Do you believe implants can cause symptoms and do you see post-surgery improvements?
Yes. Breast implants are foreign objects in the body, which inevitably activate your immune system. When implants are placed under the breast tissue, above or below your pectoralis muscle, they activate an immune response that most likely continues until they are removed. All patients develop capsules, which means all patients have an immune response to the implant, regardless of whether their implants are silicone or saline, smooth or textured. Current research suggests that this happens because the shells of the implants are breaking down over time, allowing silicone particles to bleed through, which results in chronic activation of the immune system. The placement of implants can also allow infectious agents, like bacteria and fungus, to populate in the space between the implant and capsule.
Do you perform En Bloc Total Capsulectomy?
Yes. The only way to completely remove the foreign activating agents surrounding the breast implant is to remove the implant, everything surrounding the implant, and the capsule in its entirety. This method of removal is called En bloc, meaning “all together.” En bloc is the cleanest and best way to ensure that nothing contaminates the healthy tissue left behind.
If the capsule does not come out in one piece, do you remove all remnants of the capsule?
Yes. We are committed to removing all scar capsule tissue.
In rare cases where the capsule tissue has adhered to the ribs or intercostal muscles, some capsule may be left behind after being scraped and washed with antibiotic solution. However, these instances are few and far between.
How many times have you performed En Bloc explant surgery?
Over 800 patients, as of last count. Which means nearly 1,600 explants total.
How many explant surgeries do you perform per day?
No more than two surgeries per day. Total Correction surgeries can take up to 8 hours and monopolize an entire day.
Do you require a mammogram, ultrasound, blood work, or other testing before surgery?
We do not require patients to get a mammogram before surgery. However, we do encourage you to follow the guidelines of your primary care physician. It is a good idea to have a new baseline mammogram following your explant, but you should wait 3-9 months after your surgery to have that done.
We perform our own ultrasounds at the time of your consultation should Dr. Strawn feel that you need one. Dr. Strawn is not a radiologist, but he does have the advantage of correlating what he sees on ultrasound with what he finds in the operating room.
Basic blood work is required for everyone. We send you to the lab next door and cover the cost.
Patients over 65 years of age require and EKG. Anyone with abnormal EKG or other serious medical conditions require medical clearance from a cardiologist or internist.
Do you still perform augmentation with breast implants?
No, not routinely. Scultura’s initial focus was breast reconstruction, which sometimes included the placement of breast implants following mastectomies. During this time, we were on the cutting edge of non-implant, breast conserving oncoplastic surgeries which involved mastopexies and fat grafting after larger lumpectomies, instead of removing the entire breast with mastectomies. This experience influenced our full correction philosophy after en bloc capsulectomy explants with the use of breast lifts and fat grafting.
How long is the surgery?
Total operating time depends on a number of factors including the chosen surgery and any add on procedures. The size of your breasts, the adherence of the capsules to the chest wall, and implant location (above or below the muscle) will also influence the final time. Here are some general guidelines for surgery length:
- En Bloc Capsulectomy Only: 2-3 hours
- Explant and Lift: 3-5 hours
- Explant and Fat Grafting: 4-6 hours
- Full Correction (Explant, Lift, and Fat Grafting): 6-8 hours
Do you perform surgeries other than implant removal and reconstruction?
Yes. Because we do so much fat grafting, we are experts in breast and body contouring with lipo-sculpting, tummy tucks, brachioplasties, and labiaplasties. We also preform fat grafting to the buttock, face, hands, and other areas.
How long do I need to stay in town before and after surgery?
Nearly 40% of our patients come from outside of Orange County, so we have you covered when it comes to the post-surgical process. Surgeries are performed on Wednesday, Thursday, or Friday. Pre-operative appointments and follow-ups are Mondays and Tuesdays. Most out-of-town patients will arrive on Tuesday for a pre-operative visit and leave a week later after their follow-up visit. Sticking around for your two week appointment is a luxury, but not required. We offer virtual follow-up options after the first week for those who live out-of-town.
Where is my surgery performed?
We preform all surgeries out of Galea Center for Advanced Surgery, Accredited by AAAHC (Accreditation Association for Ambulatory Health Care). Dr. Strawn also has privileges at Hoag hospital 4 miles away, but has never had to use them.
Do you have photos from previous En Bloc Total Capsulectomies?
Yes. We have thousands of photos. Some of them are on our website. Many more are printed and showcased in the office at the time of your consultation and pre-operative visit. Photos are a great tool to help you envision your outcome after surgery. It is important to be realistic and find before photos that most closely match your own breasts.
Do you use drains?
Yes. Drains are placed at the time of surgery to prevent seroma (body fluid) accumulation. We want the implant space to completely disappear, and not leave you with an encapsulated pocket of fluid that can create a new set of problems. Drains are usually removed at the first post-operative visit, 4-5 days after surgery. No care is needed for the drains. We use an antibiotic Biopatch disk, and the dressings cover the hub of the drain and stay on until your first post-operative visit.
Do you perform a nerve block?
Yes. We were the first to perform nerve blocks and muscle repairs on every explant patient. We perform a pectoralis I field block under direct visualization of the neurovascular bundle (so it’s safer than the anesthesiologist using ultrasound!).
Which anesthesiologists do you use?
We use a select group of anesthesiologists from the Newport Harbor Anesthesia Group, which is the group of anesthesiologists who cover all of the Hoag operating room. Although each anesthesiologist has his/her own technique, most anesthesia is designed to be as minimal as possible to safely perform the surgery without memory and pain while minimizing recovery time and complications after discharge.
Do you use antibiotics after surgery?
Yes. We use antibiotics while the drains are in place, 4-5 days. There is mixed evidence as to the efficacy of prophylactic antibiotics, and so we support patients’ decision to refuse their use, but we have had zero infections after over 1,750 explants, so we will continue to use antibiotics as our first choice. Our first line therapy is Doxycycline; however, we offer other options for those who may have allergies.
What pain medications will be prescribed for after surgery?
Our priority is baseline pain control after any surgery. Our regimen is to take 2 Tylenol upon waking up from your post-surgical nap (or if you don’t take a nap, when you are first ready to try and eat some food). Then, set your phone alarm for 3 hours, at which time you will take 2 Motrin, and set your 3-hour alarm. You will then take 2 Tylenol, followed by 2 Motrin three hours later. This will continue for the first 48 hours, whether you have pain or not. During this time, if you have breakthrough pain, you will take 1-2 Norco tablets every 3 hours, but only if you need them. Most of our patients take 1-4 Norco tablets during the first few days, but more is available if needed.
When do you recommend a lift after explant surgery, and what type of lift do you perform?
Not all patients need a lift after explant surgery. Although we perform all types of lifts, the most common lift, by far, with explant patients is the full anchor lift. We start all lifts with the lollipop lift, but almost always require reconstruction of the inframammary folds resulting in the anchor lift.
When do you recommend fat grafting after explant surgery?
We are big fans of total correction, which includes fat grafting at the time of explant. Dr. Strawn has been performing fat grafting for breast reconstruction since 2003. Fat grafting at the time of surgery counteracts the negative volume consequences of implant removal and subsequent collapse of the thinned-out breast tissues. Patients with smaller implants and/or lots of breast tissue may not need additional volume. The average patient has larger implants and thinned out tissues that will collapse “like a circus tent” without re-shaping from mastopexy, or volumizing with fat grafting.
Unfortunately, there can be consequences to delaying the fat grafting, such as permanent creases in your breasts caused by adhesions that may be more difficult to correct later on. Fat grafting does add more cost, more surgery time, more post-operative pain and systemic inflammation and swelling. However, in our experience, total correction at the time of explantation yields the happiest of patients, who almost never need to return for later procedures.
Are you Board Certified?
Yes. Dr. Strawn is Board Certified, a Diplomat of The American Board of Plastic Surgery (certificate expires 12/31/2029), and reports to the American Board of Medical Specialties. He is also a member of the American Society of Plastic Surgeons.
When did you start performing breast implant removal surgeries?
May 25th, 2017 was Dr. Strawn’s first official breast implant illness patient surgery with total correction reconstruction. Dr. Strawn was performing breast reconstruction and en bloc capsulectomies long before then, but in the field of breast reconstruction for cancer patients. Over the last eight years he has transitioned nearly 100% to an explant surgery focus and has performed over 1,500 en bloc capsulectomies at last count.
Where will the incision be placed?
This depends on the surgery being performed. Inframammary Incisions are the most common with en bloc only procedures. Some patients want to eliminate new breast scars by using their old peri-areolar scars. While en bloc has been accomplished through these incisions, it is challenging and often results in a total capulectomy with separate implant removal first and later capsule removal. Mastopexy incisions are used to access the en bloc capsulectomies when Lifts or Total Correction surgeries are performed.
How do you handle potential ruptures and leaked silicone?
First of all, we perform ultrasounds of both breasts during your consultation, so we will already have an idea of whether or not the implants are ruptured. Second, we take our time and perform a complete en bloc capsulectomy every time. However, some ruptured capsulectomies are difficult, especially when the capsule is adherent to the 3-5th ribs and intercostal muscles. If the capsule is tearing, then we make every attempt to keep the capsule and silicone outside the body and suction the silicone from the capsule, then complete the total capsulectomy.
Do you repair the pectoralis muscle if it is cut from its origin on the sternum and ribs?
Dr. Strawn began repairing every muscle starting back in early 2018 after seeing the results of no muscle repair with one of his explant patients. He is now a big proponent of repairing every single muscle and returning the anatomy back to its pre-implant state whenever possible.
Will you remove any permanent sutures or internal mesh that may have been used?
Yes. Most often permanent sutures and mesh are incorporated into the scar tissue capsules and are removed en bloc with the rest of the tissue. After the capsulectomy is performed, anything that doesn’t belong, including extra sutures or mesh from prior surgeries, is removed.
If you find a seroma during the surgery, do you aspirate the fluids and send to be tested to rule out BIA-ALCL?
Yes, delayed peri-implant seroma has been found to be one of the possible signs of Anaplastic Large Cell Lymphoma (ALCL), a rare type of cancer linked to breast implants, and needs to be ruled out during explant. Treatment of ALCL includes a total or en bloc capsulectomy, another reason to make it standard procedure.
Do you use any foreign materials during my surgery such as staples or permanent sutures?
No. We only use absorbable sutures such as PDS and Monocryl.
Do you prescribe medications to be taken before surgery?
No. Your anesthesiologist may give you oral medications before going to sleep.
What medications or supplements do you prescribe after surgery?
Tylenol and Motrin for baseline pain control, Norco for breakthrough pain, Zofran for nausea, and prophylactic Doxycycline antibiotic. Patients can resume supplements as soon as they are able to tolerate food and water.
Do you send my scar capsules off to pathology to be tested for cancer and inflammation?
Yes. This is elective, but encouraged with patients who have a family history of breast cancer or who have textured implants.
Do you test my scar capsule for biofilms, bacteria or fungus with PCR or Tissue Cultures?
Yes. This is elective, but provides interesting information. Because it involves and extra charge, we do not require the testing. We have already treated the biofilm, bacteria, or fungus by performing the en bloc capsulectomies and treating with prophylactic antibiotics.
Do you cleanse the breast pocket after removal?
Yes. We irrigate the breast pocket with triple antibiotic solution (Bacitracin, Ancef, and Gentamycin).
Do you take pictures or videos of the implants and capsules that are removed during my surgery?
Yes. It is very important to document that an en bloc, or a complete, capsulectomy was performed. This is best achieved with video documentation examining all 360 degrees of the implant within the capsule and the actual removal of the implant from the capsules. We take videos and photos which are available to the patient at any time. During the video we discuss the procedure, findings, volumes, and outcomes to be used as another source of medical record.
What is your follow-up process for appointments?
We like to see you often after surgery. Here is our standard follow-up procedure:
- First post-op (day 4-5): drains removed, dressings down
- 1 week later: tapes changed, incision examined
- 4 weeks: tapes changed, scar therapy discussion
- 8 weeks: release to swim and exercise
- 12 weeks: review BII symptoms and complete activity release
- 1 year: photos and review
Will you return my breast implants to me if not ruptured?
Yes. If you want them, they will be cleaned and sent home with you on the day of surgery. Otherwise, we will send them to medical waste.
What’s the typical recovery time for surgery? How long do I need to take off from work or arrange for help at home?
Recovery time depends on the surgery chosen. En bloc only is the quickest recovery, with most patients returning to work after their second post-operative appointment. Full Correction with add-on procedures will take longer. Most patients take 1-3 weeks off work. Help at home is needed for at least the first few days.
What post-explant recovery services does your practice offer?
Recovery services and products are optional, as they can potentially be expensive and time consuming. We strongly support lymphatic massage, proper nutrition and supplements, hyperbaric oxygen therapy, and many other recovery assistance modalities. Referrals are always available. Some patients benefit from post-operative nursing and/or facilities. We also encourage you to follow up with your primary and functional medicine providers as soon as possible.
Are there any potential risks and/or complications you encounter with this surgery?
Complications are extremely rare, but are a possibility with any surgery. We have extensive consent documents which cover everything from poor scars to possible death. The most common complaint with an explant surgery is usually the small post-operative breast size… but this comes with the territory of removing large volumes of implants from your breasts. Fat grafting is the best insurance we have against this complaint, but does not get everyone to their dream breast size.
Are their additional costs associated with irregularities and adhesions?
We provide scar revisions and Riggotomies (to minimize the appearance adhesions) at no additional cost to the patient. Breast deformities and adhesions are more common when no reconstruction is performed. Delayed Lifts and/or fat grafting may be necessary and would be at an additional cost.
Have you performed explant surgery post-mastectomy?
Yes. Many times. The en bloc procedure is fundamentally the same, but the cosmetic result and reconstruction challenges are dramatically different. Prior scars are usually used for access to the capsule. Muscle repair is performed. Skin excision and closure depend on planned reconstruction. If fat grafting is the reconstruction of choice, then an ideal amount of skin (not too much and not too little) is left as a base to build the breast.
How do you decide if someone needs a lift after implant removal?
Removing the implant results in two challenges: size and shape. When implants are placed, they make the breast larger, which stretches the breast tissue, permanently changing the shape. This is why, when we remove breast implants, we “take two steps back” in that we lose the volume of the implant, but we also have the added difficulty of less dense tissue (which is what causes the “pancake” look).
Thus, lifts, or mastopexies, are needed to reconstruct shape. A lift will eliminate ptosis, or skin-on-skin contact. A lift will also narrow the breast base and cone the rest of the breast tissue in addition to correcting downward, or asymmetrical, nipple areola complexes.
Someone with small implants, narrow breast width and height, no ptosis, lots of breast tissue, and forward, symmetrical nipples will not need a lift. But because of the damage implants cause to the shape of the breasts, most explant patients would benefit from a mastopexy or breast lift.
Do you perform lifts at the same time as explant?
Yes. This is a good time to perform the mastopexy (lift) reconstruction as it can prevent some of the significant folds, scaring, and adhesions that can make delayed reconstruction so challenging.
What kind of lifts do you perform?
Dr. Strawn performs all types of lifts – Anchor, Lollipop, Donut, and Crescent – However, most explants with lifts will start with a lollipop lift and ultimately end in an Anchor lift, which is often necessary to best shape inframammary fold.
How many breast lifts have you performed?
Over 1,000 post-explant mastopexies (lifts) and almost as many post-lumpectomy oncoplastic, breast reductions, and non-explant lifts.
Is a lift a good idea if I want to have children or breastfeed?
Our recommendation is usually to delay the lift until after you are through breastfeeding. The overall success rate for breastfeeding after a lift (mastopexy) is somewhere around 60%, which happens to be the overall breast-feeding success rate.
What are some other risks and potential complications of the mastopexy (lift) procedure?
First, everyone gets scars— usually the full anchor scar— after explant. Scar quality and visibility depend on post operative care and genetics. We recommend viewing photographs of scars after the lift procedure. Second, the lift procedure involves significant cutting and reshaping of the breast tissue and skin. The finished product on the table, and the results after time and gravity, are significantly different. An experienced breast surgeon knows this and anticipates the changes with his operative technique. After the breasts have had time to heal and settle into place (5-9 months) scars and breast folds are not always aligned. (The surgeon can place the scars, but he can’t control the way the breasts settle and fold) some patients require additional scar revisions to line them up with the folds.
Do you perform fat transfer at the same time as explant surgery?
Yes. Fat transfer immediately after explant surgery is an excellent time to restore some of the lost volume, reshape deformities, improve cleavage, reduce asymmetries, and fill deflated tissues. We have had excellent results with immediate fat grafting, as they are some of our happiest patients.
If patients chose to have fat transfer later, how long do you require them to wait after their explant surgery?
Five months appears to be an ideal minimum time for waiting after explant or between rounds of fat transfer.
How much fat do you typically transfer on average?
Volume of fat transfer is solely dependent on the breast fat layer and is different for every patient. We graft as much as possible, without over-grafting, which can cause fat necrosis and/or oil cysts. Retention, or survivability, of the grafted fat depends on technique, and stopping at the right volume.
What areas do you take fat from during liposuction?
The most common area is 360 degree trunk which includes abdomen, flanks, and back. We also harvest fat from the thighs and arms as needed.
What type of liposuction do you perfom?
Dr. Strawn uses his own modified version of SAFE lipo developed by Dr. Simeon Wall, Jr. of Shreveport, Louisiana. This technique uses power assisted liposuction and additional passes with cannulas that redistribute and feather the fat after the suctioning phase.
What are the risk and potential complications of the procedure?
We have had almost no complications of lipo-sculpting and fat transfer. No infections. It is rare for us now to get anything more than a small pea-sized area of fat necrosis or oil cyst (which is easily treated in the office free of charge). Contour problems from the lipo-sculpting are a potential risk, but rarely occur, and when they do, we have ways to correct them.
How many fat transfers have you performed?
Dr. Strawn participated in his first fat grafting procedure in 2013, over twenty years ago. In the last twelve years, between breast reconstruction after cancer removal and reconstruction after explant, he has performed over 1,250 fat grafting and lipo-sculpting procedures.
What can I do to prepare for surgery?
There are many things you can do to maximize your health in preparation for your surgery. Diet, exercise, hydration and sleep are always first priority. Minimizing anything that will cause illness or inflammation. Try not to get sick – consider wearing a mask in public areas. Minimize inflammation in your gut – limit your diet to whole foods, vegetables and healthy protein sources. Breast Implants (the shell, the silicone, or infections agents inside the capsule) are causing inflammation. This will be removed during your explant surgery. But its up to you to reduce the other sources of inflammation from your diet and environment for your overall health.
What is my chance of success?
Every one of our patients has stated that they feel much better after implant removal. After 3-4 months, over half of our patients are dramatically better with 80% of BII symptoms showing improvement. The other half have varied improvement, some symptoms are better, some have stayed the same. Autoimmune symptoms rarely disappear, but often improve with the reduction of systemic inflammation.
Overall, we have very happy patients. Everyone sees some improvement and a majority have a dramatic health increase. The number one complaint is breast size, which makes sense, as we are dramatically reducing breast size with implant removal. At Scultura Plastic Surgery, we treat our patients like family, from the moment they walk into the office until we hug goodbye after their one-year appointment. Dr. Strawn’s philosophy is that you are now a life-long friend and patient.
