En Block Breast Implant Removal for BIA-ALCL

That’s a great question.  Breast Implant Illnesses (BIIs) are a poorly defined set of symptoms that seem to bother some patients after undergoing breast augmentation/implantation.  These symptoms range from headaches, to coughs, to flu like symptoms, to body aches to constant fatigue.  Also, the symptoms have been noted to occur at times years after the implantation.  Unfortunately, even though there is a significant amount of chatter about Breast Implant Illnesses or BIIs, there have been no scientific studies that have shown convincingly that BII actually exists.  This is not to say that we do not believe the patient or the patient’s symptoms.  However, in many cases, the symptoms do not translate into any lab values that are irregular.  For this reason, it is hard to say what Breast Implant Illnesses truly are.

In my own experience, it has been a situation where one in 30 or 40 patients comes back years later and notes that she thinks that she may be having problems due to her implants.  We sit and go through all her symptoms.  We see and make sure she has no other physical problems that may be confounding the picture.  We then get labs done on her.  In most cases, the labs are completely normal.  This is where we are faced with a problem.  If the labs are completely normal, what are we treating?  At this point, we sit down with the patient and really have a heart-to-heart conversation.  In some cases, the patients are adamant that they wish to have the implants removed.  We believe in the team concept and are here to help the patient.  In those cases, we help the patient and get the implants out.  In more than ½ the cases where we remove the implants, we have noticed that the symptoms do not change—So the implant was not at fault.  However, the patient is often simply much less anxious and therefore we have served our purpose.  In other cases where the symptoms persist, we then work with the patient’s internist to see what else may be going on.

Again, even though Breast Implant Illnesses (BII) has a name, there is no specific diagnosis or specific exact set of symptoms.  Therefore, quite a few symptoms can be seen or noted.  I have heard patients complain of headaches, body aches, rashes, swelling, pain, numbness, burning sensation, coughs, flu like symptoms, muscle aches, joint pain, neck pain, back pain, fatigue, and an overall body listlessness.  As you can see, that is quite a few different things.  You can literally diagnose a dozen diseases with those symptoms.  So, what exactly is it? We don’t know.  However, it is true that some women after breast implantation have expressed concerns about these symptoms.  Have I seen them? Yes.  Do I see them often? No.  If we did, we would stop implanting breast implants into women.  By numbers, I probably have heard of symptoms in as few as 1 patient in 30 to 40 patients.  The biggest problem is that the disease problem is poorly defined and that there is no specific test to say that a patient definitively has the problem.

Great question.  Without an easily recognizable way of deducing a problem such as BII, we rely on simple physical exam.  For example, if you have an implant rupture, and you had a saline implant, you breast would start to deflate.  That is easily seen.  If you have capsular contraction, well then, the implant and the surrounding tissue would start to get hard.  This is easily noted and is most often picked up by the patient.  Often, the patient comes in and says that something feels different.  We examine the patient and note that YES, they are right, and the implant is in fact getting harder.  We then treat the patient accordingly.  This may require further examination or further testing with an MRI.  But again, this is easily recognizable and there are treatment protocols to follow.

So, most problems with implants are not as nebulous as BII.  Most are found by the patient or the plastic surgeon and most are in fact treatable. 

Breast implant illnesses are poorly defined so there are no great tests for them.  There are several tests that can be run to see if the patient is in a “reactive” state.  This would be tests like an erythrocyte sedimentation test (ESR) or a white blood count with a shift (WBC).  These tests in some cases may show a slight elevation.  But again, in some cases they may be normal.

Unlike breast implant illnesses, other problems with breasts can be easily found out with diagnostic tests.  As for an implant rupture with saline implants, a physical examination or an ultrasound will do.  With silicone implants, an MRI would be the gold standard.  With capsular contraction, again, a physical examination and an MRI would help diagnose the problem.

That is a great question and often a source of great anxiety. 

BIA-ALCL is Breast Implant Associated Acute Large Cell Lymphoma.  In other words, it is a cancer that is associated with breast implants.

In the last 5 to 10 years, the many plastic surgery societies around the world began to notice that in some patients, after undergoing breast implantation, there was a phenomenon of unexplained tissue swelling. In most cases, this swelling would happen often years after the breast implant placement.  The patient would present with a history of sudden swelling of the implant with a fluid collection.  This fluid collection would then be identified by ultrasound.  It would then be aspirated and would show cancer cells.  This was incredibly unusual.  In researching these cases, it became obvious that almost all these cases were related to textured implants.  Textured implants are a type of breast implant that were often used in breast reconstruction.  They are textured to help the shape of the breast look more natural.  It turns out that in some cases, the body of the patient reacts to the shape and texture of the implant and causes the local tissue to have a cancer response.  This then results in the sudden fluid development and the swelling around an implant.

A good question and a fair query.  As opposed to BIIs, BIA-ALCL has a fairly clear presentation.  So, if you have breast implants AND you suddenly have swelling around your implants over a course of a few days or weeks, it is recommended that you seek the advice of your surgeon.  If your surgeon has retired or is no longer practicing, the American Society of Plastic Surgeons can recommend someone in your local area.  Also, you can simply use one of the search engines on your computer to search for your closest plastic surgeon.  It would be prudent to go to see he or she so that your anxiety and concerns can be addressed.

Once you meet the plastic surgeon, you can get their help to go forward regarding further testing to make sure that you do not have BIA-ALCL.

In cases of patients that are in fact diagnosed with BIA-ALCL, an EN-BLOCK resection or Explantation is recommended.  This surgery is different from a regular breast implant removal in two ways.  First, the effort will be to remove the implant in its natural state.  The implant is NOT deflated or overtly manipulated.  The focus is to get the implant removed with all its local tissues still attached.  In this way, it is reasoned that the cancer and all the reactive tissue components are being removed together, out of your body.  The second is that once the implant and the tissues are removed, the effort will be to look around and remove whatever reactive tissue or capsule that may be still in place. Again, the effort is to remove everything that the implant has touched or has influenced.  In the more customary implant removal, the implant is simply removed, and parts of the shell are removed.  There is no need to remove all the shell since in some cases the surgical removal may damage some of the muscle or some of the local tissues and may cause more problems down the line.

A fair question.  The professional fee/cost is usually about 4200 to 4500$.  This is slightly more than a breast augmentation.  Of course, the focus is different and is much more on making sure that all the components of the affected tissues and the implants are removed.  This is much more meticulous and therefore more time consuming.

Also, since we are chatting about costs, we should also speak about insurance and warranties here.  Nowadays, the implant warranties supplied by the companies tend to be comprehensive.  In cases with capsular contraction, the companies now have inclusive policies that pay for the implant removal and some part of the surgery.  For BII, there is some ambiguity.  As for BIA-ALCL, there is no ambiguity.  Since this is a cancer, both the insurance company and the implant company are very much involved and do their best to help the patient.  That is refreshing and rare.

Another great question.  That all depends on what we have decided is your diagnosis.  If we are dealing with a case of capsular contraction, no.  If we are dealing with BIIs, probably not.  But unfortunately, due to the ambiguity of BII, it depends.  As for BIA-ALCL, you may need further testing depending on what we find in surgery.  Often, several MRIs will be needed as your response to the medications and your treatment course is gauged.  Again, I must point out, with BIA-ALCL, most of your costs will be covered by the insurance companies and the implant companies.

After your implants are removed, our job as the plastic surgeon and your surgeon is to make sure that you recover effectively and have a cosmetic result that is satisfactory to you.  Often, we see you at least once a week for the first few weeks until we are comfortable with your healing, and we do not forecast any problems.  In cases with BII, we will most likely follow you with your primary doctor or your rheumatologist to make sure that your symptoms subside. In cases with BIA-ALCL, we will follow you along with the oncologists for the next several years to ensure that you are symptom free.

That’s a great question.  The focus of any type of breast surgery is to make the breasts better or in the case of reconstructive surgery is to make the breasts as “normal” and as “symmetric” as possible.  The focus here is the same.  We will remove the implants and the associated involved tissues and focus on trying to make the breasts look very normal and natural and above all symmetric.

To make that happen, in some cases, we will have to plan for a breast lift.  In this procedure, when the implants are removed and the volume is now lost, we will have to change to breast contour to put the nipple areolar complexes in the right place.  In many cases if not most, this will involve a resection of some of the extra skin and a repositioning of the location of the nipple areolar complex.  The reconstruction may also involve the re-suturing of the muscle of the chest back into their original position, prior to undergoing the breast augmentation process.  In this way, we re-establish the natural contour of the breasts before the augmentation process and then simply do the lift or the recontouring from there.

Absolutely.  Our focus and our effort will be to minimize the damage to your body and your overall body form.  If in fact we can save you a scar or give you one less incision, we will definitely do that.  Our focus is to recalibrate your body, after the implant removal with a focus on a “natural” look and a “symmetric” look.