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 After Breast Implant Removal
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 and other systemic symptoms (“breast implant illness”)
- Concern about BIA-ALCL, a cancer linked to breast implants by the FDA & WHO, or other cancers including the newly linked aggressive cancer, squamous cell carcinoma
- Persistent feeling that the implants don’t align with personal body image
- Simply not wanting to live with implants anymore
Learn more about complications of breast implants and breast implant illness at BreastCancer.org.
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.
In September 2022, the FDA issued a new warning about other cancers linked to implants, specifically other lymphomas and squamous cell carcinoma.
The Connection to Autoimmune Disease
While acknowledged by the FDA, the connection between breast implants and autoimmune diseases is not yet widely recognized in the medical community. 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. NCHR also has an excellent review of the scientific literature here. The FDA page on BIA-BII is here.
For individual patients suffering from BIA-AII symptoms, many surgeons now believe that removing the implants and capsules to see if their symptoms improve is the right medical course. Dr. Lu-Jean Feng has published several studies, and Dr. H. Jae Chun says that in his clinical experience, 80% of his patients with BIA-AII see significant improvement in their symptoms after explant. These data suggest that for women experiencing BIA-AII symptoms, explanting may be the solution they’ve been searching for.
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. More about concavity here.
Proceeding with Explant Surgery
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 explant with aesthetic flat closure. However, your surgeon will have to code for the procedure correctly as a breast cancer related revision surgery and be prepared to deal with any denials and appeals processes.
Patients may encounter a surgeon who is not aware than an explant with aesthetic flat closure is considered a covered revision surgery. If your surgeon is not supportive of your decision to explant, or does not know how to code for the procedure, you may need to find another surgeon.
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 Breast Implant Removal
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.
Surgeons often assume that patients will have bothersome concavity, but this is often not the case. Patients may wish to wait until after healing from their explant surgery to evaluate their aesthetic outcome and decide whether they want to undergo any additional procedures.
Tissue rearrangement and fat grafting are the two main ways to address concavity at both the initial mastectomy and at explant. Tissue rearrangement happens during the explant procedure and can involve re-purposing excess tissue to “pad” or bulk up the mastectomy site (more about tissue rearrangement here). Fat grafting, which normally involves multiple sessions over a number of months, comes with risks that patients should be aware of before deciding to undergo this additional procedure (more about fat grafting here).
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”? Do they imply that your implants are not the cause of the issues you are experiencing? 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
Generally speaking, the more experience your surgeon has performing this surgery, the better your chances of a successful outcome.
If it is important for you to be done in one surgery, be sure you find a surgeon who is confident this can be achieved.
If your implants were under the muscle, “muscle repair” may be an option for you.
Pathology can be run to look for the presence of bacteria, fungus and BIA-ALCL (a test called CD-30). Insurance may or may not cover these tests.
Many patients want their implants returned to them. This is dependent on the facility’s policies, but you are free to request it.
You have the right to request these photos.
The surgeon should have a specific, constructive plan to address any special challenges that respects your values and priorities and gives you an optimal surgical outcome. For example, if you have a high BMI and it is important to you to be done in one surgery, your surgeon should have a plan to achieve that for you. If not, it may be time for a second opinion.
For example, for patients with a higher BMI, your surgeon may need to extend your incisions farther around towards your back in order to achieve an aesthetic flat closure.
This may depend on your anatomy and medical history.
Your surgeon should mark you up pre-operatively in a sitting or standing position so that after they close you up, the tissues will lie flat against your chest wall.
Patients may or may not experience concavity. Learn more.
You may find the following resources helpful, from Dr. Amanda Savage Brown, author of Busting Free: How to Liberate Yourself from the Quest for Better Breasts Before, During, and Long After Explant.
Note: NPOAS is not affiliated with HBII.
- BreastCancer.org “Breast Implant Removal (Explant Surgery)”
- 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
Find out more!
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