When do silicone breast implants need to be removed or replaced?
Initially, we should divide the cases where replacement or removal of silicone implants is needed into three categories. In cases where the operation is performed for medical reasons, such as aesthetic or functional problems, in those where the reason is subjective and in cases where it is done preventively. It is usually an operation that is decided jointly by plastic surgeon and patient, when one of the above reasons applies, after all alternatives have been exhausted.
Medical reasons for removing breast implants
Regarding the first category, i.e. the removal of implants for medical reasons, perhaps the most common etiology is the so-called capsule contracture. To understand better, the capsule is the membrane that the body creates around silicone implants, as is the case with any foreign body surgically implanted and is a normal reaction of the body. This capsule stabilizes the breast implants and its proper formation is extremely important for the good outcome of the operation. However, in some cases, for reasons unclear, there is a chance that this capsule hardens, thickens and muscle and other cells migrate onto it, which begin to cause shrinkage and deformation of the capsule, resulting in a change in the shape of the breast and symptoms such as pain, heaviness and hardness in the chest.
Another medical indication is rupture of implants, that is, perforation of the outer shell of silicone implants. In general, modern silicone implants undergo many tests during production in order to make sure that they will have a very long service life. However, it is possible that after many years the outer wall may deteriorate and lead to rupture. The silicone contained in breast implants is not in liquid form and does not It leaks into the tissues, but it definitely needs to be removed or replaced. The diagnosis is not always easy to make and is based on the clinical picture and the results of MRI and breast ultrasound.
The indication for removal or replacement concerns cases where the aesthetic result is poor. This may be due to inappropriate size selection, patients’ desire for a larger size, shifting implants and special problems such as bottoming out, rippling, symmastia, asymmetry, etc. Each case is examined differently in order to find the ideal solution, which may include replacement, removal and replacement in a secondarily, breast lift, fat transfer and other specialized procedures.
A very rare case is anaplastic lymphoma BIA-ALCL (Breast Implant-Associated Anaplastic Large Cell Lymphoma), which is a form of malignancy that has been associated with silicone implants, mainly rough surface. It is not breast cancer and is fully curable if the silicone implants are removed along with the capsule. Symptoms can be swelling and heaviness and usually appear 10-20 years after surgery and diagnosis confirmed by PET-Scan, ultrasound and fluid collection by puncture. Once diagnosed, removal is performed with total capsulectomy and no form of chemo- or radiotherapy is needed. The incidence rates of ALCL worldwide, especially with modern implants, are very, very low and there is no need to panic. It is necessary to perform the annual clinical examination with palpation, mammography and ultrasound which, in addition to breast malignancies, can also diagnose changes in silicone implants and capsule.
Finally, there is a special category that is not clear whether it is medical in nature or subjective, which concerns breast implant illness. Because this condition has taken on great proportions mainly on social media, we will analyse it separately.
Breast implant illness
In recent years we have seen a new trend, exaggerated by the media, concerning “breast implant disease”, known as BII (Breast Implant Illness). This condition has not been scientifically substantiated, because it mainly presents subjective symptoms that are difficult to detect, such as:
- weariness
- difficulty concentrating
- sleep disorders
- joint pain
- myalgia
- stress
- shortness of breath
- dry eye or dry mouth
- hair loss
- gastrointestinal disorders
- headaches
- depression
The above symptoms may occur individually or in combination and there is no consistent pattern of occurrence or any scientifically documented association with breast implants. The symptomatology may be to some extent psychosomatic, because it is similar to that experienced by patients with severe stress of any other etiology. We accept medically that any cosmetic intervention can cause stress to some patients and the above symptoms, if intense, are an indication for medical intervention. Unfortunately, these symptoms can be magnified when one begins to learn from various sources online or on social media and we observe the phenomenon of the “medical student”: as we read in pathology about various diseases, we thought that we were displaying all the symptoms. On the one hand, we cannot exclude the possibility that silicone implants cause some form of inflammatory reaction to the body, but on the other hand prudence and proper information are needed to avoid unnecessary stress and interventions that are not necessary.
The diagnosis of breast implants illness is difficult and we have exclude other diseases that may cause similar symptoms. If all possibilities are exhausted and at least 6 months have passed since breast augmentation surgery without the symptoms subsiding, the issue of removing the implants arises. In these cases, a total capsulectomy and removal of the implants are performed and the symptoms usually subside after a few months.
Preventive breast implants replacement
The last case concerns the preventive change of breast implants, which is also under discussion and decided individually. Previously, the recommendation of doctors was to replace implants every 10 years or so. This recommendation was for older generation implants and there was also not enough data to document when and how breast implants wear out over the years. Today, with experience, clinical studies and statistical data of 50 years, we usually talk about 15-20 years of life of implants, without this being dogmatic.
From my personal experience, I have come across cases that have had the same implants for over 30 years without the slightest problem. Similarly, I have come across cases with implant rupture in less than 10 years since the augmentation. My personal advice is to have a replacement at 20 years or earlier, if there are symptoms or a change in the breast.
Breast implants removal or replacement techniques
A key differentiation in the technique concerns the management of the capsule formed around the implants. This capsule is in some cases preserved intact, while in others it is partially or completely removed. Also regarding the replacement, this can be done together with the removal of old implants in the same operation, or it can be performed a few months after removal. The strategy chosen depends on each case and is individualized.
We distinguish, therefore, the following interventions:
- Total capsulectomy
- Partial capsulectomy
- Capsule retention
- Capsular tightening
- Replacement in 2 stages
- Additional interventions
The total removal of the capsule along with the implants is the surgery of choice when there are medical or aesthetic problems with the capsule. In cases with intense capsule contracture, implant rupture, anaplastic lymphoma, BII breast implants disease, intractable aesthetic problems, total removal of the capsule ensures a return of the breast to a previous state, as it was before the silicone implants were placed. It is a relatively laborious operation with a larger rate of complications, mainly bleeding and for this reason, when we are going to perform total capsulectomy, the simultaneous placement of new implants is more risky and it is preferable to do it in 2 stages.
Partial capsulectomy refers to the partial removal of the capsule, mainly the lower pole performed when there is no serious problem with the capsule. This technique is very useful when we want to change the plane, ie replace the implants that were above the muscle and place the new implants under the muscle or vice versa. As an operation it is less traumatic and simpler than total capsulectomy and the complication rates are much Lower.
Capsule preservation is the surgery of choice usually when the old capsule does not have a problem and we just want to place new implants, of the same or another size. It is a fairly simple and short operation, minimally invasive and atraumatic with quick recovery. Can be combined with capsule retouch, i.e. shaping the capsule with incisions placed internally or with the popcorn technique. In this way we can shrink or better shape the cavity to optimize the result.
In some more complicated cases, two-stage correction is preferable. In the first staghe we remove the implants, usually together with their capsule and after a period of usually 6 months we place the new implants. This ensures a more predictable course with fewer complications. This strategy is usually applied to serious problems, such as intense capsular contraction, rupture of implants or complex aesthetic problems.
Finally, there is a plethora of additional procedures that can be performed in case of removal or replacement of implants. A good strategy, for example, is when we want to completely remove the implants, is to replace part of the volume with fat transfer, which can be done during the same operation or at a later time. Fat can also be used as a additional procedure to any other intervention, for correction of aesthetic problems, such as long distance of implants from the sternum, rippling, double bubble, etc. In addition, a total removal of the implants may require breast lift. This is considered appropriate when relaxation coexists, where removing the implants is exacerbated and needs to be addressed. Finally, in some troublesome cases, special mesh may be used in order to better stabilize the lower pole of the chest.
Recovery after removal or replacement of breast implants
Recovery can vary considerably, depending on the operation performed. The simplest recovery is in simple replacement, without capsulectomy. Patients usually have no pain or discomfort, no drains are needed and a return to everyday life is possible in a few days. The result is immediately visible and is perfected in 3-6 months.
The recovery is a little more difficult is when partial capsulectomy is performed. The discomfort and pain is similar to a breast augmentation and needs corresponding attention for the first 6 weeks. However, in some special cases more care is needed, especially if some additional fixation is made with mesh or special seams.
In case of total capsulectomy, recovery is relatively simple and pain minimal, but drains usually need to be placed for a few days in order to limit fluid collection as much as possible. As mentioned, the total removal of the capsule and the placement of new implants in the same operation has a higher risk, especially in the first 48 hours, because there is a greater risk of bleeding. Bleeding is not vital, however collecting blood around the implants can lead to premature capsular contraction and cosmetic problems.
