Lions and Tigers and Bears… Oh My!
Breast surgery is a broad field that includes procedures such as breast augmentation, breast reconstruction, and breast implant removal. Many women choose breast implants for cosmetic enhancement or reconstructive purposes, but it’s important to understand that these procedures can sometimes lead to complications. One of the most common issues is capsular contracture, where the body forms scar tissue around the implant, causing it to tighten and potentially result in pain, discomfort, or changes in breast shape.
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Another concern frequently discussed by patients is breast implant illness (BII), a term used to describe a range of systemic symptoms like fatigue, joint pain, and skin rashes that some patients report in association with their breast implants. Plastic surgeons are highly trained to address these complications, and procedures such as capsulectomy—removal of the scar tissue capsule—have become essential in treating capsular contracture and may be considered in the management of BII. Whether for cosmetic reasons or to address complications, breast surgery requires careful consideration of the risks, benefits, and the expertise of experienced surgeons.
Understanding the Different Types of Capsulectomy Procedures
When it comes to breast implant removal, breast augmentation patients often hear a confusing mix of terms—en bloc capsulectomy, total intact capsulectomy, total capsulectomy, and partial capsulectomy. To promote consistent terminology among surgeons, the Breast Surgery Collaborative Community (BSCC) recently issued a consensus statement clarifying these definitions.
How the BSCC Defines Each Procedure
- En Bloc Capsulectomy: Removal of the breast implant capsule with a margin of uninvolved tissue for treatment of suspected or established breast implant-associated cancers after appropriate medical workup.
- Total Intact Capsulectomy: Complete removal of the breast implant capsule as a single unit.
- Total Capsulectomy (Total Precise Capsulectomy): Complete removal of the breast implant capsule, not necessarily done as a single unit or in one piece.
- Partial Capsulectomy: Removal of the breast implant capsule, where some capsule is left behind.
At Scultura Plastic Surgery, we have adopted these definitions moving forward. However, it’s important to note that this was not the working definition of en bloc during the evolution of BII and its treatment over the past decade.
The Meaning and Misuse of “En Bloc”
En bloc is a French word that means “as a whole,” “all together,” or “in a united group.” Over the years, plastic surgeons and explant surgeons have used this term with varying interpretations:
- Some define en bloc capsulectomy as removing both the breast implant and the surrounding scar tissue, sutures, and other material (such as mesh) in a single intact unit.
- Stricter definitions of en bloc capsulectomy require that there be no openings or cutting into the capsule to prevent spillage of silicone, biofilm, bacteria, or debris into the surrounding tissue during removal.
- Looser definitions may still consider the removal as en bloc capsulectomy even if small tears or openings in the capsule occur, as long as the implant and 100% of the capsule are ultimately removed together as a single unit.
Understanding Capsular Contracture
Capsular contracture occurs when the scar tissue that naturally forms around a breast implant begins to tighten, squeezing the implant and potentially causing discomfort, pain, or visible distortion of the breast.
The severity of capsular contracture is often graded using the Baker scale, with Grades III and IV representing more severe cases that may require surgical intervention.
Textured implants have been associated in the medical literature with a higher risk of developing capsular contracture, as well as a rare but serious condition known as breast implant-associated anaplastic large cell lymphoma (BIA-ALCL). While smooth implants may carry a lower risk of capsular contracture, they are not without their own potential complications.
Capsular contractures can affect both the appearance and feel of the breast, and in severe cases, a capsulectomy may be recommended to remove the problematic scar tissue and restore comfort and aesthetics.
Dr. Strawn’s Approach at Scultura Plastic Surgery
At Scultura Plastic Surgery, Dr. Jon Bradley Strawn, MD, MBA, has long used the term en bloc to describe the removal of the breast implant and its surrounding capsule in one piece. Moving forward, we will refer to this as a total intact capsulectomy.
The approach to capsulectomy is tailored based on the patient’s medical history and individual risk factors to ensure the safest and most effective outcome.
Our definition did not exclude removal classified as en bloc capsulectomy when there were minor tears in the capsule. However, our goal—especially when dealing with ruptured silicone implants—has always been to have zero tears or cuts in the capsule and to ensure no silicone leakage into the surrounding healthy tissues.
When Total vs. Partial Capsulectomy Is Performed
Capsules are more or less adhered to the rib periosteum and intercostal muscles. Some capsules are easily removed from both, while other capsules are fused with the periosteum and require “scraping” or electrocautery removal of the capsule from the ribs. The resulting hole in the capsule would preclude en bloc capsulectomy under the stricter definition.
We have never used the oncologic definition of en bloc capsulectomy because these are not cancer cases that require margins of uninvolved tissue. There is no evidence that explant surgeons were performing oncologic resections involving uninvolved tissue, but rather using the original French definition of en bloc, meaning the implant and capsule were removed “all together.”
Occasionally, the implant and capsule must be removed separately. These cases are classified as total capsulectomies when 100% of the capsule is eventually removed. If any capsule tissue remains, it is classified as a partial (or subtotal) capsulectomy.
Why Complete Capsule Removal Matters
At Scultura Plastic Surgery, we know these capsules are contaminated with free silicone, shell degradation products, bacteria, biofilm, and other debris. We believe it is of utmost importance to safely remove 100% of the capsule whenever possible.
In rare cases, the fused capsule and intercostal muscles are so thin and stretched that the risk of pneumothorax outweighs the benefit of complete removal. In our experience, this occurs in less than 0.5% of cases.)
What Recent Research Reveals About Silicone Exposure
Recent studies, including groundbreaking research by Isabelle Pluvy et al., suggest that exposure to silicone from breast implants induces an immunogenic response, leading to systemic inflammation, the expression of autoimmune markers, and the development of a spectrum of immune and autoimmune-related conditions.
More research is needed to fully understand these effects, but evidence continues to grow..
The Challenges and Benefits of Total Intact Capsulectomy
Performing a total intact capsulectomy requires a commitment to removing the entire capsule. There is still debate over whether or not this is required. In Dr. Jon Bradley Strawn’s opinion, there are not enough quality studies to support either total or subtotal removal of the capsule.
It is important to understand that a total intact capsulectomy is not an easy operation and should be performed by a dedicated and experienced board-certified plastic surgeon.
Another rarely discussed benefit of total intact capsulectomy is improved lung function. Capsules adherent to ribs 2–5 on both sides of the chest restrict the lung’s natural expansion during inspiration. Further pulmonary function studies should be performed, but for now, we believe our patients when so many of them tell us, “I can breathe so much better now.”
Key Takeaways
- The BSCC has provided clear definitions for the various types of capsulectomies.
- Past uses of the term en bloc capsulectomy did not include the oncologic definition requiring a margin of uninvolved tissue.
- Informed consent for patients considering a capsulectomy should be a shared decision-making process with their surgeon, including a discussion of the potential benefits and risks of complete capsule removal.
- There is currently insufficient evidence to conclusively support or reject leaving a capsule on the ribs during implant removal.
- At Scultura Plastic Surgery, we have achieved complete capsule removal for 99.6% of our 873 explant patients. We consistently see dramatic improvements in breathing and other BII-related symptoms.
- We will continue to use the French definition of en bloc capsulectomy and total intact capsulectomy for future implant removals.
Want to Learn More About Explantation Surgery in Newport Beach, CA?
At Scultura Plastic Surgery, we remain committed to evidence-based, patient-centered care that prioritizes safety, precision, and long-term wellness. Call us today at (949) 612-7231 or complete our contact form to learn more about the explantation procedure, recovery, and results, or how board-certified plastic surgeon Dr. Jon Bradley Strawn can help you achieve your breast goals.
