Implant revision and explant surgery

Implants are devices. Devices fail, move, become uncomfortable, or outlast the reason they were put in. Revision and explant — operations that replace, reposition or remove them — are therefore not a scandal at the edge of breast surgery. They are a central part of it. Australian rooms have been busier with these conversations since textured-device safety notices, since more open talk about contracture and rupture, and since a generation of people who were implanted in their twenties arrived at a different body in their forties.

This is a science editor’s explainer, not a recommendation to keep or to remove a device. It does not name a brand. It does not promise that the chest will look as it did before the first operation. For how implants are regulated in the first place, read breast augmentation, implants and Australian regulation. For the wider set of operations, use the breast surgery hub.

Why revision is on the table

The reasons cluster.

Integrity. A silicone implant can rupture without a theatrical deflation. The gel may stay inside the capsule (intracapsular) or, less often, move beyond it. Saline devices announce themselves by going flat. Trauma, wear, a manufacturing issue, or simply time can all be in the history; often no single event is found. Imaging, discussed below, is how a suspicion is tested.

The capsule. The body forms a scar around every implant. When that scar tightens — capsular contracture — the breast can feel firm, look spherical or distorted, and ache. Contracture is one of the more common reasons for a return to theatre. Removing or releasing the capsule (capsulectomy or capsulotomy) may be proposed, with or without a new device.

Position and shape. Implants drop too low, sit too far apart, rotate if they are shaped, or ride too high. Animation deformity — the implant moving when the pectoral muscle contracts — is a specific complaint when the pocket is under the muscle. Some of these problems are technical. Some appear after weight change or pregnancy. Some are what a particular chest was always going to do with a particular volume.

Preference and circumstance. A size that made sense at thirty may not at fifty. A sport, a new health diagnosis, or simple fatigue with being a person who has implants can be sufficient reason to explant. A TGA notice or a registry letter about a device type can prompt a review even when the breast feels fine. Anxiety after reading about BIA-ALCL is itself a reason to have a calm, factual consult — not a reason to book the first available theatre list in a panic, and not a reason to be dismissed.

Pain, seroma, or a mass. Unexplained late swelling, a fluid collection, or a lump in the breast or armpit needs investigation before anyone plans a purely aesthetic swap. Breast implant-associated anaplastic large cell lymphoma is rare and is one of the diagnoses specialists consider in that setting. Infection, ordinary cysts, and breast cancer are others. Sequence matters: assess, then operate.

What revision is not is a verdict on the original decision. People are allowed to change their minds about a device in their body.

Imaging before anyone opens a pocket

A careful revision starts with a history of the first operation: date, hospital, pocket, surface, fill, and any previous revisions. Device stickers and an operation report are gold. If they are lost, the Australian Breast Device Registry and the original hospital may still hold a trace. Guessing the implant from a ten-year-old memory is how people get surprises in theatre.

Ultrasound is often the first look at a suspected rupture or a seroma. MRI is the more sensitive test for silicone-implant integrity in many protocols and is used when ultrasound is inconclusive or when the question is more demanding. Mammography remains relevant for breast-cancer screening and for some lumps; it is a different question from implant integrity. The radiologist needs to be told that implants are present and, if known, whether they are above or below muscle.

Imaging does not dictate a date. A suspected silent rupture in a person who is well is a shared decision: operate now, watch, or seek another opinion. A symptomatic seroma is a more pressing work-up. A normal scan does not make a painful, contracted breast imaginary. The scan and the examination have to sit in the same room.

If BIA-ALCL is in the differential, the pathway includes specialist assessment, cytology of fluid where appropriate, and a discussion that should not be improvised from a search result. This journal will not walk you through a work-up you should have with a practitioner.

Explant, exchange, lift — different operations

Exchange puts another implant into a pocket that may be modified, with or without work on the capsule. It is still device surgery. All the original device risks return in a new form: rupture, contracture, malposition, the need for yet another operation. Sizing may go down, up, or stay similar. Going larger in a already-thin envelope has a visibility and rippling cost.

Explant without a lift removes the device (and, depending on the plan, some or all of the capsule) and closes the pocket. The remaining breast is whatever tissue and skin the person still has. In a small, taut breast the change can be modest. In a thin, stretched envelope the change can be a deflation that the person finds confronting. Neither outcome can be promised, and the confronting one is not a complication in itself — it is a consequence that should have been described.

Explant with a lift adds a mastopexy: skin is taken in, the nipple is raised, scars are accepted. It is a longer operation with a combined risk list (nipple blood supply, wound breakdown, the usual lift scars). Some surgeons prefer to explant, let the tissues settle, and lift later. Staging is a judgement about blood supply and about whether anyone can predict the shape until the volume of the device is gone. It is not a stalling tactic.

Fat transfer is sometimes discussed to soften a contour after explant. It is a further procedure with its own limits: not all transferred fat persists, and it is not a substitute for an implant in people who want that kind of volume. It is also not advertised here as a product.

Capsulectomy extent — partial, complete, “en bloc” in the sense of removing capsule and implant together — is a technical and, at times, ideological argument the internet has not improved. What belongs in a consult is the indication (suspected ALCL, contracture, rupture with extracapsular gel, a thin capsule that may not come out as a souvenir), the extra risk of a more aggressive dissection (bleeding, fluid, injury to muscle or lung lining in rare events), and whether the specimen will go to pathology. Demand a slogan and you will get one. Demand a reason and you may get medicine.

What cannot be promised, and how consent should sound

No operation restores a pre-implant photograph. The skin has been occupied. The gland may have thinned. Ageing and weight have continued. People who were implanted before pregnancy are not returning to a pre-pregnancy chest either. A surgeon who talks about “going back to natural” without showing you, on your own body, where the fold is and where the nipple sits is skipping the only demonstration that matters. This journal will not publish a gallery that pretends otherwise.

Scars from the original incision will be reused where possible and may be extended if a lift is added. Sensation may change again. Symmetry is a hope with a tolerance, not a specification. Further revision remains possible. Infection, haematoma, seroma, wound breakdown and, if a new implant goes in, all the device complications already named, belong on the form.

Anaesthesia is typically general, in a licensed hospital. Stay may be day or overnight. Recovery windows are ranges: desk work often in the one-to-two-week band after a straightforward explant; longer if a lift or a difficult capsulectomy was added; gym and upper-body loading later, commonly four to six weeks or more. A drain, if used, has its own instructions. Follow the written plan.

Urgent symptoms after revision are the same family as after any breast operation, with a few extras: sudden swelling (haematoma or seroma), fever, a wound that opens, a nipple in trouble if a lift was done, chest pain or breathlessness. Call the treating team. If you cannot, call 000. Our companion piece on when to seek urgent care after a cosmetic procedure is the general list; it does not replace the card you should leave the hospital with.

Practical Australian notes

Bring the old records. Check the current practitioner on the Ahpra register; revision is not the moment for a title that does not match specialist registration if the operation is complex. Ask whether they contribute to the breast-device registry, how a removed device is identified and disposed of, and whether pathology will be requested. Ask how they would reach you if a future notice related to a new implant.

Money is often worse the second time. Medicare items exist for some medically indicated explant and revision work; they do not exist as a general “I changed my mind” rebate. Funds follow items and waiting periods. Get the item number and the fund check before you treat a quote as complete. Public pathways, where they exist for symptomatic or oncological reasons, have their own criteria and waits.

A cooling-off period still applies when the context is cosmetic. Using it is not indecision. People who have lived with a device for a decade are allowed a month to decide whether they want another one.

Revision and explant are ordinary operations in a device-using speciality. They deserve the same regulatory seriousness as the first implant: TGA-aware language, a registry habit, imaging when integrity is the question, and a consent that names what the chest may look like without a product in it. They do not deserve a promise to rewind the body to a year that no longer exists. If you can leave a consult able to say why you are operating, what is being removed or replaced, and which appearance goals have been taken off the table, you have had the conversation this article exists to prepare.