What is an “en bloc” implant removal and do I need this procedure if I have my implants removed or replaced?

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Many of our patients are asking us about removing their implants and an “en bloc” capsulectomy. This has become a popular term on social media and is often incorrectly interpreted. An en bloc resection is not always indicated and can cause additional complications not associated with implant removal.

“En bloc” is a surgical term that means removing organs or tissue in continuity or as a whole and is often a procedure performed when removing a malignant tumor. In the context of breast implant surgery, it would mean removing the implant and complete excision of the capsule (the scar tissue that forms around the implant). This is a meticulous surgical procedure that often involves removing the capsule off of the chest wall and ribs, which may require a much larger incision as the implant has to be removed with the capsule as a unit.

Whenever a capsulectomy is performed, an attempt is usually made to remove the majority of the capsule. It is often more dangerous to attempt to remove all of the capsule versus just removing the majority of the capsule and leaving the adherent portion in place. Frequently, it is not necessary to remove the capsule if it is thin, as the space will collapse after the implant is removed. If there is a capsular contracture (abnormal tightening of the capsule), most surgeons will remove a portion or all of the capsule. It is frequently not possible or very difficult to remove the entire capsule without removing the implant first. In this case, the capsule is dissected away from the surrounding tissue as much as possible and the capsule is opened allowing removal of the implant, or implant material if the implant is ruptured, followed by removal of the remaining capsule as indicated. This can usually be done through a smaller incision.

If a patient has BIA-ALCL (breast implant associated anaplastic large cell lymphoma), then an en bloc resection is indicated to completely remove the implant and capsule.

Many patients feel that an en bloc resection is required if they feel that they have BII (breast implant implant illness). BII is poorly understood and there is no data to suggest that a radical en bloc resection is necessary. Simple implant removal and capsulectomy (partial or complete) should be adequate. If there is any suggestion that the capsule is abnormal, your plastic surgeon my send your capsule to be evaluated by a pathologist.

While the internet can be a valuable resource, you should always discuss your options with a Board Certified Plastic Surgeon. Your treatment should be tailored to meet your own specific requirements.

Allergan Implant Recall

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Allergan recently announced the recall of all of their Biocell textured breast implants. What does that mean if you have breast implants?

It is important to be educated on why these implants are being recalled. A rare form of lymphoma called BIA-ALCL (breast implant associated anaplastic large cell lymphoma) is a rare lymphoma. It is primarily associated with textured breast implants and most commonly with Allergan textured implants, although not exclusively.

If you have smooth implants you don’t need to worry. If you have textured implants but don’t have any symptoms, there is no reason to remove or replace your implants. If you have swelling, hardening or new masses, you should be seen by your plastic surgeon. If you are still concerned, you might consider replacing your implants with smooth implants.

We have primarily used smooth implants over the years but have used textured implants in breast reconstruction or for patients with a history of capsular contracture. All shaped implants are textured.

It is important to continue getting mammograms and monthly self breast exams. We like to see our breast implant patients (cosmetic and reconstructive) yearly or more often as needed.

We are always available if you have any questions about your implants.

My Implants Are Out-Now What?

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Many of our patients ask about removing their breast implants but it is very important to have a discussion about what we will do after your implants are removed. Let’s go thru some of the options.

1. Do nothing. This is the simplest option. Some patients are perfectly happy with this option. You will be flat or indented and may have some loose skin or sagging. If there is a large amount of skin, you may want to have some of the skin removed. Some patients choose this option but decide to replace their implants later if they are unhappy with their appearance.

2. Breast lift (mastopexy). The breast tissue that is left can be rearranged to improve the shape of the breast and remove excess skin. This is a good option if you don’t mind smaller breasts and have adequate tissue to rearrange. There will be additional scars with a lift.

3. Replace implants. While most patients that want their implants out do not want them back in, you still have the option of replacing them with a newer device. For example, a textured implant can be replace with a smooth implant.

4. Autologous reconstruction. Tissue can be taken from another part of your body (e.g. abdomen, back or buttock) to replace the volume lost after implant removal. This is usually done in breast reconstruction and there can be problems with the area the tissue is taken from.

5. Autologous fat. Fat can be taken from other parts of the body and placed into the breast. This can be a good option in patients who need a small volume replacement, have contour deformities or don’t want implants replaced.

Will Insurance Pay to Have My Breast Implants Removed?

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We see many patients in the office who are interested in having their beast implants removed or replaced, especially with the recent media attention on breast implants. They often have been told by their primary care doctors, other plastic surgeons, breast surgeons or their insurance carrier that insurance will pay for all or a portion of the cost of removal and/or replacement.

The first question we ask is if the implants were placed for a cosmetic or reconstructive (e.g. after breast cancer) indication. If placed for cosmetic indications, the answer is “maybe”. If the implants were placed for reconstruction, insurance will usually cover the procedure but the patient would be responsible for their deductible, coinsurance, etc.

If implants are placed for cosmetic reasons, the insurance carrier will usually only consider paying for removal and/or capsulectomy and only for ruptured implants or for painful capsular contracture. This would not include implant replacement or addressing the loose skin or sagging breast tissue that is frequently associated with removing an implant and not replacing it.

The problem with having your insurance carrier cover implant removal is that they will frequently deny payment after the surgery is performed and the patient might be responsible for the surgeon’s fee, anesthesia fee, and O.R. fee which far exceeds the fee that would have been charged if the procedure would have been done as a cosmetic procedure.

Also, as a way to avoid this confusion, we usually don’t charge for removal of implants if a capsulectomy or mastopexy (breast lift) is being done at the same time, as a cosmetic procedure. Our office is happy to answer any questions you might have.

Do I Need to Remove My Textured Breast Implants?

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There has been a lot of recent media coverage about breast implants and BIA-ALCL (breast implant-associated anaplastic large cell lymphoma). Many of our patients have come in or called asking about their implants and risk of BIA-ALCL. They ask if their implants need to be removed. The short answer is “probably not”. BIA-ALCL is a very rare lymphoma that is primarily associated with textured implants and also depends on the type of texturing used. Certain brands of textured breast implants have a higher incidence of BIA-ALCL than others but even in this category, the incidence is rare. In patients who are not having any problems that have textured implants, we would not recommend removal or replacement unless there was some other reason to change or remove the implants. It is important to follow up with your plastic surgeon if you have implants especially if you notice any changes in your implants. Implants do not last forever and need to be replaced periodically. That is why periodic follow up (we like to see our patients every year) is so important. It also gives us an opportunity to educate our patients on any new information regarding their implants.

Be Aware Part 3

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Be Aware Part 3

Now that we know what it takes to become Board Certified in Plastic Surgery, how do you know if your surgeon is indeed Board Certified in Plastic Surgery? There are a number of ways to check.

*You can ask. Make sure you ask “are you Board Certified by the American Board of Plastic surgery” or “are you Board Certified in Plastic Surgery”. This is very important. Simply being “Board Certified” or board certified by a board other than the American Board of Plastic Surgery is not enough.

*Check the American Board of Plastic Surgery (https://www.abplasticsurgery.org/). There is a link under the “public” tab.

*Check to see if your surgeon is a member of the American Society of Plastic surgeons (ASPS, https://www.plasticsurgery.org/) or the American Society of Aesthetic Plastic Surgeons (ASAPS). In order to be members of either of these organizations, you have to be board certified by the American Board of Plastic Surgery.

Remember, there is no Board Certification for Cosmetic Surgery by the American Board of Medical Specialties.

There are other specialties that perform Plastic Surgery procedures of defined areas such as around the eyes (oculoplastic surgeons) or the head and neck area (Facial Plastic Surgery). Many of these surgeons are excellent and they have their own Board Certifications.

In my next post, I will discuss some of the other organizations that you should be cautious about.

Be Aware Part 2

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Be Aware Part 2

In this post, I would like to clarify the issue of Board Certification in Plastic Surgery. Many doctors are “Board Certified”. This doesn’t necessarily mean that they are Board Certified in Plastic Surgery or anything resembling Plastic Surgery. Board Certification is usually associated with a specific area of medicine. For example, an OB/GYN doctor would be Board Certified by the American Board of Obstetrics and Gynecology (https://www.abog.org/) and an Internal Medicine doctor would be Board Certified by the American Board of Internal Medicine (https://www.abim.org/). Plastic Surgeons are Board Certified by the American Board of Plastic Surgery (https://www.abplasticsurgery.org/). All of these board certifications fall under the American Board of Medical Specialties (https://www.abms.org/). This organization works with the 24 specialty boards to maintain the standards for Board Certification. Confused yet?

What is confusing is that there is no law regarding what a doctor can label himself as and there are many “Boards” that do not fall under the American Board of Medical Specialties. There is no board certification for Cosmetic Surgery included in the American Board of Medical Specialties.

In order to be Board Certified by the American Board of Plastic Surgery (https://www.abplasticsurgery.org/res…/training-requirements/) the following criteria must be met (this is what I did):

PREREQUISITE TRAINING

Residents entering plastic surgery training must complete 5 progressive years of clinical general surgery residency training, sufficient to qualify for certification by the American Board of Surgery (ABS), or approved alternate subspecialty pathway.

REQUISITE TRAINING

The Board requires a minimum of 3 years of Plastic Surgery Training for Independent programs and 6 years for Integrated programs. The final year must be at the level of senior responsibility.

EXAMINATION REQUIREMENTS

To qualify for an Application for Examination and Certification in Plastic Surgery, candidates must have a Final Confirmation Letter issued by the Board.

Candidates must hold active, inpatient admitting medical staff privileges in plastic surgery in a United States, Canadian or international hospital throughout the examination process.

Candidates must have a current, full, valid and unrestricted license to practice medicine with an expiration date valid through the examination.

Active practice in plastic surgery is a requirement for admissibility to the Oral Examination.

If you meet the above requirements, you can sit for the written and oral exam which you must pass to become Board Certified. If you have finished an accredited Plastic Surgery residency but have not take your written or oral board exam, you are considered to be Board Eligible. After you become Board Certified, you have to maintain your certification (Maintenance of Certification) and, until recently, you had to re-certify every 10 years by taking a written examination.

So now you know how to become Board Certified in Plastic Surgery. In the next post, I will discuss how to know if your Plastic Surgeon is Board Certified and what some of the other “Boards” are and what their requirements are.

Be Aware! Part 1

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I received an advertisement in the mail today for a “Plastic Surgeon”. It was in one of those mailers with multiple cards for various services. I won’t mention the doctor but he seemed to have a lot of letters after his name (must be well trained). They were from organizations like the American Academy of Cosmetic Surgery, The American Board of Cosmetic Surgery and The American Society of Liposuction Surgery. Sounds impressive, huh?! As a plastic surgeon, I feel it is my obligation to educate my patients and the general public about what it takes to become a plastic surgeon and what the important organizations are in the plastic surgery world. In upcoming posts, I will also take a look at what it takes to become a member of the organizations listed above. I will break this into multiple posts.

My Training:

*4 years of college
*4 years of medical school
*5 years of general surgery residency
*3 years of plastic surgery residency

After all this training, I had to take a written and oral exam to become Board Certified by the American Board of Plastic Surgery
www.abplasticsurgery.org

There are other routes to board certification by the American Board of Plastic Surgery. This is just the way I did it.

I will discuss the important organizations in Plastic Surgery and the importance of Board Certification in Plastic Surgery in Part 2.