Does a Capsulectomy Really Improve Pulmonary Function in Women with Breast Implant Illness?

Sir:

Wee et al¹ believe that breast implant illness (BII) often causes a deterioration in respiratory function that can be improved by explantation and total capsulectomy. The authors reference their recent retrospective outcome study of 750 women who underwent explantation by the senior author (L-J.F.) during a 24-month period in 2017 and 2018.² This new publication reports results for 72 patients. The selection criteria and inclusion rate are not reported. Complications are not provided either. There is no control group (eg, patients explanted without capsulectomy, or implant replacement). Photographs depicting the aesthetic result are unavailable. The authors do not cite any studies suggesting that breast implants or capsules diminish pulmonary function. The extraordinary statement, “Capsular contracture … may mimic a restrictive lung process due to scarring and fibrosis of tissues of the chest wall” is not referenced. Respiratory symptoms play a minor role in the wide variety of complaints that comprise BII. Shortness of breath or breathing problems were not even included among 56 BII symptoms in a recent study by Lee et al.³ It has not been shown that any subjective respiratory symptoms correlate with impaired pulmonary function in patients who are labeled BII. The authors speculate that removing the posterior capsule releases constriction on the chest wall. Clearly, scar tissue will develop to replace a resected capsule. It has not been shown that a capsule interferes with chest expansion during breathing. In the authors’ previous outcome study, women reported improvement in all 11 symptom groups at a significance level of a P value less than 0.0001.² It is difficult to conceive of a physical explanation for a uniformly dramatic improvement in every physical condition evaluated. This is a clue to the limitations of subjective assessments in women who have just spent a large amount of money and made a major life decision to undergo explantation. The authors state that they always perform a total capsulectomy.^1,2 It is often impossible to remove a thin subpectoral capsule that is tightly adherent to the ribs and extends into the axilla. Attempts to do so might be dangerous. Women with breast implants usually have little breast tissue. A capsulectomy magnifies the deformity they will be left with after implant removal.^4,5

Importantly, the authors’ statistics are not supportive. For forced vital capacity, the authors report before-and-after treatment means of 3.6 ± 0.6 and 3.7 ± 0.6 and a P value of 0.008. Just eyeballing these mean values and SDs, one would think there would be no significant difference, especially with a group size of 69. Indeed, an online t test,⁶ by entering the authors’ means, SDs, and sample sizes, produces a P value of 0.132. Similarly, the authors report a P value of 0.009 for the slight difference in FEV1 values (2.8 ± 0.4 versus 2.9 ± 0.4). An online t test produces a nonsignificant P value of 0.133. Social media notwithstanding, a capsulectomy is not required unless there is capsular pathology.^4,5 En bloc resection, referring to excision of capsule along with a margin of tissue, should be done only for cases of breast implant-associated anaplastic large-cell lymphoma.^4,5,7

When performing numerous statistical comparisons, it is customary to use a more rigorous alpha level (P < 0.01) to avoid type I errors. Otherwise, spurious positive findings are possible. Such is likely the case for the authors’ findings regarding smooth versus textured implants. Unfortunately, some financially motivated operators market an en bloc capsulectomy as a cure for BII.^4,5,8 A website promoting “EnBloc Surgeons” warns: “Don’t take chances of going to a regular plastic surgeon.”⁸ By contrast, explantation alone is safe and easy for patients and is inexpensive, and there is no evidence that it is less effective for BII.⁵ Breast trauma is minimized, the aesthetic result is superior, and implant replacement at a later date is simpler.

DISCLOSURE

The author has no financial interest to declare in relation to the content of this article.