Explant surgery is common. Removing breast implants certainly hasn’t outpaced putting them in (yet), but the numbers are rapidly increasing. Body image is at the core of all aesthetic surgery procedures so it seems odd to me that so little is being written about the effect of explant surgery on body image.
Patients who have their breast implants removed are some of my happiest patients. There are however a small number of patients who struggle greatly with their body image after explant surgery. So let’s talk about that.
How do we define body image?
Body image is a complex construction. It is the summation of the thoughts and feelings that you have when you consider your own appearance. It is in some cases a struggle between a desire for self-acceptance and a desire to look different/better/more proportionate/sexier/younger. It is the tension between the idealised image in our minds of what we would like to look like, and the physical representation we see reflected back at us in a mirror. Body image is something that can be manipulated and used a means of selling: whether that product be clothes, make-up, lifestyles or surgery. Body image is also potentially a deeply pervasive lie – the image in our heads may be unattainable, and what we think we see in the mirror may be distorted by our own psychology.
I think it is fair to say that most women who have a breast augmentation with implants choose to do so based on body image. Maybe they don’t like the size of their breasts. Maybe it is an issue of proportion. Maybe there are shape issues (tuberous or constricted breast variants are very common). Maybe it is due to deflation of the breasts after breast feeding. Whatever the reason, these issues tie back in to how people perceive themselves, and their satisfaction with their own appearance. This remains the rather delicate ethical proposition of aesthetic surgery – how far do we go in offering procedures that (implicitly or explicitly) reinforce the idea that if you don’t like your appearance, then surgery is the answer. That is a tricky discussion to have, and we must be especially cautious in not removing a sense of agency or self-determination from those who have aesthetic procedures.
The point though, is that most women who have breast augmentation do so to improve their body image satisfaction.
So where does that leave us when we consider the number of women having explant procedures? What is the effect of explant surgery on body image? And what can we do to prevent a deterioration in body image whilst pursuing physical health?
The results of explant surgery
Explant surgery leads to a reduction in the volume of the breast. The effect of reducing breast volume on the breast shape is complex and depends on the quality of the tissues, how much natural breast tissue is present, what the proportion of breast implant volume to natural breast volume is, the position of the breast on the chest, and changes that have occurred in the breast over time since the implants were placed. By removing breast implants we often lead to a situation where the breast appears deflated and may sag or droop. In other circumstances, removing breast implants simply leads to a breast reverting to the (small) size and shape that the breast had prior to the implants being placed.
The job of a surgeon is to determine what the expected effect of removing the breast implants will be, and plan accordingly to correct the issues that may arise. If we come back to the effect of explant surgery on body image, then it is the surgeon’s role to safely fulfill a patient’s desire for explant whilst acknowledging and minimising the possible negative effects on body image that may follow.
What are the options for optimising the appearance of the breast after explant surgery?
In my hands there are 3 options:
- explant alone;
- explant with fat graft;
- explant with breast lift/mastopexy (+/- fat graft).
So lets look at each of these and consider the impact they may have on body image.
Women who are candidates for simple explant procedures are normally younger ladies with firm, resilient tissues. This implies sufficient elasticity in the skin and breast tissue to allow the breast to appropriately recoil into an unstretched shape following breast implant removal.
The consequence of implant removal in these ladies is a reversion to the small natural breast that was present prior to breast augmentation. We do need to consider whether the surgeon who placed the implants destroyed the natural crease and forcibly lowered the crease position to accommodate a large implant – if this happened, then it is possible that the explant scar may sit below the natural crease.
The challenge for these ladies is accepting their smaller bust size. Depending on how this impacted on their body image before having the implants, this may be difficult.
Explant with fat graft:
The addition of fat graft to the explant procedure allows some patients to partially replace the implant volume with their own tissue. This is a great option, but it is important to understand the difference between implant volume and fat graft volume.
The addition of the fat transfer helps to minimise the negative effect of explant surgery on body image. The fat graft allows us to avoid a situation where a patient feels that they have reverted to their pre-implant appearance. But we must be conscious of the limitations of the technique.
One of the challenges that I have found is in giving patients an accurate expectation of their surgical outcomes from this technique. Before and after photos are useful, but they don’t necessarily demonstrate well the difference that the addition of fat makes. The best way I have found to address this is to use intraoperative photos after I have added fat graft to one breast but not the other. This demonstrates the size of the natural breast without an implant, and it shows clearly the impact of adding the fat graft.
Explant with breast lift:
This is a necessary procedure for women whose breast has changed shape since the implants were placed, or for women whose breast has been stretched excessively by an implant.
It seems that many surgeons consider this to be a challenging procedure and there are many who simply don’t offer it. There are many surgeons who claim that the lift should only be done at a second stage. My perspective on this is twofold: my patients would rather have one operation than two; and I see quite a few patients who have already had an explant without a lift, and their breast is deformed as a consequence of their previous treatment. So if I can do in 1 operation what is needed to avoid creating a misshapen breast, I consider that to be the best option.
I often say to my patients that the lay-term “breast lift” is something of a misnomer. There are many ladies who don’t need vertical lift of the breast or nipple position, but I would still recommend a mastopexy. This is because the mastopexy is better considered to be a tightening procedure in this context. it allows me to correct for the excessive laxity in the breast after the implant has been removed.
I use a technique (which as far as I can tell is unique) to ensure that I can optimise the breast volume, whilst avoiding the need for drains.
Back to body image
So to bring this back to body image, let’s think about outcomes. The outcomes of these procedures are variable, and not every patient will benefit in the same way.
I have seen many ladies who end up with a very modest bust, regardless of the surgical technique, who are incredibly happy. These ladies seem to have a body image that rapidly adapts to having their breast implants removed. I struggle to make any generalisations about this group, but it is probably true to say that most of these ladies expressed some regret at their decision to have breast implants in the first place. Perhaps this allows their self-image to rapidly adapt following explant surgery, but I am not aware of any research to support this hypothesis.
I occasionally do see ladies who really struggle after their explant surgery. These ladies chose to have their breast implants removed for a variety of reasons. Some of these ladies describe Breast Implant Illness symptoms. Some of these ladies have aesthetic changes in the breast without BII symptoms. And others just decide to have their implants removed because they simply don’t want them anymore. Regardless, sometimes these ladies will struggle with their modest bust following implant removal. I don’t have any magic answers for this situation. Occasionally we see ladies who choose to re-implant after their explant surgery. It is important that this decision is not judged. There are a myriad of factors that can lead to this point.