Methods and Materials
From January of 2016 through September of 2020, a total of 200 sets of breast implants were removed from self-reported women with symptoms consistent with BII. Inclusion criteria consisted of all cosmetic patients with history of breast implant placement presenting with mammary symptoms (mastodynia and capsular contracture) and with or without extramammary symptoms (rash, arthralgia, etc) on physical examination. At the initial clinic visit, all patients received a questionnaire gathering information about their symptoms. Data pertaining to implant type and plane of prior implant position (submuscular vs subglandular) were collected. All patients underwent unilateral or bilateral implant removal and total capsulectomies. Specimens were sent for pathology examination and cultures (aerobic, anaerobic, fungal, and acid-fast bacilli). No patients received any previous treatment for BII. The Tulane University School of Medicine Institutional Review Board granted approval for this study.
A total resection was done to remove the implants and the capsule in its entirety (Figure 1, Figure 2, and Figure 3). This consisted of removing the implant and capsule in one single piece. The senior author was responsible for all the procedures. All patients underwent standardized total capsulectomy and implant removal using monopolar electrosurgery or blunt dissection through an incision in the inframammary fold with a 6-cm incision. A guarded flat-tipped cautery was used. A bendable extender, periosteal elevator, and lighted breast retractor were used. None of the patients had partial capsulectomy.
A 34-year-old female patient presenting with BII mastodynia unilaterally on the left breast underwent total capsulectomy to remove the silicone gel implant and capsule as one entity.
A 47-year-old female patient presenting with BII mastodynia unilaterally on the left breast underwent total capsulectomy to remove the silicone gel–filled implant (left) and capsule (right). The capsule was removed from the implant for better visualization.
A 29-year-old female patient presenting with BII mastodynia bilaterally underwent total capsulectomy to remove the saline-filled implants (top left and right) and capsules (bottom left and right). The capsule was removed from the implant for better visualization.
All capsules were removed and sent for permanent histopathology. Any periprosthetic fluid with a volume of at least 50 cc was sent for cytology and specifically for CD30 to rule out anaplastic large cell lymphoma (ALCL). The pocket was then cultured for aerobic and anaerobic bacteria, acid-fast bacteria (AFB), and fungus. This was done in the following locations: (1) inside the pocket but outside the capsule, (2) inside the capsule next to the implant, and (3) if deflated or ruptured, inside the implant itself. After implant/capsule removal, the pocket was then irrigated with a triple antibiotic solution (50,000 units of Bacitracin in 500 cc of normal saline with 1 gram of Ancef and 80 mg of gentamicin). After the initial rinse, the triple antibiotic solution was mixed "half and half" with full strength betadine, placed in the pocket, and allowed to soak for 2 minutes. The pocket was then rinsed with a third wash of triple antibiotic solution, emphasizing contact time. Finally, normal closure with suture was completed.
Closed suction drains were placed and left in place until the drainage was less than 25 cc in 24 hours. No reconstruction was done at the initial setting, and our patients were instructed to avoid having breast implants again. Patients were asked to return for follow-up appointments every month for the first 6 months (Figure 4). After 6 months, if the patient desired new breast implants, cosmetic options were discussed. Upon approval by the senior author, these options included mastopexy, breast reduction, fat grafting, and fat grafting with mastopexy. However, most patients did not desire a cosmetic breast reconstruction post total capsulectomy.
Front profiles of a 37-year-old female patient with BII mastodynia bilaterally (A) preoperatively and (B) post–total capsulectomy to remove saline-filled implants and capsule at 6 months. Front profiles of a 36-year-old female patient with BII bilaterally (C) preoperatively and (D) post–total capsulectomy to remove silicone gel–filled implants and capsule at 6 months.
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