I often consult with patients who have decided to remove their implants for a variety of reasons and not have them replaced. What is common to all patients is that they are worried about what they will look like without the implants and want to know the options.

This article explores the reasons why patients want implants removed, as well as the terms Breast Implant Illness and Breast Implant Associated Anaplastic Large Cell Lymphoma or BIA-ALCL. I also explain the likely appearance of the breast after implant removal and the options to improve saggy or empty breasts. The reasons for wanting implants removed are commonly:

• Concern that the implants are affecting health, feeling generally unwell or having recent health problems.
• Concerns about the possibility of developing cancer or BIA-ALCL (also ALCL) and feeling the implants are a “time bomb”.
• Wanting to avoid further operations in the future and implant maintenance.
• Unhappy with the appearance of the implants.
• The reasons for wanting implants have changed or are less relevant.

Breast Implant illness (BII) A small proportion of women who have breast implants develop a variety of symptoms that they believe arise from the presence of their implants. These symptoms include tiredness, “brain fog”, joint aches, immune-related symptoms, sleep disturbance, depression, hormonal issues, headaches, hair loss, chills, rash, hormonal issues and neurological issues.

There are many other reasons for these symptoms, such as other illnesses or hormonal changes. Interestingly, there have been several scientific studies investigating similar symptoms experienced by women in the population in general. For example, a Swedish study looking at a random sample of 4,200 women between 35-64 years old, found a significant number of the population experienced similar symptoms to those ascribed to BII, although they did not have breast implants. A 20-year Danish study looked at musculoskeletal symptoms and concluded that musculoskeletal symptoms were generally lower among women with implants, compared with women in the general population.

Overall, around 50% of women who feel they have BII report that their symptoms improve after implant removal–sometimes temporarily and sometimes permanently. Therefore, evidence appears to suggest that removing breast implants does not necessarily improve symptoms in everyone.

Immune system blood tests have shown no difference in levels of autoimmune antibodies between women with and women without breast implants. The small number of women diagnosed autoimmune conditions did not have any improvement when questioned over 2-years after implant removal. However, most women reported an improvement in their psychological well-being after implant removal. In medicine, it can take many years to come to a scientific conclusion and I think the most important thing a surgeon can do is listen to their patient. If the patient understands the likely outcome of implant removal and that removal won’t necessarily stop their symptoms, then there is no reason not to take them out. No one can argue that if a patient has concerns and anxiety about the implants then they are likely to be relieved when they are gone. Under these circumstances it is the best thing to do and will likely give peace of mind to the patient.

Breast Implant Associated Anaplastic Large Cell Lymphoma (BIA-ALCL) This is a rare type of lymphoma (cancer) that affects women with breast implants. It is not a cancer of the breast tissue, but it can occur within the capsule (scar tissue) that surrounds a breast implant. We do not know the exact incidence of ALCL, but it is thought to be around 1:20,000 to 1:60,000. For comparison, the general incidence of breast cancer in the UK is 1 in 9 and affects women with and without breast implants equally. Cases of BIA-ALCL have occurred between 2-28 years after breast implant insertion with the average time being 8 years. Up to 2018, there were 414 reported cases of BIA-ALCL and 16 confirmed deaths worldwide from BIA-ALCL. It is assessed to be associated with the coating around some breast implants. Most of the cases have occurred in women with textured breast implants, particularly those with a coarser texture than those with a finer texture. Not all textured surfaces are manufactured in the same way and they appear to convey different levels of risk, hence it is difficult to draw definite conclusions at this time. Texturing of an implant surface also offers advantages, such as reducing the risk of capsular contracture or hardening of the breast implant as it is squeezed by the thickened capsule. Hence, many surgeons in the UK still advocate the use of textured implants for their patients. It is vital, however, that the risks of using textured or smooth surfaced implants are fully discussed with patients prior to surgery, in order to select the implants they feel most comfortable with.

It does appear that smooth implants have a lower risk of BIA-ALCL compared to textured implants. I routinely use “micro” textured implants (Sebbin). These are classified as smooth implants, but they offer the same benefits as textured implants in reducing the capsular contracture rate. So far, they have not been associated with ALCL to date but the possibility cannot be excluded completely in any implant. There is no recommendation that patients with textured implants should have them removed as a precautionary measure. The British Association of Aesthetic Plastic Surgeons (BAAPS) advises that concerned patients need not take any action currently. They should continue their routine follow up with their healthcare professional and discuss any questions or concerns they have about their breast implants. There is not always the need to remove or exchange any current implants based on the most up-to-date scientific data available. Indeed, unnecessary surgery may cause additional harm in a small number of patients.

Any onset of swelling, pain, increase in size in the breast over days or weeks should be investigated for BIA-ALCL. There are, however, many causes for breast swelling which are not BIA-ALCL. If there is any sudden onset swelling or lump then a patient needs an ultrasound scan or MRI to look at the implants and fluid around it. A needle is used to take a sample of the fluid which is tested in the laboratory to see if there any cells present showing markers for lymphoma. ALCL is treated by complete removal of the implant with surrounding capsule This is to cure the condition, especially if it is treated early.

If implants are removed, then it is likely the breasts with be significantly flatter and droopy. This isn’t the case for all patients, but if a considerable amount of time has passed since they were originally put in, the breasts tend to lose volume and drop with time. The reasons for having implants in the first place are likely to be small breasts and this will be compounded by age related changes. Therefore, they are likely to have progressed and a patient must be prepared for this possibility. It is difficult to predict exactly how much breast tissue or droopiness there will be and how a patient will feel about it. Some patients are not concerned and pleased they had the implants removed. However, many patients are not happy with the appearance of the breasts and wish an alternative solution to improve the appearance or put new implants back in. This could either be done at the same time as implant removal or at a second stage when everything has settled, and the appearance can be properly assessed. There is no right or wrong choice, but if in doubt, it is best to do it as 2 stages to have an opportunity to decide whether further surgery is needed.

Management options are:

• No further surgery.
• Mastopexy – uplift of the breast and tightening of the loose skin.
• Fat grafting – taking fat from the abdomen or thighs and injecting it into the breast to give volume.
• Replacing the old implant with a new one. This can be done with an implant or fat graft if extra volume is required.

Further information about each option can be found in the procedure pages of my website.

This information is largely provided by the British Association of Aesthetic Plastic Surgeons and is an excellent source for reference and further information. If you would like to consult with me about any of the above concerns, then please do not hesitate to contact me.