Monique Ramsey (00:02):
Welcome everyone to The La Jolla Cosmetic Podcast. I'm your hostess, Monique Ramsey. Today I have Dr. Luke Swistun in the studio. He is, I would say, an expert on implant removal, also known explant. But what we're going to talk about today is capsulectomy, what that means and what are the different types of capsulectomy because this has become such a popular surgery and more and more women are, maybe they had their implants put in 20 years ago. They're not really, they don't want them anymore. Maybe they're having some symptoms. So for any number of reasons, a lot of women are deciding to take their implants out. And then there's this decision of the capsule that's surrounding the implant and what's the approach? Do we take the whole thing out, leave part of it? So we're going to go into that today. I think it's going to be really, really interesting. And so welcome Dr. Swistun.

Dr. Swistun (01:02):
Thank you for having me, Monique.

Monique Ramsey (01:03):
Yeah, you're welcome. Well, it's great to have you in the studio. Okay, so it's time to take out the implants. Maybe they're actually symptomatic with the capsule itself being sort of hard and contracted and they look sort of deformed or maybe they're having symptoms of BII or breast implant associated illness. And so whatever that reason is going in, let's talk about the main types of capsulectomy or techniques that you have and what the differences are.

Dr. Swistun (01:38):
Well, thanks for that introduction. This conversation really stems from patients requesting an en bloc, particularly the patients who are self-identifying as breast implant illness patients, patients who are thinking that the implants are making them sick. This is the patient population that I treat a lot of. I wouldn't consider myself an expert per se. I think any plastic surgeon is capable of treating these patients. However, there are some of us that treat a lot more of these patients than others, and we have a lot more experiences with those patients. And I think I'm sort of in that position. But the en bloc capsulectomy, that's the most commonly requested surgery, surgical procedure by these patients. What does that actually mean? The en bloc capsulectomy is a term that's sort of originated in these support groups in these online discussions about patients who are self-identifying as breast implant illness patients.

(02:30):
And the thought process was that in order to cure breast implant illness, the implant has to be removed, but also the entire capsule has to be removed with the implant still inside with the implant material still inside if the implant's ruptured so that there's no contact with the implant with the rest of the body. This is not necessarily true, but this is what the breast implant illness community support networks really believed. And then basically because of that, a lot of surgeons were getting these requests, patient presenting and asking the patient, asking them basically, can you remove my implant and capsule en bloc? That presented a couple of different issues for us as surgeons because the en bloc capsulectomy technically does not apply to this surgery. It's been used like that for a long time. But an en bloc capsulectomy, what that really means is that comes from the world of cancer.

(03:23):
The cancer surgery specifically, what en bloc really means is that it is removal of surrounding tissue around the problem area in order to get the whole problem area out. So it's the appropriate discussion when in the context of cancer. Let me give you an extreme example. If you had pancreatic cancer, if a patient had pancreatic cancer, that is a very deadly cancer. And we know that the best chance of survival for a patient with pancreatic cancer is to take five centimeters of margin around the cancer itself. And that's the priority for that cancer surgeon. It doesn't matter what is in that five centimeters because there's going to be a lot of collateral damage because the pancreas right in the center of the body. So it can be next to the colon, it's next to the liver, it's next to major vessels, it's next to the spine sometimes, and it doesn't matter.

(04:11):
The surgeon will take all of those tissues and cut into all of them in order to get the cancer out in order to give that patient the highest survival rate from pancreatic cancer and then will the deal with the collateral damage later. Now, obviously when we're talking about implants, that may not necessarily apply in the same extent. So the en bloc procedure is more of a cancer term, but an implant isn't as dangerous or as unpleasant as it is to the body, and it can have systemic effects, but it's still not cancer. So we should treat it slightly differently, I would say. So I think what the patients really meant is that when they were asking for an en bloc capsulectomy is that they really were just wanted to get the entire capsule out, all the scar tissue associated with the implant, but minimize the collateral damage around that capsule.

(04:56):
So if you talk about the patient to these patients about is this the intent? They'll be like, yes, of course. I don't want my muscle to be cut into, I don't want my breast tissue to be cut into. I don't want my chest wall to be cut into, I just want the capsule out. So the term for this didn't really exist because this wasn't the surgery that was done. I mean, total capsulectomy is a term that's out there, though plastic surgeons have used for decades that first to removing the entire capsule. But there was not really a definition of like yes, but the entire capsule all in one piece with the implant still inside, what do you call that? So recognizing the outcry of these support groups and all the breast implant illness communities and rallying around this term, the plastic surgery community has finally sort of responded, which I think is great because it shows, that's another example in the recent history that they're actually paying attention.

(05:50):
I have a lot of respect for this en bloc term that is out there because right or wrong, it was a term that allowed the support groups to sort of collaborate around a certain concept and use that as one of their means of the terminology that they used in order to support each other and ask for the correct interventions. It's not the correct term, but I would argue that the doctors didn't provide the correct term. So the support group sort of invented their own, and that's what we got. And like it or not, right or wrong, it's there and it's something that we sort of have to acknowledge as the patient's effort to help themselves before we really stepped in and help them. But again, like I said, I have all the respect in the world for that term because it really brought forward the problem and put it on the forefront.

(06:40):
And we are where we are today because of that effort by these support groups more than anything. But there was a sort of a consortium, the Breast Surgery Collaborative Community Consensus, which is kind of a copy that I have right here. And this is a consensus, it's a discussion between the American Society of Plastic Surgeons and the Aesthetic Society to sort of address these issues of terminology in this context. And one of the things that they've noticed is that the en bloc term is getting thrown around a lot and it's used inappropriately and not in the context of cancer surgery, and it's being dictated into patient operative reports by surgeons when what's being done, and it's just kind of misleading. So what they've done is they sort of agreed on the correct terminology. So the new term that they came up with for what my patients are asking for is actually a total intact capsulectomy, which makes perfect sense because what we're going for is we are removing the entire capsule intact as in the whole capsule is there and the implant's still inside.

(07:40):
And that's basically what that is. And we're trying to minimize the collateral damage to the surrounding structures to preserve the patient's function, otherwise once the capsule was removed. So that is the term that the community has now agreed on as the appropriate term for what I'm really doing for the vast majority of my patients, what they're asking for. I'm still performing the same surgery that I used to perform, I'm just calling it something a little bit more technically appropriate. So that's the big term that they released. The other term that they released recently is basically a total capsulectomy or a total precise capsulectomy, which they define as complete removal of the breast implant capsule, but not necessarily done as a single unit or in one piece, which I also agree with. That's also something that I do pretty frequently if I can't get the entire capsule out in one piece, because let's say it's dangerous.

(08:29):
Let's say the capsule is sort of in the way of me seeing the anatomy very well, and there's a risk of me kind of cutting a little bit too deep and maybe going through the intercostal muscle and into the chest where the lung is, I don't want to do that. So occasionally what I'll do is I'll remove the vast majority of the capsule with the implant inside as one piece, and then there will be a small piece left over on the chest, which I will then go back for under direct visualization so that I can minimize the collateral damage to the surrounding structures under that one piece. But this way I can see it better once the implant's out of the way, once the capsule is out of the way, so I can be a lot more precise in this dissection. So that's what a total precise capsulectomy refers to in their terminology.

Monique Ramsey (09:11):
And I would think even on the same patient, you could have one in one, you might be able to get the whole capsule out of the left breast correct. And then you go into the right breast and maybe something's adhering down to the chest wall or something.

Dr. Swistun (09:26):
That's exactly right. It's all about safety, honestly. I want to get the entire scar tissue out, but I think the most elegant way to treat that condition with patients who have, let's say, capsular contracture, obviously that's an indication to get the entire capsule out that and of itself, but even patients who don't necessarily have a capsular contracture, I think if you're already in there and if it's safe to do, and if you can do it precisely and without a lot of collateral damage, then it's still the more elegant thing to do is to remove the capsule. Sometimes you can't though sometimes, and there's a few occasions where I definitely left some capsule behind, and again, those were decisions that I made with the patient, pre-op usually, and then also during the surgery in the interest of their safety. So to give you a very extreme example, there's a patient that had multiple breast lifts in the past and she had all these incisions in her breast.

(10:13):
She was very thin, the tissue was very thin. And when I got in there, I saw that the capsule, which was very thin, was literally immediately over the artery that is supplying the blood flow to her nipple. And I knew that if I cauterized that capsule off of the artery, I will damage the artery and the nipple will die. That would be an instance where I would not necessarily take that sliver of capsule over the artery. I'll probably take out 95% of it everywhere else, but that little piece of capsule I would leave behind to preserve her function, her form, her nipple, basically. And usually we can identify upfront that there's a patients that present in certain ways and just by their history and by their physical exam, we can have that discussion prior to the surgery.

Monique Ramsey (10:51):
Oh, interesting. So you might know somebody who might be a partial even before you get in the OR.

Dr. Swistun (10:59):
Yeah, a vast majority of the times I was able to actually have that discussion prior to going into the or I'll tell the patient, we may not be able to get it all out in the interest of your safety, are you okay with that? And the patient said, yes, do your best. Good to go.

Monique Ramsey (11:11):
Is any of the imaging, the breast implant ultrasound, does any of this ahead of time help or clear a path for what you might do in the or does it not matter?

Dr. Swistun (11:25):
It usually does not change my management. I think imaging is important to make sure that we're not dealing with cancer. So let's say we typically, I always advocate screening my patients on time for routine breast cancer screening, which isn't necessarily a mammogram. I actually tend to favor ultrasounds because a lot of patients with breast implant complications such as capsular contractures, they will basically refuse to have a mammogram because those are extremely uncomfortable. And then there's a lot of patients who also don't want to be exposed to continuous radiation every year because that in and of itself can also predispose them theoretically to higher rates of cancer, which has not really ever been shown in this context, but logically, that's the extrapolation that they made, which is not unreasonable. But anyway, ultrasound is another option. There's lots of centers of excellence for imaging right now that can offer a patient 3D ultrasounds, which can be perfectly adequate for breast cancer screening, for routine breast cancer screening.

(12:22):
And that's how I use those studies is I just want to make sure that we don't have sort of like something that's suspicious for cancer in the breast that I'm about to operate on to remove an implant. Because if we identify, let's say hypothetically that there is cancer in the patient's breast and we pick it up on screening imaging, there's a whole very well documented evidence-based protocol of how to deal with that cancer, which is basically, well, it's suspicious, let's get a biopsy. Okay, the biopsy, it is positive for cancer, but we measured it on the ultrasound. The lesion is only less than a centimeter in size, so this patient can just have a lumpectomy rather than a total mastectomy with radiation. And that would treat their cancer. Versus the other option that let's say we forget about the imaging. Let's say we ignore it, we don't do the imaging, and then I do breast surgery, and then obviously I take the capsule out and maybe some breast tissue out if it's a lift, and then we submit all that for pathology because that's what we do as a standard. And then the pathology comes back two weeks later and says like, Hey, you know what, there's actually cancer in this specimen and we don't know where the rest of it is because you just rearranged the entire breast. So in order to treat the cancer that's left behind after your surgery, the only option for this patient now is to have a total mastectomy. She's no longer a candidate for a lumpectomy or something else. So that's a situation I've never been in, but that's a situation I never want to be in. So I really do advocate screening as indicated based on the patient's age and risk factors. And once we have a good imaging that says, yes, we saw everything we needed to see and there is no suspicious lesions go ahead and proceed. That basically minimizes our likelihood of having a surprise like that on the other side of surgery.

Monique Ramsey (14:11):
In terms of percentages, the partial, you said you don't see that very often. More often it's going to be the total precise or the total intact. Is it like 5% where you can't get the rest of the capsule out or?

Dr. Swistun (14:26):
Yeah, I think probably about 5% honestly.

Monique Ramsey (14:29):
And so then finally, back to the en bloc, the term that everybody uses, that's not the right term, but that is one of the ways or one of the types of capsulectomies is an en bloc. So how do you know who needs an en bloc capsulectomy?

Dr. Swistun (14:48):
So the en bloc capsulectomy, that term is really reserved only for patients who actually have cancer of the capsule, which is really the ALCL, the breast implant associated lymphoma, which is not a common disease. I think that we're finding more and more examples of it now that we're actually looking for it, but that is really the only time that term actually applies technically appropriately. So I've done this surgery literally once in my life. I had one patient who, I was a patient of the practice previously and she had textured implants and she presented several years later with swelling on one side, on one breast, and that swelling was new. It was about four or five years after her original augmentation with a textured implant. We ultrasounded it and the ultrasound showed fluid. And what you're supposed to do in that situation is you need to rule out A LCL, so you put a needle in there to aspirate some of the fluid and you send it out to a lab and they look for CD 30 markers specifically. And if there's a CD 30 marker present, then typically that would diagnose that patient as the A-L-C-L, and then before you do surgery, actually should get a hematology oncology consultation to help you manage that patient. Because this is now a cancer patient and we want to optimize their management. But that is what would dictate an en bloc capsulectomy. Now it's a priority to get the entire capsule out, and this is an instance where you are actually allowed to take a little bit of collateral, do a little bit more collateral damage. You are taking a little bit of a margin around this capsule, so some healthy tissue, maybe just a few millimeters here and there, but just some healthy tissue around that just to make sure that you have the entire capsule because that is the cure for the ALCL, the cancer. I did that surgery once I was successful. There is a great video that another surgeon had taken of me actually opening that, and we were very happy that the entire thing came out with all the fluid and with all the basically cancer cells inside, which were later confirmed by pathology. So we had zero spillage in the operative field, and basically we opened capsule afterwards in a separate room once the patient was already in recovery. So that was a good success story and a huge learning experience for me.

Monique Ramsey (16:57):
Now was her other breast totally fine? And did you just do an explant and capsulectomy on the other side? Or what was the

Dr. Swistun (17:03):
Correct.

Monique Ramsey (17:03):
Okay.

Dr. Swistun (17:04):
Correct. I mean, she did not have cancer on the other side. She decided to get rid of her implants anyway because of this experience, so we decided to remove the implant and the capsule on the other side. On the other side, I just basically performed a total intact capstulectomy, quote, unquote.

Monique Ramsey (17:17):
Yeah. Now you mentioned she had textured implants and that's something that was a thing back in the day. Now everything's smooth, I think, right?

Dr. Swistun (17:27):
Well, it's textured implants specifically are sort of off the market now, not all the brands, but the brand associated most with the A LCL is off the market because of that association.

Monique Ramsey (17:38):
Okay. After surgery, you've taken out the capsules. Do you send the capsule to the lab?

Dr. Swistun (17:44):
Every time.

Monique Ramsey (17:45):
Every time. Okay. Okay.

Dr. Swistun (17:46):
So from my general surgery and oncologic surgery training days, I think whenever I talk to a surgical oncologist who are treating breast cancer on a regular basis, they basically said, you know what? Anytime you do anything to the breast as far as removing any sort of tissue from the breast, send it out for pathology because that is your opportunity to document this patient did not have breast cancer in the tissue that we removed at this time. We screen them all the time, this is even better, cuz this is just actual tissue now that we're sending out. So that's the more definitive way of saying, confirming that.

Monique Ramsey (18:19):
And I know you do videos after the surgery. Talk a little bit about after the explant and capsulectomy, the video that you make for the patient.

Dr. Swistun (18:31):
Yeah, so it's sort of something that started, originally when I started doing breast implant illness surgeries, so to speak, or had a lot of patients who were self-identifying as breast implant illness patients, they all requested these videos. And I think it had to do with the fact that they really believed that the implant is making them sick and the capsule around it has to be removed. But I think the patients really wanted proof that everything is out. And there's a thought out there that not every plastic surgeon will remove all the capsule, even though they'll tell you, but it's like, oh yeah, I removed the capsule. Well, how much of it? Well, like half of it. So you never really know until you see the specimen. So the common recommendation from the social media groups was request a video or at least a picture of your specimen to confirm so that you can confirm that everything was removed.

(19:20):
So these are requests I was getting on a regular basis early on, and so we just got in the habit of just filming everything and being very, very transparent with patients. A lot of patients just get closure out of these videos, especially the patients that were suffering with complications of breast implants, just to see that everything is out and this is what it looked like and that was in my body, but it's not in my body anymore, and everything's removed. That gives them a really large, sort of a huge, it allows them to step forward and recover. Basically it just opens up a door saying there's nothing else holding it back. Right now, it's up to you. Go forth and heal. For me, it's a learning experience because honestly, all these patients present with different symptoms. They have this, they have that, they have pain here, they have pain if they pull over here and then they have a tightness and sometimes there's nerve pain associated with that, and sometimes there's sick systemically. So we look at the specimen and we analyze and this is what we find, and a lot of times it'll actually correlate with the symptomatology. So I think it makes me a better surgeon to go through the mental exercise of seeing what we removed and how that relates to what the patient was reporting before the surgery so that next time I see a patient, I can be a lot more prepared for that discussion based on my experience.

Monique Ramsey (20:36):
Yeah, there they're great videos because I've seen one or two and I would think it would be just that closure. You mentioned sort of some peace of mind and some of us like to geek out on the science.

Dr. Swistun (20:52):
Lots of patients do.

Monique Ramsey (20:53):
It's interesting. It's so interesting and so to see, oh, maybe on this side it was really tight and crackly and on the other side it was really thin or it was really thick. It's very interesting. Last I want to just talk about healing and recovery. Depending on any of these four types of capsulectomy, does it matter in terms of healing? Are they different or are they all pretty much the same?

Dr. Swistun (21:19):
I think they're very similar, honestly. My protocol for recovery is pretty much the same, whether you get a capsulectomy or a total capsulectomy or partial or a lift or no lift, it just takes the tissue an X amount of time to heal. Typically six to eight weeks out, everybody is pretty much healed and they're very close to back to their normal baseline activities. The first three weeks are critical because there's a lot of raw surface area that needs to come together. We have a drain in each breast for about six to nine days, depending on if they had capsulectomy only versus a lift, which rearranges the breast tissue and closes that space up. And then we really stress that the patient is careful and not to overdo it for at least three weeks. And then once after three weeks, everything seals up and they're really pretty much outside of that complication window and they can start doing more. So they can start doing range of motion exercises at three weeks of the upper body and getting back into lower body cardio and stuff like that. And typically after five weeks, patients start doing a little bit of upper body workouts as well. And again, six to eight weeks out they're like, yeah, I'm pretty much already doing everything.

Monique Ramsey (22:22):
Well thank you Dr. Swistun for joining us today and going through all of these new terms. And we'll have links in the show notes. If you have any questions for Dr. Swistun, all you have to do is make an appointment for a consultation. It's super simple and he'll go through everything with you and do an exam and walk you through exploring if you want to take out your implants and have a capsulectomy and what kind we might be looking at and recovery and all that. So thank you again.

Dr. Swistun (22:54):
Sure. And I want to say that it's time for us to scrub our websites and mine in particular, I have to go back in there and change some of this terminology now that this is the new terminology. It's just I've been so busy. I haven't had time for that, but that's coming up. I do need to do that.

Monique Ramsey (23:08):
Alright, well thank you again and everybody please like and subscribe and share with a friend and give us a review. So we'll see you on the next one.

Dr. Swistun (23:16):
Thank you, Monique.

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