going flat
after Explant

Foreword: Every patient’s medical situation is unique. The information is not meant to be comprehensive and may or may not apply to your situation. Any and all information provided by Flat Closure NOW and its representatives is for informational purposes only and should not to be considered medical or legal advice. Statements should not be taken as a substitute for medical advice from a licensed physician. 

Please speak to your healthcare provider if you are considering explant

 

what is 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. The decision to explant 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:

 

  • Physical discomfort - tightness, pain, temperature differential, numbness

  • Persistent feeling that the implants misalign with body image

  • General dissatisfaction with the implants’ appearance

  • Exhaustion with multiple corrective or exchange surgeries (required every 10-15 years)

  • Capsular contracture - hardening of the scar tissue surrounding the implant

  • Implant rupture or silicone leakage

  • Chronic infection or inflammation around the implants

  • Various other medical complications

  • Concern about BIA-ALCL, a cancer linked to breast implants by the FDA and WHO

  • Simply not wanting to live with implants anymore


 

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 explant, keep in mind:

 

  • Even the best surgeon cannot always remove 100 percent of the breast implant as well as surrounding scar tissue

  • Explant does not mean your chest will be perfectly flat

  • Revision surgery may be necessary if you are not happy with the cosmetic result

  • Explanting may cause changes in the way your chest feels to you, meaning your sensation. You may be left with numbness, pain, or itching. Over time, these changes may abate or persist.

 

For more information on explant risks, visit the American Society of Plastic Surgeon’s (ASPS) page.


 

Considering Explant Surgery

 

Preface: 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.

 

is Explant Surgery covered by insurance?

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.

Total Capsulectomy Explant

Things to Know: How Explant Might Affect Your 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.

 

going flat after explant & Ensuring You Get a great flat result

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:

 

  1. Communicate your affirmative decision to go flat clearly. Write down your rationale. Show your surgeon photos of what you want AND what you are hoping to avoid. Find them at FCN’s Photo Gallery.

  2. Evaluate your surgeon’s response. Do they accept and respect your decision?  Or, do they try to talk you out of it, or make statements about hedging your bets, “leaving a little extra in case you change your mind”?  If there’s pushback, it may be time to find a new surgeon.

  3. Ask specific questions about technique - how they will achieve a flat contour in your specific case? (see the section below)

  4. Listen to your intuition! If you feel uncertain about your surgeon’s competence or their commitment to producing an acceptable flat result, you should seek a second opinion.

Questions to Ask Your Explant Surgeon
 

  1. About your cosmetic result

 

  • Have they performed flat mastectomy closures for previous explant patients? Ask to see photos of their work.

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

  • How will they address any special challenges in your case – for example, existing defects or obesity?

  • How much concavity should you expect, and how will this be addressed?

  • Should you expect contour defects due to pectoral muscle and rib cage changes from the implants?

  • How will they avoid “dog ears”? Will they extend the incisions further on the lateral chest (under your arms) in order to achieve a flat contour?

  • How will they ensure the closure is tight enough to present a flat contour when you are upright, not just when you’re lying down?

 

2.  Medical questions: please see the ASPS page for a complete list.

 

  • What specific training and experience do you have in breast implant removal?

  • Are my implants under or over the muscle? How does this affect my risks?

  • Will you perform an “en-bloc” procedure to remove the entire capsule?

Tip: You can download a PDF of these questions here. Then simply print and take to your appointment!

 

Will Explanting 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 Glossary
 

 

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

 

Further Reading on Explant

 

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Flat Closure NOW is a 501(c)(3) non-profit organization dedicated to ensuring understanding that “going flat” is a valid, beautiful, healthy surgical option after mastectomy.

Email: flatclosurenow@gmail.com

 

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