Questions to Ask Explant Surgeons
Please do your due diligence in asking questions to ensure a proper explant (full capsule removal through En Bloc or Total Capsulectomy).
1. Surgeon Background:
- Is the plastic surgeon board certified in plastic surgery and does he/she have medical board certification in their state? See American Board of Plastic Surgery and do a Google search of “Medical Board of [insert physician’s state].” How long has the physician been board certified in plastic surgery?
- Does the surgeon have hospital privileges? If so, at which hospitals? Has the surgeon ever had hospital privileges removed? Is the anesthesiologist board certified?
- Does the surgeon have microsurgery training?
- How many years have they been a plastic surgeon?
2. Can they do en bloc or total capsulectomy? How committed are they to having the capsule fully removed?
- Some surgeons interchange the two terms and can confuse them with capsulectomy (only partial capsule removal), make sure your surgeon understands the difference between them. Ask for a detailed step by step of the procedure so that you are both on the same page. Ask how committed the surgeon is to having the capsule fully removed as this will correlate with healing and is important so that you don’t waste money on a second surgery.
- Will the entire capsule be removed even if it is stuck to the rib cage and/or the Thoracoacromial vessels? Read more on Dr. Chun’s post.
3. How long will the surgery take? What will happen if the surgery goes longer than anticipated? Will everything still be removed and will there be any extra costs associated, such as for anesthesia and facility usage?
- If it is a proper explant of en bloc or total capsulectomy it should not be scheduled for less than 2 hours.
4. How many explants have they done recently or in the past month? How many explants have they done in the last year? How many explants have they done total?
- Please find a surgeon with at least 50+ explants so that there is a foundation of experience.
5. Will he or she be the only one operating on you or will there be anyone else, such as a resident student?
6. What type of incision will be made? What type of scarring is to be anticipated?
7. What kind of anesthetic is used and what is to be expected with it? What is added to the anesthetic, such as nausea meds and antibiotics? If you are MTHFR positive will that affect your anesthesia procedure?
- See MTHFR and Anesthesia for safer anesthesia and ones to avoid.
8. Do they use steroids and nerve blocks?
- These are not always necessary. Steroids are anti-inflammatory, they suppress the immune system. With implants we already have a weak immune system and so these may not be necessarily helpful to a quick recovery. Lyme ladies should also be cautious with lyme as by suppressing patients’ immune systems, this allows the Borrelia and other co-infections to grow, rather than allowing the immune system to attack the infections. Nerve blocks are also an extra feature and many surgeons may not need to use this.
9. Do they use the cauterization technique?
- This is a technique to control bleeding and is often used with those experienced in en bloc or total capsulectomy.
10. Will antibiotics be administered during or after surgery and what kind? Will antifungals be prescribed if needed? If pathology comes back positive for bacteria and fungi, will antifungals be prescribed then?
- Antibiotics often cause an overgrowth of fungi in the gut. Antibiotics and immunosuppressive drugs such as steroids are major factors contributing to higher frequency of fungal infections post surgery. Many of us with implants already have weakened immune systems and candida in the gut. Antifungals can be important for us to take with the antibiotics to mitigate the opportunistic fungi growth that accompanies antibiotics.
11. What kind of pain killers and/or nausea medications will be prescribed (intravenously during surgery and orally after surgery)? How will these affect constipation?
12. Ask the plastic surgeon to feel and look for masses, cysts, or any other possible anomalies once your implants and scar capsules have been removed.
13. What type of bandaging will be used (i.e. cotton or a polyester and synthetic blend–for people who may be allergic to synthetics)? How will the plastic surgeon apply your bandaging to minimize swelling?
- If you are concerned about having a reaction to the dressing, ask about another alternative (i.e. bringing a cotton sports bra to be used after your surgery).
14. Do they provide a compression bra?
15. Will drains be used, what should you expect with this, and who will remove them? What happens if a drain falls out early – will the surgeon put it back in (or will someone else) and is there an extra cost associated with this?
16. What kind of stitches are used and are they dissolvable or do they have to be removed? Will any foreign material be used such as staples, permanent stitches, mesh, etc.?
- Your body is already sensitized to chronic foreign body reaction from the implants, we highly recommend against all foreign materials.
Pathology & Pictures:
See Pathology page for detailed information.
Capsules and swabs should be sent to pathology, additionally, if necessary: a lymph node (if deemed oversized), and seroma/effusion aspirate (this is rare).
If you have implants and develop unilateral swelling, seroma, breast mass, or even capsular contracture, you should push for CD30 BIA-ALCL testing to rule out BIA-ALCL. This is especially important with textured implants.
17. Will your capsules be sent to pathology?
18. Will your surgeon take swabs of your chest and inside your capsule?
19. Can your surgeon sign off to have the swabs and capsules tested for bacteria, fungi, atypical cells, CD30, white blood cells, and foreign material (gel bleed)? How much will these tests cost you?
- You can request to have a very detailed pathology report, noting the following: Pathological lesions, if there is any foreign material (such as silicone), lymphocyte infiltration, chronic inflammation, and histologic features.
- If you have textured implants (saline or silicone) or polyurethane implants please insist for CD30 BIA-ALCL testing to be done on the capsules.
Update: As of December 2020, the ASPS is aware of 992 BIA-ALCL cases worldwide. It is widely accepted that there is a direct correlation between textured implants and the development of BIA-ALCL. There have been no confirmed cases of a BIA-ALCL in a patient with smooth only device, that is not to say it will not eventually happen.
20. If you have an enlarged lymph node filled with silicone what is their take on removing it? Is there a minimal lymph node size used to gauge the removal as necessary? Will it be sent to pathology? Is there an additional cost for having lymph nodes removed and for pathology?
- Removal of a lymph node is called a biopsy. Normally lymph nodes are no larger than 0.5 in (1.3 cm) in diameter and are difficult to feel. They can enlarge to greater than 2.5 in (6 cm). Lymph nodes are an important part of your immune system and they help your body to recognize and fight off infections. Conservative removal is advised.
21. If you have a rupture and there is silicone spillage and contamination in the chest, will they do their best to remove as much as possible? How will they remove it?
22. If seroma or effusion (fluid collection) is found will they aspirate and send the fluid and capsules for CD30 testing to rule out ALCL? How much will it cost?
- Breast implant associated anaplastic large cell lymphoma (BIA-ALCL) is a cancer of the immune system and knowledge base on it is still developing. There is a BIA-ALCL FB support group and currently there are 125+ women with the diagnosis. It is more commonly found in textured implants. Do not assume the doctor will test for fluid collection or send capsules off for testing, these can easily be discarded unless requested by the patient.
23. Will any video or pictures be taken? You can ask to see if the surgeon will video any parts of the surgery.
24. Ask your surgeon for pictures to be taken during surgery. The following pictures are some examples of what women have received from their surgeons:
- Implants with capsules still around it (if surgeon does en bloc)
- Implants and capsules, with capsules off
- Picture of inside your chest after full capsule removal
These are to ensure that everything was taken out.
25. Can the surgeon make note of the appearance and labeling on the implants, and record any identifying marks, characters or numbers?
Have Implants Returned To You:
26. Will your implants be returned back to you immediately after removal or at the postoperative appointment? Will they be left uncleaned if requested? Can they be shipped off somewhere at your request? If you have saline implants and the saline appears contaminated, will your surgeon have it sent off for testing? How much will the testing cost you?
- If you have saline implants, Mycometrics and Real Time can test saline fluid for mold and microorganisms.
- Implants are your property and you can arrange beforehand to have them returned to you. This can be important as you may want to inspect them yourself or keep them for any legal proceedings. However, if you are interested in legal avenues do not handle your implants; you must have them sealed by the surgeon, maintain a chain of custody, and keep them sealed so evidence is not tampered.
- Plastic surgeons may be offered free implants or get kickbacks when they return implants back to the manufacturer. This protects manufacturers from lawsuits. Some will say they can not return them or have other excuses, but there are also many who will return them to you. There is a government website where you can search if a doctor is getting payments from a manufacturer (such as fees in research, consulting, speaker, sponsor, etc).
Post-Surgery Related Questions:
27. What are the signs of an infection after explant?
28. What happens if there is a complication? Who can you call if you have problems or questions after surgery?
29. What are the pre-surgery and post-surgery directions? How many follow-ups are there after surgery?
30. How long will it take for your breasts to heal? What should you expect?
31. Can you have a copy of your surgery pictures, operative report, and any tests (if they are available) at your first postoperative appointment?
32. If there is a deposit, what happens if you have to cancel or reschedule the surgery?
33. Will your surgeon write a Medical Necessity Letter?
- Even if you don’t have insurance, which is usually the primary purpose of this letter, it maybe good to have for your records. For many of us this surgery is a medical necessity due to the debilitating severity of the symptoms.
34. Through which circumstances will insurance cover an explant? If applicable, will your surgeon’s office work with insurance? See insurance codes.
35. Ask the plastic surgeon if he or she is currently involved in any breast implant research. If so, what type of research? With whom? Who is gathering and analyzing the data? For what purpose? Ask to see a copy of the study or proposal.
36. It may be beneficial to get it in writing beforehand that full capsule removal will be done, get it signed, and make a copy for your own records. There have been instances where ladies thought they were getting a proper explant and then woke up from surgery and were told the capsule was left in as the surgeons had decided it was not needed to be removed. These ladies had to get second surgeries by other surgeons so that they could finally heal.