The V–Y capsulotomy release for correcting capsular contracture

Evaluating the Necessity of Capsulectomy in Cases of Textured Breast Implant Replacement

BACKGROUND

Capsulectomy has traditionally been recommended as a treatment for capsular contracture after breast augmentation. With the advent of breast implant-associated anaplastic large-cell lymphoma (BIA-ALCL), and the Food and Drug Administration's decision to ban Biocell textured devices, this operation has taken on new importance. This review was undertaken to better inform clinical recommendations for women with textured devices.

METHODS

An electronic search was performed using PubMed to identify all the available literature on the subject of capsulectomy and open capsulotomy (the alternative treatment).

RESULTS

Fifty-seven articles on this topic were identified. Capsulectomy was widely recommended for treatment of capsular contracture, although many authors recommended leaving thin capsular tissue behind in the absence of symptoms. En bloc resection was recommended only for women with a diagnosis of BIA-ALCL. No information supported a prophylactic role for capsulectomy in asymptomatic women with textured breast implants who are concerned regarding their future risk of BIA-ALCL. Routine pathologic examination in asymptomatic patients was not supported.

DISCUSSION

Capsulectomy adds substantially to the surgical risk, discomfort, recovery time, and expense. Implant removal or replacement without a simultaneous capsulectomy is atraumatic and poses negligible risk.

CONCLUSIONS

Capsulectomy introduces additional morbidity and is not mandatory for asymptomatic patients. Implant removal or exchange for smooth implants without a capsulectomy may be an acceptable choice for many women who do not demonstrate capsular pathology. However, any symptoms or surgical findings suggesting pathology warrant a capsulectomy. En bloc resections are reserved for patients diagnosed with BIA-ALCL.

An Algorithm for the Management of Explantation Surgery

Creating pleasing breast aesthetics after an explantation can be challenging, especially when performed with a total capsulectomy. The necessity of a capsulectomy for a variety of breast issues is not completely agreed on and can increase adverse events, patient morbidity, and cost of the operation and often impairs the final aesthetic result. In this article, an algorithm for the management of explantation patients provides a framework for treatment of the capsule and the breast to optimize outcomes.

Not All Breast Explants Are Equal: Contemporary Strategies in Breast Explantation Surgery

SUMMARY

Breast implant removal and replacement has been a common secondary breast procedure in the long-term maintenance of breast augmentation, but more recently growing concerns about silicone-related systemic illness, breast implant-associated anaplastic large cell lymphoma (BIA-ALCL), and changing perceptions of aesthetic beauty have seen breast implant removal without replacement become increasingly requested by patients. Explantation can be challenging, especially when performed with a total capsulectomy. Currently, there is no evidence regarding whether a partial or total capsulectomy has any effect on BIA-ALCL risk mitigation in patients that have textured implants without disease. Total capsulectomy with incomplete resection of a mass can contribute to hyperprogression of BIA-ALCL and death. There have also been cases of BIA-ALCL diagnosed years after removal of the textured device and "total capsulectomy." Therefore, the common practice of simple prophylactic capsulectomy in a textured implant to mitigate future disease has not been established and at the current time should be discouraged. In addition, aesthetic outcomes can be quite variable, and patients should have appropriate preoperative counseling regarding the indications and contraindications for explantation, associated risks, financial implications, and postoperative appearance. The authors review salient aspects related to the planning and management of breast implant removal.