Hi, my name is Adam Perry. I'm a plastic surgeon in Long Island, New York. I have a breast practice of which about half is breast reconstruction and most of that is microsurgical breast reconstruction and about half my practice is cosmetic breast surgery and most of that is breast implant removal. Today I want to share with you some of the key things that I have learned about breast implant removal. First, I want to talk about my preoperative routine. All patients are screened for breast cancer according to the United States Preventive Services Task Force, recommendations which were just recently updated in April of this year. Secondly, it's important to tailor your visit to the patient's concerns. Patients will come to you and they will have different reasons for wanting to have their breast implants removed. Some will have capsular contracture, others will be primarily an aesthetic consideration, others will be for breast cancer reconstruction and some for breast implant illness. But it's important to identify what it is that the patient is concerned about and so you can use that time to address their specific concerns. It's good to use data and avoid general statements. And so a lot of information in this field is evolving and it's very helpful to keep up to date so you can back up what you're saying with data. Do not make any guarantees. I know that sounds common sense, but I have plenty of patients that come to the office and say, hey, I saw so-and-so and they said that they could guarantee a 100% and on-block capsulectomy. It's really important to be realistic with your patients so you can build a foundation for a strong relationship with your patient. Always discuss the aesthetics. Now many years ago when I started doing these operations, I didn't pay attention to the aesthetics. It was a secondary consideration. Patients would come to me and say, I really want my implants out. I just want them out. I don't care what I look like. And so I focused on the removal of the implant and the capsulectomy, but I didn't focus on the aesthetics. And what I found was over time patients returned to the office and they were unhappy with their appearance and sometimes it would be six months, sometimes it would be a year, but eventually quite a few of them returned. So I learned to address the aesthetics at the time of the breast implant removal. It's important to set expectations and so take your time, show pictures, use drawings if you're comfortable doing that, or if you have access to software, use that as well. But show pictures that are similar to the patient you're seeing. Really do your best to set realistic expectations for the patient. And I have three absolute contraindications to this operation. Number one is active smoking. Number two is uncontrolled diabetes. And the third one is very rare, but occasionally it's when I just can't connect with the patient and I feel they have unrealistic expectations and in those situations I don't operate. I want to take a moment to reiterate how important it is to tailor your conversation with the patient according to their concerns. So the aesthetics, some patients will be seeing you for revision of their breast reconstruction after having breast cancer, others just straightforward capsular contracture, and others will be there to see you for breast implant illness. Each one of those conversations is very different and it will help you by understanding what the patient wants, it will help you give them their best option. For example, if somebody's there for a breast cancer reconstruction, then I'm going to tailor the conversation about autologous reconstruction, deep flap, or other free flap. If they're there for straightforward capsular contracture, that's going to be a different conversation than the type of capsular contracture and surgery I might do for breast implant illness, or if it's a straight aesthetics visit. And then the aesthetics have to be woven into all these visits. So it's just really important to get that information from the patient and listen to them. I'd like to take a moment to talk about capsulectomy nomenclature. The breast surgery collaborative community recently put out a statement on the different categories of capsulectomy. There are four, and the two that are germane to my practice are total intact capsulectomy and total capsulectomy. So patients will come to my office and ask for an on block capsulectomy. They're not asking for a cancer operation to remove the implant, the capsule, and a margin of healthy tissue. They're asking for a total intact capsulectomy. So I think that's just important to point out that those terms within the context of breast implant removal can sometimes be used interchangeably, although we know that they have different definitions outside of breast implant removal surgery. One of the things you will have to decide is if your patient needs emastopexy or not. And so to show how I think about it and how I make my decisions, I put together this table. Now there's some nuances. For example, what plane the implant's in, if the patient has had previous surgery, or the patient's preferences in terms of scarring and scar placement. However, in general, this is how I think about emastopexy. If the patient has a large breast and a large implant, I'm going to likely do a wise pattern emastopexy. If the patient has large breasts and there's a small implant, I might just do a lower pole imbrication or just take the implant out. Or if the patient wants a lift, I'll do a wise pattern lift. If the patient has small breasts and a large implant, it's a very challenging situation. I'm very concerned about the blood supply in this particular scenario. And so I'm conservative. I'm either going to just shorten the nipple the full distance with a lower pole imbrication, or I'll just take out the implant and that's it, or I'll plan to do a staged lift several months later. And if the patient has small breasts and a small implant, I will do either nothing, just take the implant out, or I'll do a lower pole imbrication. I use the term lower pole imbrication, so I just want to go over that. It's a technique, and I use it for two reasons. One, I use it to address lower pole volume, where I think the patient could use a little more volume in the lower pole. And also for a nipple to fold distance that I think is a bit too long, and where I see that a patient will have excess lower pole droop. So this is a sketch that I would typically make for my patients. I use a lot of sketches and drawings. This sketch shows a breast with a good nipple position, but once the implant's out, the lower pole is droopy, but still the nipple position is reasonable. So a lower pole imbrication is helpful and a powerful technique in this situation by designing an ellipse, incorporating your inferior mammary fold incision, scoring that, deepithelializing that, then doing your implant removal through that area. And then when you close, you fold that tissue in and it adds some volume to the lower pole and also shortens the nipple to fold distance and addresses any potential excess droop of the lower pole. Remember, the aesthetic considerations are extremely important. Patients will come to the office, they'll ask you for the explant and the capsulectomy, and the aesthetics might be a secondary concern for them. For me, it's not. It's a primary concern. It's at the same level as capsulectomy and implant removal. It's important to talk about the scars, the shape, the potential need for revision. Be realistic and don't sugarcoat. And also explain to the patient that you don't have control over what the breast will look like once the implants are removed and the capsulectomy is done, but that you, with her, will formulate a strategy and you will use your techniques to get the best aesthetic outcome you can possibly get. I perform all of my explant surgeries at the same outpatient surgery center. I have the same anesthesia team and the same OR team. This helps with efficiency and also promotes an excellent patient experience. Patients receive pectoralis nerve blocks for these surgeries. If you have an experienced anesthesia team, that can be done in the PACU and it can save you a little bit of time. If you don't have an experienced team or if you have a patient that you don't think will tolerate that, then you can do it in the operating room after general anesthesia has been induced. I always send the capsules to pathology. That's part of the operation. Become friends with your pathologist. Make sure that the pathologist understands what you're looking for. That's always a little bit different depending on what you're doing the explant for. You want to make sure that the tissue that you're sending gets analyzed properly. And then photographs and video are an important part of the operation. I consider photographs as important as the operative report. I will remove the implants and at the end of the case I will photograph them. Those are for the patient, educate the patient, but also for the record. And occasionally I'll take video as well. I'd like to share a few operative pearls. The first one is that subpectral dissection and prepectral dissection are what I consider two different operations. In the next slide I'm going to explain why I say that. But knowing the difference between these two operations will help you perform them better and plan for them better. Next, always obtain photographs of the explanted material and capsules. As I said, I consider it part of the record, but providing those photos to the patients helps them with closure and it really does have a therapeutic effect for many of the patients. It's very important and I recommend that you do it. And then finally, to place drains or not to place drains. I always drain these patients because when I haven't, I found that the seroma rate is very high. And this is annoying for the patients. Many of them complain about that and then can result in office drainages or rarely going to IR for drainage. So I just drain all the patients. When you're planning a mastopexy with breast implant removal and capsulectomy, it's important to identify the blood supply. The blood supply for a subpectral mastopexy is going to be pretty robust. It will come from the internal mammaries as well as contributions from the thoracromial artery that will go through the pectoralis major muscle, through the breast parenchyma, to the skin and nipple. You can do a pretty extensive mastopexy as long as you stay in the subcutaneous plane. As far as dissection in a subpectral implant, I recommend starting from lateral to medial. Medially, it can be very difficult. It's very tight, generally scarred in. Laterally, as the pectoralis major muscle veers off the implant towards its humeral attachment, there will be an angle there that's easier to start the dissection. Once you get that started, you can put your lighted retractor under there and proceed with your dissection from lateral to medial in an efficient manner. What I find is the most difficult part of the dissection is the posterior capsulectomy. And that's because in a subpectral dissection, the capsule is right on the chest wall. It's sitting on ribs, and the space between the ribs is either intercostal or pec minor. Laterally, the pec minor gives you a margin of safety because there's an extra layer there between you and an injury to the intercostals and potentially being in the chest. The part that I feel is the highest risk for the posterior dissection is medially and inframedially where there's no pectoralis minor muscle. And you can see in this photograph, in the inframedial portion, you can see that the pectoralis minor ends just short of that. And then sometimes you have a pectoralis major muscle that's been over-released or it's just very contracted in the upper pole of the breast. And in patients with small breasts with not a lot of breast tissue, that will show as a lumpy upper breast or a mass in the upper breast. And so that can be treated with Botox. That's very effective. However, it needs to be done multiple times and repeated. This is a view of a posterior capsulectomy for a subpectoral breast implant. You can see why I think it is the most risky part of this surgery. You can see a rib just close to the incision as well as intercostal muscle, and you can see how thin that is. When I perform pre-pectoral capsulectomy, I find that I have a higher rate of total intact capsulectomy. It's a lot simpler to dissect the breast tissue off of the capsule without the pectoralis muscle to deal with. And posteriorly, you have the margin of safety of the pectoralis major muscle. And so even if you extend your dissection beyond the capsule, you're in a safe zone of muscle. I find that there is a lot less bleeding, lower hematoma rate, and lower seroma rate. However, because the implant is in front of the pectoralis major muscle, the blood supply that had previously traversed the pectoralis major muscle into the breast parenchyma to the breast skin and the nipple has been divided. You have to assume that is completely divided. And therefore, your blood supply will be coming through the breast parenchyma. And so your dissection for mastopexy generally should be more conservative in order to preserve the blood supply to the nipple and your breast skin. I think it's important to take post-operative photographs. And I have all patients come back at six months for post-op photos. And as I said before, the aesthetics pre-operative discussion, one of the things that should be on with aesthetics is scarring. And I think these photos illustrate why. I think these photos illustrate the importance of discussing shape pre-operatively and the risk of asymmetry post-operatively. And so in this patient, you have the right side slightly larger than the left. The patient's very happy. But if I were to take this patient back for a revision, I would make the right side a little bit smaller to match the left side. One of the things I found is that when I'm doing breast implant removal and capsulectomy, sometimes it's very difficult to determine whether the patient will need a breast reduction or not. I'm not always comfortable doing a breast reduction with an X-plant for concerns over blood supply. But in this case, in this patient, post-operatively, it's very clear that she needs a breast reduction. So she'll need a revision. And that's part of the pre-operative counseling as well. So make sure you cover that. This patient has an animation deformity. In the left picture, looks like a pretty reasonable result. She's in repose. However, when she flexes her pectoralis muscles, we see an animation deformity. This is challenging to treat. But I have successfully treated it in the past with re-elevating the breast tissue off of the pec major and reattaching the pec major muscle and fat grafting. I've spoken about the photographs. I just want to share what my typical photograph is. I'll put the patient's initials, the date. That's been covered here. However, on the left and the right, I will put the sizes if I can read them and any other information that I can glean from the implants themselves. When I perform a total intact capsulectomy, sometimes I will take some video and share that with the patient. I find that it's educational for the patient. That crunchy sound is all calcium, not very calcified calcium. Okay. Now I'm going to open it. And it's definitely ruptured. You can see the shell here. But it's inside. This is a very calcified capsule. And I like to show that to patients to help educate them on what the, when they see calcified in the literature online or a Baker IV capsular contracture, just to show them and help educate them. My post-operative routine, patients go home after the surgery because I use nerve blocks and Expirella, mostly just use NSAIDs, rarely narcotics. Patients get a follow-up call the following day. And then the first in-office visit is at one week for drain removal. At three weeks, I give a telehealth option for out-of-town patients. But at six weeks, I see the patients in the office again to remove any dressing or Dermabond and go over scar massage and schedule the long-term follow-up at six months for the photos. My revision rate is about 15%, and the average time to revision is 30 months. The most common revisions are things like retained areola, various scarring concerns, and shape concerns. To recap, tailor your discussion preoperatively depending on what the patient's concerns are, whether the patient is a BII patient, breast cancer reconstruction patient, or a capsular contracture patient. Educate the patient and counsel them preoperatively so that they have a realistic understanding about the aesthetic outcome of the surgery. Prepare for subpectral and prepectral operations differently. Take photographs. Schedule long-term follow-ups so you can take photographs and learn from your operations and expect revisions. Thank you very much. Hi, I'm Dr. Kelly Kuehn. I am a plastic surgeon in Los Angeles. And today, I'm going to talk about my current practice with how I manage explants. So what's new with explants? You do not have to do everything. So what exactly is necessary when you're taking an implant out? You're going to hear different things from different people on the panel today. And I think we've probably made it worse for ourselves by doing too much. But I also think you need to do something so that these patients look great and feel good about their bodies. This is a patient that I learned a lot of hard lessons with. I took her implants out, I did a lift, I did fat grafting, capsulectomy, you can see she had a contracture, and she had the most bizarre result I have ever created as a plastic surgeon. And I had to go back to the operating room and fix her, and she turned out fine. But this was one of the first patients where I started to realize that sometimes doing a lot is just a lot, and you're not helping the patient. So I've really changed my practice over the last several years. So this explant boom has hit every single one of you, I'm positive. So is it BII? Is it the change of aesthetics? Probably both. I think that the BII groups are extremely vocal, and they are multiplying, they are all over every type of social media. And I also think the aesthetic is actually more natural these days. Women that had big implants placed 20 years ago just want to feel like themselves and have a normal proportion again. It starts getting hard to dress that top heavy proportion when you hit your 40s and 50s. So in 2023, there were over 41,000 explants in the United States, and that was a 9% increase from the prior year. So it's increasing even with some of the research about capsulectomy, and it's probably because women are now pursuing explants because they don't need the more expensive options, and it's actually financially doable for them. And like I said, the look is changing. Women are in a different stage of life, and they're just ready to be rid of the implants. And the other issue is I think a lot of us weren't great with telling our patients about monitoring ruptures and potential exchange in the future. And so patients are now learning that these aren't lifetime devices when they have a complication, and they don't want to deal with this in 10 years. So all of these things together means more implants are removed. So what I find the most important part of any interaction I have with patients for an explant is just to over-educate about absolutely everything because these explant groups hurt our patients. These women think that they need absolutely everything done or they won't look good. And they also never seem to understand the risk because it's very downplayed in these groups and these explant expert surgeons really downplay these risks as well. So I think the most important thing is to educate the patient about what does the implant do to your tissue. And the way I discuss it in layman's turn is I just say the implant projects or sticks out from the chest the most in the center of your chest. So it thins the tissue the most there. It also pushes breast tissue to the sides. And so when that implant comes out, the middle of your chest is thinner and flatter, and you have a wider breast with tissue on the sides that you really didn't remember having before. Your muscle also is often stretched and elevated if it's submuscular, and it can contract very strangely if you don't repair this. And I know this is controversial. A lot of people don't think it works. It works. I do it all the time. It rarely fails. And I see consults all the time where people had really nice explants, but the muscle was not repaired and the muscle movement makes them nuts. So in general, what you see is that the muscle will move more than it does naturally, but also if they've had a dual plane, it often will fold on itself when they contract the PEC, which can feel strange and make people uncomfortable when they exercise, but it looks nutty too. And who wants that? Just fix it. And then I spent a lot of time educating about the need for capsulectomy. And luckily we have the ACERF papers and there's several other papers now, one from Norway, one from Australia, I believe. So we can say, hey, this just isn't something you need. Let's do evidence-based care. Let's not do additional procedures that increase your major complication rate. And most patients are on board with that. If you just sit down with them and let them see the literature, I will send it to them on our office messaging and it's really helpful. And I just found that if patients don't trust me and demand things that aren't necessary, they're not gonna trust me after surgery if there's a problem. And so I just cut them loose. This is not a patient for my practice. So in the operating room, there's a few things that I've started doing about six or seven years ago. And it's, again, a lot of the things we develop in our practices have to do with difficult patient situations. So I always take intra-op photos. I think patients need to see what their bodies look like right when the implant comes out. So I take the implants out as the first part of the surgery. I sit them both upright and I take a photo. And then when I'm done doing every step of what I'm doing, I do the same thing. So I think it's really important that they can appreciate what our interventions do because a lot of these things are subtle, but they make an impactful difference. And if they don't see the before and the after when we do it, they don't appreciate it as much because these patients never have a completely normal looking breast. This patient turned out very nice after having long-term contractures, but she's hollow in the upper portion of her breast. She needs to understand what the implant did and that it wasn't my fault. So I've really moved to doing the bare minimum. And my bare minimum is removal of the implant and doing what I call an internal lift. So you need to be clear with patients with what your internal lift does, what your version of the internal lift does. And I'll talk about it a little bit in the next couple of slides. And I'm very clear with them. This is not a formal mastopexy. This isn't a breast lift. You don't have scars. I don't have control over the envelope and where the nipple ends up like I would with a full mastopexy. So you're gonna have a bit narrower base diameter of your breast. So your breast will fit your body better than it did right when the implant came out. And your NAC will slightly lift. So usually one to one and a half centimeters is typically what I get when I do an internal lift. So with an internal lift, there's two things that I do, and this is my version. I know people do different things. So muscle and mountains are my two Ms of an internal lift. So the first thing is to repair the pectoralis major muscle. And as you can see here, I'm grabbing it with an alice, separate it from the overlying breast with cautery. And you really need to make sure you separate it enough so you don't have any tethering of the breast to the muscle because it can look really strange when you suture it back down. Now, by doing this, it allows the breast to float up over the muscle a little bit. I always rough up the underlying capsule because you need something that is raw so it heals nicely to the chest wall. So I often use a bovie scratch pad on a tonsil. I find that this does a really nice job of making a rough surface. If your capsule is a little thicker and it does not look like it's going to work, then I just remove a portion of the capsule so I have a good repair. Now, I suture it to the chest wall and people always ask, what am I suturing to? So I suture to periosteum and intercostal fascia with a 2-0 PDS. I promise you can do it, I believe in you. Even with a capsulectomy, you will find something to suture to and it does stick down. And I think with a full capsulectomy, the whole thing is raw. So it tends to work well, even though you're missing some of your fascia sometimes, sometimes, and also some of your periosteum. Hopefully not, but you can still get a good repair. I believe in you. Again, you can do it. The next thing I do is I suture that mountain range of breast tissue that has been pushed to the sides. I use a 2-0 Vicrylor PDS, whatever I'm in the mood for. You really need to make sure that you sit patients up if you do any of this type of suturing for an internal lift because they often look great while they're laying flat. And then when you sit them upright and gravity pulls, you will see tethering. Now it does often get better as the stitches dissolve, but sometimes it doesn't. And I think it's best just to get it right the first time and you don't have to worry about it as the patient's healing. And they don't have to stare at something strange and then torture you about it. So I usually do my stitching lateral to medial, inferior to superior. And it really doesn't matter what you suture to. You can suture from the breast tissue to the pec or the chest wall, whatever capsule if you have left, just as long as you have something that is going to hold a stitch, it really does a nice job of narrowing the breast and raising it a little bit. So you can redistribute the breast tissue in a way that makes sense. This patient had a huge hollowed area and was very, very droopy. And I was able to give her a pretty decent result from having long-term contractures without doing a lift or any fat grafting. It's important to note though, you may need to do some dissection, mostly lateral and medial to get movement enough on this tissue where you can move it and you can actually get it to redistribute where you want. And then if this isn't enough, if you have a patient where you're like, this person needs a lift, this person really has very little volume and you're going to do a lift or grafting in addition to the internal lift, don't do both. I've just found that that is the kiss of death for having strange scarring complications. It's just so important that you pick your poison and tell patients it's often best to come back another day. So if you do a capsulectomy in addition, you're really setting yourself up for problems. So your graft take, of course, is going to be less, especially if they are very thin and don't have a lot of tissue. You've lost your back wall, you're going to lose a lot of your graft. This is especially problematic in a thin patient where you don't have a lot of donor site. You don't want to squander that graft. So educate your patient. It's just not a good idea. Let's wait on this. And then you're obviously going to have more healing issues with your lift if you've done a capsulectomy. I find that I don't have a lot of NAC compromise. I don't have a lot of healing issues when it comes to the incision, but I do have a lot of funny scarring with the capsulectomy when you add a lift. So it's important that you just make sure the patients understand that by choosing this, you are choosing a bit more problem. And this is very helpful for patients, again, to see photos. So if you're doing a lift, take a photo before and after so they can see what your lift did. Same thing for fat grafting. And I am a huge fan of staging everything. I just find the results are superior if you stage everything you do when it comes to explants. So post-op, less is more. Drains is kind of the area that I have changed the most. I have just completely stopped using drains for explants. Whether there's a capsulectomy or not, you don't need it. I've never had a seroma. I'm sure I will at some point, but you're just not gonna get a seroma. There's no reason to do drains. And all they do is cause weird scarring complications and torture your patients. So if you are going to try to wean yourself off of a drain, you can always just put it on suction for a few hours, take it off of suction to lessen the chance that everything's gonna suck down strange, or just pull the Band-Aid off and try it without a drain. I promise it'll be okay. And then taping. I utilize taping a lot to help support what I've done internally. So either a Pravena vac, the Bellaform is great for this, but also foam tape can be helpful as well. Now you just wanna make sure you don't leave this on for too long. The Pravena's on for a week. I do foam tape for a week, maybe two at the most. Adhesive can be really problematic. Patients hate it, and I don't think it's doing a whole lot after that time period anyway. And then bra wear. So I think that bra wear can be really, really helpful, just acting as a splint for the first couple months. These patients are often so excited to never wear a bra again, having their implants out, but you just have to educate them you can do that. You're gonna affect your results though. So it's best to, for at least a couple months, support all of the work that we do internally and externally, and allow your body to heal. So the only thing I always add is that I do take capsules out in certain situations, and I always discuss this with patients. I think I have found that if you don't take Baker-4 contractures out, sometimes patients continue to have breast distortion as well as pain. So I always recommend capsule removals for those patients. I also remove capsules for patients that have a silicone rupture. I've had a handful of patients come back with contractures, even with the implant out in pain. So I think those capsules, it makes sense to remove. And then I always have a discussion with my textured implant patients. We have no data to support implant or textured capsule removal to reduce risk of ALCL. And there's some evidence that it doesn't reduce the risk, but I always have these discussions with my patients because we don't have great data. I think that's something that you should really give them the option if they would like to have that capsule out. So I actually really enjoy this patient population. I think it's a win-win because you have a happy patient who has often been told by other people, they're gonna look terrible, don't take out your implants, and they end up looking great. So it's a win. They're happy to have them out. You are happy to have a happy patient. And like I said, you really don't have to do a whole lot. And I find that they heal beautifully and are so grateful. So thank you again. Let me know if you have any questions. Feel free to send them to me over DM or over on my website by my email. Thanks. Good morning. I'm Dr. Mindy Hawes from Nashville, Tennessee and the immediate past president of the Aesthetic Society. And thank you so much for including me on this panel. My talk is explantation. Not everyone needs a capsule like Tamir or mastopexy. My disclosures, both unpaid educational advisory boards for Cientra and Allergan in the past year. To start off on this talk, when talking about capsules here, I am never talking about a capsule like this. It's clearly a thickened pathologic capsule that needs to be removed. This is not what I'm referring to. I'm referring to instead those thin grade one, maybe grade two capsules that really aren't hurting anybody. When I see patients with implants, I like to separate them out into silicone versus saline because I treat them two different ways if they're there for explant. If it's silicone, I like to use ultrasound to see whether or not the implant's ruptured so I can make a plan. Also, if there's a chance that it's textured, I wanna check for seroma. If it's saline, I haven't traditionally used ultrasound but recently had a patient who was a ruptured saline that the whole pocket was filled with seroma fluid. So it would have helped me in my preoperative planning to have done an ultrasound before. So I ultrasound everybody now. With saline, it's possible to deflate them ahead of time if it's a thin, soft capsule and see how the breast tissue reacts. It's possible to tape up their breast tissue and see if they're gonna need or wanna mastopexy. And it's also possible, just like with silicone, to just remove the implants. Again, I like ultrasounds. You can do handheld, you can use table ones. These are both available in my surgery center. And I recommend you ultrasound everybody you're getting ready to move an implant on. That way you teach yourself what looks normal and what abnormal looks like by ultrasound. On the left here is an intact implant and from up to down is outside to inside. Normal breast tissue, that double railroad track line, is the edge of the implant capsule. On the right is a ruptured implant. You see how you see kind of overlapping railroad track lines? That's where the shell has been ruptured and it's folded over itself. You also see that snowstorm appearance, which appears when the gel gets hydrated. And that's pretty pathognomonic for a ruptured gel implant. Again, this is the same patient. This is another view from her ultrasound. And you can see all that hydrated gel as well as the implant capsule folded over itself. This is the same patient, her MRI, which again, you can see the implant folded up and it's actually probably the best MRI I've ever seen to show rupture. So when I see a patient who's there for an explant, if she's not sure whether or not she wants implants back, it's nice to be able to remove them or if they're saline, deflate them. This was actually a saline patient who opted to remove them. We gave her four months to allow her tissues to contract and see what happened and then we're able to resize her. She decided she did want implants back. And despite how it looks there in that middle picture, I only had to revise skin in the periureolar region on the right side. She did not need a lift. And we switched her from her 750 fill to a 285. And last note, more than a year out, she was happy with volume. Further the gift of saline, you can preoperatively deflate them. And this is a patient at a partial deflation. We deflated both. She waited five months to come back and decide maybe she did want implants back, but allowed her to test drive her breast size before she ever had them removed. And again, decide that when her tissue shrunk up, she really didn't want a lift. She just wanted volume back. A postpartum patient who presented with a pretty significant double bubble. You can see there on the left. Who did not like her big heavy implants. We went ahead and deflated her as she was still breastfeeding. Allowed her to complete breastfeeding. And over the course of the next six to eight months, her tissues continued to shrink up. And this is her even at four months. We then downsized her from that previous size to a 350 high profile. Now in hindsight, I should have used a moderate profile. Initially, she was happy, but then she lost more weight and decided she wanted volume back. And she talked me into replacing these with 510s. Now I should note when I done the downside, this is again with someone, I didn't take out her old capsule. She'd had smooth salines. I used that capsule in continuity with her pectoralis muscle to define a new sub glandular plane. And it kept her pec muscle length. So we realized yet again that 510 was too big. And went back and downsized again. This time doing a vertical mastopexy. We did not change her back under the muscle. She did not want the animation to form it again or any chance of a double bubble. But did the mastopexy and used a moderate profile 300cc implant. And she was very happy with this until she decided she has systemic symptoms and we ended up removing the implants under local. And she's been very happy ever since. If you do a good mastopexy, it will stand up to implant removal as well. The other nice thing about breast, if you don't take out the capsule, here we just removed gels. She was in the middle of dental hygiene at school. Did not want to do anything definitive. We took them out, let her tissues contract. Leaving the capsule behind allows for smoother contraction of that overlying breast tissue. You're less likely to get scarring down or deformity of the breast tissue. And then I oftentimes will tape the breast to give the patient an idea of how much volume is actually theirs. And this is four months after explant. She's thinking about a lift, not sure if she wants a smaller implant. And by taping her up, we can show her what the breast volume actually is. And it doesn't over promise on upper pole fullness when you are thinking about not using an implant. It's also nice to use those capsules for support when you're upsizing, but in particular, downsizing an implant. This was someone who finally accepted her implants were too big and decided to downsize and to do a lift. You can see that we downsize breast tissue as well as her implant volume and then use thermocoagulation and bico sutures to support that lower pole, which in my hands acts much like a scaffold or mesh. Again, the capsule can be your friend. The other use for capsule is keeping a nice layer if you wanna do immediate fat injection. This was someone who works out heavy, does a lot of lifting, did not want her implants under the muscle and decided she did not want silicone, was gonna stick with saline, decided to have a lift to tighten up her breast tissues. And we also did 100 cc's of fat injection by lateral upper poles in the subcutaneous layer since we had capsule to keep that separate from her implant and allowed her for softer edge to the breast. This is her at a year. This woman had subpectral implants that we removed and did not remove capsule, allowed this to contract. And she came back a couple of years later and decided she wanted implants back. So we placed implants, did a mastopexy and placed them subglandular using the capsule in continuity with her pec to create the posterior pocket of the implant. She was happy with this until she wasn't, left the state and had implants removed again. Sometimes salines refuse deflation. She was submuscular and simply want, the breasts were soft, but with a too complete release of the muscle on the left and rather an incomplete release on the right, she had asymmetry in breast height. We changed her to subglandular and it kept that submuscular capsule intact without any mesh, used it as the posterior pocket, closed off the posterior pocket, again using thermocoagulation and then closing off the pocket for a new subglandular site change. This is her at a year. And her before and her afters. The other nice thing about those capsules and allowing them to deflate, you can see what you have. This is a patient and it's important to show patients before and after pictures because they can see they don't necessarily need a lift even though they're all sure that they do. This was a patient with deflation and then her final results several months later with implants out, no fat grafting, nothing else done. Now the horror stories. This was a patient with a pathologic capsule, grade four. It was painful. She decided she just wanted them out, did not want implants back. I took these out through an inframammary fold incision, did a capsulectomy. This was her at just a few weeks and then this is her at four months. And you can see how her tissues contracted back, her nipple-reeler complexes became inverted. That was two weeks it was starting to happen and we started aggressive massage and by four months it was really tight and tethered. Almost as if I'd done a breast lift but I had not. We ended up going back to fat graft this. But again, without the capsule to monitor and keep those tissues from sticking down, this was her scar contraction. So good before and after pictures before explantation I think is important. Patients can usually find, if you've got enough of them, someone who looks like them. Usually my rule of thumb is that the breasts typically go back to wherever they were before you had implants, unless you needed a lift before and you didn't have one, in which case you'll probably need a lift now. The other elephant in the room is what about those patients that believe that they have systemic symptoms? We have seen with numerous studies, one of which I was part of, there's another one in Australia, and there's another one that was just published in the Netherlands that shows that women with systemic symptoms who believe they have breast implant illness, who have their implants removed, most get better regardless of whether or not the capsule is removed. And this was seen in a Netherlands study where 78% of them had no capsule removed. Our study result that was funded by ACER, that was done by Dr. Caroline Glixman and Pat McGuire, our simply contributed patients, showed that no capsulectomy showed the same symptom drop off as did the quote unquote en bloc, the total capsulectomy, or the no capsulectomy. And we now call en bloc total intact. Regardless, same symptom drop off. So it's not the capsule, whatever it is. So in summary, implant exchanges removals are on the rise, probably because implants have been around now for over 40 years. Patients' weight changes, clothes change, fashion and lifestyle changes, the age of the implants. Maybe they've had children and they just want a different breast. I would propose that you don't always need to automatically do a capsulectomy. Use your capsule. You can deflate or remove the implants when necessary. And let the capsule do the work for you to contract the breast up so you can see what the breast actually looks like. You can then decide if the patient needs a lift or needs an implant. And just because it's our aesthetic as a plastic surgeon doesn't mean it's what the patient wants, which is why your own before and after pictures are so important. If you're replacing implants, or even if not, you can thermocoagulate that capsule to shape, especially if you're doing a lift or an aug pexy. Use the capsule to define your sight change. Whether you're going on top of the muscle, you can use that capsule to keep the pectoralis muscle at length. Or if you're gonna go under the pec, you can use the posterior capsule in continuity with the pectoralis muscle to again keep the pec out at length. You can use the capsule to support that. And also remember, you can tape your breast up to explore different lift options. And again, lots of before and after pictures to show patients what they can expect. Thank you so much for allowing me to speak. These are my cats, Loki and Thor, who are so glad I'm no longer president. ♪♪

breast reconstruction

cosmetic breast surgery

breast implant removal

capsular contracture

breast implant illness

capsulectomy

mastopexy

pre-operative assessment