Foreword: Every patient’s medical situation is unique. The information in this introduction is not comprehensive, and may or may not apply to your individual situation. Please speak to your healthcare provider if you are considering explant. Any and all information provided by Not Putting on a Shirt and its representatives is for informational purposes only and should not to be considered as medical or legal advice. Statements should not be taken as a substitute for medical advice from a licensed physician.
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Introduction to Going Flat at Explant
Explant is the surgical removal of breast implants. According to Dr. H. Jae Chun, whose practice is focused exclusively on explant surgery, proper explant also includes complete removal of the scar tissue that forms around the implants (total capsulectomy), and is especially critical in cases where the patient is experiencing symptoms of BIA-AII (breast implant associated autoimmune illness), or ASIA (autoimmune/inflammatory syndrome induced by adjuvants), both generally referred to as “breast implant illness“).
Note: Autologous reconstruction (breast mounds created from the patient’s own tissue) can also be removed, but this is less common.
Explant rates have increased 10% over the last few years, and that trend will likely continue. Women’s reasons for explanting include, but are not limited to:
- Physical discomfort – pain, temperature differential, numbness, mechanical dysfunction
- Capsular contracture – tightening of the scar tissue surrounding the implant
- The likelihood of multiple corrective or exchange surgeries (at least 20% of patients require exchange within the first 10 years) – both to complete the initial reconstruction and to maintain it
- General dissatisfaction with the appearance of the implants
- Implant rupture, or silicone leakage
- Chronic infection or inflammation around the implants
- Various other medical complications, including BIA-AII symptoms
- Concern about BIA-ALCL, a cancer linked to breast implants by the FDA & WHO
- Persistent feeling that the implants don’t align with personal body image
- Simply not wanting to live with implants anymore
BIA-ALCL is Clearly Linked to Implants
Certain breast implants (textured implants, especially those manufactured by Allergan) are clearly linked to a significantly increased relative risk of developing a type of lymphoma (BIA-ALCL). Risk estimates vary but have been climbing steadily in recent years. Growing awareness and testing for BIA-ALCL surely contributes to this unsettling upward trend, and it is important to consider both the high level of uncertainty involved in these estimates as well as the fact that the numbers we have today are likely low (due to many factors). These implants were banned by dozens of countries before bring recalled in the US by the manufacturer in July of 2019.
The Connection to Autoimmune Disease is Less Clear Right Now
A growing number of women are connecting their deteriorating health after implant reconstruction with the implants themselves – and deciding to explant. These women can face serious pushback from their medical and insurance providers. Why?
The National Center for Health Research’s BIA-AII page explains why these women’s interests are not being served by the status quo:
“Although well-designed large and long-term studies are lacking, for decades women with implants have reported developing autoimmune symptoms that later improved when their implants were removed.
If you already have an autoimmune disease, breast implants could make your symptoms worse. If autoimmune disease runs in your family, you may be at increased risk of developing an autoimmune reaction to breast implants.”
– National Center for Health Research
The link between breast implants and autoimmune diseases is not as clear as for BIA-ALCL, probably for reasons the NCHR delineates in this excellent report.
The short answer is, there is no certainty on this issue right now. For individual patients suffering from BIA-BII symptoms, many surgeons now believe that removing the implants and capsules to see if their symptoms improve is the right medical course. Dr. Chun says that in his clinical experience, 80% of his patients with BIA-AII see significant improvement in their symptoms after explant. Listen:
Are There Specific Risks to Going Flat After Explant?
Quality of life studies on going flat vs. mastectomy with breast mound reconstruction (BMR) are mixed. This means that statistically speaking, BMR offers no clear or significant benefit to women, and going flat presents no harm. We also know that patients tend to overestimate the negative impact of going flat and overestimate their projected satisfaction with BMR. All of these factors suggest that going flat after explant may be the best option for some women.
The Explant Procedure
General Risks. For more information on the risks associated with explant surgery, please see the ASPS page – it presents similar risks to those inherent in any breast surgery, but unique to explant is a small risk of pneumothorax (only for implants placed under the muscle). Talk to your surgeon about your specific risk profile.
Changes in sensation. This is a risk of all breast surgery. Since explant involves both tissue removal and relief of tension on the tissues from implants and scar tissue, women can experience changes in sensation both for the better and for the worse. Some women report numbness, pain, or itching – but others report that their sensation actually improves after explant, and they begin to regain feeling at their chest wall.
Additional surgeries. While it’s an important goal, it may not always be possible at the initial surgery to safely and completely remove the scar tissue that has formed around the implants. There may also be aesthetic reasons for additional surgery – skin contracture and/or muscle changes as a result of the implant removal, for example.
Heads Up: Potential Anatomic Changes From Implants
Pectoral muscles. Most breast implants are placed under the pectoral muscle. This involves some separation (cutting off of the chest wall) of part of this muscle. Ask your surgeon whether your implants are under or over the muscle, and how they approach potential muscle repair during explant. Muscle repair is an aspect of explant that seems to be largely a matter of surgeon preference based on their own clinical experience.
Physical therapy can drastically improve your muscular function after mastectomy or explant. Ask your surgeon or your PCP for a referral. The Lymphedema Association of North America certified physical therapists (find a PT here) are trained in mastectomy massage for breaking up scar tissue as well as general rehabilitation post-mastectomy.
Rib cage. The forces produced by tissue expanders and implants between the pectoral muscle and the rib cage, can cause rib cage deformation – this means that there may be an indentation (concavity) left where the implant was removed. This is usually purely a cosmetic issue that may improve with time.
Proceeding with Explant
For more detailed information, visit the National Center for Health Research’s excellent page on insurance coverage for explant.
In the US, the Women’s Health and Cancer Rights Act of 1998 requires almost all insurance companies (Medicaid being the biggest exception, where coverage varies by state) to cover all breast cancer related surgeries. This includes medically necessary explant with aesthetic flat closure. However, your surgeon will have to make the determination about medical necessity. The usual list of symptoms that fit the bill for “medical necessity” are:
- Ruptured silicone gel breast implants
- Severe capsular contracture
- Infections that don’t go away
- Chronic breast pain
- Breast Implant-Associated Anaplastic Large Cell Lymphoma (BIA-ALCL), a cancer of the immune system)
Unfortunately, insurance companies usually won’t cover the cost of breast implant removal for autoimmune or connective tissue diseases or other systemic complications. If you have any of the conditions listed in the bullets above, you should focus on those in your insurance claim because insurance companies are more likely to cover these symptoms.– National Center for Health Research
Find a Surgeon
If your surgeon says that your explant procedure itself and/or your aesthetic flat closure won’t be covered by insurance, and the out of pocket cost is prohibitive (we have seen prices vary from several thousand to over ten thousand dollars), you may want to consider a second opinion.
Our Flat Friendly Surgeons Directory is growing every day, and includes surgeons recommended for explant – you can also filter your search results to show only surgeons who are ALSO listed on the HBII and BII explant lists! (Note: NPOAS is not affiliated with HBII or BII). Note: insurance coverage varies by provider, insurance plan, and also over time.
Aesthetic Flat Closure After Explant
Removal of excess skin
While your explant surgeon will not be able to identify and account for all factors contributing to appearance of the end result, there is one aspect they do have almost full control over: whether or not to remove the excess skin that previously covered the implant. This is where you can advocate for yourself to ensure you receive the best possible aesthetic result.
Unfortunately, some plastic surgeons think the patient will “change her mind” and decide to leave the stretched excess skin behind after the implant removal. This creates a “deflated” appearance that can be deeply upsetting for the patient. The extra skin can be removed with a subsequent surgery, but since many patients who explant are exhausted and concerned with the risk of multiple surgeries related to their reconstruction, most patients just want to be “one and done.”
Let’s be clear: women are allowed to and may change their minds. But this does NOT justify any surgeon’s actions overriding the patient’s clear directive. An aesthetic flat closure typically does not preclude future reconstruction, but it may make it a longer process.
Will my chest be concave?
Whether or not your final chest wall contour includes any areas of concavity is determined in part by surgical technique and in part by your unique anatomy. The removal of the capsules often produces a thinner “flap” of skin over the mastectomy site, which can make any existing concavity of the underlying chest wall structures more pronounced. Fat grafting and tissue rearrangement are the two main ways to address concavity at both the initial mastectomy and at explant.
Some plastic surgeons (even some breast surgeons) can employ newer techniques to minimize concavity by re-purposing excess tissue to “pad” or bulk up the mastectomy site (LEARN MORE).
Take steps to ensure a good result.
As with going flat at the time of mastectomy, explant patients need to take steps to protect their decision and ensure they get an acceptable surgical result. First and foremost, listen to your intuition! If you feel uncertain about your surgeon’s competence or their commitment to producing an acceptable aesthetic flat closure, you should seek a second opinion.
- Communicate your affirmative decision to go flat clearly. Use the term “aesthetic flat closure” to describe your desired final result. Write down your rationale. Show your surgeon photos of what you want AND what you are hoping to avoid. Use our Explant Brochure, or use your own images.
- Evaluate your surgeon’s response. Do they seem to accept and respect your decision? Or, do they try to talk you out of it or make statements about hedging your bets “in case you change your mind”? If there’s pushback, it may be time to consider a new surgeon.
- Ask specific questions about technique (below) – how they will achieve an aesthetically pleasing flat contour in your specific case?
Questions to ask your surgeon
- Have they performed en bloc or total capsulectomy and aesthetic flat closure before?
- Will one surgery be sufficient, or should you expect to need revision surgery(ies)?
- How do they manage the pectoral muscle?
- Do they routinely send excised materials for pathology? If not, you can request this.
- Is their pathologist willing to provide an official statement of all relevant findings?
- Will your implants be returned to you?
- Do they routinely document the encapsulated implants, unencapsulated implants and chest cavity with photos? You can request this.
- How will they address any special challenges in your case – for example, obesity, large implants, capsular contracture, or allografts?
- How will they avoid “dog ears”? How far will the incisions extend on the lateral chest in order to achieve a flat contour?
- What type of flat closure incision/scar pattern will your surgeon use, and why?
- How will they account for gravity’s effect on the tissues to ensure a smooth closure?
- Should you expect concavity? What is their approach to addressing concavity?
Note: NPOAS is not affiliated with HBII.
Further Reading on Explant
BreastCancer.org “Special Report: Breast Implant Illness and BIA-ALCL”
National Center for Health Research Autoimmune Symptoms and “Breast Implant Illness Page
American Society of Plastic Surgeons’ Medical Information on Explant
“Why some breast cancer survivors are getting their implants removed.” Beth Greenfield, Yahoo Lifestyle article, October 2018
“Breast Implants and Cancer.” Sandhya Pruthi. Mayo Clinic website article, June 2016
American Cancer Society’s Page on the Women’s Health and Cancer Rights Act (WHCRA)
Food & Drug Administration’s Breast Implant Risk Page
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