The Importance of Total Capsulectomy in Treating Breast Implant Problems.

I was exchanging breast implants and performing a capsulectomy the other day (to treat a breast encapsulation) when my anesthesia provider expressed surprise at my method. Specifically, she had commented that she has never worked with a breast implant revision specialist who had removed the WHOLE collagenous capsule when treating a breast encapsulation. Apparently she has only seen plastic surgeons either make slits in  capsules (capsulotomy) or only partially remove them.  

Evidently, she was part of a growing support group of women who had their breast implants removed for mainly medical reasons and were firm believers that any associated capsules needed to be removed in their entirety during the same operation. Up to now I had no idea that performing a total capsulectomy is “a thing” and supposedly I am among a minority  who do this par for the course.

  One of the leading theories for breast encapsulation relates to bacteria and their byproduct, biofilm (a type of organic shield, if you will), surrounding the surface of the breast implant itself. One can safely assume that if a breast implant is supposedly contaminated by bacteria so is its associated surrounding capsule. Therefore, it is only logical to remove the collagen capsule in its entirety when removing or exchanging a breast implant, whether it be silicone or saline.   I created this video below to help patients better understand the vexing process of breast encapsulation and methods to treat it. Though breast augmentation​​ is one of the most popular plastic surgical procedures performed today, it is also one of the most capricious or unpredictable because breasts often times have a mind of their own and do not behave in the way we would like them to.​   Dr Haworth 2017

Drastic or Fantastic Plastic Boob Job?

 
Fake pre-pectoral breast implants
Artificially round and hard appearing breasts after an overfilled “above the muscle” breast implant augmentation. The patient desired a more natural and smaller pair of breasts to match her frame
Natural, conservative result after breast implant revision and breast lift perform simultaneously.
Natural result afterexchange of her overfilled implants to memory gel silicone implants “under the muscle” along with a mastopexy (breast lift).
What is wrong with this revision breast implant and lift surgery I performed? According to this patient, apparently everything!     At first, this patient came to me with ostensibly straightforward requests to “make” her breasts smaller and “better-shaped” in accordance with her body frame.  Of note, she had undergone a previous “above the muscle” breast augmentation which, in my humble opinion, left her with a net result of breasts which were too big, too round and too fake. In essence, her breasts did not lend to a pulchritudinous appearance and that is why she sought my expertise in the first place. Indeed, she wanted to get remarried after having children and was seeking “christian boobs” to attract a decent husband. So I did what any self-respecting, honest and aesthetically minded board certified plastic surgeon would do and that was to perform a capsulectomy (remove her collagenous scar capsules),  substitute her overfilled saline implants with smooth Memory Silicone Gel  implants placed “under the muscle” and conclude with a bilateral mastopexy (breast lift). I thought the surgery was an unqualified success and, further punctuated by her exceptional healing vis-à-vis scarring.     So why was she unhappy? I was thoroughly puzzled since we both had extensive discussions prior to the surgery about the usual risks, alternatives and benefits including what she exactly wanted from the surgery. I know she wanted to go smaller (check), she wanted to be natural (check), she wanted to appear more youthful and perky (check) and indeed she conceded that I did achieve these goals. However,she also expected her breasts to be firm and more round  she felt that her result was too natural, both in look and to touch and therefore something went wrong.  
Fake pre-pectoral breast implants
BEFORE: Artificially round and hard appearing breasts after an overfilled “above the muscle” breast implant augmentation. The patient desired a more natural and smaller pair of breasts to match her frame
Natural, conservative result after breast implant revision and breast lift perform simultaneously.
AFTER:Natural result after exchange of her overfilled implants to memory gel silicone implants “under the muscle” along with a mastopexy (breast lift).
Fake pre-pectoral breast implants
BEFORE
Natural, conservative result after breast implant revision and breast lift perform simultaneously.
AFTER
                      But after further, protracted postoperative conversations with her, I realized where the disconnect was. I did not give her what she exactly wanted from the surgery because I gave her what she asked for and not what she wanted. In essence, this was a story of missed and unrealistic expectations.     More and more of these situations arise in a plastic surgery practice simply because unrealistic expectations are instilled in us 24/7 by social media. The main platforms culpable for this insidious brainwashing are the mobile apps Instagram, Snapchat and YouTube with their interminable repository of Photoshopped/FaceTuned manipulated models and instructional contouring videos. Young women come to me wanting cheekbones, buttocks or breasts like Abigail or Jocelyn Instastar simply because they are famous and therefore more popular and loved.    
Social media and Instagram star Abigail Ratchford
Social media and Instagram star Abigail Ratchford
Indeed, one patient requested Bella Hadid’s nose even though, in my opinion her rhinoplasty ended up with an “inverted V” deformity and a somewhat pinched, boxy tip. However, it did not matter to her because she considered Bella her idol andwas willing to accept a possible substandard result with potential nasal obstruction. Ah, the power of celebrity!     Recently, I had the experience of operating on another young woman who had beautifully shaped breasts with a natural cleavage. She wanted to go only slightly bigger yet have a bigger gap between her breasts. The surgery went flawlessly but the patient was dissatisfied. She agreed her breasts were fuller with a wider cleavage but she now voiced that I should have known all along she wanted her breasts to look fake, round and hard! After this perplexing conversation, I sat down and pondered the meaning of what I really do.
Social media and Instagram star, Joselyn Cano.
Social media and Instagram star, Joselyn Cano.
    It is one thing to make abnormalities such as unnatural breasts look natural but it’s  another thing altogether to make natural looking breasts look deliberately unnatural and possibly unappealing. For decades, I have endeavored to create natural results by making the deformed normal and the normal beautiful but now a new aesthetic standard has emerged in our culture and ultimately, it may not have positive consequences.   But who am I to judge?  Fake is the new real.     Randal Haworth MD, FACS