Explant
with

Flat Closure

FCN's Treasurer, Katie P. Fink, after removing her breast implants.

Before we begin, it's important to note that each mastectomy patient's medical history is unique with different variables that may affect the final outcome.

The information provided below is meant to be used as a guide, but is not comprehensive and may not apply to your situation. We are breast cancer patients, not doctors. ** Information provided by Flat Closure NOW shouldn't be taken as a substitute for medical advice from a licensed breast surgeon or oncologist. **

Please speak to your healthcare provider if you are considering explant.

Sondra's Implants & Capsules after Total Capsulectomy Explant 

Meeting with Explant Surgeons

 

Consulting with a surgeon about explanting breast implants can seem daunting, but know that you are not alone. Many, many mastectomy patients have traveled this road before you (including us!). We hope that the guidance below helps in communicating your wishes with ease and clarity.



Write down your "why"
 

Whether it is because your health is suffering, secondary cancer concerns, or other reasons, it's important to articulate your honest, authentic feelings when meeting with the explant surgeon - even if they are raw. Write it down if you need to! The “whys” help medical providers understand the patient’s perspective.


Show your surgeon photos

Be sure to show your surgeon photos of the aesthetic flat closure you'd like. You can find all sorts of gorgeous mastectomy pictures right here in our flat photo gallery. Though your particular result may differ from the photo you show your surgeon (which is why it's important to ask questions - more on that below), it still helps your surgeon visualize your ideal outcome. 
 

 

Ask questions!

 

We advise patients to always “interview” their medical providers when it comes to their mastectomy surgery or breast implant removal. This is important because not all medical providers are created equal (it’s one of the reasons we created this org!); some providers will listen without judgement, support your choice, and provide an exceptional aesthetic flat closure while others will not. Below are some questions we suggest asking to help you understand how they will achieve an aesthetic flat closure in your specific case and if that surgeon is the right fit for you. You can download the list here - print it and take it with you to your appointment! 

 

  1. What specific experience do you have in breast implant removal?
     

  2. Are my implants over or under the muscle? How does this affect my final outcome?
     

  3. Will you perform an “en-bloc” or a “total capsulectomy” procedure to ensure removal of the entire capsule?
     

  4. Have they performed flat closures for previous explant patients? Ask if they have photos of their work.
     

  5. Will they be able to make you flat in one surgery? How likely is it that you will face additional surgery?
     

  6. How will they address any special challenges in your case - for example, concavity.  Will fat grafting be necessary? Or should you have muscle damage, how will that be repaired?
     

  7. How much concavity should you expect and how will this be addressed?
     

  8. Will there be contour issues due to pectoral muscle and rib cage changes from the implants?
     

  9. How will they avoid “dog ears”? Will they extend the incisions further under your arms in order to achieve an aesthetic flat closure?
     

  10.  Will they ensure the closure is aesthetic when you are upright as well, and not just when you’re lying down?

Listen to your intuition

 

Make sure to have your wishes to have an "explant with aesthetic flat closure" notated in your medical record. ​​Evaluate your surgeon’s response. Do they accept and respect your decision? If there’s pushback, it may be time to find a new surgeon. Listen to your intuition! If you feel uncertain about your surgeon’s competence or their commitment to producing an aesthetic flat closure, you should seek a second opinion.

Frequently Asked Questions About Explant

What is an explant?


What is an "explant"? The word explant is used in the breast cancer
community to refer to a woman’s choice to have her
breast implant(s) removed after beginning or going
through the reconstruction process after mastectomy.
The decision to remove breast reconstruction isn’t
easy... but it’s not as uncommon as you might think.
In 2017, more than 19,000 breast cancer patients had
their breast implants removed, according to the
American Society of Plastic Surgeons.
Overall, that number represents a 3 percent increase
over 2016, and a 19 percent rise since the year 2000. Breast cancer patients may choose to explant due to one or more of the following: SECONDARY CANCER CONCERNS: Concern about BIA-ALCL, a cancer linked to breast implants by the FDA and WHO
Physical discomfort: tightness, pain, temperature differential, numbness
dissatisfaction: General dissatisfaction with the implants’ appearance
capsular contracture: hardening of the scar tissue surrounding the implant
rupture: Breast implant rupture or silicone leakage
infection: Chronic infection or inflammation around the implants
Persistent feeling that the implants misalign with body image
they're OVER IT: Yes, some patient simply do not want them anymore :) Sometimes because after trying them, their inner self doesn't resonate with the look and feel of implant. Sometimes breast reconstruction patients just get burned out - due to the multiple corrective/exchange surgeries or other medical complications they've endured.

Whatever the reason is, we want you to know that we are here for you and each reason is valid! There is a beautiful world of explanters and flatties here to support you along the way. You are not alone. Ask your surgeon what you can reasonably expect in terms of going flat after explant. Lots of factors contribute to whether or not your chest will be flat afterwards, including whether or not your body formed scar tissue around the implant or whether or not the implant is removed intact. Your surgeon can answer some of your questions but it’s impossible to know all of the answers until the explant surgery is underway.




What are the risks?


Explant surgery has the same risks as most operations, including infection, tissue death, and blood clots. The one risk that is unique to explant (at least for those whose implants are under the pectoralis muscle) is pneumothorax. Pneumothorax happens when air leaks into the space between the lung and the chest wall causing the lung to collapse. This complication is serious but usually treatable. If you are considering having explant surgery, keep in mind: Even the best surgeon cannot always remove 100% of the breast implant as well as surrounding scar tissue
Having breast implants removed does not guarantee your chest will be perfectly flat. Be very clear that you want an aesthetic flat closure.
Revision surgery may be necessary if you are not happy with the cosmetic result.
Explanting may cause changes in the way your chest sensation. You may regain sensation but you may also experience other nerve sensations like pain, "zaps" or "itching" - over time these side effects could disappear or stick around. Each patient's medical situation (and body) is unique. For more information on explant risks, visit the American Society of Plastic Surgeon’s (ASPS) page.




Does insurance cover an explant?


In the United States the Women’s Health and Cancer Rights Act of 1998 requires almost all insurers to cover breast cancer related surgeries, including explant and flat plastics closure, meaning contouring excess skin after removing the implant and capsule. That said, not all plastic surgeons understand the law, and not all plastic surgery practices know how to handle the logistics, such as insurance claims, pre-approvals, and reimbursements. You’ll need to be diligent about making sure all paperwork is filed properly. (And, if you are insured by Medicaid/Medicare know that coverage varies state-by-state so be sure to do your homework.) If your surgeon says that your insurance won’t cover your explant, consider getting a second opinion.




How will explant affect my body?


Pectoral muscles. When it comes to the surgical treatment of breast cancer, breast implants are often placed under the pectoral muscle. To make space for an implant, tissue expanders are inserted under the muscle and slowly filled with saline. As the device expands (think of a balloon slowly filled with liquid) it lifts the muscle up and away from the ribcage to create what’s called a pocket for the implant. After several months of slowly filling the tissue expander, a second surgery is scheduled to take out the expander and put in an implant. Afterwards, some women report their pectoral muscles are not as strong as they were before surgery. Although removing the implant can help restore some of the muscle’s previous strength, the pectoral muscles may never regain their original strength. That said, physical therapy can help your body integrate the change. Ask your plastic surgeon, breast surgeon, or primary care doctor for a referral to a physical therapist to help you regain the pectoralis muscles’ full strength and function. (Referral requirements vary by insurance plan in the United States.) Another excellent resource is the Lymphedema Association of North America, an organization that certifies physical therapists who are trained in general rehabilitation post-mastectomy. Rib cage. Like any medical device, tissue expanders and implants can prompt changes in surrounding structures. In particular, implants may leave an indentation in the rib cage that gives a concave appearance after explant. This is usually a cosmetic issue and doesn’t affect function. While your 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 flat result. How to Avoid Looking “Deflated” After Explant. Because the skin is (usually) stretched to fit implants, it’s important that your surgeon has the skill and patience to contour and trim excess skin once implants are removed. If a surgeon either lacks the skill or doesn’t allot enough time to achieve a flat closure, he or she may leave excess skin (also called redundant skin) on the chest wall. To the untrained eye, the result may look “deflated” (right). Such a result can be deeply upsetting to the patient, particularly if she specifically asked to be flat prior to explant. Although excess skin can be removed in follow-up surgeries, most people want the best result possible from the fewest trips to the operating room. Other times, redundant skin is due to a miscommunication or a misalignment of expectations between patients and surgeons. Worse-case scenario is when a surgeon unilaterally decides the woman will “change her mind” and, therefore, leaves skin to accommodate future implants. To be clear, breast cancer patients are allowed to change their minds. This does NOT justify a surgeon overriding a patient’s clear directive. A flat closure typically does not preclude future reconstruction but it may make the process longer. So, 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 cosmetic result:




Will explant heal my autoimmune disease?


Anecdotal evidence has long hinted at a possible connection between breast implants and the onset of autoimmune (AI) disease and/or a collection of ailments called “breast implant associated illness." Until very recently there was scant evidence linking breast implants to AI disease. But in early 2019, that changed. A study came out of M.D. Anderson in January of 2019 looking at long-term data for almost 100,000 patients with breast implants. The data, which was provided by breast implant manufacturers themselves as required by the FDA, showed that silicone implants are associated with higher rates of autoimmune disorders including Sjogren syndrome, scleroderma, rheumatoid arthritis. It also showed an increased incidence of stillbirth and melanoma (a cancer of the skin). Further discussion about the evidence on breast implant associated illness (BIAI) can be found at Midwest Breast & Aesthetic Surgery's blog.




Will Explanting Reduce My Risk of BIA-ALCL?


Breast Implant-Associated Anaplastic Large Cell Lymphoma (or BIA-ALCL for short) is a type of non-Hodgkin’s lymphoma linked to breast implants. Textured implants, specifically, put women at a 60- to 70-fold increased risk of developing this type of immune system cancer relative to the general population. Further research is needed to understand the relationship between the condition and breast implants and how explant affects a patient’s risk of the disease. In 2019 the Food and Drug Administration held a public meeting of the General and Plastic Surgery Devices Panel of its Medical Devices Advisory Committee to discuss the safety of breast implants in light of new information about BIA-ALCL and “breast implant illness.” Check back as we will be updating our information to reflect new developments on this topic.




Explant terms to know?


Explant: the surgical removal of breast implants and any scar tissue that formed around them (capsules) Capsule: scar tissue that forms around a breast implant over time Capsular contracture: when scar tissue that normally forms around a breast implant becomes overly tight, leading to cosmetic problems, discomfort, and often to explant Capsulectomy: surgical removal of all scar tissue associated with the breast implants Pocket: the space created by a tissue expander to receive a breast implant Pectoral muscle: the large paired muscles under the breasts that cover the front of the rib cage and are involved with shoulder mobility Tissue necrosis: when fat, skin, or other tissues die after surgery - may lead to cosmetic defects and/or require surgery Breast-implant associated anaplastic large cell lymphoma (BIA-ALCL): a cancer of the immune system associated with textured breast implants





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