Every patient who decides to have breast augmentation with implants should be aware that further surgery will be necessary during her life. Whether the implant will be changed or removed, an additional breast lift and/or autologous fat treatment should be discussed in due course. The many sources of information on the Internet cannot replace a consultation with an experienced specialist in plastic and aesthetic surgery. We will be happy to assist you!
Breast implants do not last a lifetime, but they are designed to last a long time. Implants are constantly being developed, especially the resistance of the usually multi-layered outer shell and the dimensionally stable filling material. A rupture can occur with a probability of about one percent per year. This means that after about ten years the implants will have a defect in ten percent of women.
An en-bloc resection is a surgical technique. The French term en-bloc means "in one piece". In the case of an implant removal, this means the removal of the capsule tissue. Therefore, this operation is called "capsulectomy" in English ("-ektomia" in ancient Greek for cutting out). The technique originates from tumour surgery. When removing tumours, the surgeon must work with the greatest precision in order to leave non-malignant cells in the body. A similar procedure is used in the surgical treatment of infected wounds. Here, too, the surgeon must very carefully separate infected tissue and the associated instruments from healthy tissue. Good sensitivity and experience is required to show the boundaries between the altered scar tissue and the healthy tissue.
By removing a calcified capsule, the shape of the breast improves and the breast feels softer. If BIA-ALCL is suspected, the capsule should be removed because of the malignant white blood cells suspected in it (Clemens MW, et al., 2016, J Clin Oncol). For many patients it is a comforting feeling to know that everything has been done to remove the implant and possible residues. It is our task to inform you comprehensively. We are here to advise our patients, both on breast augmentation and on the removal of breast implants. In each case, we will of course thoroughly examine the professional justifiability of the jointly made decision.
After ten years, a regular check and, if necessary, replacement of the implants is recommended. Experience shows that implants are replaced earlier in women who have undergone breast cancer surgery. The en-bloc implant removal should be weighed separately. This applies in particular to patients in whom:
- advanced capsular contracture or calcification of the capsule,
- suspicion of a breast implant associated anaplastic large cell lymphoma (BIA-ALCL) was raised,
- the magnetic resonance examination suggests a defective breast implant, or
- there is a high level of suffering when Breast Implant Illness (BII) is suspected.
A capsular contracture is detected by palpation of the breast. Indications of an implant rupture result from newly occurring pain and deformation of the breast. Finally, a magnetic resonance tomography is required to substantiate the suspicion of implant rupture. However, a residual uncertainty remains, despite a magnetic resonance tomography. The suspicion of BIA-ALCL results from an increase in the size of the breast, usually several years after breast augmentation. The diagnosis of BIA-ALCL is confirmed by an ultrasound-assisted removal of fluid that has accumulated around the implant. Intensive research is being carried out on examination methods for determining Breast Implant Illness (BII). There are laboratory tests to detect certain autoimmune diseases. For patients with Breast Implant Illness (BII), both autoimmune disease testing and all other blood tests may be normal.
The following points must be taken into consideration when comparing the prices of breast surgery:
- the value added tax of 19%
- the remuneration for plastic surgery
- care necessary within the scope of the treatment
- the work of the anaesthetist
- materials and equipment required during the above mentioned procedure
- the compression garment including a change of supply
- the follow-up cost insurance
- dressing changes and controls immediately after the operation
- examinations to check your well-being after several weeks or months
- the constant availability of the surgeon during the 2 weeks after the operation
- the drugs used to treat pain in the first days after the operation
- the drugs for the prevention of thromboembolic diseases
- the medical stockings for the prevention of thrombosis
Many patients compare different offers before an operation. For a direct comparison, all expenses including post-operative treatment must be taken into account. The education, experience, skills and competences of a doctor are more difficult for a layperson to compare than the costs. Enquire about the qualifications of the doctor to whom you entrust yourself. The terms "cosmetic surgeon", "aesthetic surgeon" or "cosmetic surgeon" are not protected. It is different with the professional title "plastic and aesthetic surgeon", these medical doctors have all completed a corresponding six-year training course. The situation is similar for ear, nose and throat doctors and oral and maxillofacial surgeons, these specialists can acquire the additional qualification "plastic surgery" after two years of further training and are thus qualified for operations in the head area. The medical activity also includes research, for example within the framework of a medical doctorate or habilitation. The ability to integrate scientific findings into rational treatment decisions is strengthened by independent scientific work. Professional experience in a leading position strengthens the sense of responsibility and the competence to solve complex and difficult challenges. The cost of treatment is relevant to the decision, but trust in the doctor should ultimately be decisive.
Unfortunately, it is not possible to give an exact price without an examination, since, among other things, the scope of treatment and any previous illnesses and/or pretreatments cannot be taken into account. You can find an indication of the costs on our costs page.
Over the years, Dr. Stahl has continued to develop the techniques of en-bloc resection. Various scholarships led him to outstanding cosmetic surgeons in Brazil, New York, Atlanta and Salt Lake City. PD Dr. Stahl became senior consultant and permanent deputy to the medical director at the University Hospital of Tübingen in 2015. From 2016 to 2018, he moved to Lüdenscheid as Clinic Director. PD Dr. Stahl has refined his microsurgical techniques over the course of his university career, so that today he enjoys a reputation in specialist circles as a particularly gentle and precise surgeon.
Brazil has been a pioneer in aesthetic surgery for decades and is considered the cradle of cosmetic surgery.
The techniques of breast surgery have been decisively influenced by Brazilian plastic surgeons such as
Ivo Pitanguy, Liacyr Ribeiro, João Carlos Sampaio Góes.
Dr. Santos Stahl has already operated hundreds of breast enlargements independently during her specialist training in Brazil with first-class surgeons. Later, Dr. Santos Stahl acquired the German and European specialist qualifications. Dr. Santos Stahl has also expanded her spectrum and knowledge with the most influential plastic surgeons in Dallas, Oakland and Salt Lake City - thanks to a scholarship from the largest professional association of plastic surgeons in Germany (VDÄPC).
Medical decisions and recommendations must be based on proven effectiveness. In order to be able to assess the validity of scientific evidence, the scientific competence of a doctor is important. For this purpose, an additional qualification as an investigator and experience in the conduct of clinical trials are advantageous. These requirements apply to Dr. Santos Stahl and PD Dr. Stahl.
Before every operation, a meticulous check is made several times to ensure the highest possible patient safety. Only when all requirements have been met according to the checklist, the operation is started.
Before the operation, the breasts and the regions from which the fat cells are removed are marked in a standing position. If the operation is carried out in twilight sleep, you will be given medication to take away your fear and reduce your sensitivity to pain. If you are not in a deep sleep anyway, you will at best feel that something is going on on the surface of your body.
In order to operate more gently and prevent the formation of bruises, an adrenaline solution is injected in the area of the planned skin incision ("tumescent technique"). In order to be able to work with the greatest precision, the operation is performed with magnifying glasses. The capsule is displayed through a small skin incision of five to six centimetres. Using a scalpel and dissecting scissors, the capsule tissue is removed from the pectoral muscle without coming into contact with the implant.
The following steps depend on the patient's wishes. Depending on this, a new implant can be inserted, the breast can be tightened and/or an autologous fat treatment can be performed. Depending on the findings, drainage tubes are inserted into the wound, which can be removed again after a short period of time. The wound is closed with fine stitches, which dissolve after about three weeks. In the operating theatre, before the breast augmentation surgery is completed, you will be placed in a sitting position (while still asleep) to check whether the shape of the breast, both sitting and lying, corresponds to the desired result. Finally a bandage and a special support bra will be applied. The removed implants and the capsule are photographed. The implant remains the property of the patient after the operation.
The outpatient procedure takes 60 to 180 minutes. Immediately after the operation you will be continuously monitored in a so-called recovery room. You can have a drink and, if you tolerate this well, eat something after you have fully awoken. Before you leave the practice, control appointments are arranged and the behavioural measures are discussed with you in detail. You will be given a comprehensive written report and a telephone number where you can reach the surgeon 24 hours a day in an emergency.
Before, after and even during the operation you can watch movies or your favourite series with virtual reality glasses. This is not only entertaining, but the distraction has been proven to reduce pain sensitivity.
Health concerns are driving many women to inquire about en-bloc implant removal. When breast implants feel like a foreign body, patients often ask for removal first. Not only the implants but also the breasts themselves change over time. Weight fluctuations, pregnancies, hormonal changes, changes in skin elasticity and mammary gland tissue can lead to sagging breasts. Similar to a flabby belly after pregnancy, sagging skin must be expected after the removal of an implant. In contrast to pregnancy, implants are removed or changed on average after eight to nine years (Auclair E., et al., 2020, Aesthet Surg J). A regression of the skin is therefore unlikely. The larger the breast implant, the weaker the connective tissue after removal. For many women beautiful full breasts are the reason for breast augmentation with implants. If only the implants are removed later, it is very likely that the patients are dissatisfied with the appearance of their breasts. A combination with a breast lift and/or an own fat treatment is possible and recommended. We are happy to advise you.
During the consultation, we will first of all carefully evaluate all findings and information regarding the previous breast augmentation, especially the operation report and the implant identification card. It is helpful if you send us this information in advance by e-mail. In order to be able to recognise any risks in good time and to better prevent them, you will be asked questions about preventive medical checkups, pregnancy, family planning, previous illnesses and allergies, occupation, medication and general risks of the operation. It is important to let us know if you smoke or take dietary supplements, as these can have a major influence on your operation.
Next, your breast will be measured accurately. This will also include a note of any minor differences in the sides of the breast. Further characteristics important for planning, such as skin elasticity, a possible curvature of the spine or chest deformations will be examined. All patients are photographed for precise planning of the operation. On the basis of this thorough examination and a discussion of your goals, you will be shown various alternatives and all associated risks and limitations. During the consultation you will receive all the information you need to decide which treatment is right for you. It is very important to discuss your expectations openly with your surgeon. Often a poorly informed patient or surgeon is the cause of an unsatisfactory result, even if there are no complications during the operation.
The surgeon will discuss all details of the surgery with you, including the type of anesthesia used, the facility where the surgery will take place, follow-up cost insurance, preparatory measures and behavioral measures after the implant change. You will be given a transparent and comprehensible explanation of how the costs of the operation are made up.
If you are unsure or do not feel fully informed, do not hesitate to ask your doctor any questions. At the end of the consultation we will also be happy to offer you a second consultation. It is not unusual for patients to have questions afterwards. It is very important to us that all your questions are answered before the operation.
- All your questions about possible complications and alternative treatments should be answered before surgery.
- Keep nicotine and alcohol consumption to a minimum.
- The intake of hormonal medication (pill) should be temporarily discontinued.
- Blood-thinning medication (e.g. ASS, Thomapyrin®) must be discontinued ten days before the operation after consultation with your attending physician.
- Stop taking vitamin preparations (A, E) and food supplements (e.g. omega-3 fatty acids, St. John's wort preparations) four weeks before the operation.
- Surgery restricts your fitness for air travel. In the four weeks following the operation, do not plan any air travel for professional or private reasons.
- Take out follow-up cost insurance before an aesthetic operation.
- On the day of the operation, shower with a disinfectant soap (e.g. HiBiScrub® Plus, Octenisan® Wash Lotion, Prontoderm® Shower Gel).
According to § 1 paragraph 1 No. 2 of the German Drug Advertising Act, the comparative pictorial representation of the success of treatment by means of before/after photographs may not be published on the Internet. Nevertheless, before/after pictures can be used in patient education. We would be pleased to show you before/after pictures in the course of a personal educational interview to show you the possibilities and limitations of cosmetic surgery. It goes without saying that we adhere to all legal regulations regarding data protection.
We systematically examine and compare the appearance, well-being and satisfaction of our patients after an operation. This includes not only uniform photo documentation, but also the survey of patient satisfaction with breast shape and size. At the same time, we also systematically examine a possible influence of the intervention on the patients' perceived self-confidence and attractiveness. We encourage our patients to rate us on Jameda and Google. Many patients are willing to share their experience with other patients to help them make the right decision. During the counselling interview we are happy to put you in contact with these patients.
Capsule tissue is the body tissue that is in contact with the surface of the implants. The tissue reacts to the implant and changes over time. The capsule tissue consists of scavenger cells (macrophages), giant cells, cells of connective tissue (fibroblasts) and white blood cells (lymphocytes). In implants with a rough surface, small silicone particles have been found in the space between the cells and in the macrophages. These particles were not found in implants with smooth surface (Copeland M, et al, 1994, Plast Reconstr Surg).
The spread of fine silicone particles into the body tissue around a breast implant is called silicone bleeding or yellow bleeding. The phenomenon of yellow bleeding was already described in 1978 (Barker DE, et al., 1978, Plast Reconstr Surg). Smallest amounts of silicone penetrate the outer shell of an implant (Yu L.T., et al., 1995, Plast Reconstr Surg). The distribution of silicone particles is influenced by the nature of the shell and the cross-linking of the silicone. In several patients silicone particles were detected in the lymph nodes (Zambacos GJ, et al., 2013, Aesthetic Plast Surg). Silicone particles were also detected in other body regions in a case report (Kappel RM, et al.,2016, Clin Med Rev Case Rep). Even after tattoos of the skin it is known that the color pigments are transported via blood and lymph vessels and accumulate in lymph nodes and other organs (Lehner K, et al., 2014, PLoS ONE). Gel bleeding can be distinguished from an implant rupture. In the case of an implant rupture, the silicone remains in the composite. An implant rupture can be detected with magnetic resonance imaging. The detection of gel bleeding requires the examination of a tissue sample under the microscope (van Haasterecht L, et al, 2020, J Biophotonics). The health risks posed by the rough surface of certain implants should be considered separately. The rough surface of breast implants is suspected to cause BIA-ALCL.
The removal of the capsule tissue requires a skin incision in the crease under the breast. The removal of the capsule tissue is accompanied by a larger scar. The removal or replacement of an implant is often combined with a breast lift using the "T-incision technique". In these cases the removal of the capsule tissue does not cause a larger scar.
When removing the capsule tissue, there is a risk of secondary bleeding, injury to the lung skin, damage to the nerve plexus and the vessels of the armpit. The risks of removing the capsule tissue are greater if the implant is inserted under the pectoral muscle. The removal of the capsule tissue in the area of the ribs can cause permanent pain. Removal of the capsule tissue reduces the breast volume.
The risks of breast surgery without removal of the capsule tissue are low (Swanson E., 2020, Ann Plast Surg). The duration of surgery is shorter. Less pain occurs in the days following the operation. Patients often return to work within a few days.
In general, the general risks of surgery (inflammation, thrombosis) are increased for smokers. After breast reconstruction as a result of breast cancer, the overall risks are higher. In principle, there is always the possibility of extending the operation and removing the capsules. A conspicuous capsule or an accumulation of fluid will cause the surgeon to perform a capsule removal.
A single case is described in which BIA-ALCL was detected after implant removal without capsule removal. Everything indicates that in this single case the BIA-ALCL was overlooked during implant removal (Chacko A. et al., 2018, Insights Imaging). There are also four known cases in which BIA-ALCL was detected after en-bloc implant replacement. In these cases, the implants were replaced and the capsules removed due to capsular contracture. In these patients the implants were exchanged for smooth implants (Clemens MW, 2019, Meeting of the American Society of Plastic Surgeons).
The risk-benefit ratio should be carefully considered in a preventive surgery. Prevention makes sense if the risk of falling ill and the severity of the disease is greater than the risk of the operation. Removal of a capsule at least theoretically increases the risk of removal or replacement of an implant. There are no fact-based figures from meaningful studies. Removing an implant or replacing it with smooth implants without removing the capsule reduces the risk of BIA-ALCL. The risk of capsule removal is greater if the implant is below the pectoral muscle than if the implant is above the pectoral muscle. If BIA-ALCL has been detected on one side, implant removal en-bloc on both sides is recommended (Mark W Clemens M.W., et al., 2019 Aesthet Surg J).
Retrospective studies indicate that 50 to 74 percent experience an improvement (Melmed E.P., et al., 1998, Plast Reconstr Surg). In 30 to 35 percent the complaints after an operation are unchanged. In 10 to 15 percent a worsening was reported (Bridges AJ., et al., 1993, Ann Intern Med).
When examining the removed capsule under the microscope, silicone particles are often detected (Melmed E.P., et al., 1998, Plast Reconstr Surg. 1998). However, this detection does not have any consequences. In more than 82 percent of the cases no further abnormalities are found. In 0.36 percent of the cases, breast cancer is detected without prior suspicion (Lapid O, et al., 2014, Aesthet Surg J). In case of doubt, we always send the tissue for examination.