Drainless Implant Removal: A Technique to Minimize Breast Disfigurement After Explantation

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Any views and opinions expressed are those of the author(s) and/or participants and do not necessarily reflect the views, policy, or position of ePlasty or HMP Global, their employees, and affiliates.

An 82-year-old female patient with a previous history of subglandular breast augmentation 40 years ago presented with grade IV capsular contracture and asymmetry (Figure 1).

Figure 1: Preoperative image of an elderly female patient with prior breast augmentation who presented with bilateral capsular contractures and ruptured silicone gel implants requesting bilateral breast implant explantation. 

The patient desired to have breast implants removed. The explantation was performed through previous inframammary incisions without placement of new implants. Operative exploration revealed bilateral intracapsular rupture. The silicone was removed while preserving the entirety of the capsule, the pocket was irrigated, and the subsequent wound was closed in multiple layers. The senior surgeon elected to not place drains at the conclusion of the operation with the aim that a naturally formed temporary seroma would shape the breast pocket.

Following the procedure, bilateral controlled seromas developed in the breast pocket (Figure 2). Three to six months following her surgery, the seroma naturally reabsorbed with minimal breast disfigurement and excellent symmetry. She recovered well with high patient satisfaction and no further reconstruction was needed.

Figure 2: Postoperative image following breast implant explantation. No intraoperative drains were used. Patient is satisfied with her symmetric shape with no deformities or further reconstruction needed.  

Breast implant removal (BIR) following reconstruction or primary augmentation is not as uncommon as one might think. In fact, in 2011 the Food and Drug Administration released an update on the safety of silicone breast implants providing a cumulative rate of breast implant removal at 8 to 10 years postoperatively to be between 7.3% and 32.4%.^1,2 According to the American Society of Plastic Surgeons’ (ASPS) 2022 annual statistics, of the 151,641 breast reconstructions, 24,316 breast prostheses were removed, corresponding to about 16.1%. In addition to reconstructive efforts, patients with cosmetic implants also experienced removal of 37,679 implants of the 298,568 breast augmentation procedures performed, equating to about 12.6%.³ Bucher and colleagues who investigated the overall complication rates of implant-based reconstructions showed that 37.6% of patients and 15.1% of implants required prosthesis explantation due to severe complications. This number may see an increase in the years to come as women share their experiences with breast implant illness (BII) and other complications via social media.⁴ By comparing Google search trends and national BIR case volume, Tian et al from Duke University showed an increase in BIR facilitated by the mainstream and social media.⁵ This trend is seen despite a lack of consensus in the scientific literature of the direct cause of breast implant illness.
 
Indications for breast implant removal have been well documented as numerous studies have attempted to categorize reasons for explantation. In addition to BII, other indications for breast implant removal include capsular contracture, implant rupture, breast implant–associated anaplastic large cell lymphoma (BIA-ALCL), wound infection, and patient preferences including age-related changes, pregnancy, weight gain or loss, or changes in public opinion.^1,2,4-6

The decision to perform capsulotomies or capsulectomies is a crucial operative decision. Making full-thickness incisions through the capsule without removing any capsular tissue, also called capsulotomies, is commonly used for aesthetic disfigurement and uncomplicated capsular contractures and has low morbidity, short operation time, minimal anesthetic risk, and no reported deaths.^6,7 On the other hand, a partial capsulectomy removes part of the capsule, often the anterior portion.⁶ Total capsulectomies have been historically indicated when patients experience breast implant illness, complicated grade 4 capsular contracture, removal of textured implants due to risk of BI-ALCL, and/or patient preference.⁸ En bloc capsulectomy, or removal of the entire capsule in addition to some of the surrounding breast tissue, should only be performed for individuals with BI-ALCL.^9,10
 
For many years, the gold standard following breast implant removal was a total capsulectomy.¹¹ In a retrospective study of the medical records of 200 patients presenting with BII, the authors found that 96% of these patients noted symptom improvement or complete resolution of symptoms after total capsulectomy.¹² However, in recent years, total capsulectomies for BII and capsular contractures have been challenged. A patient safety advisory issued by Glicksman et al found that improvement of BII symptoms is independent of how much capsule was removed.⁸ Other literature suggests that there has been no proven benefit for capsulectomy.⁷ For example, a review by Swanson et al in 2021 reported that a capsulectomy has not shown to be effective in patients with capsular contracture, with 53% recurrence rates of contracture.⁷ Instead, researchers argue that total capsulectomies increase the cost and the risk of morbidity, secondary deformities, skin perforation, large wounds, nerve injury, bleeding, pneumothorax, muscle damage, rib pain, and hematoma.^7,10,11 
 
Recent studies highlight the importance of making an informed decision on capsule removal and understanding that less invasive options are available with less risk, cost, and morbidity. The senior author prefers to perform capsulotomy or partial capsulectomy when the patient desires implant removal. These minimally invasive procedures can successfully address contour abnormalities formed from calcification or excessively thickened capsule. Additionally, these procedures are viable options for enlarging the implant pocket to accommodate a larger breast implant.

The optimal surgical treatment for achieving patient satisfaction and aesthetic results after breast implant removal varies. The choices following breast explantation include simple implant removal alone, replacement with an implant, removal with mastopexy, lipofilling, or both mastopexy and lipofilling.¹³ In a retrospective study analyzing patients with implant revision surgery due to capsular contracture in Germany, mastopexy was performed in 61.7%, fat grafting in 54.7%, and no aesthetic treatment in 25.4% of cases.¹⁴ A study conducted by Hefel evaluating patient satisfaction in breast explant patients found higher patient satisfaction with less invasive procedures, such as implant removal, when compared with mastopexy with or without lipofilling.¹³ Additionally, a study evaluating patient photos after breast explantation for measures of attractiveness, symmetry, naturalness, and size found that fat transfer to the breast, or lipoaugmentation, was preferred on all 4 measures when compared with implant replacement.¹⁵ In comparison, a study evaluating outcomes for 20 patients with breast implant removal followed by mastopexy resulted in high satisfaction, low complication rates, and improvement in psychological and social wellbeing.¹⁶
 
Another factor to consider when optimizing aesthetic result following breast explant is the time for cosmetic breast surgery. A retrospective study of 720 patients who underwent breast explant found that 39.2% of patients had breast remodeling at the time of explant procedure.¹⁷ Mangialardi et al in 2022 described that one-stage mastopexy and lipofilling immediately following implant removal had high patient satisfaction.¹⁸ In contrast, Metzinger et al reported many patients did not want immediate breast implant replacement and decided for delayed replacement. This allows time for the tissue edema and inflammation to resolve, and a more informed decision to be made regarding potential mastopexy or fat grafting.¹² In addition, studies report that cosmetic construction should be delayed if patients smoke, have nipple elevation greater than 4 cm, and decreased breast thickness less than 4 cm.^17,19
 
In order to optimize patient satisfaction and aesthetic result following breast implant removal, it is important to perform a comprehensive breast evaluation for breast tissue volume, elasticity of skin, breast symmetry, and patient belief to determine type and timing of cosmetic breast surgery.²⁰

The secondary deformities that can occur following breast prothesis removal include breast deflation, loss of projection, breast/skin laxity or excess, wrinkling of skin, and nipple inversion.^11,19,21 Due to secondary deformities, a study by Peters et al found 33% of patients who underwent explantation alone felt disappointed in their breast appearance and 13% felt mutilated.²² Not all patients desire to have a concurrent or secondary procedure following explantation, and this can permanently leave this patient population with secondary deformities.
 
Seroma formation after breast surgery is defined as serous fluid collection that develops under the skin flaps or in the axillary dead space.²³ While seroma formation in the context of breast implant removal is not frequently reported in the literature, it is more often described as a complication of mastectomies.²⁴ According to Srivastava et al, drain removal within 24 hours post mastectomy can increase the risk of seroma formation during patients’ recovery. This could be problematic if the seroma becomes infected, potentially requiring  tissue expander removal depending on its location.²³ However, in cases like this where there is no prosthesis replacement, treating an infected seroma with aspiration and antibiotics alone is a plausible option. However, in our patient population we have not encountered such a scenario.
 
Multiple case reports have detailed that seroma formation post breast explant can mimic the appearance of breast implants,^25-27 highlighting the method proposed in this report. The anatomy of secondary deformities can be attributed to the expansive force imparted by breast implants resulting in notable deformities to the regional anatomy.¹⁹ Thus, forgoing drain placement after breast implant removal can increase the probability that a seroma will form in the breast pocket. The increased mass imparted by the seroma mimics the breast implant expansive forces to bridge the healing period post breast implant removal. Thus, seroma can minimize secondary deformity formation of implant removal without the need of additional surgery.
 
In the senior author’s experience, drain placement can worsen disfigurement of the breast, leading to contour indentations, nipple disfigurement, wrinkling, and pruning (Figures 3 and 4). This case report illustrates the ease, safety, and efficacy of using a controlled seroma with no drains, deformities, or revision surgeries necessary. This technique could be a great option for older women who no longer desire implants or further reconstruction. Anecdotally, the senior author has successfully used this technique in 9 additional patients. Further studies are needed to evaluate the safety and efficacy of this technique.

Figure 3: Intraoperative photo of female patient following trauma to the breast that required left silicone implant explantation. Drain was placed causing contour deformities and disfigurement by sucking the skin and muscle to the chest wall.  

Figure 4: Intraoperative photos of breast implant explantation. (A) Before bilateral removal of 330 Allergan NS subglandular implants versus (B) after bilateral removal of implants. (C) Deformity created by drain placement in the right breast directly compared with the left breast, where no drain was placed. (D) Close-up of drain deformity.