Implant removal en bloc: what you can expect
Every patient who opts for breast augmentation with implants should be aware that further surgery will be necessary in the course of their life. Whether an implant change or removal is carried out, an additional breast lift and/or autologous fat treatment should be discussed at the appropriate time. This is completely independent of whether the procedure is intended for medical or aesthetic reasons. 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!
Implant removal en bloc can have the following advantages:
- Better shaped and softer breast after removal of calcified capsule
- End suffering from Breast Implant Illness
- Minimizing the risk of BIA-ALCL
- better health and a clear conscience
What our patients say
Information at a glance
Operation duration
3 hours
Anesthesia
Twilight sleep
Hospitalization
Outpatient
Costs
Aftercare
6 weeks
Thread tension
Self-dissolving threads
Socially acceptable
after 5 days
Additions or alternatives
What is the lifespan of breast implants?
The durability of breast implants is limited: There is no lifetime guarantee or lifetime durability, this also applies to modern breast implants. However, they have been developed for a long service life. Implants are constantly being further developed, in particular the resistance of the usually multi-layered outer shell and the dimensionally stable filling material. A rupture (synonym for tear) can occur with a probability of around one percent per year. This means that the implants are defective in ten percent of women after around ten years. This means that the implants used must be removed or replaced for medical reasons at the latest at the end of their service life. You can find more information on the various modern implants on the Breast augmentation with implants page. You can also find out more about the versions there. Round implants are more likely to shape a plump breast, while ergonomic breast implants are recommended for a natural breast. The above-mentioned page also describes the features and quality of the products of the various manufacturers (including B-Lite).
What is an en-bloc implant removal?
An en bloc resection is a surgical technique. The meaning of the French term en-bloc in the dictionary is “in one piece”. Breast implant removal is defined as the removal of the entire capsular tissue. This is why this operation is known in English as a “capsulectomy” (“-ektomia” is ancient Greek for cutting out). The technique originates from tumor surgery. When removing tumors, the surgical expert must work with the utmost precision to avoid leaving malignant cells in the body. A similar procedure is used for the surgical treatment of infected wounds. Here, too, the surgeon must very carefully separate affected tissue and the instruments associated with it from healthy tissue. Good dexterity and experience are required to visualize the boundaries between the altered scar tissue and the healthy tissue.
What are the advantages of en-bloc implant removal?
The removal of a calcified capsule improves the shape of the breast of the affected women and the breast feels softer. If BIA-ALCL is suspected, the capsule should be removed because of the malignant white blood cells it contains 1 . For many patients, it is reassuring to know that everything has been done to remove the implant and any residue. Our job is to provide you with all the important information you need. We are on hand to advise our patients, both with questions about breast augmentation and questions about the removal of breast implants. In each case, we will of course thoroughly examine the professional justifiability of the decision we make together.
Procedure for en-bloc implant removal
Preparation
Before the procedure, the breasts and the areas where the fat cells are to be removed are marked in a standing position. If the operation is performed under twilight sedation, you will be given medication to relieve your anxiety and reduce your sensitivity to pain. If you are not already deeply asleep, you will only feel painless touches on the surface of your body.
The OP
In order to be able to work with the greatest precision, the operation is performed using magnifying glasses. The capsule is exposed through a small skin incision of five to six centimeters. The scalpel and dissecting scissors are used to remove the capsular tissue from the pectoral muscle without coming into contact with the implant. Depending on the patient’s wishes, a new implant can be inserted, the breast lifted and/or an autologous fat treatment carried out. The wound is closed with fine stitches. These dissolve again after about three weeks. Before the procedure is completed, you will be placed in a sitting position. This serves to check whether the shape of the breast achieves the desired result when sitting and lying down.
After the procedure
The duration of the outpatient procedure is approx. 60 to 180 minutes. Immediately after the operation, you will be continuously monitored in a so-called recovery room for a longer period of time. When you are fully awake again, you can have a drink and, if you wish, eat something. Before leaving the practice, check-up appointments are arranged and the behavioral measures are discussed together.
For whom is en-bloc implant removal advisable?
From a medical point of view, a regular check-up and, if necessary, replacement of the implants is recommended after ten years. In women who have undergone breast cancer surgery, experience has shown that the old implants are replaced earlier. Implant removal en bloc should be considered separately. This applies in particular to patients in whom:
- advanced capsular contracture or calcification of the capsule is present,
- BIA-ALCL (abbreviation for breast implant associated anaplastic large cell lymphoma) was suspected,
- the MRI examination suggests a defective breast implant, or
- there is a high level of psychological distress if Breast Implant Illness (BII) is suspected.
A capsular contracture is detected by palpation of the breast. Indications of an implant rupture are symptoms such as newly occurring, in some cases even severe pain and a deformation of the breast. Ultimately, an MRI scan is required to confirm the suspicion of an implant rupture. However, a residual uncertainty remains, despite an MRI scan. The suspicion of a large cell lymphoma (BIA-ALCL) arises from an increase in breast size, usually several years after breast augmentation. The diagnosis of BIA-ALCL is confirmed by ultrasound-guided sampling of fluid that has accumulated around the implant. Intensive research is being carried out into examination methods for detecting Breast Implant Illness (BII). There are laboratory tests to detect certain autoimmune diseases. In patients with breast implant disease (BII), both the tests for an autoimmune disease and all other blood tests can be normal, as there is a medical indication.
Silicone implants & “Breast Implant Illness”:
Are you affected?
For many years there has been intensive discussion that silicone implants cause numerous complaints. Many of these complaints are summarized under the term “Breast Implant Illness” (BII). Causal relationships are examined in medicine according to the Bradford Hill criteria. A causal relationship, such as brain tumors and cell phone use, must be objectively and substantiated on the basis of these nine criteria. The explanation of terms, an illustrative example and the reference to Breast Implant Illness help to better understand the complex relationships.
Explanation of terms
Example
Breast Implant Illness
Explanation of terms
| The more frequently an illness is observed after an event, the more likely a causal relationship is. |
Example
| All students in a class receive excellent A-level grades in mathematics. You probably had a good teacher. |
Breast Implant Illness
| Scientific studies come to different conclusions. The overall quality of the studies is still inadequate. |
Explanation of terms
| If the conclusions of different studies, in different countries, at different times are similar, a causal relationship is likely. |
Example
| Climate researchers around the world agree – CO2 emissions are responsible for climate change. |
Breast Implant Illness
| The conclusions of the studies are contradictory, with the majority of voices currently denying a connection. |
Explanation of terms
| If there are no other risk factors, a connection is likely. |
Example
| If a new watch with a new battery stops after one day when handled correctly, it is probably a manufacturing defect. |
Breast Implant Illness
| The symptoms described are very different and occur in a variety of diseases. The causes and triggers of autoimmune diseases are still insufficiently researched. |
Explanation of terms
| The accumulation of a disease at a certain time after a damaging influence makes a causal connection probable. |
Example
| If abdominal pain occurs before or weeks after a visit to a restaurant, food poisoning is unlikely. |
Breast Implant Illness
| The duration until the symptoms appear varies in the scientific reports from one to 15 years. |
Explanation of terms
| If there is a connection that a damaging influence exists over a long period of time, this should be associated with a higher probability of illness. |
Example
| The more cigarettes someone smokes, the greater the risk of lung cancer. |
Breast Implant Illness
| No differences in the incidence of disease were found for unilateral or bilateral breast implants, saline implants, pacemakers or small joint prostheses. |
Explanation of terms
| The existence of a biological explanation supports a causal explanation. |
Example
| UV rays can damage the human genome and therefore also cause skin cancer. |
Breast Implant Illness
| Definition: The existence of a biological explanation supports a causal explanation. Example: UV rays can damage the human genome and therefore also cause skin cancer. Breast Implant Illness: Foreign bodies are recognized by the body’s immune cells and trigger an immune response. |
Explanation of terms
| Consistent observations from laboratory tests and observations in patients indicate a higher probability of a causal relationship. |
Example
| The harmful effects of particulate matter can be consistently observed in animal experiments and in traffic-intensive areas. |
Breast Implant Illness
| Test results on humans and tests in the laboratory are very different. |
Explanation of terms
| Eliminating the risk factor should reduce the incidence of the disease. |
Example
| When a smoker stops smoking, the likelihood of developing lung cancer decreases. |
Breast Implant Illness
| A temporary improvement in symptoms was observed in 38 patients after implant removal. |
Explanation of terms
| Similar risk factors should lead to similar diseases. |
Example
| Since smoking leads to lung cancer, it is likely to have an influence on the development of bladder cancer. |
Breast Implant Illness
| Silicone implants in other parts of the body are not suspected of causing diseases. |
Sources: 1JanowskyEC, et al. 2000. N Engl J Med 342(11):781-790. Balk EM, et al. 2016. Ann Intern Med 164:164-175. Colaris MJL, et al. Immunol Res. 2017 Feb;65(1):120-128.
2Perkins LL, et al. 1995. Ann Plast Surg 35:561-570. Hochberg MC, et al. 1996. Curr Top Microbiol Immunol 210:411-417. Wong O. 1996. Regul Toxicol Pharmacol 23:74-85. Whorton D, Wong O (1997) et al. West J Med 167:159-165. Janowsky EC, et al. 2000. N Engl J Med 342:781-790. Rubio-Rivas M, et al. Clin Rheumatol. 2017 Mar;36(3):569-582.
3Colaris MJL, et al. Immunol Res. 2017 Feb;65(1):120-128.
4Pavlov-Dolijanovic S et al. 2017. Rheumatol Int 37(8):1405-1411
5Rohrich RJ et al (2000) et al. Plast Reconstr Surg 105(7):2529-2537
6 With the exception of ALCL, no disease caused by silicone is known to date.
Can an en-bloc implant removal be combined with a breast lift?
Concerns about their health lead many women to inquire about en bloc removal of implants. When breast implants feel like a foreign body, patients are often primarily concerned with their removal. Not only the implants, but also the breasts themselves change over time. Weight fluctuations, pregnancies, hormonal changes and a change in skin elasticity and breast tissue can lead to sagging breasts. Similar to a sagging stomach after pregnancy, sagging skin must be expected after the removal of an implant. In contrast to pregnancy, implants are removed or replaced after eight to nine years on average 2 . A regression of the skin is therefore unlikely. The larger the implant used, the weaker the connective tissue will be after removal. For many women, beautiful, full and sometimes large breasts are the reason for breast augmentation with implants. If only the implants are removed later, there is a high probability that patients will be dissatisfied with the appearance of their breasts. A combination with a breast lift and/or autologous fat treatment is possible and recommended. We will be happy to advise you on this.
What is capsular tissue?
Capsular 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 capsular tissue consists of phagocytes (macrophages), giant cells, connective tissue cells (fibroblasts) and white blood cells (lymphocytes). In the case of implants with a rough surface (textured implants with a roughened surface), small silicone particles were detected in the space between the cells and in the scavenger cells. These particles were not found in implants with a smooth surface 3 .
After years, breast implants are covered by the body with coarse fibrous tissue, a so-called capsule. Over the years, the tissue around the implant shrinks and compresses it. This is referred to as capsular contracture or capsular fibrosis. The picture shows an implant (1) compressed into a ball and the surrounding capsule (2) held aside with surgical instruments (3).
What is gel bleeding?
The spread of fine silicone particles into the body tissue around a breast implant is known as silicone bleeding or gel bleeding. The phenomenon of gel bleeding was already described in 1978 4 . The smallest amounts of silicone penetrate the outer shell of an implant 5 . The distribution of silicone particles is influenced by the nature of the shell and the cross-linking of the silicone. In this context, silicone particles were detected in the lymph nodes of several patients 6 . Silicone particles were also detected in other parts of the body in a case report 7 . This problem also occurs after skin tattoos. It is known that the color pigments are transported via blood and lymph vessels and accumulate in lymph nodes and other organs 8 . Gel bleeding must be distinguished from an implant rupture. If the silicone implant ruptures, the silicone remains bonded. An implant rupture can be detected with an MRI scan. The detection of yellow bleeding requires the examination of a tissue sample under the microscope 9 . The health risks posed by the rough surface of certain implants should be considered separately. The rough surface of breast implants is suspected to be associated with BIA-ALCL. It is assumed that this is triggered by the textured surface or that the probability is increased. The BIA-ALCL is also discussed on this page.
What are the risks of removing the capsule tissue?
The removal of the capsular tissue requires a skin incision in the underbust fold. 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 capsular tissue does not cause any major scarring.
When removing the capsular tissue, there is a risk of secondary bleeding, injury to the pleura, injury to the nerve plexus and the vessels in the armpit. The risks of removing the capsular tissue are greater if the implant is inserted under the pectoral muscle. Removal of the capsular tissue in the rib area can lead to permanent pain. The removal of the capsular tissue reduces the breast volume.
The risks of breast surgery without removing the capsular tissue are low 10 . The duration of the operation is shorter. There is less pain in the days following the operation. Patients often return to work within a few days.
The general surgical risks, such as inflammation or thrombosis, are generally higher in smokers. After breast reconstruction as a result of breast cancer, the overall risks are greater. In principle, it is always possible to extend the operation and remove the capsule. A conspicuous capsule or an accumulation of fluid will prompt the plastic surgery expert to perform a capsulotomy. Breast augmentation revision is a demanding procedure and an optimal result is never achieved as easily as with the first operation.
1. upper thoracic artery 2nd thoracic vertebral artery 3. subclavian artery 4. anterior artery encircling the humerus 5. median nerve 6. ulnar nerve. 7th intercostal arm nerve 8. lateral thoracic artery 9. intercostal nerve 10. pleura 11. vein of the lateral chest and abdominal wall
1. ribs 2. straight abdominal muscle 3. belly button 4. external oblique abdominal muscle 5. inner oblique abdominal muscle 6. transverse abdominal muscle 7. nerves from the spinal cord
Does en-bloc implant removal protect against BIA-ALCL?
A single case is described in which a BIA-ALCL was detected after implant removal without capsule removal. Everything indicates that in this individual case the BIA-ALCL was overlooked during implant removal 11 . Furthermore, four cases are known in which a BIA-ALCL was detected en bloc after an implant exchange. In these cases, the implants were replaced and the capsule removed due to capsular contracture. The implants in these patients were replaced with smooth implants 12 .
In the case of preventive surgery, the risk-benefit ratio should be weighed up particularly carefully. Prevention makes sense if the risk of falling ill and the severity of the disease are greater than the risk of complications during surgery. Capsule removal increases the risk of removing or replacing an implant, at least in theory. There are no fact-based figures from meaningful studies. Removing an implant or replacing it with a smooth implant without removing the capsule reduces the risk of BIA-ALCL. The risks of removing the capsule are greater if the implant is placed under the pectoral muscle than if the implant is placed over the pectoral muscle. If a BIA-ALCL has been detected on one side, implant removal en bloc on both sides is recommended 13 .
Frequently asked questions
If you would like to find out in advance about the price of the procedure to remove silicone implants, please contact us.
Dr. Stahl has continuously developed the techniques of en bloc resection over the years. 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 medical director at Tübingen University Hospital in 2015. From 2016 to 2018, he moved to Lüdenscheid as Clinic Director. Dr. Stahl has continued to refine his microsurgical techniques over the course of his university career, so that today he enjoys a reputation among experts as a particularly gentle and precise surgeon.
Silicone particles are often detected when the removed capsule is examined under the microscope 16 . However, this proof has no consequences. In over 82 percent of cases, no further abnormalities were found. In rare cases, precisely 0.36 percent of cases, breast cancer is detected without being suspected beforehand 17 . In case of doubt, we always send the tissue for examination.
AUTHOR
Dr. Stéphane Stahl
We provide you with extensive expert knowledge in order to select the best possible treatment path together with you.
Privatdozent Dr. med. Stéphane Stahl is the former Director of the Clinic for Plastic, Reconstructive and Aesthetic Surgery / Hand Surgery at Lüdenscheid Hospital. Dr. Stahl studied medicine at the Universities of Freiburg and Berlin.
He passed the European specialist examination for plastic and aesthetic surgery in 2011 and the German specialist examination in 2012. This was followed by further specialist qualifications and additional qualifications (including quality management, medical didactics, physical therapy, emergency medicine, laser protection officer, hand surgery) as well as prizes and awards.
In 2015, he completed his habilitation in plastic and aesthetic surgery in Tübingen. He is an experienced microsurgeon, sought-after expert witness and regular speaker at specialist congresses. Following a multi-stage selection process, Stéphane Stahl became a member of the American Society for Aesthetic Plastic Surgery (ASAPS), one of the world’s largest and most influential specialist societies for aesthetic surgery.
His authorship includes numerous articles in prestigious peer review journals and standard surgical textbooks.
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- Lehner K, et al., 2014, PLoS ONE ↩︎
- van Haasterecht L, et al, 2020, J Biophotonics ↩︎
- Swanson E., 2020, Ann Plast Surg ↩︎
- Chacko A. et al., 2018, Insights Imaging ↩︎
- Clemens MW, 2019, Meeting of the American Society of Plastic Surgeons ↩︎
- Mark W Clemens M.W., et al., 2019 Aesthet Surg J ↩︎
- Melmed E.P., et al., 1998, Plast Reconstr Surg ↩︎
- Bridges AJ., et al., 1993, Ann Intern Med ↩︎
- Melmed E.P., et al., 1998, Plast Reconstr Surg. 1998 ↩︎
- Lapid O, et al., 2014, Aesthet Surg J ↩︎
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