Plastic Surgery Practice Co-Chief Editor Keri Stephens sits down with New York-based board-certified plastic surgeon and microsurgical breast reconstruction guru Constance Chen, MD, FACS, to discuss the breast implant explantation process. The podcast, which follows Chen’s article about the topic, delves into why patients are increasingly removing their breast implants and what factors affect the appearance of their breasts post-explanation. Pregnancy, she says, is a key determinant.
Chen also shares how explant patients can enhance their appearance via fat grafting, although she calls it far “less predictable” than other methods. Finally, Chen addresses breast reconstruction patients, in particular, and reveals why plastic surgeons need to think beyond breast implants and embrace flap-based procedures. She also highlights the trend of women forgoing reconstruction and staying flat. And, that, Chen contends, is a perfectly viable option as well.
Hello and welcome to the Plastic Surgery Practice Podcast, a part of the MEDQOR Podcast Network. My name is Keri Stevens, and I’m the Co-Chief Editor of Plastic Surgery Practice. Today I’m talking to Dr. Constance Chen, a New York-based board-certified plastic surgeon, and leader in microsurgical breast reconstruction. Dr. Chen is also a Clinical Assistant Professor of Plastic Surgery at Weill Cornell Medical College, and a Clinical Assistant Professor of Plastic Surgery at Tulane University School of Medicine. Dr. Chen recently wrote an article for PSP about what to expect after breast implant removal, and is going to be here today to discuss it. Dr. Chen, thank you for joining me today.
Dr. Constance Chen:
It’s such a pleasure to be here. Thank you for inviting me.
Of course, we loved our interview with you about re-sensation techniques, and today just want to delve into breast implant removal. So to start, breast implant safety and breast implant illness, or BII, is being talked about heavily lately. Removing implants almost seems to be a trend among celebrities and social media influencers, and in your private practice, have you seen an influx of patients concerned about BII, and asking to remove their implants?
Dr. Constance Chen:
Absolutely, I have seen a huge influx of patients who are interested in removing their implants in the last several years, since before the pandemic. What’s interesting to me, is many of these patients have been to several plastic surgeons, who tell them that for one reason or another, they cannot have their implants removed: in particular cosmetic patients, because they’ll look deformed afterwards, they’ll be concave, some have gone to a lot of well-respected and in my opinion, talented plastic surgeons, who just don’t believe that you can remove implants and have a person look normal afterward.
And I just saw one of those patients yesterday, and I had removed her implants, and did a lift afterward. She definitely looks better than when her implants were in, and she could not believe how good her breasts look. And she was wondering, are these going to disappear? I was like, “No, no, no. You have plenty of breast tissue, you’re going to look great.” And she just looks like she had a lift. She looks wonderful. So the answer is yes, I have seen a lot of people who want their implants out, both patients who have undergone breast implants for cosmetic reasons and reconstructive reasons, and you can take them out safely and look fine afterward.
No, that’s so good to hear. In addition to BII, what are some of the other reasons people in your practice are taking out their breast implants?
Dr. Constance Chen:
So the classic reason people take out their breast implants are the ones that the breast implant manufacturers talk about: namely capsular contracture, infection, and rupture. According to the implant manufacturers, about 50% of women within seven years after their implants are placed will for one reason or another have another operation, often to remove them. Capsular contracture is something that every single woman who has breast implant will have a capsule around their implant, but sometimes it’s soft and filmy and you can’t feel it. Sometimes over time it becomes very hard, and calcified, and thickened. And I’ve seen them where they’re so thick that when you open it looks like there are rocks inside. They just become rock-hard and they start squeezing. That’s usually when people want their implants out. It’s not medically dangerous, but it’s just painful and they want their implants removed.
Another reason, infection. That’s truly the only medical emergency with breast implants. If you have a little infection, you might be able to address with antibiotics. If you have a bigger infection, meaning there’s pus, you are starting to become septic: that’s actually medical emergency and they might need to be removed immediately. That’s not that common, but if you do have breast implants, it’s a good idea to take antibiotics around procedures such as teeth-cleaning and colonoscopies, because those procedures can cause a low-grade bacteremia that can seed your breast implant and cause problems. And that’s been reported 20 years after cosmetic breast implants were placed, where someone became septic and it became an emergency. So if you just take a day or two of antibiotics around those procedures, it’s just sort of a prophylactic safety measure to try to prevent infections, just like if you had a heart valve or a pacemaker or something like that.
And then finally rupture, I think, is the one that a lot of people think about, hear about. All implant manufacturers in the United States have a 10-year warranty. If you have saline implants, it’s usually pretty clear when your implants are ruptured, because they just deflate, and it looks funny. It’s not necessarily dangerous. We use saline in contact lenses and IV fluids, but it just may look weird. So most people will remove their implants, and either completely or replace them, when their implants have saline implants rupture.
If you have silicone implants, the FDA recommends a breast MRI every two to three years as surveillance, because silicone implant ruptures are usually silent, meaning you have no idea that it ruptured. If it presents as anything, it is as a pain or discomfort. Silicone implant ruptures, if they rupture and they’re left untreated, that is a little bit more of a problem. It does not deflate, because the silicone doesn’t… If anything, it interacts with your body, and what I’ve seen is that breast actually gets bigger, because it irritates the tissues and causes inflammation. If you have a silicon implant rupture, as long as you’re healthy enough to undergo surgery, I think most plastic surgeons would agree that it’s probably a good idea to remove the implant, replace it if you want. But having loose silicone floating around is just, it’s not… It’s supposed to be an inert, but it is gooey and it’s just not something you want affecting your tissues.
That’s very good to know. To switch gears: what factors will affect the appearance of your breasts after explanation?
Dr. Constance Chen:
So the biggest factors are how much breast tissue you have left and how big your implants are. So in other words, let’s take one extreme. If you’ve had mastectomy, so no breast tissue and large implants, and you remove the implants and don’t do anything else, you’re going to look pretty deflated. All you’ll be left with is skin, and you can do a number of things. You can remove the implant, replace it with a different size implant; you can remove the implant, go flat, at which point you may or may not want to resect some of the extra skin. One thing about skin is, unlike… Human beings are organic, so your skin will shrink over time. So if you remove the implant and leave it alone, the skin may just shrink on its own to something that kind of conforms to your body. The other option with implant removal, if you’ve had breast reconstruction and after mastectomies, is you can switch to natural-tissue reconstruction, with either flaps or fat grafting.
Now, if you’ve had implants for cosmetic reasons, if you were a tiny… If you had small breasts, AA, AAA, very little breast tissue, over the time that you had your breast implants, you’ve lost 10 pounds. So you have even less mass in your body and you have giant implants, let’s say 500 cc, 600 cc implants. It may be very much like a mastectomy, where when you remove the implants, if you don’t put something back in, the implants have stretched out your skin, so you have more skin than you had before. They have compressed your breast tissue, so that what breast tissue you did have is now thinned out. So you may look very deflated and empty. I even use the words mutilated and deformed, because people need to be prepared for what they see, if you’ve had very small breasts, very large implants.
But again, the thing to know is that over time your skin does shrink. And if you have not had mastectomies, what breast tissue you have will re-expand. And frankly, I had a patient, for example, she was from Germany. She was probably a AA, quite flat when she had her breast implants in place. 20 years later, they were bothering her. She was about a C cup at that point. So fairly large breast implants, 300-400 cc’s. When I removed them, she just looked like skin and ribs, and it did not look good. Within a couple of weeks, her skin had shrunk so that she looked basically as she did before surgery: she did not look like she had extra skin. She looked like she had small breasts, and she said, “This is exactly how I looked before surgery.” I think one reason that her skin contracted so readily, was that she was 40 years old at that time, had not had children. Somehow not having breastfed, your skin, even though it’s been stretched out by the implants, she just had enough elasticity in her skin, that her skin contracted.
On the other hand, if you have a fair amount of breast tissue to start out with, meaning you’re a B or C cup, you really don’t have very big implants. Say you have 100-200 cc implants. When you remove the breast implants, you might not even be able to tell that you ever had breast implants. Some people the following week, when they have implant removal, when they have plenty of breast tissue, look perfectly fine. And you can’t even tell they ever had breast implants. And then there’s a large portion of the population where they’re kind of in-between. They weren’t teeny tiny to start out with. Maybe they gained some weight or they maintained their weight. They had sort of medium-sized breast implants. The first week after implant removal, if they don’t have anything else placed, it may look deflated and wrinkled and not so good, but after a few weeks or a month or they just wait, it just… The skin contracts, the tissues re-expand, and they look perfectly fine.
I’ve had many patients who were thinking about scheduling additional surgeries such as breast lifts and whatnot later on, but realized they looked just fine, and canceled their surgeries. I would say eight or nine times out of 10, when you remove breast implants, and someone who’s undergone implant surgery for cosmetic reasons, and you don’t do anything else, they end up looking perfectly fine at the end of the day. Sometimes you have to wait: it may not be the following week, it may be a few weeks or even months, but most people go fine.
Okay. So again, you know, you cover this a bit. But in the article you say that if someone has gained a significant amount of weight, or has become pregnant with breast implants, the skin may have stretched irreversibly.
Dr. Constance Chen:
There is something about pregnancy. I don’t know, something about the milk ducts being engorged, and you see this even in people who have not had breast implants: it’s very common for people whose breasts have become large because of pregnancy; after pregnancy, their milk evolution happens, their milk ducts dry up, the skin is still stretched out, and they become droopy. And so that’s just a common thing that happens, and that happens with implants too. Somehow, if someone has had multiple pregnancies with implants, you can’t always predict, but their skin may have a little bit less elasticity.
That said, at the same time, if someone comes to me and they want implant removal, and they don’t want a new implant: if they have a fair amount of breast tissue to work with, and they’re worried that they’re going to be droopy, if they have breast tissue, I can do a lift at the same time as surgery. If they don’t have breast tissue, meaning they either have small breasts or the implants were so large they compress their breasts, so that it’s very thin tissue there, then I’ll often suggest that they’ll have a better cosmetic result at the end of the day, if they remove first, except that it’s going to look terrible for some period of time, let their skin contract, and their breast tissue re-expand. So once you have something to work with, then you can lift and do all sorts of things to make their breasts look better. A lot of times it just looks better on its own, and they don’t have to do anything at all. But if it doesn’t, that’s a better time to do things, if they do not have enough breast tissue to start out with.
Okay, and so in the article, you also talked about: for people that undergo implant removal, and they want additional breast volume without implants, they could undergo fat grafting. And I know you also mentioned fat grafting earlier in this conversation. But can you elaborate on that process, and exactly how much fat sticks, after undergoing fat grafting?
Dr. Constance Chen:
Sure. So fat grafting is something I do a lot of. But it is different from breast implants in that it’s not as predictable. Meaning fat grafting involves liposuction, processing the fat so you get rid of the plasma and all the impurities, and you’re just left with the pure fat cells. Then you inject the fat cells in small aliquots into the breast tissue. So it needs to be injected into some type of tissue. So for example, if you’ve had mastectomy, you can inject it into the pectoralis muscle, but it needs to be injected into some sort of tissue and not just empty space, because in order for the fat cells to survive, the nutrients have to diffuse through the fat cell wall by osmosis. So you need to be about a millimeter from a blood vessel, even if it’s just a capillary.
So you ask how much of that fat survives. I usually tell people on average, half of the fat will be resorbed and excreted by the body, but sometimes it’s 70%, sometimes it’s 30%. So it’s very variable. You do know it’s not all going to stick around, though. If you place an implant, what you put in is what you get. With fat grafting, whatever you put in, you know some of that is going to go away. It’s just going to be excreted by the body, because not all of the fat cells will survive. And it takes weeks and even months, to know how much of the fat is going to survive. So usually you try to over-correct; however, so say you want 200 cc’s more volume in each breast. That means you have to, on average, inject 400 cc’s of fat. But that means that you might… Which means 800 cc’s altogether.
But as I mentioned, you have to purify the liposuction aspirant. So that means you need something like 2000 cc’s of lipo aspirant. For someone who is very thin, that’s a lot of fat to get out of them. And frankly, the thinner you are, the more liposuction is uncomfortable. It hurts, because at risk of giving too much information, it’s a steel rod going in and out of your body, and when you don’t have a lot of fat, it’s going against the muscle. And people can be pretty black and blue and bruised and swollen, more so… Even though it’s the same thing as cosmetic liposuction, with cosmetic liposuction, people are often contouring little bits here and there. That may not be enough for fat grafting. If you have a little lump at your hip that you just wanted to smooth out, maybe that’s 50 cc’s or 100 cc’s. But if you need 2000 cc’s, you need to scrape out every fat cell you can, from every part of your body that has fat. That can be pretty uncomfortable after surgery.
People talk about feeling like they were run over by a mack truck several times. That said, it’s still usually an outpatient procedure. It’s tiny incisions, three millimeters large, or something. And I would say the first week is the worst. That’s when people… If you’re going to be black and blue and bruised, that’s when you’ll really get black and blue and bruised. After the second week, people tend to turn around. Certainly, in rare cases, it may take three weeks; but usually after two or three weeks, someone has gotten a lot better. And then it takes months for the swelling and I mean every bit of swelling to go down, for you to know how much volume was going to be left in your breasts.
Yeah, I went underwent fat grafting with my most recent breast reconstruction surgery. And I can attest it is extremely painful and very, very bruised. But to close this podcast: today, the day we’re taping this, is actually Breast Reconstruction Awareness Day. And some statistics have come out that breast reconstruction patients really don’t know their range of options available to them. In fact, only 23% of women know what breast reconstruction options are available. Can you talk about that, just as a plastic surgeon, talking about breast implants and any reconstruction, what patients should know?
Dr. Constance Chen:
Yes. So whenever someone comes to talk to me about breast reconstruction, I start out by talking to them about the mastectomy, if they have not had their mastectomy yet. So one thing to know, is that there is something called nipple-sparing mastectomy, where you can preserve your entire skin envelope before the breast reconstruction, or even if you decide to have no reconstruction. And I mentioned that, because that’s the one thing that is not reversible. If you have a traditional mastectomy, which is what most breast surgeons do, where you have a straight line across your chest… It is nice to be able to do a nipple-sparing mastectomy, if you can find a breast surgeon who does that in his or her practice. Because it preserves your options to make you look like you have a normal breast after surgery. So that’s number one.
But then that’s the breast surgeon. From the reconstructive aspect, you have multiple options. One option is going flat: we talked about that a little bit earlier, prior to the podcast. That’s a perfectly viable option. And frankly, 70% of people who undergo breast reconstruction do not get reconstruction, in part because it may not be available, but more it’s a trend right now for people to decide to go flat, because they don’t want to deal with reconstruction for whatever reason. If you want to reconstruct your breasts, there’s two main pathways. One is some type of tissue expander and implant reconstruction, and the other pathway is some type of natural tissue reconstruction. Tissue expanders and implants can be smooth, they can be textured, they can be saline, silicone. Some people do direct to implant. You can go over the muscle, you can go under the muscle.
Like with nipple sparing mastectomy, usually the next thing I tell people, if they are not sure what to do, but they think they want something, they don’t want to go flat: if you’re not sure what you want to do, get a tissue expander over the muscle. It’s the least painful, least invasive, quickest surgery. I think many people are surprised to learn that not all surgeons do all things. So just as not all breast surgeons do nipple-sparing mastectomy, not all plastic surgeons do tissue expanders implants over the muscle. But it is a tremendous difference in pain and postoperative recovery, and frankly, in my opinion, appearance too, to get implants over the muscle versus under the muscle. Because the breast tissue is over the muscle. Traditionally, implants were placed under the muscle because the muscle provided an extra layer of tissue. People were worried that the implant would erode through the skin.
But these days, you can put things like acellular dermal matrix, and things like that, around an implant as an extra layer. But even if you don’t do that, there are ways to do above the muscle breast reconstruction, so that it’s just significantly more comfortable. If you don’t want to go the implant route, you can do some type of natural tissue reconstruction. Traditionally that has meant the TRAM or latissimus dorsi flap, which are muscle flaps. It’s an older technique: I personally don’t do those, because there is a principle in plastic surgery that if you’re going to reconstruct something, the ideal is to replace like with like. And if you look at the breast tissue on an operating room table, it just looks like skin and fat. So when you replace skin and fat with skin and fat, you get something that looks a lot like what was there before.
So when I reconstruct breasts using what we call flap surgery, I will do perforator flaps where you take skin and fat from either of the lower abdomen or the upper inner thighs or something, to reconstruct the breast. What I do is I connect an artery to veins, and I also reconnect the nerve as we talked about last time, to create a living breast that has sensation. The other thing that you can do, if you don’t want to go the flap route, is fat grafting naturally. So you do serial fat grafting, meaning multiple rounds of liposuction and grafting the fat.
The reason you can’t do it in one round is, as I mentioned earlier, not all of that fat is going to survive. So if you try to do a lot, you may look great immediately after surgery. But you’ll find that most of that will go away, because it’s just not going to survive in an empty space. So you have to layer it little by little. So the benefit of fat grafting is it’s smaller incisions and it’s outpatient. The downside is it will take multiple surgeries to get to the volume that you want, and if you’re very thin, it will not be as comfortable.
Implants are going to be easier: there’s only one surgical site, your chest. Flaps are more complex, but you have a living breast, so you don’t have to worry about implant problems. And if you gain and lose weight, they gain and lose weight with you, and they just become a part of your body. But you do have other scars, and other drains, and things like that. It’s just a more complex procedure. But because it comes with its own blood supply, it’s more predictable just as implants are a little bit more predictable. Fat grafting is just not as predictable as those other methods.
Thank you so much. This was very informative, Dr. Chen. And to our listeners, thank you for joining me as well. As always, be sure to subscribe to the MEDQOR Podcast Network, to keep up with the latest Plastic Surgery Practice podcast episodes. And be sure to check out plasticsurgerypractice.com, for the latest industry news. Until next time, take care.