Explanting After Reconstruction

More and more women are explanting after reconstruction. Women explant their reconstruction after mastectomy due to a number of complications. These complications include pain or discomfort caused by capsular contracture, various infections, discovering symptoms of breast implant illness and the possibility that many symptoms they attributed to their cancer treatment, (i.e. chemotherapy, radiation, preventative hysterectomies causing surgical menopause in premenopausal women, as well as side effects from breast cancer related drugs) could actually be caused by their breast implants instead.  Some of these women have immediate reactions to their implants while others take longer to accumulate symptoms and some are suffering more severely than others.

Regardless, when women discover many of the negative effects of breast implants such as capsules and implants harboring mold or bacteria that could be making them ill or the silicone implant could be decomposing and leaking or ruptured inside of their chest cavity contaminating them with silicone chemicals and heavy metals they move to explant their reconstruction.

While the possibility of going through yet another surgery or second mastectomy and contemplating the idea of further reconstruction without implants versus going flat, is definitely agonizing, and fear-producing for women who have already been through the trauma of breast cancer treatment and loosing their natural breasts completely, it is a place many come to when discovering and researching breast implant illness and the negative effects of having breast implants inside of their body.

Breast cancer and subsequent breast implant illness survivors repeatedly express they were not informed of the possible negative health affects of either saline or silicone breast implants, the multiple surgeries involved going forward with reconstruction, nor were they provided other essential information to enable proper informed consent before they decided to reconstruct with breast implants. Most express that had they been provided the long list of possible risks and other complications, they would never have chosen reconstruction for themselves. These women commonly feel they were too quickly steered toward breast implants, or another type of flap reconstruction (that also sometimes includes implants), and never provided the option to “go flat.” Many women who had expressed the desire to go flat often say they were dissuaded or discouraged from doing so. Another common theme is the pressure and rapid pace by which these reconstruction decisions are required to be made, in the middle of a life-altering diagnosis, without the time to carefully consider all options.

Our knowledge and experience of going flat is evolving and we would like to point out there is a difference between going flat (explanting your breast implants) and aesthetic flat closure which is a procedure which removes excess skin and breast tissue to create a smooth chest.  Not everyone is a candidate for aesthetic flat closure and it’s not an easy procedure to do well. In one surgeon’s words, “Flat closure is very confusing and most people don’t understand what’s involved. Flat closure requires tight skin as well as even contour at the mastectomy site and surrounding tissues. I have to remove that excess skin after the implant removal or patients will have loose skin fault that will prevent a flat appearance. But more importantly, the surrounding tissues especially subcutaneous fat cannot be very thick. After the mastectomy the breast area only has skin on top of the muscle with no subcutaneous fat. So if the patient is heavier and has thicker subcutaneous fat of the surrounding areas, the contrast between thicker surrounding areas and the mastectomy site where there’s no subcutaneous fat, is the reason for the concavity at the mastectomy site. As a result flat closures can only be achieved in thinner patients with very thin subcutaneous fat in the surrounding areas.”

The most significant points we would like to stress to women facing explanting their reconstruction breast implants due to breast implant illness is that proper explant which procedure is an En Bloc Capsulectomy or Total Capsulectomy (remove implant and all capsule tissue plus any other foreign body such as mesh or dermal matrix if used) is paramount to your healing from symptoms of breast implant illness and to preventing more cancer.  At this time oncologic surgeons and reconstruction surgeons may not remove capsules or think it’s necessary. For your best healing, choose a surgeon dedicated to removing all the capsule tissue.  Also, going flat without aesthetic flat closure may be the norm for most as many won’t be a good candidate for aesthetic flat closure.   

Women ask if fat transfer to the breast works and the answer is it’s not suitable to build breast mounds. In order to build a small breast mound you would need a series of fat transfers that don’t fail but most fat transferred to the breast does fail and especially when done at the time of explanting and especially in a post mastectomy breast.  In a post mastectomy breast there are no veins, capilliaries and lymph to keep the transferred fat alive and there is no connective tissue to hold the fat in place. When fat transfer fails it can cause other complications such as cysts, necrosis, calcifications, inflammation, pain and problems detecting cancer. Women also report deformities in their breasts and at the harvest sites from fat transfer.   

Further many women consider flap reconstruction such as DIEP (deep inferior epigastric perforator, the main blood vessel moved) right after mastectomy or as an option later during or following implant removal. Branches of blood vessels are relocated during the procedure as well as nerves and muscles. Sadly, we are hearing increasing reports of complications after flap surgery. Flaps of all kinds require skilled microsurgeons with special equipment. Explant and flat closure do NOT require microsurgery. Despite medical studies showing only 1 or 2 percent flap failure, anecdotally those percentages are looking much higher. One woman in our group referred to her flap as “barbaric.” Cancer survivors may heal more slowly after chemotherapy and radiation too and should carefully research flaps in groups devoted to that topic and in medical literature. Flaps are very long surgeries — often more than eight hours (for both breasts). Mortality risks increase with length of anesthesia. Cognitive changes are not infrequent with any long surgeries and are especially common over the age of 60. Complications from flaps include major necrosis of the newly created “breast,” hematomas, infections — including severe ones requiring months of wound vacuums — at the donor site, and blood clots. Typically women spend at least a night in the ICU following flap surgery and then several days in the hospital. Flaps are MAJOR surgical procedures for purely cosmetic purposes to achieve a mound simulating a breast. They have no advantages for cancer treatment or further screening. Some women have reported extreme pain for months, disfigurement and an inability to drive even after half a year after DIEP. Others have had entire breasts turn necrotic when blood flow and nerves fail to regenerate. Since both the abdominal area used for harvesting tissue and the chest muscles will be very sore, mobility will be challenging for most for months. The chest and abdomen/core are used for getting up from sitting or reclining as well as for walking. Some women report that they have never regained full use of their abdominal muscles, resulting in poor quality of life and disability. Cosmetic results also vary and flaps typically require several revisions, requiring more surgery and more anesthesia. Each surgery will then entail further detoxing and recovery.

The safest option for women after breast cancer is going flat and more and more women are refusing complicated invasive revisions to their post-mastectomy body.

The resources in our group focus on surgeons who are experienced in proper explant and we are now adding a notation if they also do good aesthetic flat closure, not that aesthetic flat closure is necessary.  

Below are some additional resources we gathered to support women explanting their breast implants placed following reconstruction for breast cancer related surgeries.

Facebook support groups for those considering or explanting to FLAT-i.e., no further reconstruction of breast mounds but still able to use breast forms or prosthesis if desired:

Fabulously Flat

Fierce, Flat, Forward

For women considering further surgical reconstruction of breast mounds post-explant:

DIEP Flap Support Group

Website(s) listing flat friendly surgeons:

Flat Closure Now

Not Putting On a Shirt