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, meaning they have an immune response to the implant, regardless of whether their implant is silicone or saline, smooth or textured. Current research suggests that this occurs because implant shells break down over time, allowing silicone particles to leach out and resulting in chronic immune activation. The placement of implants can also allow infectious agents, such as bacteria and fungi, to colonize the space between the implant and the capsule.
What is an en bloc capsulectomy?
En bloc capsulectomy is a type of breast implant removal surgery where the implant and the scar tissue around it (capsule) are removed together in one piece. The term “en bloc” is literally French for “in one piece.” Modern terminology further clarifies whether the capsule was removed completely (total) and whether it remained intact.
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.”
Why is an en bloc the preferred method for explant surgery?
En bloc is the cleanest and best way to ensure that nothing contaminates the healthy tissue left behind. This is ideal for patients who have BII symptoms or other symptoms associated with breast implants.
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 remain after scraping and washing with an 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 explantations 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 encourage you to follow your primary care physician’s guidelines. It is a good idea to have a new baseline mammogram following your explant surgery, but you should wait 3–9 months after your surgery to have that done.
We perform our own ultrasound during your consultation if Dr. Strawn feels 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 aged 65 or older require an EKG. Anyone with an abnormal EKG or other serious medical conditions requires 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 several factors, including the chosen surgery and any add-on procedures. The size of your breasts, the capsules’ adherence to the chest wall, and the 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 perform so much fat grafting, we are experts in breast and body contouring, including liposculpting, tummy tucks, brachioplasties, and labiaplasties. We also perform fat grafting to the buttocks, 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 Orange County, so we have you covered for the post-surgical process. Surgeries are performed on Wednesday, Thursday, or Friday. Pre-operative and follow-up appointments are on 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 perform all surgeries at the Galea Center for Advanced Surgery, which is 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 displayed in the office during 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 during surgery to prevent the accumulation of seroma (body fluid). We want the implant space to completely disappear, leaving you without an encapsulated pocket of fluid that can create new 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 drain hub and remain in place 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!).
Will you use cautery during surgery to reduce bleeding? How will you control bleeding or blood clotting if necessary to do so?
Yes, I use bipolar electrocautery to reduce bleeding during surgery.
Which anesthesiologists do you use?
We use a select group of anesthesiologists from the Newport Harbor Anesthesia Group, which covers all of the Hoag operating rooms. 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, for 4–5 days. There is mixed evidence regarding the efficacy of prophylactic antibiotics, so we support patients’ decisions to refuse their use. However, we have had zero infections after over 1,750 explantations, so we will continue to use antibiotics as our first line of defense. Our first-line therapy is Doxycycline; however, we offer other options for those with allergies.
What pain medications will be prescribed after surgery?
Our priority is baseline pain control after any surgery. Our regimen is to take 2 Tylenol upon waking from your post-surgical nap (or, if you don’t take a nap, when you are first ready to try to eat). Then set your phone alarm for 3 hours, at which time you will take 2 Motrin. 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 explantation. 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 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 tissues that will collapse “like a circus tent” without reshaping with a breast lift (mastopexy) or volumizing with fat grafting.
Unfortunately, delaying fat grafting can have consequences, such as permanent creases in your breasts from adhesions that may be more difficult to correct later. Fat grafting does add more cost, more surgery time, more post-operative pain, 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 a board-certified plastic surgeon, 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 nine 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 periareolar scars. While en bloc has been accomplished through these incisions, it is challenging and often results in a total capsulectomy 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 3rd to 5th ribs and intercostal muscles. If the capsule is tearing, we make every attempt to keep the capsule and silicone outside the body, suction the silicone from the capsule, and then complete the total capsulectomy.
If you are dealing with a ruptured silicone implant where silicone has traveled to the lymph nodes, do you check the lymph nodes for silicone through ultrasound and localization techniques, and do you remove lymph nodes that cannot be saved?
If silicone has leaked into your lymph nodes, you may experience inflammation, pain, and swelling in the armpit region. If you suspect this has happened, you’ll need to make an appointment with your primary care doctor or a general surgeon for a biopsy and removal.
If I see any abnormal, concerning tissue, including a lymph node, during surgery, I will remove it during the en bloc process and have it evaluated by pathology for your safety.
Do you repair the pectoralis muscle if it is cut from its origin on the sternum and ribs?
Dr. Strawn began repairing every muscle in early 2018 after seeing the results of not repairing muscles in one of his explant patients. He is now a strong proponent of repairing every muscle and restoring the anatomy 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 surgery, do you aspirate the fluid and send it for testing 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 surgery. Treatment of ALCL includes a total or en bloc capsulectomy, another reason to make it a standard procedure.
Do you use any foreign materials during my surgery, such as staples or permanent sutures?
No. We use only absorbable sutures, such as PDS and Monocryl.
Do you prescribe medications to be taken before surgery?
No. Your anesthesiologist may prescribe oral medications to take 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 fungi with PCR or Tissue Cultures?
Yes. This is elective, but provides interesting information. Because it involves an extra charge, we do not require the testing. We have already treated the biofilm, bacteria, or fungus by performing en bloc capsulectomies and administering 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 capsule. We take videos and photos, which are available to the patient at any time. In the video, we discuss the procedure, findings, volumes, and outcomes. This video serves as an additional source of medical records.
What is your follow-up process for appointments?
We like to see you often after surgery. Here is our standard follow-up procedure:
- First week post-op (Days 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
Can I have a copy of my complete file, including operative reports, images, and test results, at our first follow-up meeting?
Yes.
Will you return my breast implants to me if they are 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 the medical waste facility.
Will you pack up and return my uncleaned implants and capsule tissue to me if I request?
Yes.
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 possible with any surgery. We have extensive consent documents that cover everything from poor scars to possible death. The most common complaint with 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 it does not get everyone to their dream breast size.
Are there additional costs associated with irregularities and adhesions?
We provide scar revisions and Riggotomies (to minimize the appearance of adhesions) at no additional cost to the patient. Breast deformities and adhesions are more common when no reconstruction is performed. Delayed breast lifts and/or fat grafting may be necessary and will incur 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 (neither too much nor 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 enlarge the breast, stretching the breast tissue and permanently changing its 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 remaining breast tissue, while also 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 the explant surgery?
Yes. This is a good time to perform mastopexy (breast lift) reconstruction, as it can help prevent significant folds, scarring, 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 the 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 around 60%, which is also the overall breastfeeding 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 surgery. Scar quality and visibility depend on postoperative 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 differ significantly. 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 lost volume, reshape deformities, improve cleavage, reduce asymmetries, and fill deflated tissues. We have had excellent results with immediate fat grafting, and these patients are among our happiest.
If patients choose 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 waiting period after explant surgery or between rounds of fat transfer.
How much fat do you typically transfer on average?
The volume of fat transfer depends solely on the breast fat layer and varies from patient to 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 the 360-degree trunk, which includes the abdomen, flanks, and back. We also harvest fat from the thighs and arms as needed.
What type of liposuction do you perform?
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 risks 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 see anything more than a small pea-sized area of fat necrosis or an oil cyst (which is easily treated in the office free of charge). Contour problems from lipo-sculpting are a potential risk but rarely occur; when they do, we have ways to correct them.
How many fat transfers have you performed?
Dr. Strawn performed his first fat grafting procedure in 2013, over 20 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 ways you can maximize your health before your surgery. Diet, exercise, hydration, and sleep are always the first priority. Minimizing anything that will cause illness or inflammation. Try not to get sick—consider wearing a mask in public areas. Minimize gut inflammation—limit your diet to whole foods, vegetables, and healthy protein sources. Breast Implants (the shell, the silicone, or infection agents inside the capsule) are causing inflammation. This will be removed during your explant surgery. But it’s 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 reported feeling 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 reduced systemic inflammation.
Overall, we have very happy patients. Everyone sees some improvement, and the majority experience a dramatic improvement in health. 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.