S05E94 - Better Understanding Breast Implant Capsulectomy: Controversy and Science

In this engaging episode Three Plastic Surgery and Fourth Podcast, DDr. Lawrence Tong @yorkvilleplasticsurgery join his co-hosts Dr. Sam Jejurikar @samjejurikar, Dr. Salvatore Pacella @sandiegoplasticsurgeon, and Dr. Sam Rhee @bergencosmetic to delve into the latest terminology and recommendations for capsulectomy, issued by the Breast Surgery Collaborative Community.

The discussion not only clarifies the four types of capsulectomy procedures but also tackles the heated controversies surrounding breast implant illness (BII) and breast implant-associated lymphoma. With a balanced mix of personal surgeon experiences and rigorously discussed patient outcomes, the episode aims to provide viewers with a comprehensive and evidence-based understanding of these complex issues. 

Tune in to hear their thoughts on patient advocacy, the impact of social media on patient perceptions, and the indispensable role of informed consent in surgical practice.

#BreastImplantIllness #Capsulectomy #MedicalPodcast @3plasticsurgerypodcast #podcast #plasticsurgery #cosmeticsurgery #plasticsurgeon #beauty #boardcertified #aesthetic #3plasticsurgeonsandamicrophone ⁠#bergencosmetic ⁠#bestplasticsurgeon #beforeafter #aesthetics #realpatientrealresult #boardcertifiedplasticsurgeon #njplasticsurgeon #njplasticsurgery #nyplasticsurgeon #nyplasticsurgery   

Transcript

S05E94 - Better Understanding Breast Implant Capsulectomy: Controversy and Science

Dr. Lawrence Tong: Alright, welcome to PLE three Plastic Surgeons and a fourth. My name is Dr. Lawrence Tong. I am joined as always by my esteemed colleagues, Dr. Sam Dekar, Dr. Sal Patella, and Dr. Sam Re. Their Instagram handles are at, uh, at Sam Dekar for Dr. Sam Dekar. Uh, at San Diego Plastic surgeon for Dr. Patella and at Bergen Cosmetic for Dr. 

Sam Ri. My name is Lawrence Tong at Yorkville. Plastic surgery, and today our topic is going to be about a recent statement that came out from the breast surgeon, sorry, breast surgery, a collaborative community, and they are a group of plastic surgeons and breast surgeons who came out with some, um, terminology and recommendations for how we talk about, um, something called capsulectomy. 

So, um, I'll just [00:01:00] start off with, uh. Uh, talking, uh, actually, Dr. Rhee wants to say something.  

Dr. Sam Rhee: Yeah, let's go with the disclaimer really quickly.  

Dr. Lawrence Tong: Yes. Sorry about that.  

Dr. Sam Rhee: no problem. This show is not a substitute for professional medical advice, diagnosis, or treatment. This show is for informational purposes only. Treatment and results may vary based on the circumstances, situation, and medical judgment after appropriate discussion. 

Always seek the advice of your surgeon or other qualified health provider with any questions you may have regarding medical care, and never disregard professional medical advice or delay seeking advice because of something in this show. 

Dr. Lawrence Tong: All right. Thank you. 

very much. So, um, the statement had to do with, uh, terminology regarding, uh, capsulectomy. So, in, in general, what is capsulectomy? Capsulectomy is an operation that is done, um, to remove Breast implant capsules. Now, um, breast implant capsules can happen for a variety of reasons, but it's basically a [00:02:00] scar that forms around the breast implants. 

So they put this out because there's a lot of, um, different terms that were used previously and, um, they want to sort of make everything consistent. So the four types of capsulectomy that came out was as follows. Um, and I like to think of it as,  

Dr. Sam Jejurikar: Before you get into that, LT, why is there so much controversy about capsulectomy? I think that's probably something we should touch upon, right? Like, why has this become such a hot topic? Um, it's not the operation of itself. It's some of the diagnoses that we're seeing and some of the controversial things. 

Um, You know, one of the things that you had mentioned was that there were plastic surgeons, breast surgeons, but I think there were also patient advocates on this consortium as well. And I think it had a lot to do with breast implant illness and also with breast implant associated lymphoma. And there's a lot of controversy among patients and a lot of controversy among plastic surgeons about whether [00:03:00] or not these things are, you know, what operations are actually required in what circumstances. 

And so I think that's why this terminology actually. you.  

know, came about, I think for patients, patients that might be listening to this podcast, the reason they potentially want to hear about this is if they think they might have breast implant illness or they're worried about it, this terminology can be pretty helpful to help figure out what you need. 

So sorry to, sorry to interrupt. Keep going.  

Dr. Lawrence Tong: No problem. So the terminology that they have come up with was 4 different types of, um, operations. Um, and they have, um, named it as follows. Number 1, um, is on block capsulectomy. That means that the, um, implant and the capsule with some surrounding normal tissue is removed. So that's an operation that is removing the whole thing intact with some normal tissue, a rim of normal tissue around it as well. 

The next [00:04:00] category is total intact capsulectomy, which means they've Uh, the surgery involves removing the implant plus the capsule in one, in one piece. The next category is total capsulectomy. Um, that's the whole thing, but not necessarily as one piece, and it can be removed in multiple pieces. And then the last category is partial capsulectomy, which means that, um, the capsule is removed, but some of it is removed. 

Is left behind. Um, so, you know, the reason why, um, Dr. Jejurikar said that there was a controversy about this is because what we've seen is that, um, we have, and you guys have probably experienced it, have patients come in and they're concerned that they have, uh, something like breast implant illness and they, they instantly come in wanting to have, um, On block capsulectomy. 

What's your experience with, um, um, you know, those types of patients?[00:05:00]  

Dr. Sam Jejurikar: Um, you know, I think, I think breast implant illness is a topic that is very much so a very hot topic among patients and among plastic surgeons. And it is generally some divergence of opinion among the plastic surgery community versus many patients that are out there. Um, just to be clear, breast implant illness. 

It's the only diagnosis that I know of, maybe you guys can think of other things where it was actually a diagnosis that I think patients came up with, um, basically based off of, um, many different symptoms, whether it's fatigue, hair loss, changes in nail growth, um, you know, muscle aches, joint pain, stuff like that, you know, where when you look at the symptoms that can make up breast implant illness, there's, I think more than a hundred symptoms at this point that can classify underneath it. 

There's. Tens of hundreds of thousands of women that are out there that think their implants have caused these symptoms. So you don't want to be, um, you don't want to be [00:06:00] dismissive of these large groups of people that are experiencing problems. But the plastic surgery community has really tried to look into whether or not there's any direct linkage between, you know, between, um, implants and these. and these. 

symptoms that are out there. The patients that come in that say that they have these symptoms, a lot of times what some surgeons are pushing is an aggressive operation, which is called an on block capsulectomy. And it's important because an on block capsulectomy, The way most surgeons have defined it is different than the definition that Dr. Tong has, has just defined. The way most surgeons typically define it is removing the implant and the capsule in continuity with each other, but not necessarily taking a rim of surrounding tissue. 

The rim of surrounding tissue is typically something that you would reserve for a cancer sort of diagnosis. Um, But that's what surgeons typically will, will talk about. And to be clear, non block capsule activity is not just a difficult technical endeavor, but there's risks, real risks that goes along with it. 

You can injure the skin flaps along the front [00:07:00] portion of the capsule and even more importantly, posteriorly, and if the implants behind the muscle, there's a real potential to actually get into the thoracic cavity and cause issues with the lungs and whatnot. So, um, you know, the question is whether or not, Total capsule removal is required, whether or not on block or, you know, removal of the capsule in continuity is required. 

I'll say that I tell people that I'm not sure why taking out a rim of normal tissue would ever be indicated. If they feel strongly that the capsule, entire capsule comes out, I'll do my best to do that. I can't guarantee I can do it in continuity with the implant in some really severe cases as well. But we'll do it. 

I don't know if it has, um, if it's medically necessary, I tend to believe that it's not.  

Dr. Sam Rhee: I'd like to back up just a little bit because I think if you've are not someone who has breast implants, or you're maybe considering them. You might think this sounds really scary. So we're talking about breast implant illness. We're talking [00:08:00] about capsulectomies. We're talking about all these sort of issues that can happen after breast augmentation with that implants. 

And, and these are issues that I also have my thoughts about, but I also want to point out that these are relatively uncommon complications. So as we talked about, capsular contracture is the formation of scar tissue around an implant. And in most cases, um, this is a relatively asymptomatic Normal, you know, normal occurrence. 

I mean, maybe one in six patients might have some capsular contracture, and out of those, most of them don't really have any issues. And as plastic surgeons, we've classified capsular contracture, which is the scar tissue that forms around an implant. And, you know, Usually, the grades go from 1 to 4. Grade 1 is almost, it's not visible, you can't see it, it feels very natural, there's no symptoms. 

Grade 2 [00:09:00] is very minor, um, maybe slightly firm to the touch. Breast, um, but usually normal in shape. It's usually with grade three or four that patients start having more concerns about capsular contraction. That's where the, uh, breast will be very firm or appear, um, tight appearing, or the shape has changed to some degree. 

Um, and with grade four you can have soreness or tenderness or pain associated with the capsular contracture. And again, this is a Um, there are a lot of factors that go into why people develop capsular contracture. We as plastic surgeons know what some of these factors are. Some of it's genetic, some of it is the uh, environmental circumstance in which the implant is And for a lot of us, we are fanatic, we are obsessive about avoiding capsular contracture. 

And most surgeons who place breast implants are very familiar and engage a lot [00:10:00] of techniques to minimize the risk of capsular contracture. But as we have talked about, there are some complications such as potentially breast implant illness or severe capsular contracture where there Um, treatment, uh, is indicated, and this consortium is really helping to define some of those terms, helping patients understand what the different, uh, possibilities in terms of treatment are. 

And as Sam has said, uh, it also helps patients and surgeons come together for common terminology so that we can express our opinions about what we think is most helpful for patients. 

Dr. Salvatore Pacella: So, so this has been a very hot topic in aesthetic surgery research over the last several years. So, um, I sit on the board of directors of an organization called the Aesthetic Society Education and Research Foundation. It is the research foundation that's associated with our main cosmetic [00:11:00] surgery society, the Aesthetic Society. 

Um, There's a series of papers that came out over the last two to three years, uh, by two authors, Glickman, or excuse me, McGuire and Glicksman, and it looked at the various indications for capsulectomy. Um, so they took a group of patients and they described their symptoms. So some had this breast implant associated illness, uh, type of symptomatology. 

And then they, they did a huge analysis comparing the type of capsulectomy on their symptom impact. And the study was very, uh, insightful. It was a validated study. It had great power. And they found zero difference in the type of capsulectomy performed in the impact on patients. So in other words, patients symptoms improved. 

With removal of the implant, partial capsulectomy, total capsulectomy, or in block capsulectomy, exactly the [00:12:00] same. So, this is a scientific paper that sort of demonstrates that the type of capsulectomy is not necessarily important. It's the presence of doing a capsulectomy and the implant removal that's important on improving symptoms.  

Dr. Sam Jejurikar: Yeah. And the other thing they looked at too was they looked at certain enzymes, metalloproteases in the capsules as well, which has been thought to be linked to breast implant illness. And they actually found that when they looked at every capsule that had been sent and patients that reported breast implant illness. 

They couldn't actually find any of this, and so it even raises the question whether a capsulectomy at all is required for patients that have this. But, um, but yeah, that being said, so, you know, the question, the question, ultimately, that many patients that are primary breast augmentation patients that are coming to see me for a consultation will ask me this question. 

Do you think that there's a high probability that I could get breast implant illness? What do you think? You know, [00:13:00] what do you think is the likelihood that I could get it? Do you even think it's real? How do you guys answer that question?  

Dr. Salvatore Pacella: Uh,  

Dr. Lawrence Tong: say that. Yeah, go ahead. Sam.  

Dr. Salvatore Pacella: Okay. Um, so So, I, I sort of go over the original data that we found for textured devices, right? And so, we know from looking at the data of indications of breast, um, of large cell lymphoma, so lymphoma or breast implant, well, not breast, breast implant illness, but lymphoma, okay? That's something we have a validated understanding of. 

The risk associated with textured devices. A developing breast implant associated lymphoma is about 1 in 2, 900, okay? And there's a massive proportion of these that were from one company with one type of Texturing, it's called the biocell texturing, aggressive texturing. It was made basically by dousing the implanted salt and creating this sort of textured granular [00:14:00] surface. 

If you look at systematically the other companies that had textured devices, the way they make their texture was very, was imprinted mechanically. Very low rate of textured devices. In smooth devices, the risk of breast implant associated lymphoma is essentially negligible. Okay, and in patients who developed Breast Implant Associated Lymphoma that had smooth implants, 99 percent of the time they previously had a textured device in. 

So, To me, you know, the lesson is clear. We use smooth devices, right? And so I tell patients. 

you know, I only use one company. It's not the company that was associated with breast implants, associated lymphoma. I use a smooth capsule. And that usually, um, you know, the fear is usually dissipated after that. So I don't know what you guys do.  

Dr. Sam Jejurikar: That's a great answer, but that's a different question though altogether, right? I mean, I think that's about lymphoma. Breast implant [00:15:00] illness is the one that I think is so much more controversial because there are some surgeons that are out there that say it does not exist. And there are other surgeons who make an entire practice out of doing on block capsulectomy on patients. 

They have entire practices doing on block capsulectomies for patients who have breast implant illness. So, how do you answer the breast implant illness question, Dr.  

Dr. Salvatore Pacella: Well, well, let me, let me sort of tether that, tether that. So when I, when I bring up the concept of do, The general question is, do breast implants cause problems, okay? So, we know that it causes one problem, breast implant associated lymphoma, okay? We know that there's possibly some connection between another problem, breast implant illness, okay? 

And so I say, well, this is the data for the problem that we know about, okay? The other problem is something that we can't necessarily put our finger on. Now, that doesn't necessarily mean that there's not a connection. There's some intermediate factor between the presence of getting implants and the [00:16:00] development of breast implant association, or breast implant illness. 

But there's nothing in the literature that says that. There's nothing in a study that shows that there's any cause, effect, or complication related to that. And in fact, I also bring up the statement, you know, arguably no other medical device in the history of humankind has been studied more extensively than silicone breast implants. 

You know, from the Dow Corning scare in the 1980s.  

Dr. Lawrence Tong: I'll just, uh, I'll just bring up 1 thing. That's important. We've been talking about, um, capsular contracture, uh, breast, Implant associated lymphoma and breast implant illness, um, as sort of on the even plane. But the fact is that there is no, um, universally accepted medical definition of what breast implant illness is, and it's not a recognized, uh, distinct medical condition. 

That's not to say that. Women don't have these symptoms and that's not to say [00:17:00] that there may not be an association with the breast implants for causing this, but as of yet, it is not a recognized, uh, distinct medical condition. And as stated before, it's controversial because the. The symptoms vary So, much. 

Fatigue, brain fog, joint pain, autoimmune like symptoms, and the mechanism, a physiologic mechanism to link breast implants to some of these things is, is very, very difficult. And the research, um, as, uh, has been pointed out, um, earlier, It's, it's not conclusive. There's nothing to show that there's anything special between at least the, um, the pathology in the capsules, uh, between, um, breast implant illness and somebody who has no symptoms at all. 

Um, and it, I think that's, it's further, um, propagated because online, there are communities where patients share their [00:18:00] experiences. And this may potentially lead to, you know, validation of symptoms that other people may have because they latch on to it. So there is definitely some skepticism by health care providers. 

And I think, I think that's healthy. We shouldn't just, um, accept that, um, you know, what a lot of people say is maybe true without research and, you know, further research is definitely required. But I just want to make the point that as of yet, it's not a recognized medical diagnosis.  

Dr. Sam Rhee: I'll say this, when I talk to patients about this, especially when they're concerned about any risks associated with breast implants, I will, I will say, um, in my experience, I've done hundreds of breast augmentations and I might have seen one or two possible breast implants. related illness cases and I wasn't sure at all. 

Uh, I, having read the reports and seeing what's out there, um, [00:19:00] I don't discount that there is a BII, a breast implant associated illness. There may very well be. The issue is, is that if it does occur, it's pretty rare and it's really hard to study rare conditions. And as Sal said, you need a lot of power. 

You need numbers in order to be able to tease out. And we just haven't had those numbers yet, or, or the types of studies that can tease that out. Um, I will never discount anybody's, um, personal experience. And certainly I've had, uh, patients, both mine or others, who have come to me, and for whatever reason, they would like to have their implants removed. 

And they would, or, you know, with or without a capsulectomy. And I will never say never, like there are, there are plastic surgeons who will absolutely refuse to do that. If, if, uh, especially if they come with, uh, issues that are vague or what they feel is unsubstantiated. And I, I think that's wrong. I think a [00:20:00] patient can choose certainly to do what they want to do. 

I think the issue really is, is that when they come with a Uh, whatever experiences that they've had, and they're asking for some of these procedures, you have to let them know, I know you've read about on block hapselectomy, but this is a, this could actually be detrimental to your health in a way that you hadn't anticipated. 

And this consortium has said an on block hapselectomy, where you're taking out healthy tissue, in addition to the complete capsule removal, it's really only indicated for cancer. It's not indicated for BII or any other condition. And so this gives us again, a base to talk to patients about. Now, the issue really is, is that when some of these patients come in and they have very strong ideas about the type of procedure that they want, because they've talked to others, how do you deal with that? 

Um, and, and I'd be interested in hearing like, Because some of it is really about their, [00:21:00] their beliefs and, and respecting that to a certain degree. 

Dr. Sam Jejurikar: I think, um, I agree with everything you just said there, Sam. That's basically my approach as well. I think when you have capsular contracture, which we know is an inflammatory condition, and then you have patients that have autoimmune diseases, it's not hard to extrapolate that there could be a few patients where they could get a systemic effect from this. 

local inflammatory reaction. So then how do I handle someone that comes in and says that they want their implants out? I will say that I think this, this consortium has been really helpful because the terminology now is that I'm not, I'm not going to use the terminology on block capsulectomy, but instead we'll talk about a capsule capsulectomy in continuity with their implants. 

If in some cases, you guys know this as surgeons, sometimes it's really kind of easy. Like you'll start doing the dissection and it's pretty straightforward. Pretty easy to get it out and to do, you know, to take out the entire capsule in continuity with the implant. Pretty easy comes off in the soft tissue, you know, and if I can do it,  

Dr. Salvatore Pacella: [00:22:00] sub glandular, you know, it's like, Pretty  

Dr. Sam Jejurikar: So glandular or, you know, or maybe a saline implant that doesn't have as thick of a capsule as a, as a, as a silicone implant. Sometimes it isn't easy. and where it's, where it's difficult is when you're doing an implant that's behind the muscle. Stuck to the chest wall. Visualization might be a little bit difficult. 

So, you know, if someone says that I insist on getting my entire capsule out, I will tell them I will do my best to get an incontinuity with the implant. I will do my best to get it off the chest wall. But if we're in a situation where. The implant is stuck to the chest wall, and I feel really uncomfortable that I might do more harm than good. 

There's no data to support me doing that, and I can't look you in the eye and tell you that I can guarantee that the entire capsule will come out. I will do my best, but I can't guarantee it. And, and I've lost patients because of that, because there are other surgeons that'll say that they'll get it out, that it's medically necessary, but I think the data is conclusive that that's just not true.  

Dr. Lawrence Tong: One [00:23:00] of the other statements, um, that was interesting, um, that they've just made is that capsulectomy does not guarantee that, uh, a patient can't develop breast implant associated with lymphoma. So the other recommendation that they make is that even if somebody has had a capsulectomy, um, they should continue to monitor the breasts for, uh, for symptoms of cancer in the future.  

Dr. Sam Rhee: I've gone back in, um, post capsulectomy, uh, implant removal in a few patients when years later they've decided to Go back and have implants placed. And it's surprising, uh, how rapidly the body heals. I mean, even in patients who had relatively thick capsules, um, that scar tissue really resolves well. And so I don't feel. 

Like I'm leaving a time bomb or that there's some major issue from doing a partial capsulelectomy [00:24:00] or, or if there's some areas that are, um, difficult technically, or may push the, put the patient at risk. Um, I have seen firsthand, I've seen these capsules, they resolve, they heal. And universally, I think you are right. 

Once the implant is removed, once you've done whatever capsulectomy you feel is appropriate, patients feel better. They, their symptoms resolve well. I have never, I don't want to say never, but I don't think I've ever seen a patient really where they continue to have whatever issues they had regardless of the type of capsulectomy that, that was performed. 

Dr. Lawrence Tong: You're talking about BII, right?  

Dr. Sam Rhee: Yes, 

Dr. Salvatore Pacella: Well, you know, Sam, I, I, I sort of have witnessed the opposite. I think, you know, I, I would say that, um, you know, being in practice for close to 15 years, I've probably had 30 patients come in to see me that were convinced that their implants were causing brain fog, fatigue, et cetera, you [00:25:00] know, fibromyalgia. 

They've taken them out. We've taken them all out. We've given them the benefit of the doubt, did as much of a capsulectomy as we can. And I can't recall any patients saying that their symptoms improved. Systemic symptoms, yeah. Um, I, I, I just, I have not seen it personally. Um, you know, and I, I share that information with patients who come in. 

Dr. Lawrence Tong: Yeah, I  

Dr. Sam Jejurikar: Now, I, I, I, I can't say I agree with Pacella on that. I probably had a dozen patients who I was, I mean, I've, like you guys, I've seen like more than a hundred patients come in with self reported BII more often than not as capsular contracture. Implants are too big causing mechanical issues, but there's been at least a dozen who have said that, um, they had sort of vague BII symptoms. 

And my experience has been that at least half of them In a delayed manner, maybe several months after the fact, they began to experience improvement in their symptoms. [00:26:00] Um, so I, I can't say that I, and I'm, I'm more convinced than not that it's a real phenomenon. 

Dr. Lawrence Tong: well, I, I tell patients. That I'm going to be doing this operation on is that A, I can't guarantee that I can remove it in one piece, if that's what they're looking for. And more importantly, B, I can't guarantee that their symptoms are going to change at all. So, um, I think that's fair because, uh, you know, a lot of times I think patients get relief. 

Maybe because they're so focused on getting that implant out that just having it out psychologically makes them feel better. I think there is a good proportion of patients, uh, where that effect, uh, does occur, but whichever, you know, whatever the mechanism for them to have their symptoms, uh, relief, uh, that's good. 

And I think that the fact that, uh, with [00:27:00] Glixman's, uh, research showing that capsulectomy. Whether it's partial, whether it's intact, um, whatever type it was, all showed good improvement in symptomatology is, uh, you know, confirms that or backs that up at least. 

Dr. Sam Rhee: I like what the consortium said. They said it's always a patient's choice to elect to undergo a procedure such as a capsulectomy, provided the risks are clearly understood. But it's our responsibility as plastic surgeons to ensure that patients get the best evidence based information. And right now, a lot of patients are given a lot of misinformation on internet and social sites. 

And so it is incumbent on us to talk to our patients. We have our own Uh, data that we've seen personally as surgeons, but there's also a lot of data out there where, as Sal has said, has Larry has said, as Sam has said, where, um, yeah, there's still a lot that we don't know. And, um, it is tough for patients to navigate, especially when they're on TikTok or Instagram, and they're seeing [00:28:00] someone relate a single experience, which could be very different than what most, Most people have. 

I mean, even amongst us, us four surgeons, we're having some variation in terms of our own experiences, in terms of what we see, so I can only imagine how different other patients experiences can be if you just look at it one at a time.  

Dr. Lawrence Tong: All right. Um, any last words to add from any of our panel here? All right. That's good. This is a very interesting topic. I'm sure that we'll be revisiting it in the future. Once again, thanks everybody for watching and thank you for my esteemed colleagues and we will see you the next time.