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The Path to Health-EnBloc Capsulectomy

My Health Mission

"I completely understand the concerns and questions you have regarding breast implant disease(BID) and en bloc capsulectomy treatment but also textured breast implants and their association with BIA-ACLC. I hope that the information that I provide in my website devoted exclusively to these topics will help you. I encourage you to email me with other specific questions or concerns you may have. "

Dr. Ed Domanskis

EN BLOC CAPSULECTOMY

EN BLOC CAPSULECTOMY & TEXTURED SILICONE IMPLANTS

  

What is an enbloc capsulectomy?

An enbloc capsulectomy is when the silicone or saline breast implant and its surrounding fibrous capsule is removed together “en bloc” rather than cutting into the capsule, removing the breast implant and after this removing the capsule.


Why would I want to have an en bloc capsulectomy?

An en bloc breast capsulectomy or explant breast implants when performed properly will cause the least amount of contamination of the breast with silicone and will assure you of removal of as much silicone for silicone is present microscopically within the capsule.


Who performs en bloc capsulectomy?

A plastic surgeon certified by the American Board of Plastic Surgery that has vast experience with breast surgery and breast implants in particular.


Where is an en bloc capsulectomy performed?

I usually perform this surgery in an accredited outpatient surgical facility or hospital, whichever the patient prefers.


Do I need a general anesthetic?

I usually recommend a general anesthetic but it could be performed under intravenous sedation.


How long does an en bloc capsulectomy take?

An en bloc capsulectomy usually takes me about two plus hours.


What do you do if you find fluid or other abnormalities in the breast space?

I will take cultures for bacteria, mold and fungus and send the fluid for analysis and testing.


What do you do with the capsule and implant that is removed en bloc?

First, I photograph them for your record and then I ALWAYS send this to the pathologist to examine. After they examine them, we can provide them to you in separate containers and marked.. Also, I instruct the pathologist to look for immune reactivity cells, silicone within the capsules,cancer or BIA-ALCL(see below).


What is the pathologist looking for?

The pathologist is looking for any abnormalities that are in the capsule.


What type of abnormalities can be found in the capsules?

The most serious is an unusual type of lymphoma called Breast Implant-Associated Anaplastic Large Cell Lymphoma, or BIA-ALCL. BIA-ALCL  is a type of non-Hodgkin's lymphoma (cancer of the immune system).which has to date been found in about 500 patients that have had breast implants.


What is this lymphoma caused from?

No one knows what this type of lymphoma is caused from but it has primarily been associated with textured breast implants, both silicone and saline textured implants.


Tell me more about this lymphoma?

BIA-ALCL is a rare and highly treatable type of lymphoma that can develop around breast implants. BIA-ALCL occurs most frequently in patients who have breast implants with textured surfaces. This is a cancer of the immune system, not a type of breast cancer. The current lifetime risk of BIA-ALCL is estimated to be 1:3817 - 1:30,000 women with textured implants based upon current confirmed cases and textured implant sales data over the past two decades. When caught early, BIA-ALCL is usually curable.

Common symptoms include breast enlargement, pain, asymmetry, lump in the breast or armpit, overlying skin rash, hardening of the breast, or a large fluid collection typically developing at least more than one year after receiving an implant, and on average after 8 to 10 years. For any patient experiencing these or any symptoms,I recommend they see their doctor for evaluation.

BIA-ALCL has been found with both silicone and saline implants and both breast cancer reconstruction and cosmetic patients. To date, there are not any confirmed BIA-ALCL cases that involve only a smooth implant. BIA-ALCL patients seem to have an allergic reaction to textured devices over many years. Currently, it is not possible to test for who is at risk of this disease.


How is lymphoma diagnosed besides by the pathologist examining the capsule and what signs do I look for?

The most common symptoms are unexplained breast enlargement, asymmetry, fluid buildup(seroma) or a lump in the breast or armpit, but may be rarely more subtle such as overlying skin rash, hardening of the breast. Women who develop these symptoms should see their plastic surgeon to be evaluated with a physical exam and further testing.

  1. Following a physical examination, patients with BIA-ALCL symptoms may receive an ultrasound or a magnetic resonance imaging (MRI) of the symptomatic breast to evaluate for fluid or lumps around the implant and in the lymph nodes.
  2. If fluid or a mass is found, patients will require a needle biopsy with drainage of the fluid to test for BIA-ALCL. This fluid will be tested for CD30 immune staining (CD30IHC)      performed by a pathologist. Testing for CD30IHC is required to confirm a diagnosis or rule out BIA-ALCL. Fluid collections ruled out by CD30IHC for BIA-ALCL will be treated as typical seromas by a physician. Specimens not testing for CD30 may miss the diagnosis of BIA-ALCL.


What other reasons are there for having an en bloc capsulectomy?

Many women have had health issues (BREAST IMPLANT DISEASE or Breast implant illness) which they feel have been caused by breast implants and  many have felt much improved after their removal including the capsule.


What is BREAST IMPLANT DISEASE(BID)?

There are many symptoms that patients experience with BID such as fatigue, cognitive dysfunction (brain fog, memory loss) joint and muscle pain, hair loss, recurring infections, and problems with thyroid and adrenal glands or other endocrine glands.


Are there any negatives to getting an en bloc capsulectomy?

I am committed to removing the entire capsule which may be very difficult to peel it off of the chest wall.  Sometimes, the scar to do an en bloc capsulectomy needs to be longer to have good visualization and to remove yje entire implant with the surrounding capsule en bloc. 


Do you prescribe me antibiotics?

Yes, we prescribe you antibiotics as well as give you some IV in surgery and use an antibiotic irrigation to further cleanse the space after the en bloc capsulectomy.


Will I have a drain?

Yes, I usually place a drain in each breast which stays until the drainage is minimal, about several days.


How long is the recovery from an en bloc capsulectomy?

The recovery from an en bloc capsulectomy is usually several days before resuming light activity and a full two weeks before heavy activity or anything that would raise your blood pressure and possibly cause you to bleed. The healing process with swelling still continues after this for even over a year.


Is an en bloc capsulectomy painful?

Yes, it can be painful, especially if the breast implant has been placed under the pectoralis muscle.


Do I get pain pill?

Yes, we do give patients pain pills.


Are other complications possible?

Yes, other complications like bleeding, which may require another surgery, infection which would be treated with antibiotics, loss of sensation, unevenness of the breasts, scarring and feeling of hardness which usually goes away as well as pulomary embolus or a blood clot that forms in the leg and travels to the lungs which in rare cases may cause death may occur.


How can I prevent these complications?

You can limit these complications from happening by refraining from aspirin or compounds that contain aspirin as well as herbals. Also, limiting your activity after the surgery for a minimum of two weeks. Finally, moving around, at least your legs, to prevent clots from forming. You should also tell me if you have had any problems with bleeding in the past or are taking any medication and/or drugs.

 

How much does an en bloc capsulectomy cost?

An en bloc capsulectomy price is $7500+ for this procedure only.


Will I possibly need any other procedure at same time?

It really depends on if your breasts are droopy and you want them reshaped or uplifted? In most cases it will require a breast reconstruction.


Will my insurance cover an en bloc capsulectomy?

Your insurance may cover an en bloc capsulectomy. We do provide you the information like operative report, all notes, photographs and laboratory and pathology results to submit to your carrier. We also provide the letters required for you to apply to your insurance for a refund.


Can I have other cosmetic procedurs done at sme time?

Yes, other cosmetic procedjures can be done at the same operation

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Do you offer financing?

Yes, we have several financing companies that offer excellent financing options like CareCredit and Alphaeon. If our patient does not qualify, we offer in-house financing.


Where is your office?

My main office is in Newport Beach (California) but I also have a satellite office in Miami and operate in San Francisco as well as Anguilla, Nassau and the EU. 


How long do I need to be there?

It would be preferable to be in the area for two weeks but that in most cases is not possible. Some of my patients have returned home after just a couple of days.


Can you help with travel arrangements?

Yes, we provide concierge services to our patients including helping with accomodations and travel arrangements.


How can I arrange a consultation if I am far away from your offices?

I do offer FACETIME/SKYPE/WHAT’S UP/TuTOK and telephone consultations.


What happens if I have a complication?

We offer complication insurance for a nominal charge which should cover the costs of complication care.


How do I proceed?

You can fill out the contact form and let us know what you wish.

En bloc capsulectomy specimen with silicone breast implant surrounded by intact total capsule
En bloc capsulectomy specimen with silicone breast implant surrounded by intact total capsule

Video

Dr. Domanskis in the operating room performing an en bloc capsulectomy and breast reconstruction.

TEXTURED BREAST IMPLANTS

What is a textured implant?

A textured implant is a breast implant that has a coating or texturing layer

.

Are all breast implants textured?

No, they either have a smooth coating or a textured coating.


Can saline filled breast implants be textured?

Yes , saline implants can also be textured.


Why are breast implants textured?

The thoughts of the manufacturers of breast implants was that the texturing prevented or limited the chances of capsular contracture.


What is capsular contracture?

Capsular contracture is when scar tissue, or a capsule, forms around a foreign object like a breast implant and “walls it off” from the rest of your body to a degree that it becomes uncomfortable or painful and the breast feels firm.  A capsule that surrounds breast implant may contract or scar and tighten around the breast implant and cause the breast to feel hard. This is called capsular contracture.


Are there different degrees of capsular contracture?

The degree of an incidence of capsular contracture is graded using the four-grade Baker scale: Grade I — the breast is normally soft and appears natural in size and shape. Grade II — the breast is a little firm, but appears normal. Grade III — the breast is firm and appears abnormal with Grade 4 with extreme firnness, diistortion and pain.


Is capsular contracture dangerous?

No, capsular contracture is not dangerous but it can be uncomfortable to painful and make the breast hard and distorted.


Does capsular contracture occur on both sides in patients that have breast implants?

Not necessarily. It can occur on one side or both sides and just be a little firmer or feel very hard like golf balls.


Why does capsular contracture occur?

In certain people who scar, it may be a “natural” process. In others, it could be due to bleeding, fluid or seroma formation, or previous or present infection. 


What were the reasons why capsular contracture occurred less with textured breast implants?

It is felt that texturing which is made up of uneven surfaces broke up the circumferential scarring.


Does texturing work?

In some studies of patients that have textured breast implants, the incidence of capsular contracture has been shown to be less.


Do you use textured implants?

No, I do not use any textured implants!


Does the body really grow into the textured breast implant?

In my experience, the capsule becomes adherent or grows attached to the texturing of a textured breast implant in the minority of the patients that have textured implants.


So, why use textured breast implants?

I did use textured implants for a while when they were introduced by the manufactures- Allergan and Mentor but because I did not see a significant difference in the rate of capsular contracture, stopped using them.


What are some of the other problems that can occur with textured breast implants?

Textured breast implants may cause a seroma or fluid within the capsule that surrounds the breast implant but the most troublesome is that an unusual lymphoma has been associated with silicone and saline breast implants but to date, only textured ones. Breast Implant-Associated Anaplastic Large Cell Lymphoma (BIA-ALCL) Individuals with breast implants may develop breast implant-associated anaplastic large cell lymphoma, or BIA-ALCL. BIA-ALCL is not breast cancer—it is a type of non-Hodgkin's lymphoma (cancer of the immune system).


How is this lymphoma diagnosed?

This lymphoma is diagnosed by pathological examination of the breast capsule, laboratory test being done on the fluid if present within the cavity. In a statement to healthcare providers, the FDA said they want doctors to consider if BIA-ALCL is an option when a patient presents with a peri-implant seroma or fluid collection. The steps they want physicians to take include collecting fluid and sending it to a pathologist to look for signs of cancer. Additionally, if they see masses around an implant, they want them to consider the possibility it is BIA-ALCL.


What should I be looking for?

The most common symptoms are unexplained breast enlargement, asymmetry, fluid buildup or a lump in the breast or armpit, but may be rarely more subtle such as overlying skin rash, hardening of the breast. Women who develop these symptoms should see their physician to be evaluated with a physical exam and further testing.

  1. Schedule a follow-up appointment with your treating physician to discuss and concerns you may      have about your breast health.
  2. Following a physical examination, patients with BIA-ALCL symptoms may receive an ultrasound or a magnetic resonance imaging (MRI) of the symptomatic breast to evaluate for fluid or lumps around the implant and in the lymph nodes.
  3. If fluid or a mass is found, patients will require a needle biopsy with drainage of the fluid to test  for BIA-ALCL. This fluid will be tested for CD30 immune staining (CD30IHC)      performed by a pathologist. Testing for CD30IHC is required to confirm a diagnosis or rule out BIA-ALCL. Fluid collections ruled out by CD30IHC for BIA-ALCL will be treated as typical seromas by a physician. Specimens not testing for CD30 may miss the diagnosis of BIA-ALCL.


Does this type of lymphoma occur with other textured implants besides breasts?

Recently, a patient that had textured buttock implant was diagnosed with this lymphoma. 


Should I be concerned if I had textured breast implants or other textured implants?

BIA-ALCL is a rare and highly treatable type of lymphoma that can develop around breast implants. BIA-ALCL occurs most frequently in patients who have breast implants with textured surfaces. This is a cancer of the immune system, not a type of breast cancer. The current lifetime risk of BIA-ALCL is estimated to be 1:3817 - 1:30,000 women with textured implants based upon current confirmed cases and textured implant sales data over the past two decades. When caught early, BIA-ALCL is usually curable.

Common symptoms include breast enlargement, pain, asymmetry, lump in the breast or armpit, overlying skin rash, hardening of the breast, or a large fluid collection typically developing at least more than one year after receiving an implant, and on average after 8 to 10 years. For any patient experiencing these or any symptoms, they should see their doctor for evaluation.

BIA-ALCL has been found with both silicone and saline implants and both breast cancer reconstruction and cosmetic patients. To date, there are not any confirmed BIA-ALCL cases that involve only a smooth implant. BIA-ALCL patients seem to have an allergic reaction to textured devices over many years. Currently, it is not possible to test for who is at risk of this disease.


What is the treatment of this lymphoma?

1. When a woman is diagnosed with BIA-ALCL, her physician will refer her for a PET/CT scan to look for any disease that may have spread throughout the body. Any spread of the disease determines the stages, which is important for treatment.

2. Newly diagnosed patients will be referred to an oncologist for evaluation of BIA-ALCL, staging of disease, and treatment planning.

3. For patients with BIA-ALCL only around the implant, surgery is performed to remove the breast implant and the scar capsule around the implant essentially an en bloc capsulectomy.

4. Lumps in the armpit may be disease that has spread to the lymph nodes or may still be a normal enlargement of the lymph nodes. Testing of the lymph nodes may be performed with a needle biopsy or with a surgery to remove a lymph node for testing. Additional tests may sometimes include blood tests and a bone marrow biopsy.

5. Some patients with advanced cases may require further treatment with chemotherapy and in rare cases include radiation therapy and/or stem cell transplant therapy.


Where can I find more information on this lymphoma?

Additional information, downloadable manuscripts, and resources on BIA-ALCL are available online at www.thepsf.org/PROFILE and at www.plasticsurgery.org/alcl .


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Edward Jonas Domanskis,M.D.

1441 Avocado Ave #307 Newport Beach, CA 92660 us

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