Welcome to the Era of the Explant

In the Weekend Australian Magazine of June 19th 2021, a glossy article was published about the harm woman have suffered due to their breast implants.

“I just want my body back” was the theme expressed by women who regretted their decision ever to have breast implants inserted.

The article draws attention not only to the risk of a serious illness (Breast Implant Associated Anaplastic Large Cell Lymphoma), known as BI-ALCL, but also to the increasingly recognised syndrome of Breast Implant Illness (BII).

BI-ALCL is serious, but rare, with 120 Australian women having being diagnosed to date with 5 deaths.

BII is far more common with many woman suffering from fatigue, brain fog, chronic gut issues, joint pains, skin rashes etc.

Specialist plastic surgeons (my colleagues) rightly cast the blame for many of the complications of breast implants on to a group of doctors who call themselves “Cosmetic Surgeons”. Many of these doctors have no surgical qualifications and poor surgical skills and judgement. However, in many cases, it is the implants themselves that are to blame. For decades surgeons have been recommending textured (often tear drop) silicone breast implants. Many women, who have these particular types of implant, have had complications including BII.  These are the implants that are now considered too dangerous to use and have been withdrawn from the market.

As a Specialist Plastic Surgeon with 40 years’ experience, I have been a witness to the growth of the “cosmetic surgery industry” and seen the operation of breast augmentation become commoditised as demand has increased. Clinics have been established that operate as ‘Factories” for breast implants. They use glossy advertising campaigns to attract vulnerable women. Their motivation has been profit rather than patient care.

30 years ago I became concerned at the complications I was seeing in women with silicone implants being placed on top of the muscle.  The implants often became surrounded by a thick wall of scar tissue known as a “capsule”.  Implants were often misplaced and, with implants in front of the muscle, it made having a mammogram difficult and painful.  Many implants were being ruptured as the breasts were compressed during a mammogram.

I made the decision to abandon silicone-filled implants for the far safer saline-filled implants.  I made the decision always to place the implants behind the muscle.  This allowed mammography to be performed without interference and without risk to the implant.  As well, with the increased coverage afforded by the muscle, it became increasingly difficult to tell the difference between saline and silicone implants.

Most of these implants are still in place 30 years later.  Very few have encapsulated and fewer still have leaked.  Of course if a saline implant does leak then the salt water is harmlessly absorbed by the body. Smooth walled saline breast implants have never been subject to a moratorium or recall and are undoubtedly the safest breast implants.

I have always resisted the use of implants with a textured surface.  These were introduced in an attempt to reduce the incidence of capsular contracture (which occurred almost exclusively in implants placed in front of the muscle).  We now know that BI-ALCL and BII occur almost exclusively in women with these textured implants.  Although current research is focusing on the role of a rare type of microscopic bacteria, which are occasionally found embedded in the textured surface of these implants, my own experience leads me to a different conclusion.  I believe that BII, which occasionally progresses to BI-ALCL, is triggered by inflammation caused by textured breast implants.  It is easy to understand how the textured surface of a breast implant can behave in a way similar to sandpaper.  The rough surface of these textured implants continuously abrades the capsule around the implants causing inflammation.  I believe that it is this chronic inflammation which leads to women becoming ill.  My theory is supported by the fact that microscopic examination of the capsule following removal shows chronic inflammation.  It is also evident that women feel a lot better once the breast implants are removed.

This morning I saw one of my patients for a 6 week post-operative review following removal of her textured breast implants.  I listened intently as my patient described how her symptoms of fatigue, foggy thinking, memory loss, hair loss and muscle aches and pains had all subsided just weeks after removal of her textured breast implants.  She said that she had previously put all these symptoms down to her increasing age but she now realised that it was her textured breast implants that were making her ill.  This is the situation that I see on almost a daily basis in my practice i.e. women feeling much better once their textured breast implants have been removed.

Interestingly, in my experience, women with smooth-walled implants don’t suffer from BII and are known not to develop BIA-ALCL.

So what advice should we be giving women?

If you already have breast implants, it is important that you make every effort to find out exactly what type of implants they are.  If you feel your breasts are too large, too hard or misshapen or if you have symptoms of fatigue, foggy thinking, memory loss, hair loss, rashes and muscle or joint pains, then you should consider implant removal, or explant surgery as it has become known.

Simply removing your breast implants need not be too complicated and may be all that it is required.  Where implant removal can become complicated and even dangerous is when heroic attempts are made to remove a thin scar tissue “capsule” that is closely attached to the muscle or to the rib cage.  Be aware of the surgeon who says that he “always removes all of the capsule”.  In my practice, although I often do remove all of the capsule, there are certain situations where such an attempt is clearly dangerous and unwise.  All experienced explants surgeons agree with this view and indeed it is the formal recommendation of the American Society of Plastic Surgeons that the ONLY reason for total capsulectomy is when treating extensive BIA-ALCL.

Of course we shouldn’t lose sight of aesthetic considerations. Removing breast implants often leaves stretched skin and an indented chest wall. In other words there is considerable deformity as well as loss of breast volume. Breast reconstruction can form part of the explant surgical procedure and may consist of insertion of another implant although many women would like to avoid this for obvious reasons! Preferably a breast lift or mastopexy (an excellent form of auto augmentation as it rearranges your own breast tissue to increase breast fullness and projection as well as tightening the skin) combined with Autologous Fat Transfer is an excellent way to restore your breasts and add at least 1 cup size to your breast volume.  The fat is placed all around the breast but mainly around the cleavage to provide an excellent aesthetic enhancement. But beware, this is a specialised procedure requiring specialised techniques for the fat to survive.  Understandably, it has not yet been adopted by many surgeons who prefer the simpler option of using breast implants.

For those women who do not have breast implants but who are considering breast augmentation, the first procedure to consider is Autologous Fat Transfer Provided you have some additional fat available in the abdomen, hips or thighs, then this fat can be harvested, processed and carefully grafted into your breast to produce a natural breast augmentation. I find that most women are satisfied with the volume increase (which is 1-2 cup sizes) and are very happy with the totally natural look.  For women who need a little more volume then the safest implant to use is a smooth-walled saline implant placed behind the muscle.

Of course every woman is unique and has different requirements. Please be sure to discuss all these options with your surgeon.

Allan Kalus

Specialist Plastic Surgeon, Avenue Aesthetic Surgery.