 00:09:49,260
examine the data.
150
00:09:49,830 --> 00:09:54,330
Gotcha. That makes a lot of sense to
me. So what are their recommendations?
151
00:09:54,810 --> 00:09:56,820
So they did two things.
152
00:09:56,880 --> 00:10:01,020
They provided definitions
for different types of
153
00:10:01,020 --> 00:10:02,940
capsulectomy procedures,
154
00:10:02,940 --> 00:10:06,090
and they provided
management recommendations.
155
00:10:06,630 --> 00:10:09,360
Let's start with the
capsulectomy definitions.
156
00:10:09,900 --> 00:10:13,950
The statement defines four
basic types of capsulectomy.
157
00:10:14,490 --> 00:10:16,650
There's the total intact capsulectomy.
158
00:10:16,950 --> 00:10:21,630
This is complete removal of the
breast implant capsule as a single
159
00:10:21,630 --> 00:10:24,480
unit with the implant contained within it.
160
00:10:25,140 --> 00:10:29,040
This has often been done historically
when there's a ruptured implant,
161
00:10:29,520 --> 00:10:34,470
particularly with the old non
cohesive gel implants to help
162
00:10:34,500 --> 00:10:36,720
contain the silicone gel.
163
00:10:37,440 --> 00:10:39,540
Then there's a total capsulectomy.
164
00:10:39,810 --> 00:10:43,470
So that's complete removal
of the implant capsule,
165
00:10:43,950 --> 00:10:47,310
but not necessarily all done in one piece.
166
00:10:47,820 --> 00:10:50,910
So you're getting all of the capsule
out, but you're taking it out.
167
00:10:50,970 --> 00:10:55,440
Whatever is easiest and
least traumatic without any
168
00:10:55,590 --> 00:10:59,670
need to keep it in one piece. Third,
169
00:10:59,670 --> 00:11:01,680
there's a partial capsulectomy.
170
00:11:01,680 --> 00:11:05,160
This is probably most commonly performed.
171
00:11:05,430 --> 00:11:10,080
This is removal of the breast implant
capsule where some capsule is left
172
00:11:10,080 --> 00:11:13,890
behind. And as I said, this
is probably the most common.
173
00:11:13,890 --> 00:11:16,950
What we generally do
when we remove implants,
174
00:11:17,670 --> 00:11:22,410
most commonly probably in the
United States when there's no issue,
175
00:11:22,770 --> 00:11:27,720
but we're just removing the implants
for preference or for a rupture,
176
00:11:28,200 --> 00:11:29,940
is we examine the capsule.
177
00:11:29,940 --> 00:11:34,380
And if the capsule's thickened or
calcified or in any way looks unhealthy,
178
00:11:34,620 --> 00:11:39,480
that portion of capsule is removed.
If the capsule looks thin, pliable,
179
00:11:39,510 --> 00:11:41,970
glistening, healthy white membrane,
180
00:11:41,970 --> 00:11:44,820
like it looks early after
the implant is placed,
181
00:11:45,360 --> 00:11:50,070
that's left alone and
remains and seems not to
182
00:11:50,070 --> 00:11:52,860
create an issue for patients. Final,
183
00:11:53,920 --> 00:11:56,500
the procedure I already described,
the en bloc capsulectomy,
184
00:11:56,500 --> 00:12:01,330
this is removal of the
breast implant capsule with a
185
00:12:01,330 --> 00:12:03,400
margin of uninvolved tissue,
186
00:12:03,730 --> 00:12:07,960
and that's the last of the
four types of capsulectomy.
187
00:12:08,470 --> 00:12:11,950
Wow, I didn't realize that. There are
four types. That's really interesting.
188
00:12:12,550 --> 00:12:15,250
And now can we go to the
management recommendations?
189
00:12:15,610 --> 00:12:20,260
So I'll bottom line the management
recommendations, because again,
190
00:12:20,410 --> 00:12:22,810
there's been a lot of
controversy about this,
191
00:12:22,810 --> 00:12:27,400
and some people have suggested that
if you do an en bloc capsulectomy,
192
00:12:27,400 --> 00:12:31,120
it's somehow better at
improving the symptoms.
193
00:12:31,570 --> 00:12:35,680
And basically the consensus group
194
00:12:35,680 --> 00:12:40,330
stated that the absolute and only
195
00:12:40,330 --> 00:12:44,680
indication for an en bloc
capsulectomy is for an
196
00:12:44,680 --> 00:12:49,570
established or suspected
breast implant associated
197
00:12:49,570 --> 00:12:54,100
cancer after appropriate
medical workup. In other words,
198
00:12:54,100 --> 00:12:59,080
after you've demonstrated
some proof that there is or
199
00:12:59,080 --> 00:13:03,160
likely is a breast
implant associated cancer.
200
00:13:03,790 --> 00:13:08,620
So that specifically
excludes any recommendation
201
00:13:08,680 --> 00:13:13,150
for en bloc capsulectomy for
breast implant associated
202
00:13:13,150 --> 00:13:13,983
illness.
203
00:13:14,320 --> 00:13:19,000
Okay. Could you share anything about how
they arrived at these recommendations?
204
00:13:19,360 --> 00:13:24,340
So these recommendations were based on a
205
00:13:24,340 --> 00:13:28,510
bunch of recent research on
206
00:13:28,510 --> 00:13:33,430
outcomes in a very large
number of patients who had
207
00:13:33,550 --> 00:13:38,290
different types of capsulectomies
trying to treat breast implant
208
00:13:38,290 --> 00:13:39,580
associated illness.
209
00:13:39,970 --> 00:13:43,240
And a lot of this research was
done by a plastic surgeon in St.
210
00:13:43,240 --> 00:13:45,250
Louis named Patricia McGuire,
211
00:13:45,610 --> 00:13:49,390
but there are some other researchers
who have been examining this as well.
212
00:13:50,140 --> 00:13:54,550
And that data and research was cited,
213
00:13:54,550 --> 00:13:55,330
in other words,
214
00:13:55,330 --> 00:13:59,830
referenced or listed in
the consensus statement.
215
00:14:00,310 --> 00:14:04,720
And that basically supports
the notion that there's no
216
00:14:04,720 --> 00:14:09,550
improvement with outcomes
doing an en bloc capsulectomy
217
00:14:09,970 --> 00:14:14,530
compared to a total capsulectomy
or potentially a partial
218
00:14:14,560 --> 00:14:15,393
capsulectomy.
219
00:14:16,120 --> 00:14:19,210
Okay. You've given a lot of
information in this episode.
220
00:14:19,330 --> 00:14:21,400
What does it mean overall, Dr. Bass?
221
00:14:21,850 --> 00:14:26,770
So these recommendations are things
that surgeons are going to bring up
222
00:14:27,250 --> 00:14:32,020
to patients when they have a
consultation requesting breast implant
223
00:14:32,020 --> 00:14:36,370
removal. Patients can decide
how they want to be treated,
224
00:14:36,910 --> 00:14:41,620
but doctors generally feel
best when they're making
225
00:14:41,620 --> 00:14:46,420
decisions that are based on
recommendations that are based
226
00:14:46,420 --> 00:14:50,380
on data. So data-driven
decision making, in other words,
227
00:14:50,380 --> 00:14:55,310
where there's some medical proof
that patients do better with a
228
00:14:55,310 --> 00:14:59,150
given option or do the same
with one option or another,
229
00:14:59,600 --> 00:15:03,830
generally guides most surgeons
and their decision making.
230
00:15:04,340 --> 00:15:09,050
But given the careful review
by all the stakeholders here
231
00:15:09,800 --> 00:15:11,730
of what the data shows,
232
00:15:12,110 --> 00:15:15,350
and we didn't have this data
five years ago or 10 years ago,
233
00:15:15,500 --> 00:15:19,880
this is data that's only been
obtained in the last few years,
234
00:15:20,240 --> 00:15:21,860
but now that we've got it,
235
00:15:21,860 --> 00:15:26,720
that's hopefully going to let
us be much more precise in
236
00:15:26,720 --> 00:15:30,800
giving patients what they need
to be healthy and feel their best
237
00:15:31,160 --> 00:15:35,000
without anything excessive
that's not needed to help them.
238
00:15:36,410 --> 00:15:37,640
Thank you for this update.
239
00:15:37,820 --> 00:15:41,930
We always like to keep our listeners
aware of the latest information in plastic
240
00:15:41,930 --> 00:15:42,763
surgery.
241
00:15:43,280 --> 00:15:47,360
Thank you for listening to the Park
Avenue Plastic Surgery Class podcast.
242
00:15:47,390 --> 00:15:49,310
Follow us on Apple Podcasts,
243
00:15:49,370 --> 00:15:51,620
write a review and share
the show with your friends.
244
00:15:51,800 --> 00:15:55,280
Be sure to join us next time to avoid
missing all the great content that is
245
00:15:55,280 --> 00:15:58,850
coming your way. If you want to
contact us with comments or questions,
246
00:15:58,850 --> 00:16:00,050
we'd love to hear from you,
247
00:16:00,140 --> 00:16:04,820
send us an email at
podcast@drbass.net or DM us on
248
00:16:04,820 --> 00:16:06,590
Instagram @drbassnyc.
00:00:01,170 --> 00:00:03,720
Welcome to Park Avenue
Plastic Surgery Class,
2
00:00:03,780 --> 00:00:07,440
the podcast where we explore controversies
and breaking issues in plastic
3
00:00:07,440 --> 00:00:10,260
surgery. I'm your co-host, Summer Hardy,
4
00:00:10,320 --> 00:00:13,500
a clinical assistant at Bass
Plastic Surgery in New York City.
5
00:00:13,860 --> 00:00:17,670
I'm excited to be here with Dr. Lawrence
Bass, Park Avenue plastic surgeon,
6
00:00:17,700 --> 00:00:19,770
educator and technology innovator.
7
00:00:20,490 --> 00:00:23,880
The title of today's episode
is Capsulectomy Update.
8
00:00:24,780 --> 00:00:28,020
So I'm gathering this has something
to do with breast implants.
9
00:00:28,050 --> 00:00:30,090
What is the basic topic, Dr. Bass?
10
00:00:30,360 --> 00:00:33,810
Well, this episode is
about capsulectomy surgery.
11
00:00:34,440 --> 00:00:38,100
This is done to the capsules
that form around implants.
12
00:00:38,610 --> 00:00:43,050
It's about some guidance for patients
13
00:00:43,440 --> 00:00:47,640
who are thinking about removing their
breast implants because of health
14
00:00:47,640 --> 00:00:52,410
concerns, and there are some recent
new advisory recommendations.
15
00:00:52,920 --> 00:00:57,720
Okay. So let's start at the beginning.
What is a breast implant capsule?
16
00:00:58,200 --> 00:01:02,550
The breast implant capsule
is a white glistening
17
00:01:02,550 --> 00:01:07,080
membrane comprised of
rows of collagen fibers
18
00:01:07,500 --> 00:01:10,800
that the body forms
around the breast implant.
19
00:01:11,370 --> 00:01:16,230
The body recognizes that the implant
is not a natural part of the body,
20
00:01:16,680 --> 00:01:21,600
and it lays down some collagen
around the implant to wall it off.
21
00:01:22,080 --> 00:01:26,880
And the way this appears to the surgeon
when the capsule is healthy is as a
22
00:01:26,880 --> 00:01:30,300
thin pliable white glistening membrane.
23
00:01:30,600 --> 00:01:35,520
Okay, thanks for explaining Dr.
Bass. So why is this surgery done?
24
00:01:36,060 --> 00:01:40,890
Well, there are lots of reasons we do
surgery on the breast implant capsule.
25
00:01:41,430 --> 00:01:44,700
Sometimes we do this for
an implant malposition,
26
00:01:44,700 --> 00:01:49,320
an implant that either didn't settle
in the right position or that has
27
00:01:49,650 --> 00:01:51,570
distorted over time.
28
00:01:52,200 --> 00:01:56,040
One of the main reasons that an implant
distorts over time is because of
29
00:01:56,070 --> 00:01:57,870
capsular contracture.
30
00:01:58,350 --> 00:02:02,760
Basically a thickening and
tightening of the breast implant
31
00:02:02,790 --> 00:02:07,290
capsule that makes the breast feel firmer,
32
00:02:07,860 --> 00:02:12,210
but also can shift the implant
out of symmetric placement.
33
00:02:12,870 --> 00:02:13,950
So those are very,
34
00:02:13,950 --> 00:02:18,060
very common reasons that
capsule surgery is done,
35
00:02:18,570 --> 00:02:21,330
and there's not a lot of
controversy about that.
36
00:02:22,140 --> 00:02:27,030
But there are also newer
issues that are under a lot of
37
00:02:27,030 --> 00:02:30,750
discussion these days and
for the past several years.
38
00:02:31,440 --> 00:02:33,780
So one is something,
39
00:02:33,870 --> 00:02:38,370
and we've mentioned these on
the podcast before and again,
40
00:02:38,370 --> 00:02:40,590
brought updates about this before.
41
00:02:41,130 --> 00:02:43,800
One is breast implant associated illness,
42
00:02:44,400 --> 00:02:47,670
so that's one item.
43
00:02:48,270 --> 00:02:53,130
And another is breast
implant associated ALCL or
44
00:02:53,640 --> 00:02:57,090
a tumor that forms in the capsule,
45
00:02:57,600 --> 00:03:01,870
not in the implant, but in the
capsule around the implant.
46
00:03:02,470 --> 00:03:06,190
And that ALCL is anaplastic
large cell lymphoma.
47
00:03:06,190 --> 00:03:10,810
It's a very rare tumor
that can form around the
48
00:03:10,810 --> 00:03:13,060
capsule. And more recently,
49
00:03:13,810 --> 00:03:18,460
breast implant associated squamous
cell carcinoma has been demonstrated,
50
00:03:18,460 --> 00:03:22,390
which is even more rare than
51
00:03:22,420 --> 00:03:23,800
ALCL.
52
00:03:24,250 --> 00:03:28,660
And all of that seems to be
associated with textured implants,
53
00:03:28,660 --> 00:03:29,493
by the way.
54
00:03:29,860 --> 00:03:31,570
Okay, that makes sense.
55
00:03:31,720 --> 00:03:34,870
But could you provide some
definitions about these things?
56
00:03:35,230 --> 00:03:40,120
So let's go back and discuss in a little
more detail breast implant associated
57
00:03:40,120 --> 00:03:44,410
illness. So this is a
syndrome of symptoms,
58
00:03:44,920 --> 00:03:49,360
more than 90 different symptoms
that have been attributed
59
00:03:49,840 --> 00:03:53,320
to breast implants in one way or another.
60
00:03:53,830 --> 00:03:58,300
And it's controversial. We don't
understand exactly what causes it.
61
00:03:58,300 --> 00:04:02,680
We don't understand exactly what the
62
00:04:02,680 --> 00:04:04,840
spectrum of symptoms are,
63
00:04:05,500 --> 00:04:10,390
but a number of people
who have implants in place
64
00:04:10,450 --> 00:04:14,470
felt very strongly that the
implants were responsible
65
00:04:14,800 --> 00:04:17,740
for fatigue, weakness,
66
00:04:18,430 --> 00:04:21,250
all manner of illness symptoms,
67
00:04:21,760 --> 00:04:26,350
and that they got better when
the implants were removed.
68
00:04:26,830 --> 00:04:31,750
Okay, got it. So what are the
causes and what is the treatment?
69
00:04:32,260 --> 00:04:33,093
So again,
70
00:04:33,220 --> 00:04:38,080
this is controversial and I don't
think we fully understand this
71
00:04:38,080 --> 00:04:39,310
scientifically.
72
00:04:39,640 --> 00:04:44,320
It's immensely difficult
to study an illness that
73
00:04:44,740 --> 00:04:49,000
can have 90 different
diagnosable symptoms.
74
00:04:49,810 --> 00:04:54,430
So that's so broad and so many of those
75
00:04:54,430 --> 00:04:59,350
symptoms are things that all of us
experience from time to time that it
76
00:04:59,350 --> 00:05:03,640
makes it very difficult
to rigorously study this
77
00:05:03,640 --> 00:05:04,630
scientifically.
78
00:05:05,110 --> 00:05:10,090
But some of the possible reasons that
have been cited for causing breast
79
00:05:10,090 --> 00:05:14,230
implant illness are impurities
and heavy metals in the
80
00:05:14,230 --> 00:05:19,150
implants or mold that's associated
81
00:05:19,150 --> 00:05:24,130
with the implants or bacterial
colonies that live on the surface
82
00:05:24,130 --> 00:05:26,800
of the implants. And
these are called biofilms.
83
00:05:27,220 --> 00:05:31,540
And biofilms live on all medical
implants, not just breast implants.
84
00:05:31,540 --> 00:05:36,400
They live on our teeth and that's why
we brush our teeth all the time to try
85
00:05:36,400 --> 00:05:38,260
to keep those to a minimum.
86
00:05:38,860 --> 00:05:43,060
But they've been listed as possible
87
00:05:43,060 --> 00:05:48,010
causes for this problem.
In terms of treatment,
88
00:05:48,610 --> 00:05:53,440
the treatment relates to removing the
89
00:05:53,440 --> 00:05:58,400
implant and possibly to
removing the capsule.
90
00:05:59,090 --> 00:06:03,080
Okay. And overall, you mentioned
that this is controversial.
91
00:06:03,080 --> 00:06:05,750
What's the controversy
around these procedures?
92
00:06:06,080 --> 00:06:10,670
So the issue is how much
improvement or what percentage of
93
00:06:10,670 --> 00:06:15,350
patients we can expect to
improve if we remove the
94
00:06:15,350 --> 00:06:16,183
implant.
95
00:06:16,640 --> 00:06:21,290
And also there's a controversy
about whether there's a need to
96
00:06:21,290 --> 00:06:26,240
perform a capsulectomy and whether
that has a benefit in alleviating
97
00:06:26,240 --> 00:06:29,150
the symptoms. In particular,
98
00:06:29,720 --> 00:06:34,220
one of the procedures that's
sometimes done for breast implant
99
00:06:34,220 --> 00:06:37,970
associated illness includes what's
100
00:06:37,970 --> 00:06:40,550
called en bloc capsulectomy.
101
00:06:41,600 --> 00:06:46,310
So this is taking out the capsule in a
102
00:06:46,310 --> 00:06:51,230
single piece, including a rim of
normal tissue around the capsule.
103
00:06:51,680 --> 00:06:56,600
And that's traditionally used in cancer
surgery. We use that for example,
104
00:06:57,110 --> 00:07:01,310
for cases of breast implant associated
105
00:07:01,730 --> 00:07:05,180
ALCL or squamous cell carcinoma.
106
00:07:05,780 --> 00:07:08,060
Okay. Well, if that's the case,
107
00:07:08,060 --> 00:07:11,570
then why not perform the
biggest removal possible?
108
00:07:12,410 --> 00:07:13,610
The reason is this,
109
00:07:13,610 --> 00:07:18,050
everything we do has a cost
or a risk as well as an
110
00:07:18,050 --> 00:07:18,740
advantage.
111
00:07:18,740 --> 00:07:23,090
So it seems like a great idea to
take out the most tissue you can
112
00:07:23,540 --> 00:07:27,650
for the greatest chance of helping
patients with breast implant associated
113
00:07:27,650 --> 00:07:28,880
illness improve,
114
00:07:29,510 --> 00:07:33,980
but that won't necessarily provide more
115
00:07:33,980 --> 00:07:35,210
improvement,
116
00:07:35,420 --> 00:07:39,080
and there's definitely
increased risk to en bloc
117
00:07:39,650 --> 00:07:44,060
resection. So it's only worth
it if there's a proven benefit.
118
00:07:44,600 --> 00:07:48,770
And in many ways, this echoed the
experience with cancer therapy.
119
00:07:48,770 --> 00:07:52,370
If you went back to the
middle of the 20th century,
120
00:07:52,370 --> 00:07:55,130
there was this notion that
the more you take out,
121
00:07:55,130 --> 00:07:59,150
the greater your chance of cure.
And when it was carefully studying,
122
00:08:00,920 --> 00:08:05,780
it's more like Goldilocks and the three
bears, not too much, not too little,
123
00:08:05,780 --> 00:08:10,070
just right. So more
wasn't necessarily better,
124
00:08:10,070 --> 00:08:14,240
but it definitely has
more risk, more recovery,
125
00:08:14,780 --> 00:08:19,760
more potential for deformity
or medical complications.
126
00:08:20,330 --> 00:08:24,020
Okay. I'm starting to get an
understanding of the issues here.
127
00:08:24,440 --> 00:08:26,180
So what's the news?
128
00:08:26,870 --> 00:08:27,290
Well,
129
00:08:27,290 --> 00:08:32,270
there's been a consensus statement
on breast implant capsulectomy
130
00:08:32,270 --> 00:08:35,300
from the breast surgery
collaborative community.
131
00:08:35,960 --> 00:08:39,530
Can you explain what this group is
that's putting the statement out?
132
00:08:40,790 --> 00:08:44,750
FDA has developed a very strong
133
00:08:44,750 --> 00:08:49,130
priority to create these
collaborative communities,
134
00:08:50,270 --> 00:08:55,220
to bring together all the
stakeholders to help solve
135
00:08:56,340 --> 00:08:58,230
challenges, controversies,
136
00:08:58,230 --> 00:09:03,180
basically to get input from everybody
involved rather than saying, well,
137
00:09:03,180 --> 00:09:08,160
let's ask the manufacturer, or let's ask
the doctors, or let's ask the patients.
138
00:09:08,460 --> 00:09:11,730
Well, no, you really need
to ask all of those groups.
139
00:09:11,730 --> 00:09:16,260
All of those groups need to be
looking at the data, discussing it,
140
00:09:16,650 --> 00:09:20,220
providing input from their perspective,
141
00:09:20,550 --> 00:09:22,770
probably to get to the right answer,
142
00:09:23,190 --> 00:09:26,130
certainly rather than excluding anybody.
143
00:09:26,130 --> 00:09:31,020
So this breast surgery collaborative
community is a consortium
144
00:09:31,020 --> 00:09:34,680
of patient advocates, board
certified plastic surgeons,
145
00:09:35,430 --> 00:09:37,830
medical device manufacturers,
146
00:09:38,100 --> 00:09:42,420
and others with a vested interest
in enhancing breast surgery
147
00:09:42,420 --> 00:09:43,253
safety.
148
00:09:43,590 --> 00:09:48,030
So they were assembled to
clarify some of these issues and
149
00:09:48,030 --> 00:09:49,260
examine the data.
150
00:09:49,830 --> 00:09:54,330
Gotcha. That makes a lot of sense to
me. So what are their recommendations?
151
00:09:54,810 --> 00:09:56,820
So they did two things.
152
00:09:56,880 --> 00:10:01,020
They provided definitions
for different types of
153
00:10:01,020 --> 00:10:02,940
capsulectomy procedures,
154
00:10:02,940 --> 00:10:06,090
and they provided
management recommendations.
155
00:10:06,630 --> 00:10:09,360
Let's start with the
capsulectomy definitions.
156
00:10:09,900 --> 00:10:13,950
The statement defines four
basic types of capsulectomy.
157
00:10:14,490 --> 00:10:16,650
There's the total intact capsulectomy.
158
00:10:16,950 --> 00:10:21,630
This is complete removal of the
breast implant capsule as a single
159
00:10:21,630 --> 00:10:24,480
unit with the implant contained within it.
160
00:10:25,140 --> 00:10:29,040
This has often been done historically
when there's a ruptured implant,
161
00:10:29,520 --> 00:10:34,470
particularly with the old non
cohesive gel implants to help
162
00:10:34,500 --> 00:10:36,720
contain the silicone gel.
163
00:10:37,440 --> 00:10:39,540
Then there's a total capsulectomy.
164
00:10:39,810 --> 00:10:43,470
So that's complete removal
of the implant capsule,
165
00:10:43,950 --> 00:10:47,310
but not necessarily all done in one piece.
166
00:10:47,820 --> 00:10:50,910
So you're getting all of the capsule
out, but you're taking it out.
167
00:10:50,970 --> 00:10:55,440
Whatever is easiest and
least traumatic without any
168
00:10:55,590 --> 00:10:59,670
need to keep it in one piece. Third,
169
00:10:59,670 --> 00:11:01,680
there's a partial capsulectomy.
170
00:11:01,680 --> 00:11:05,160
This is probably most commonly performed.
171
00:11:05,430 --> 00:11:10,080
This is removal of the breast implant
capsule where some capsule is left
172
00:11:10,080 --> 00:11:13,890
behind. And as I said, this
is probably the most common.
173
00:11:13,890 --> 00:11:16,950
What we generally do
when we remove implants,
174
00:11:17,670 --> 00:11:22,410
most commonly probably in the
United States when there's no issue,
175
00:11:22,770 --> 00:11:27,720
but we're just removing the implants
for preference or for a rupture,
176
00:11:28,200 --> 00:11:29,940
is we examine the capsule.
177
00:11:29,940 --> 00:11:34,380
And if the capsule's thickened or
calcified or in any way looks unhealthy,
178
00:11:34,620 --> 00:11:39,480
that portion of capsule is removed.
If the capsule looks thin, pliable,
179
00:11:39,510 --> 00:11:41,970
glistening, healthy white membrane,
180
00:11:41,970 --> 00:11:44,820
like it looks early after
the implant is placed,
181
00:11:45,360 --> 00:11:50,070
that's left alone and
remains and seems not to
182
00:11:50,070 --> 00:11:52,860
create an issue for patients. Final,
183
00:11:53,920 --> 00:11:56,500
the procedure I already described,
the en bloc capsulectomy,
184
00:11:56,500 --> 00:12:01,330
this is removal of the
breast implant capsule with a
185
00:12:01,330 --> 00:12:03,400
margin of uninvolved tissue,
186
00:12:03,730 --> 00:12:07,960
and that's the last of the
four types of capsulectomy.
187
00:12:08,470 --> 00:12:11,950
Wow, I didn't realize that. There are
four types. That's really interesting.
188
00:12:12,550 --> 00:12:15,250
And now can we go to the
management recommendations?
189
00:12:15,610 --> 00:12:20,260
So I'll bottom line the management
recommendations, because again,
190
00:12:20,410 --> 00:12:22,810
there's been a lot of
controversy about this,
191
00:12:22,810 --> 00:12:27,400
and some people have suggested that
if you do an en bloc capsulectomy,
192
00:12:27,400 --> 00:12:31,120
it's somehow better at
improving the symptoms.
193
00:12:31,570 --> 00:12:35,680
And basically the consensus group
194
00:12:35,680 --> 00:12:40,330
stated that the absolute and only
195
00:12:40,330 --> 00:12:44,680
indication for an en bloc
capsulectomy is for an
196
00:12:44,680 --> 00:12:49,570
established or suspected
breast implant associated
197
00:12:49,570 --> 00:12:54,100
cancer after appropriate
medical workup. In other words,
198
00:12:54,100 --> 00:12:59,080
after you've demonstrated
some proof that there is or
199
00:12:59,080 --> 00:13:03,160
likely is a breast
implant associated cancer.
200
00:13:03,790 --> 00:13:08,620
So that specifically
excludes any recommendation
201
00:13:08,680 --> 00:13:13,150
for en bloc capsulectomy for
breast implant associated
202
00:13:13,150 --> 00:13:13,983
illness.
203
00:13:14,320 --> 00:13:19,000
Okay. Could you share anything about how
they arrived at these recommendations?
204
00:13:19,360 --> 00:13:24,340
So these recommendations were based on a
205
00:13:24,340 --> 00:13:28,510
bunch of recent research on
206
00:13:28,510 --> 00:13:33,430
outcomes in a very large
number of patients who had
207
00:13:33,550 --> 00:13:38,290
different types of capsulectomies
trying to treat breast implant
208
00:13:38,290 --> 00:13:39,580
associated illness.
209
00:13:39,970 --> 00:13:43,240
And a lot of this research was
done by a plastic surgeon in St.
210
00:13:43,240 --> 00:13:45,250
Louis named Patricia McGuire,
211
00:13:45,610 --> 00:13:49,390
but there are some other researchers
who have been examining this as well.
212
00:13:50,140 --> 00:13:54,550
And that data and research was cited,
213
00:13:54,550 --> 00:13:55,330
in other words,
214
00:13:55,330 --> 00:13:59,830
referenced or listed in
the consensus statement.
215
00:14:00,310 --> 00:14:04,720
And that basically supports
the notion that there's no
216
00:14:04,720 --> 00:14:09,550
improvement with outcomes
doing an en bloc capsulectomy
217
00:14:09,970 --> 00:14:14,530
compared to a total capsulectomy
or potentially a partial
218
00:14:14,560 --> 00:14:15,393
capsulectomy.
219
00:14:16,120 --> 00:14:19,210
Okay. You've given a lot of
information in this episode.
220
00:14:19,330 --> 00:14:21,400
What does it mean overall, Dr. Bass?
221
00:14:21,850 --> 00:14:26,770
So these recommendations are things
that surgeons are going to bring up
222
00:14:27,250 --> 00:14:32,020
to patients when they have a
consultation requesting breast implant
223
00:14:32,020 --> 00:14:36,370
removal. Patients can decide
how they want to be treated,
224
00:14:36,910 --> 00:14:41,620
but doctors generally feel
best when they're making
225
00:14:41,620 --> 00:14:46,420
decisions that are based on
recommendations that are based
226
00:14:46,420 --> 00:14:50,380
on data. So data-driven
decision making, in other words,
227
00:14:50,380 --> 00:14:55,310
where there's some medical proof
that patients do better with a
228
00:14:55,310 --> 00:14:59,150
given option or do the same
with one option or another,
229
00:14:59,600 --> 00:15:03,830
generally guides most surgeons
and their decision making.
230
00:15:04,340 --> 00:15:09,050
But given the careful review
by all the stakeholders here
231
00:15:09,800 --> 00:15:11,730
of what the data shows,
232
00:15:12,110 --> 00:15:15,350
and we didn't have this data
five years ago or 10 years ago,
233
00:15:15,500 --> 00:15:19,880
this is data that's only been
obtained in the last few years,
234
00:15:20,240 --> 00:15:21,860
but now that we've got it,
235
00:15:21,860 --> 00:15:26,720
that's hopefully going to let
us be much more precise in
236
00:15:26,720 --> 00:15:30,800
giving patients what they need
to be healthy and feel their best
237
00:15:31,160 --> 00:15:35,000
without anything excessive
that's not needed to help them.
238
00:15:36,410 --> 00:15:37,640
Thank you for this update.
239
00:15:37,820 --> 00:15:41,930
We always like to keep our listeners
aware of the latest information in plastic
240
00:15:41,930 --> 00:15:42,763
surgery.
241
00:15:43,280 --> 00:15:47,360
Thank you for listening to the Park
Avenue Plastic Surgery Class podcast.
242
00:15:47,390 --> 00:15:49,310
Follow us on Apple Podcasts,
243
00:15:49,370 --> 00:15:51,620
write a review and share
the show with your friends.
244
00:15:51,800 --> 00:15:55,280
Be sure to join us next time to avoid
missing all the great content that is
245
00:15:55,280 --> 00:15:58,850
coming your way. If you want to
contact us with comments or questions,
246
00:15:58,850 --> 00:16:00,050
we'd love to hear from you,
247
00:16:00,140 --> 00:16:04,820
send us an email at
podcast@drbass.net or DM us on
248
00:16:04,820 --> 00:16:06,590
Instagram @drbassnyc.