The Dishonesty of Referring to Total Intact Capsulectomy as “En Bloc” Resection or Capsulectomy

Sir: When I set out to write this, it was to address the public. After researching the literature, I found nothing consistent with respect to the nomenclature in our literature and decided to write to the editor instead. The following will read like a mixture of an address to the lay public, and to my colleagues. For the sake of complete transparency, “en bloc” means “in block,” or in one piece. Concretely speaking, the term en bloc resection of a capsule and implant should be correct. It is not correct from the perspective of surgical history and oncologic principles. In the surgical sense, en bloc resection of a given tumor refers to the complete removal of the tumor with a thickness of uninvolved tissue (the thickness is referred to as the margin and its dimension depends on tumor type), in many cases along with the adjacent lymph nodes. The goal is to never get close enough to the tumor to see it but to scoop out enough good tissue covering it, so no tumor cells are left behind to multiply, regrow, and spread. This principle was first elucidated by Halsted in the 1890s and has since formed the backbone of surgical oncology.1 Classically, this principle applied to breast surgery, but it has been extended to every tissue we operate on, from skin to bone.2 A surgeon cannot resect a prosthesis, she can only remove it. because the prosthesis, though it may be adherent to surrounding tissue, cannot have cellular connection to the adjacent tissue, because as we all well know, the implant is without cellular or extracellular content. Because of this, we refer to the removal of an implant as just that, and not a resection of a prosthesis. Thus, what would it take to make it a true en bloc resection? Well, what are we resecting? The capsule. If it is determined, or even believed without empirical data that the capsule is the root of all ailments related to breast illness, it stands to reason that a true en bloc resection is warranted. If a surgeon were to apply the same principal to a capsulectomy, en bloc capsulectomy wound involve taking an arbitrary margin of healthy tissue around the capsule, and never seeing it (the capsule) either grossly or on pathologic examination. That would mean chest muscle and rib on the deep surface and muscle and breast tissue and possibly skin over the superficial surface of the implant. That would be maiming, and that would be malpractice. Whoever the first “physician” was to use this term to describe capsulectomy as an en bloc resection was either misinformed or a self- aggrandizing con artist who either forgot, or never knew, the effort involved in the more complex tumor surgery. There is no citation in the peer-reviewed literature that refers to this procedure as such, but the Internet is replete with references to this operation, in many cases by our board-certified peers. There is a reference in a textbook on augmentation mammaplasty that completely discounts the meaning of en bloc resection, and does not distinguish between a complete capsulectomy and en bloc capsulectomy, mistakenly defining an en bloc implantectomy as an “en bloc surgical technique for complete capsulectomy.”3 Removing a capsule intact with the implant should be called just that. It would be interesting to see the specimen from one of these “en bloc” resections, and even more interesting to see what kind of normal tissue margin around the capsule they were able to obtain. The definitions as I understand them, noted in layman’s terms to the extent that I could, are as follows: Capsulotomy (for “implantectomy4”): Incision into the capsule (to remove an implant only, or alter the pocket). Partial capsulectomy: Removal of only the thickened or calcified portion of the breast capsule (when other sections are too thin to remove without significant damage to the adjacent tissue). Complete capsulectomy: Complete removal of the breast capsule but not together with the implant, such that the contents of the capsule, including any intracapsular fluid, is spilled or exposed to surrounding tissue during resection of the capsule. Complete intact capsulectomy: Complete removal of the intact breast capsule along with the implant sill inside of the spheroid scar. En bloc resection of capsule (en bloc capsulectomy): Complete removal of the breast capsule with the implant contained inside, with a defined margin of healthy tissue on gross and histopathologic examination. I believe we need to define the extent of breast prosthesis explantation to prevent ill-conceived social media and marketing efforts from redefining surgical nomenclature and misinforming the public. DISCLOSURE The author has no financial interest to declare in relation to the content of this article. Jacob Gerzenshtein, M.D.University of Central Florida College of MedicineOrlando, Fla.