Explant Recovery: Under vs. Over the Muscle, and What Adding a Capsulectomy Actually Costs

Let me walk through how recovery from explant surgery actually looks — including the difference between removing implants under vs. over the muscle, what adding a capsulectomy does to your recovery, and why I really don't want anyone being talked into an en bloc capsulectomy unless they actually need one.

This is a topic where the surgical decisions you make really do shape how easy or hard your recovery is.

When we remove implants, the biggest factor affecting recovery is whether the implant was placed under the muscle or over the muscle.

If your implant was placed under the muscle, two things tend to happen with recovery:

• We repair the muscle when we take the implant out. Anytime we do muscle surgery — releasing it, repairing it, suturing it — you have more pain and discomfort afterward.
• The recovery is a bit more tender, especially when you start reintroducing activity in the first couple of weeks.

In my own practice, the difference is smaller than people often expect because I do:

• Long-acting nerve blocks at the time of surgery
• ERAS-style multimodal protocols (Journavx, Motrin, sparing opioid use)

These have dramatically reduced the pain gap between under-the-muscle and over-the-muscle explants. But I've also had surgery in both positions personally — and under-the-muscle is genuinely more tender.

If your implant was placed over the muscle (subglandular or subfascial), recovery is generally easier:

• No muscle work required
• Less post-op tenderness
• Faster return to normal activities

So all things equal, over-the-muscle explants are a softer recovery.

This is where the choice of operation has the biggest practical impact on your week-by-week experience.

There's a study from the Cosmetassure database that's worth knowing about. Cosmetassure is a specialized insurance that plastic surgeons can purchase to cover patients' complications from cosmetic procedures (since regular health insurance often won't).

The Cosmetassure database is a great resource because it captures real-world complication data across many practices.

When they looked at patients having implant removal with vs. without capsulectomy:

• Adding a capsulectomy doubles your major complication rate
• The absolute rates are still low
• But the relative increase is 2x

In other words: capsulectomy is not free. It carries real complication risk.

• Hematomas (blood collections requiring intervention)
• Seromas (fluid collections)
• Infections
• Wound issues
• Damage to surrounding structures during the more extensive dissection

The longer, more extensive the surgery, the more chances something can go wrong.

Some surgeons routinely use drains after capsulectomies. I generally don't — but if your surgeon does, that's an additional layer of inconvenience to your recovery:

• Living with drains for 1–3 weeks
• Stripping and emptying daily
• Garment management around them
• Aesthetic awkwardness during recovery

(I've written separately about Why Surgical Drains Are Generally Miserable and about exit-point placement for drains for patients in this situation.)

I don't want to leave the impression that capsulectomy is never appropriate. There are real indications:

• Severe capsular contracture (Baker grade III/IV)
• Ruptured silicone implants (especially older ones)
• Documented capsule cancer (BIA-ALCL or BIA-SCC) — the only indication for an en bloc capsulectomy
• Certain implant-related infections

For BII / SSBI symptoms without one of the above, capsulectomy is not supported by the evidence and unnecessarily doubles your complication risk.

This is where I genuinely get fired up.

No one should be having an en bloc capsulectomy with their implant removal unless they have BIA-ALCL or BIA-SCC. Full stop.

• The implant stays inside the capsule
• The capsule plus implant are removed
• AND a rim of normal surrounding tissue is taken as well

The "rim of normal tissue" part is what makes it en bloc. It's an oncologic technique borrowed from cancer surgery — used to ensure cancer cells aren't spilled during removal.

The only legitimate indication for en bloc capsulectomy is documented cancer of the capsule — BIA-ALCL or BIA-SCC. Both of those cancers are rare enough that essentially nobody should be having an en bloc operation. The operation is overkill for everything else.

A subset of "explant experts" tell women with BII symptoms that they're more likely to feel better if their implants are removed en bloc.

Multiple studies in multiple countries have shown this is not true. The way the implant is removed does not change the rate of symptomatic improvement. (See Do All Explants Need Total Capsule Removal? and the heavy metals myth post for more detail.)

If a surgeon does an en bloc on you without a cancer diagnosis, the recovery is meaningfully worse:

• Larger incision — instead of a small, cute scar, you get a much bigger one
• More tissue removed — including normal tissue you didn't need to lose
• More breast deformity afterward
• Higher complication rates
• Longer healing
• More expensive surgery
• And — most importantly — no symptomatic benefit over a simpler removal

For my patients undergoing explant — with or without capsulectomy — here's what recovery generally looks like:

• Most patients feel pretty good
• Most don't need their opioid medication beyond the first day or two
• I rely on nerve blocks, Journavx, and scheduled Motrin for pain control
• Patients are typically comfortable by day 5–7

• Most patients are released back to work at one week
• Most are able to drive by this point
• The under-the-muscle patients are a bit slower than over-the-muscle patients

• Activity restrictions continue — no heavy exercise
• Normal daily functioning is fine
• I want you behaving yourself while everything heals

• Most restrictions lift
• Patients can return to full activity, including exercise

If your implant was under the muscle:

• Pain lasts a bit longer
• Returning to chest-engaging activities (push-ups, certain yoga positions, heavy upper-body lifts) is a bit more challenging for the first couple weeks back

But by one month out, recovery converges for both groups.

If you're thinking about explant surgery, please understand the real recovery costs of each option:

• Simple removal (over the muscle) → easiest recovery
• Simple removal (under the muscle, with muscle repair) → slightly more tender
• Add a capsulectomy → doubles major complication rate (still low overall, but 2x)
• Add a capsulectomy with drains → also adds drain management to your week
• En bloc capsulectomy → biggest incision, most tissue removed, worst cosmetic outcome, no added benefit (unless you have capsule cancer)

If a surgeon is recommending en bloc for your BII symptoms, please get another opinion before agreeing to it. You can find a surgeon who will do the right operation without putting you through the unnecessary version of the procedure.

Explant recovery is shaped by two things: whether your implant was under or over the muscle, and whether you have a capsulectomy.

• Under the muscle → more tender, but manageable with modern pain protocols
• Over the muscle → easier recovery
• Capsulectomy added → doubles complication rate, sometimes adds drains
• En bloc capsulectomy → should essentially never be done outside of capsule cancer

The right operation for you depends on your specific anatomy and diagnosis — not on what an explant influencer told you to demand. Please don't let anyone talk you into an en bloc you don't need. There's no upside to it for non-cancer indications, and the downsides are real.