En Bloc Capsulectomy
Many women wish to have appropriate breast surgery that includes EN BLOC capsulectomy for BREAST IMPLANT RELATED ILLNESS or BII. This EN BLOC term is not a new concept. This Latin term, EN BLOC, refers historically to surgical procedures to remove cancers and other tumors in their entirety with a margin of normal tissue around them. The intent of an EN BLOC removal of the tumor was to circumferentially remove cancer without cancer touching any other part of the normal tissue surrounding it to prevent oncologic cross-contamination. This is still a legitimate technique for removing cancers today. This has since been extrapolated colloquially onto the removal of the breast implant capsule after previous breast surgery.
The EN BLOC removal means that the implant and the capsule are removed as one large piece with a cuff of normal tissue around it.
This can be surgically performed, of course, by Dr. Jacobsen. However, it is important to realize that the essential elements of effective breast surgery for ladies are to remove the capsule, the gel of the implant, the shell of the implant, and its contents. Dr. Jacobsen has been doing this for 25 years.
Dr. Jacobsen always sends the capsule tissues that are sometimes abnormal or thickened to the laboratory for pathologic review and screening for cancer. If there is fluid around the implant, this is also sent to the laboratory. The capsule is permanently removed. Sometimes in rare instances, unfortunate ladies with radiation or previous breast cancer or advanced capsular contractures and portions of the capsules can be attached intimately to the ribs and intercostal muscles and cannot be removed practically or safely without causing damage to the normal surrounding tissues. But the capsule and the implant are permanently removed to the greatest extent safely possible.
On another page of my website, you will see a reference to breast implant-related lymphoma. So far, none of the capsules Dr. Jacobsen has removed have shown any element of this or other cancers. This will likely be the case for you as well.
To respect the pure nature of the surgical technique of EN BLOC removal, the incision will have to be quite excessively large so that the surgical instruments and Dr. Jacobsen’s hands can reach from the bottom of the breast across the top of the breast up to the superior aspect of the breast and still be able to remove this through the incision as one piece surgically to remove the implant and the capsule in its entirety as one piece incision has to be across nearly the entire breast. EN BLOC removal requires a large incision on the breast, which is unfavorable and unnecessary.
This EN BLOC concept is surgically impractical. If appropriately done will entirely deconstruct the breast and render the unfortunate woman with an unreasonable large incision.
Capsule removal of the breast and removal of the breast implant is sometimes done in parts rather than EN BLOC for the woman’s safety and the operation’s overall effectiveness. But the removal includes the capsule, the implant shell, and all the gel that may have leaked.
There is no evidence in the surgical literature that complete versus subtotal capsulectomy changes the outcome of the patient’s perception of their breast implant illness care.
Occasionally the implant ruptures outside of the capsule. This requires the removal of the capsule, the breast implant, the leaking gel, and any of the breast tissue around the breast implant that has been affected by that silicone gel. This sometimes requires some women to remove a considerable portion of the breast. This is unusual and rarely necessary, however.
It is quite important, however, for all women to have the entire capsule removed and all the elements of the breast implant where there is ruptured or not. As said previously, however, sometimes, some of the aspects of the capsule must be left behind to preserve critical structures.
Dr. Jacobsen knows how to do this effectively and safely and to ensure you have all the benefits of removing her implant for your recovery, whether for pain or breast implant-related illness.
The most common complication after this operation is bleeding. Although the incision may be relatively small, the surface area inside your breast around the capsule is quite large. So we ensure you have a compressive surgical bra and limit your activity significantly for the first 48 hours after the surgery to prevent bleeding. Sometimes drains are utilized as well.
Breast Implant Illness – Frequently Asked Questions/Talking Points Q
[from www.surgery.org]
What is Breast Implant Illness (BII)?
There are many women now with breast implants who self-identify and present with various systemic symptoms and deeply believe that these are related to their breast implants. They refer to these symptoms as Breast Implant Illness (BII). Breast Implant Illness (BII) is a term used by women who have breast implants and who self-identify and describe a variety of symptoms including (but not limited to) fatigue, chest pain, hair loss, headaches, chills, photosensitivity, chronic pain, rash, body odor, anxiety, brain fog, sleep disturbance, depression, neurologic issues and hormonal issues that they feel are directly connected to their saline or silicone, textured or smooth breast implants.
The recent increase in patients reporting Breast Implant Illness (BII) symptoms appears to be related to social media. There is one Facebook group alone with more than 50,000 members, all of whom report Breast Implant Illness (BII) symptoms. This is not to say that social media is the cause of Breast Implant Illness (BII) however, it may account for the rapid increases in patient reporting.
BII is not an official medical diagnosis so far and there is no ICD-10 diagnostic code for this phenomenon. There is no guarantee that any surgery will reverse breast implant illness. Since he cannot be measured before the operation and cannot be measured after the operation.
Is there a link between medical-grade silicone implants and any disease?
Silicone is an element that exists in nature as crystalline silica, which has been shown to activate the immune system in conditions such as systemic sclerosis which has been seen in stonemasons. The silicone used in breast implants is different. So far this silicone substance not been proven to cause any disease. This silicone does not exist in nature, it is created by hydroxylating silica to form polydimethylsiloxane. Medical grade silicone has had antioxidants, dyes, and plasticizers removed during processing.
There is medical-grade silicone is nearly all implantable medical devices. Examples include:
Total knee joint
Total hip joint
Brain shunts
Some heart valves
IV catheters
Port-A-Caths
Nasal Splints
Chest tubes
Cardiac bypass tubing
Internal defibrillator devices
Prosthetic limbs
Facial masks for burn patients
Pacemakers
Spinal stimulators
Drains, internal in the body
Foley catheters
Feeding tubes
Syringes
Silicone sheets for scar management
None of these devices and the associated silicone within them have been associated with any disease or condition.
The reason this silicone is used in medical devices is that it is indeed inert to the human body just like glass or sand. These substances have been known to NOT cause any allergic reaction as there are for many other medical materials, drugs or substances. This is why this material is used in medical devices.
It is interesting to note that the silicone used in nearly ALL other medical devices has not been implicated in any illness of any sort.
We have seen patients with a large “load” of silicone in their knees and hips from replacements but believe it is only the silicone in their breasts that is causing problems.
Are there any tests that would indicate a connection between breast implants and symptoms that are being labeled Breast Implant Illness (BII)?
There is no diagnostic testing specifically for Breast Implant Illness (BII). This is one of the current areas of focus for the Aesthetic Surgery Education and Research Foundation, the research arm of the American Society for Aesthetic Plastic Surgery. There are tests for autoimmune diseases that can be performed to evaluate for potential causes of a patient’s symptoms. There are patients who have symptoms they attribute to Breast Implant Illness (BII) with positive immune testing and others with all laboratory tests which show no abnormalities.
Is there any scientific data showing causation between implants and these symptoms or any disease entity?
In 1999, The Institute of Medicine Committee on the Safety of Silicone conducted an extensive review of the available literature and concluded there was no demonstrated clear link between silicone implants and any systemic illness. There have been studies of many different sizes and designs to look at the safety of breast implants themselves. These have looked at specific autoimmune disorders and diseases. In aggregate, these studies show little to no links between breast implants and any disease. Studies of patients who have symptoms that they have related to their breast implants have not shown consistent laboratory abnormalities to define a distinct syndrome. To date, there has been very little in the way of research into this entity that has been labeled Breast Implant Illness (BII) by women with breast implants.
BII is not new. Only the name is new. In the early 90s there was a great “scare” regarding breast implants and there was a moratorium on their use for years except for reconstructive purposes. Over the next 15 years the breast implant was the most studied medical device in the history of man! 100,000s of women all over the world were studied. Dr. Jacobsen participated in the studies. NO connection between breast implant silicone and auto-immune diseases or other illnesses were discovered even remotely and as a result the FDA after exhaustive consideration re-approved the silicone implants for general use in 2006.
You can read this report here:
FDA Update on the Safety of Silicone Gel-Filled Breast Implants
Does implant removal improve a patient’s symptoms or cure a patient who has a medically diagnosed disease entity like an autoimmune disease?
Various studies show different degrees of improvement in patient symptoms after removal of their breast implants, some of which are temporary, and some showing permanent resolution of symptoms. There are no studies that specifically show which symptoms may or may not improve with implant removal with or without capsulectomy. There is no current definitive epidemiological evidence to support a direct link between breast implants and any specific disease process. However, this does not mean further research is not indicated. In rare and unusual disease processes, it can take years to come to a scientific conclusion. There are many factors that can affect the interaction between a patient and her breast implants. Further study is required to determine the best way to potentially screen patients prior to breast implant surgery and to determine which of the multitude of reported symptoms might improve with implant and capsule removal. A lack of a direct, proven scientific link does not mean that the symptoms experienced by these patients are not real. Some patients have legitimate concerns about a potential link between breast implants and symptoms, so it deserves our attention and further scientific research to better determine what symptoms may improve with an explanation of implants.
What are ASAPS and ASERF doing to better understand this group of systemic symptoms being called Breast Implant Illness (BII)?
Because there are many women that self-identify as having Breast Implant Illness (BII), we are listening. ASAPS and ASERF are developing a new scientific study to examine this entity. We are also providing our members with a questionnaire to use to collect a record of complaints from patients with implants, as well as one to utilize for post-explantation. We cannot yet define BII and therefore cannot say with any certainty that it exists, because we do not have any tests we can run to prove or disprove its existence. However, we can listen to and partner with our patients to determine what is the best course of action to address their complaints, be it explantation or otherwise.
What should a physician do when a patient complains of Breast Implant Illness (BII) symptoms?
Do not ignore your patient’s concerns. Their symptoms are real and whether or not they can or cannot be attributed to their implants isn’t relevant since there is simply no existing way to prove nor disprove causation or association. Options can include further medical workup with or without the consultation of a rheumatologist, observation without medical workup, implant removal without capsulectomy, exchange with or without capsulectomy, removal with total capsulectomy, or removal with EN BLOC capsulectomy. Patients who present with concerns of Breast Implant Illness (BII) have real symptoms that often cannot be categorized into any specific know disease entity. This does not mean their symptoms are not real and they deserve a full evaluation. The various options need to be discussed and hopefully, with further research, we may be able to determine which patients may see symptom improvement or resolution with removal of their implants and which may not see any change.
What is the risk of developing Breast Implant Illness (BII)?
As there is no definitive link between the often subjective and divergent list of symptoms and no means for testing, there is no ‘known’ risk. Many of the symptoms described by breast implant patients are experienced by the general public on a regular basis with or without implants. That isn’t to write-off a potential connection, but no connection has been established to-date. Patients should, however, be informed of the risks that can be associated with breast implants, including (but not limited to) BIA-ALCL, a rare spectrum of disorders that can range from a benign accumulation of fluids around the breast (seroma) to an extremely rare lymphoma. They should know that BIA-ALCL is not a cancer of the breast tissue itself and that when caught early, it is readily curable. If the disease is advanced, chemotherapy or radiation may be required.
If after the discussion of risks and the possibility of no improvement of symptoms post explantation is discussed with a patient, what should be done if the patient demands an “EN BLOC” or “total” capsulectomy with their explantation?
There are many medical inaccuracies perpetuated on the internet. BII patients tend to believe that a total capsulectomy is necessary to remove all causative agents and they prefer it EN BLOC, oftentimes without having a full understanding of what size incision is necessary for EN BLOC. Rather than react, first discuss the reasons you would perform a total capsulectomy with any patient. Not all plastic surgeons routinely perform a capsulectomy with explants, but some do. If you wish to perform capsulectomy on a patient, it is important to explain that it is not always possible to remove all of the capsules. Sometimes a portion of the capsule must be left behind or is disintegrated with the use of electrocautery to prevent significant damage to muscle, rib or lung. Explain what size incision is necessary for an EN BLOC (as many may not be aware of how large an incision may be necessary). If they had an axillary approach or periareolar approach for breast implant placement, it must be explained to them that they cannot have the procedure done through those incisions. It is recommended to reinforce that there are increased surgical risks associated with EN BLOC capsulectomy which requires a complete dissection of all the tissues surrounding the breast implant and, that we do not have enough collective data to guarantee any improvement in the symptoms they have labeled Breast Implant Illness (BII).