Trish: Hey chickies. We finally got Dr Gavin Sandercoe on, so I’m really, really excited because what Dr Sandercoe is going to cover today is what we couldn’t kind of get properly on the Facebook Live on Thursday night so, all about explant, breast explant, and implant surgery replacement, sorry, breast implant removal and replacement.
Dr Sandercoe: Okay.
Trish: So, thanks heaps for coming along.
Dr Sandercoe: That’s okay.
Trish: So, he’s now going to answer all your questions, I’ll just kind of, I’ll slide off, all right.
Dr Sandercoe: I’ll quickly talk about the three different types of implant removal. First one, the simplest one, is just removing the implant, leaving the capsule in, that’s a really good option in terms of cost and if your capsule is completely healthy and normal, leaving that behind is a good thing because it gives some stability to what the surgeon does after. So if they’re doing a lift or a fat transfer or placing another implant.
Next step up would be a partial capsulectomy, where we take out part of the capsule and that would really only be done, in my mind, for people that want some of the capsule tested, that have got a normal capsule, or people that want a muscle reconstruction that have got a normal capsule.
The next step up from there would be to do a complete capsulectomy, and that’s where we get rid of the entire capsule as well as the implant. But in a complete capsulectomy, you’re sort of, it’s assumed the surgeon is allowed to remove the implant to get the last bits of capsule out, because as you get, from the inframammary fold, as you get higher and higher up towards the armpit and towards the top of the implant it actually becomes very difficult to operate around the implant and it becomes a safer operation to lift the implant and then take out the rest of the capsule.
The last option, and the most aggressive option, is an en-bloc capsulectomy, where the implant and the capsule are completely removed, all in one piece. That’s usually performed for either cancer surgery or for women who believe they’ve got breast implant illness. Performing that operation requires having a longer incision. Although you can put an implant that is 12 centimetres wide in through a 4 or a 5 centimetres incision, you just can’t get one out through that incision. You need about 10 centimetres to get out a 12 centimetres implant.
From that point, you then start talking about how you are going to leave things alone, let it all settle, work out if you need another operation, or whether it’s safe to do a lift. Sometimes it is, sometimes it’s not. And, if you are going to do a lift at the same time, are you prepared, as a patient, for the inherent unpredictability as to your final breast result? When you’re removing implants, it’s like taking out the bottom floor, the bottom two floors, of the Great Pyramid and hoping that it’s going to land completely symmetrically right dead bang in the middle, so that when you do your lift, your nipples are in an appropriate spot on your chest wall as well as on your breast mound.
And my advice to patients at the moment is, don’t do the lift at the same time, let it all settle for three months, let us work out where your breast is going to settle down into. And if your breasts settle centrically, great let’s go ahead and do that. If your breasts settles a little bit on the low side, you may decide the shape’s actually quite good and you don’t want a lift. And then whether you’re going to have implants back in or not and whether you’re going to do a change of plane and go from in front of the muscle to behind the muscle. Or whether you’re going to try and use the same plane and have the surgeon either tighten up the pocket or put in a new bigger implant.
So, the questions that I was given last week before the first attempt at the Facebook Live were, can I have a reduction, lift and leave the implants in? Absolutely, yes. That’s completely safe. It gets done all the time. If you have implants in, you need to accept that your breasts are still going to age normally over the top of the implants. If you have an implant that is in behind the muscle, the muscle is going to act as a glide plane and it’s going to allow the breast to slide over the end and eventually become a waterfall or a Snoopy nosed. Now, for some women than might be 10 years, it might be 50 years, but age and gravity are things that plastic surgeons just can’t fight against.
I had a question of: if you remove the implants for good can you do a skin tightening or a breast reduction at the same time? So, yes you can do a breast reduction or a lift at the same time but your final shape is going to be unpredictable because there’s no way of knowing where your upper breast border is going to end up. You can always predict where a lower breast border is, you’ve got some chance of predicting the medial, or the closest to the sternum, breast border, not much chance of predicting the lateral, or the outer breast border and almost no chance of predicting where the upper breast border is. So, yes you can do it. In my patients and the way that we do the costings in my practise, it’s actually cheaper to do two stages. That’s just because if we do it in two stages, you’re using two Medicare item numbers at a time, which means you get more money back from the government.
I’ve got a question that says, does your skin look loose or saggy after taking the implants out, if the skin has been stretched to accommodate the implants? Yes, that can be the case and that’s one of the reasons that we often leave patients for three months before trying to do anything more again. I think that the number of women that get to three months after their explant operation that go, “Hey, you know what, this is okay, I’m okay with this breast shape, I don’t need a lift anymore, I don’t feel the want for it,” even though they know that it’s going to be cheaper than having had it done all the first time, I think more than half of them don’t go through with having a lift operation afterwards. And that’s because some skin will retract and some skin won’t and, you know, you can’t predict that.
I’ve got a question with some photos and that was about whether a breast structure still has its under breast fold and that’s just because the surgeon misplaced that lower scar, should have been a centimetre lower, but some of it can be fixed under local anaesthetic if you need it be done. It’d probably be more comfortable to have it done under a quick sleep, or a general anaesthetic, but it can certainly be done under a local if it was absolutely necessary.
So, we have some anonymous questions, “I’d like to have my breast implants removed and I want them replaced, but is there any benefit to waiting six months to put your new implants in?” That depends on what you’re doing and how you’re doing it. If you’re going to use the same pocket, if you’re behind the muscle and you want to stay behind the muscle and you want to downsize? Absolutely, there’s lots of good reasons to wait that six months. If you want to stay in the same pocket and up size? Less good reason. If you are looking, if you’re someone that has recurrent capsular contraction, somebody that no matter what we do, you know, you always get a capsular back. I’ve seen a few of those girls that have seen myself, as well as other surgeons, and kept of going down the pathway of implants out, implants in at the same time. Characters of that capsular contracture, suggest there’s a biofilm or a low grade infection that contributes, if you don’t give your body time, without an implant, to get rid of that stuff, that’s in your chest wall, it’s going to keep coming back. So, it depends on your situation as to whether waiting six months is a good idea or not.
“Does insurance or Medicare ever cover the removal of implants?” Yes. So, there’s about three or four item numbers, or Medicare codes, that cover removal of implants. They usually stipulate that they’re a removal of implant only, or removal or implants with the complete capsule, or a removal of implants with capsular [inaudible 00:08:50] and replace the implants. Now, if you’ve got health cover that covers that Medicare code, you will get implants removed and if your implants need to go back in, or you’re choosing to get the implants back in, your health fund should cover the cost of the implants themselves. So, Tracy just asked, that’s what she had right? I think that’s correct Tracy.
“How much recovery time do I need to plan for time off after your implants are removed?” Again, that depends. So, if you’ve got implants that are in front of the muscle, you probably really need a couple of days to a week. If you’ve got implants behind the muscle and your surgeon is doing a muscle repair, and that’s part of what I do normally for my patients that have behind muscle implants, you’re going to be sore for a couple of weeks. And if you’re going back to a desk job you’re probably going to be okay in a week, or going back to heavy lifting, or if you’re a nurse who moves patients round, or you’re a labourer, you’re probably going to need like three or four weeks for that muscle repair to start being solid so you can use your chest again. I normally tell patients six to eight weeks to let that repair get nice and solid before they go to the gym and start doing pec workouts or push ups or anything like that.
“How much does a breast implant removal cost?” Now that’s a big of a how long’s a piece of string. For somebody that just wants the implants out, capsule not touched or just a segment of the capsule taken for testing, that’s a pretty quick operation so that’s a much faster operation than somebody that wants an en-bloc muscle repair, all the bells and whistles, you know. So, it depends exactly what you’re asking your surgeon to do as to how expensive the operation is likely to be.
“How does the removal procedure work?” So, I normally use the same scar that the implant was put in through, as a preference. However, if you had your implant put in through a periareolar scar, or a scar around the nipple, or a transaxillary scar, or transumbilical, for people who have had salines put in in the States by those guys, that’s not acceptable scar to do a proper removal operation with. So I always use an inframammary scar.
The length of the scar is determined by how much work you want me to do. If I’m just removing the implant only, I’m going to just use exactly the same length scar that you’ve got. If I’m doing, if I’m doing removal of scar and a partial capsulectomy, I can usually do that through whatever scar you’ve currently got. If I’m doing an en-bloc, I need that scar to be about 2 centimetres shorter than your implant is wide. So, if you’ve got a 10 centimetres implant in, I need about 8 centimetres, if you’ve got a 12 centimetres implant in, I need about 10 centimetres. The scars in the inframammary fold are usually pretty good. I’m struggling to think of a patient that has had a bad scar there. And that includes my local Indian population, that includes Asians.
I really don’t quite understand the need for some people to use a periareolar scar, which means that you have to put your implant either through the breast gland or around the breast gland and potentially contaminate it. Or through the armpit, which is a dirty area. I mean, really, would you eat a chocolate bar that someone had shoved under their armpit? It’s an area that has got sweat glands, it has got different bugs that live in it. To me, it sounds crazy to pass implant through that area.
So Natalie has just asked healing time. So, if you go back, yeah, look two weeks is about normal for recovery for somebody that’s going to go back to an office job, that would be very reasonable.
Alright, “if you have the implants removed because of possible leakage or leakage eruption, how does the surgeon ensure he gets all the implant out?” So, because your implant will have a pocket, your surgeon will scoop everything out, you can tell if you’ve gotten all the implant out. Getting all the silicon out is sometimes a little bit harder. Now, if you’ve got an old school implant. So, a third generation implant where the gel is thinner, more like Caramello Koala than Turkish Delight, then your surgeon needs to work a bit harder to get that out. So, I normally wash the pocket out with Chlorhexidine. Chlorhexidine is an antiseptic that we use on the skin sometimes but it’s also a really great detergent, for lack of a better word. It sort of mops up that loose silicone, helps you get it out. If you’re having a complete capsulectomy, anything that is attached to the capsule will come out with it and that helps things along.
“Do you do checks, tests for ALCL automatically or does the patient have to ask?” Any time that a surgeon sends a capsule away to the pathologist, they will test that capsule and they will look at what the cells are in that capsule. A normal capsule is made of mostly fibreglass and collagen. If the pathologist sees white blood cells or lymphocytes there they automatically will test for CD30 and all of those markers that are involved in ALCL. Asking for a CD30 test on a normal capsule, I can ask for a pathologist to do it, but it’s sort of within their rights to say, “I won’t do it,” because it’s a complete waste of time. If they can’t see white cells in the capsule, you can’t have a white cell marker taken up in the capsule. It’s like looking for a shark swimming around the ocean in the middle of the Sahara Desert. If there is no ocean there, there can’t be a shark.
There’s a question on there about which hospitals I operate at. I will operate at Norwich Hospital in Sydney.
And Gwen’s just asked, that she’s had an explant and replacement and the left nipple points out a bit, will that resettle and point forwards over time? Possibly. The brand of implants that I use, I’m a Mentor person, I like their gel, I like their texturing, I think there’s increasing evidence that micro-texturing is a fairly safe option. Majority of my implants are teardrops, so I like to have some texturing and at the moment there are no smooth teardrops on the market. Although you could probably argue that the new Motiva is essentially smooth, I’m not sure how I feel about that because I don’t really want to put in a teardrop that doesn’t have the texturing to stop it from rotating and I might change my mind in a little while, you know, once I get some experience with the Motiva brand, as rounds.
And my current philosophy on that is – the European regulatory boards and the Australian regulatory boards were terrible at pointing out some of the implant brands that have come and gone, including PRPs. So I work on the theory that an implant has to get through the USFDA testing process and then I’ll start thinking about it. So when Motiva get through USFDA testing, I’ll probably start having a think about using their rounds when I need to use rounds because I think that their nano-texturing offers some benefit over a straight smooth. But I think it’s going to be a very long time before I’m accepting of nano-texturing as an option for a teardrop shaped implant.
So the next question that was here is, “Can you always tell if the implants are contaminated and, if so, what happens then?” So, a normal capsule looks like thin, filmy, wet tissue paper. It’s a single layer of collagen that’s wrapped around the implant, you can see through it, so in a normal capsule I can look through, I can see, it’s just like a sheet of contact over your ribs, it’s like a sheet of contact under your muscles – I can see all your muscle fibres. As soon as that starts to thicken up, it becomes like cardboard. As soon as it’s cardboard you know that you’ve got capsular contraction. Whether or not you can feel it or not, you’ve got a capsular contraction and that means that there’s some biofilm there. I have never had a normal looking capsule sent to the pathologists and had the pathologists write back to me and say there’s something wrong with this capsule.
The word contaminated makes me want to talk a little bit about the discussion that happens in some of the breast implant illness groups about bugs, and parasites, and funguses on capsules. Now, if you have a complete capsulectomy, whether it is an en-bloc or an implant complete capsulectomy, anything that’s on the inside of that capsule comes out with the capsule anyway. So swabbing it, testing it, is going to add nothing to your treatment, so it’s sort of like me saying, “I’m going to shell out an abscess but I’m going to make you have antibiotics anyway.” From a surgical perspective, there’s just, there isn’t any logic to doing it that way.
Natalie has just asked, “Do you have to take the capsule out?” If you’ve got a normal capsule, there is no reason that you have to take it out. It would make sense for –
“What situation would you leave the capsule in?” Look, I’d leave the capsule in if the capsule is normal, if the patient didn’t want the capsule out because they were trying to save money by making sure that their operation was as fast as possible. I’d leave parts of the capsule in, even for people who want it out, if it means that I need to mutilate them. So, if I need to destroy their pec major muscles to get out a capsule that looks normal, I tell my patients I’m not doing that, I’m not up for that, I’m not going to mutilate you for what looks like a normal capsule. I’m not going to take out a chisel and break your ribs to get out a capsule that is normal. An abnormal capsule that is thick and looks like cardboard, comes out easily, they always come out easily as soon as they got capsular contracture. It’s normal capsules that are difficult to get out.
So the next question was about leaking contamination ALCL. So, ALCL is a problem, what you need to remember about ALCL is that it is a very, very rare complication of having breast implants. We don’t really have all the answers as to why it happens yet but current theories are that it might be due to micro-contamination, or a biofilm. It might be due to constant irritation from texturing and that constant little jiggling and moving that happens with anything that’s got some grip.
So, at the moment, the ways to prevent ALCL are to either smooth implants only, which have got other problems, and/or, do everything that you can to prevent biofilm. And the standard 14 point plan that was put out by the US and the international task force that included who has done a lot of research on biofilm, that’s standard practise for most plastic surgeons now anyway. With macro-textured implants, so Biocell implants or implants, that’s your highest risk, and you’re probably based on the most recent evidence probably at about one in five thousand. So, your risk is far, far less than your risk of having normal breast cancer.
I’m assuming that everyone watching is Australian, because the forum is for Australian girls. Your risk as an Australian woman of having breast cancer is about one in eight. So, if you look around, you know, the classroom that you’re in, or the bus that you’re in, there are going to be a few people around you that may have breast cancer in their lifetime. If you look around the town that you’re in, one of your or two of you in the entire town, or the entire suburb, might get ALCL if all of you have got implants. If you’ve got a Mentor or a micro-textured implant, your risk goes down further and there was a recent paper that put the risk at about one in sixty thousand. And if you’ve only ever had smooth implants, to date there have been no reported incidents of ALCL with, in a woman that has only ever had a smooth implant. There has certainly been instances where women that have had a textured implant in and it’s been switched out to a smooth that have had ALCL later. There are a couple of reports of that.
So, you know, it is one of those things, you’re sort of, textured implants are there because they solve some problems but they’ve created an ALCL problem. And, you know, one of the things that we may find in the future is that people are going to Motiva and the nano-textured implants that have got, to date, no ALCL cases. I would also put out that Motiva is a relatively new brand, it’s fairly widely used in Europe. It’s a newcomer in the Australian market and the New Zealand market, so I don’t think we have the same length of follow up at the moment with that. So, I can’t be certain that they are going to be part of the solution of the ALCL problem.
Natalie has asked, if I had a 20 year old daughter that wanted breast implants, would I be okay with it or would I talk her out of it? At the moment, I would say yes. I would be okay with it but I would make sure my daughter knew exactly what she was getting herself into. So, you know, going in one day and seeing a surgeon and getting some implants in is not going to be the way that things need to be in the future because everyone needs breast surveillance, you don’t give up looking after your breasts and having ultrasounds and mammograms and all those sorts of things, you do need to watch what’s going on.
Now, if I had a 20 year old daughter that wanted breast implants more importantly, which implants would I be happy with her having and where would I want her to have them? Now, again that becomes a question about risk management and lifestyle. So, most people know that I’m a triathlete, my family all does triathlon. If my daughter wanted to be a triathlete and wanted to continue swimming, I would advise her that one – implants are a dumb idea whilst you’re doing a sport, unless you’re super thing and you’ve got nothing there because every girl that’s got more than a C cup tells me how difficult it is when they run.
If you go under muscle, you’re going to lose some muscle strength. So if you’re a swimmer or a climber or anything like that then you’re going to have some loss of strength, but your trade off for that is that your capsular contraction rate, and some of your other problems, go down. Now if you’re okay with the idea of knowing that going in front of muscle gives you more risk of nerve damage to your breasts. If you’re okay with the idea of going in front of the muscle, is going to give you a little bit more implant visibility, especially if you’re more thin. If you’re okay with the idea that going in front of the muscle is going to give you a slightly higher capsular contracture rate, then go for it. I think that in front of the muscle is a good option as long as you understand all of those risks as part of your informed consent process.
I would also try and encourage my 20 year old daughter to think about not having breast implants until she’s had a family. You know, everyone that’s a Mum knows that pregnancy ruins your body, you get one chance at fixing it well, if you have got implants in and they stretch the skin and then you add on breastfeeding and lactation over the top, you’re going to get a second round stretching that skin, that might give you stretch marks that can’t come out and will not go away. Whereas if you leave your breasts completely natural and then refill afterwards – absolutely.
The bigger question later is, would you do fat transfer in a 20 year old girl? I don’t think that the answers are completely out on that one either. So, what we do know is if you’ve got adequate fat stores, fat transfer is a really good way of going up another cup size each time you do a fat transfer. I think that the Brava external expansion device is getting harder and harder to find in Australia. The distributor from Brava gave up for a couple of years ago, so if patients want Brava now we need to try and get it directly from the States for them.
I think that fat transfer has proven to be safe, it’s proven to work, it’s a little bit unpredictable. We know that it does not increase your rate of having a recurrence of the breast cancer if fat transfer is used as part of your reconstruction. What we do not know, and we won’t know for a couple of decades, is if you do fat transfer for a thousand 18-20 year old girls, does that change their breast cancer risk over their lifetime? And, we might find in 20 years time, if you inject a thousand 20 year old girls with their own fat, that their breast cancer risk goes down but we might also find that it comes up. And if we change somebody’s risk of breast cancer from one in eight in Australia at the moment, to one in six, is that an acceptable risk to take on when implants are adding on a risk of one in four thousand of ALCL?
So, I think we’re a good 20 years away from having a solid answer as to whether fat transfer changes long term breast cancer risk. And, I don’t know, if my 20 year old daughter wanted fat transfer to her breasts I think I’d probably be more accepting of that than an implant, in terms of overall things, cause at the moment we just don’t know.
Did you have other questions?
Dr Sandercoe: Good, perfect. Pretty much spot on 30 minutes.
Trish: Slide back in. Thanks ladies that was awesome. So if you want to get a hold of Dr Sandercoe, you can just go to www.drgavinsandercoe.com.au or just DM us and we’ll send you a link to the website. So thanks so much, that was awesome. And sorry for all the background stuff but we’re here at a conference in Melbourne and people going back and forwards, but yeah, sorry! Bye.
Dr Sandercoe: Alright, see you.