An interview with Dr. Cole on questions you should ask your Explant Surgeon before surgery:
Will you operate on me if I don’t live near you?
Explant and en bloc capsulectomy surgeries should not be taken lightly. Patients who need these procedures require careful pre-operative evaluation, precision surgery and careful, thorough post-operative care. Part of the pre-operative evaluation should include a pinch test, a test to determine how much residual breast tissue will likely remain after explant. By having an idea of how much breast tissue will be left, I can determine how much blood supply will remain.
We need a blood supply to keep all the overlying breast skin alive, and this is especially critical if a breast lift (mastopexy) is planned. I know that if a patient doesn’t have at least 3 cm of breast tissue when pinched, she is at risk of nipple loss, and I consider that a “never, never” complication. I haven’t figured out yet how other surgeons are able to effectively perform pre-operative exams like this over the phone or worse, in the pre-operative area on the way into the Operating Room.
Also, the post-operative course is a critical period where I work very, very closely with patients. It requires drain management, various pressure dressings techniques, wound care and very close follow up. Initially, I see patients every 3 days before progressing to once a week, and this typically lasts about 2-3 weeks. It’s critical that I am right there in order to minimize complications and optimize safety, and in case anyone has a question or concern. I want to be immediately, physically available should there be anything at all that I need to address.
The idea of a patient having a problem several states away when there’s nothing I can do to help is my nightmare. Patients with BII have been through enough, and I want to be there for them. I’m not comfortable phoning it in or leading them into a situation where they might need my help but can’t get it. For those reasons, I ask that patients be available for a thorough, careful pre-operative evaluation and a 2-3 week post-operative period.
Do you have hospital privileges?
Hospital privileges are important if you were to have a serious complication during surgery that would require entry to a hospital to save your life and a surgeon without hospital privileges cannot help you in those circumstances.
Yes. I have privileges at all St. Lukes and St. Alphonsus’ Treasure Valley locations.
Is the surgical facility accredited?
Yes. All St. Lukes and St. Alphonsus’ Treasure Valley locations are major JCAHO-accredited facilities.
How many En Bloc explants have you done?
Approximately 100 in the last 1-2 years.
Can you provide photos of previous En Bloc/Total Capsulectomy explants?
I have provided great photos on our website that highlights exactly what an en bloc capsulectomy should be. I also typically show several additional photos at the time of consultation. In addition, I’m happy to take photos intra-operatively and provide them to you post-op.
Are you committed to removing all capsule tissue from my chest?
Yes.
Will you drain or remove any fluid from your implants before explanting you or during explanting you?
No. I prefer to leave everything intact to can better remove everything associated with your implants.
If a seroma is discovered during explant will you aspirate and send the fluid and capsules for CD30 Immunohistochemistry to rule out BIA~ALCL?
Yes.
Will I receive antibiotics during the surgery, what kind will be used and how will they affect me? Will I receive any other medication such as an anti-nausea medication?
Pre-operative standard-of-care antibiotic therapy includes 1-2 gms of Ancef for these procedures. The powerful anti-nausea medication, Zofran, is universally available in all Operating Rooms.
Will you use cautery during surgery which reduces bleeding? How will you control bleeding or blood clotting if necessary to do so?
I, like all surgeons, use Bovie electrocautery to provide hemostasis.
Will any foreign materials be used such as staples, permanent stitches, mesh, etc?
I don’t use any permanent materials during either the explant/ en bloc capsulectomy or the mastopexy.
What kind of pain medication will be prescribed and how will it affect me?
I typically prescribe Percocet 5/325 1-2 tabs every 4-6 hrs and disponse 30 tabs. This has worked very well for my patients.
Are pieces of capsule tissue sent to pathology to check for bacterial and fungal infections and also the rest of the capsule to check for silicone, various immune reactivity cells, cancer or BIA-ALCL if applicable. Do you send the implants to pathology to document their state and if they are leaking or ruptured. Will you test saline fluid for colonization by microorganisms such as mold if applicable by sending to labs that test for fungus such as Mycometrics or Real-Time Lab? How much will any of this testing cost?
I send all materials to Pathology for evaluation and documentation. The cost for this evaluation is included in the overall cost of the procedure.
What do you do to clean out the chest pocket if it is contaminated with silicone and or microorganisms?
All abnormal tissue related to the implant is surgically removed and the pocket is copiously irrigated with saline prior to closure.
If you are dealing with a grossly ruptured silicone implant where silicone traveled to the lymph nodes, does he check lymph nodes for silicone through ultrasound and localization techniques and remove lymph nodes that cannot be saved?
If I see any abnormal, concerning tissue including a lymph node, I will remove it and have it evaluated by pathology for your safety. However, lymph nodes affected by such a scenario would typically be found in the axilla (armpit).
While I am happy to provide excellent breast surgical care, I am not a lymph node dissection surgeon. In the scenario described, any palpable or abnormal lymph nodes in the axilla should prompt an ultrasound evaluation, probable needle biopsy to evaluate silicone particulate versus infection versus breast malignancy, and finally a General Surgery evaluation for possible lymph node excision/ dissection.
Do you take pictures or video of the explant procedure?
Yes, and I’m happy to provide them to you post-op.
Can I have a copy of my complete file including operative reports, pictures and tests at our first follow up meeting?
Of course.
Will you pack up and return my uncleaned implants and capsule tissue to me if I request?
Yes.
What should I expect with drains and how will I care for drains while I have them? Who will remove the drains?
I always leave one drain in each breast for safety reasons. Once I remove the implant and all related tissue, it creates a potential space that can fill with fluid. If this fluid becomes infected, you can become very sick. Without a drain, if you develop a fluid collection, it can require surgery to remove and that’s the last thing I want for my patients.
The body can absorb 30 cc per surgical site per day. So when the drain is putting out less than 30 cc per day, I’ll remove it. This can range from 3 days to 2 weeks, but usually, the drains are removed within 1-1.5 weeks. The drains require drainage and soap water to the drain site each day. I will personally remove the drains.
What are the signs of an infection after explant? What are the signs of a seroma or hematoma after explant? What are the procedures if symptoms of these occur?
Infection presents with pain, redness, swelling, drainage or puss (thick yellow snot-like fluid) and eventually fever and chills. A seroma or hematoma will present as a noticeably enlarged breast. Infections may be treated with by-mouth antibiotics or worse-case scenario: operative washout and hospital admission for IV antibiotics. Seroma or hematoma is treated with prevention: drains at surgical sites and a compression wrap that I place in the OR. If a fluid collection occurs, this may be watched, drained in the clinic or may prompt operative evacuation.
If you are explanting due to rupture, capsular contracture, pain or infection and your insurance covers you for explant will the surgeon work through your insurance or provide you the letters required for you to apply to insurance for reimbursement?
Yes, I’m happy to work with insurance and I’m contracted with all major companies.
What are after surgery directions for compression, wound care, sleeping, massage and who will I call if have problems or questions after surgery?
I have a time-proven post-operative regimen that optimizes patient safety, minimizes complications and consistently provides successful results. It involves compression dressings, drain and wound care, post-operative antibiotics, massage and much more that would require more than a simple paragraph to address. I am happy to discuss the various aspects of my post-operative regimen during consultation. I am also available 24/7 via my answering service so patients always have access to me.
Will he/she prescribe antibiotics for bacterial infections in the chest or antifungals if the implants are colonized with fungus or if you experience an overgrowth of fungus in the gut and body due to antibiotics from surgery?
I am happy to treat bacterial infections of the breast and any infections that may result from the use of antibiotics, including yeast infections. If a more sophisticated fungal infection occurs, which is very rare, I would discuss this with an Infectious Disease physician for expert direction.
How long will it take for my breasts to heal and feel normal? When will the follow-up appointments be and how many?
While the operative site will usually be sore for 3-4 weeks, the completion of soft tissue healing won’t be complete for about 6 months. Technically, soft tissue continues to heal for 12 months, but you will have an approximate idea of your result at about the six-month time point. When “you will feel normal” is very difficult to answer as each case is dependent on that actual patient. Most patients begin to feel pretty normal around the two week post-op period and slowly progress back to normal life between 3-4 weeks. It’s important during this time to remember that your body is still healing, and although patients begin to feel normal and desire to return to normal activity, it’s critical to give your body the time it needs to complete the healing process.
I follow patients very closely. I typically see patients back on post-op day 2 or 3 (based on patient convenience), and then every 3-4 days for 2 weeks. Assuming the post-operative course is going very well and the drains are out, I will then see patients about once a week until week 3-4. Every case and every patient is different. Some patients desire more follow up, some prefer less. I’m happy to work with the individual patient as long as safety is maintained and a satisfying result is achieved. I use compression dressing for the first 2 weeks, then transition to a sports bra from 2-6 weeks post-op.