Breast Augmentation Revision
Breast Implant Revision Overview
According the American Society of Plastic Surgeons, approximately 296,000 women underwent breast augmentation in 2010. This represents a 2% increase from 2009, and breast augmentation remains one of the most popular cosmetic procedures in the United States. Approximately 60% of these women undergoing breast implant surgery will choose a silicone breast implant. Despite the growing number of women undergoing breast augmentation, breast implant surgery is a complex procedure that requires years of training and experience and should be performed only by a plastic surgeon who is board certified by the American Board of Plastic Surgery.
Breast augmentation surgery is accomplished by surgically creating a space beneath the breast and pectoral muscle of the chest for a prosthetic implant. It is usually performed under deep sedation center. Breast augmentation, as with all surgeries, must be performed under the strictest of care with meticulous surgical technique by a board-certified plastic surgeon and an anesthesiologist or nurse anesthetist. Proper performance of breast implant surgery requires a thorough preoperative history and physical, precise measurements of the breasts, chest wall, and soft tissue, and selection of the proper implant for the individual patient.
Factors that will effect the method of breast augmentation and implant choice are:
- Starting size and shape of the breast
- Quality of skin and the presence of stretch marks on the breast
- Distribution and quality of breast tissue
- Overall thickness of the soft tissue of the breast
- Location and size of the nipple and areola
- The Position of the lower crease (inframammary fold) of the breast
- Shape and prominence of the ribs and breast bone
- Width of the rib cage
- Shoulder height
Despite optimal preoperative planning and a well-executed surgery, revisional procedures of breast implants are sometimes necessary. A breast revision is more complex than a primary procedure, since the area has already undergone trauma from previous surgery. Factors that make revisional surgery more difficult include scar tissue, altered implant position, thinning of the tissue or skin, and distorted breast shape.
During your consultation, Dr. Zemmel will perform and complete history and physical. Dr. Zemmel will evaluate your complete breast history. Please bring all relevant information to the consultation including implant cards, names and locations of your prior surgeons, and previous medical records. This will assist Dr. Zemmel in diagnosing your issues and formulating a comprehensive treatment plan.
There are a number of reasons women seek breast implant revision surgery. The following summarizes the most common reason for revision as well as the general approaches to treatment.
All prosthetic body implants have a lifetime including breast implants. Today’s breast implants are safe and durable, but with many years of normal usage, rupture will occur. Saline implants are filled with saline (salt water) solution and silicone implants are filled with cohesive silicone gel. If a saline implant ruptures, the saline solution flows out of the implant and is harmlessly absorbed by the body. The implant and breast will deflate over a short period of time alerting the patient for the need of replacement. The rupture rate for newer saline implants is approximately 1.8% per year.
Fourth generation cohesive silicone implants have a rupture rate of approximately 1% at 6 years. If a cohesive silicone gel implant ruptures, there is theoretically little change in shape of the breast, and the implant is said to rupture “silently.” The FDA therefore recommends a schedule of periodic breast MRIs to evaluate the implant for rupture. The chance of gel leakage or migration is very low with cohesive gel implants. Older generation silicone implants have a significantly higher rupture rate and are often found to be ruptured on reexploration. Depending on the severity of leakage complete, capsulectomy may be required.
In the event of a saline or silicone rupture Dr. Zemmel recommends replacement. Dr. Zemmel usually replaces both implants at the same time, and if applicable Dr. Zemmel’s staff will discuss any warranty issued by the original manufacturer. Dr. Zemmel will discuss these issues at length with you at length during your consultation.
Breast Implant Size Changes
Breast augmentation has a very high postoperative satisfaction rate. Over time, however, breast will age and change shape and consistency. Therefore many women desire changes in size of the breast. Many women desire to go somewhat larger while other desire a smaller breast size.
Increasing Breast Implant Size
Many women desire to increase the size of the breast. This can be done by increasing the size of the implant. Dr. Zemmel will measure your breasts and will help you decide what final size is right for you. Dr. Zemmel desires his patients to have a well-proportioned, balanced result. He wants his patient to have a natural breast augmentation result. Therefore Dr. Zemmel does not recommend extremely large implants, as the complication rate is higher with these implants. Treatment usually consists of reopening of the breast, removal of the old implants, increasing the size of the pocket by opening the capsule and placement of the new implants.
Decreasing Breast Implant Size
Decreasing the size of an implant requires careful preoperative planning. A significant size decrease can cause deflation of the breast and increased ptosis (sagging) of the nipple and areola. Decreasing the volume of the implant causes a simultaneous decrease of the diameter of the implant. The original breast implant pocket may therefore require capsulorraphy, or suturing of the capsule and pocket to close down the space. A mastopexy (breast lift) may also be necessary to achieve optimum shape and nipple position.
Treatment of Rippling
Rippling of a breast implant is when folding of the breast implants becomes visible beneath the skin and breast tissue. There are several factors that may increase the risk of rippling. Thin women with thin skin and little breast tissue are at a higher risk of rippling. As a general principle, the thinner the overlying soft tissue covering the implant the higher the risk of feeling and seeing implant beneath the soft tissue covering. Saline implants have a higher risk of rippling than silicone gel implants, and subglandular implants (over the muscle) have a higher risk than submuscular (under the muscle) or dual plane implants. Under filling a saline implant can cause the edges of the implant to become wavy.
Treatment of Capsular Contracture
Many different artificial materials have been used to create prosthetic implants. Prosthetic implants are in use for joint replacement of the knees, shoulders, and hips. Plates and screws are used to repair bones. Breast implants are constructed of silicone rubber shells containing either saline solution or cohesive silicone gel as the filler materials. When a prosthetic implant is placed, the body heals around the implants and gains “tolerance” to the new device. Many materials have been developed that are tissue compatible. Usually a thin wall of soft tissue forms directly around the implant to serve as the interface between the implant and the body. This is called the capsule. In rare cases the capsule becomes thickened and firm, and distortion of the shape of the implant and tenderness of the breast can occur. Capsular contracture can be dividing into grades 1, 2, 3, and 4, with grade 4 being the most severe. Over time, the implant tends to become rounder, and the forces of contracture pull the implant in an upward sideways direction. Occasionally, the overlying skin and soft tissue can become thin and distressed.
Severe capsular contracture is usually addressed surgically and is corrected in the most severe cases. Dr. Zemmel’s treatment plan may consist of:
- Complete removal of the implants
- Replacement of the implants
- Changing from saline to silicone implants
- Capsulotomy (incising the capsule)
- Capsulectomy (complete removal of the capsule)
- Pocket reassignment (changing from subglandular to submuscular)
The surgical treatment of capsular is complex, and Dr. Zemmel will discuss all of the available options with you.
Correction of Implant Malposition
High implants occur when the breast implant fails to drop over the first few months after surgery. A number of factors may lead to this including incomplete pectoralis major muscle division, an undiagnosed elevated inframammary fold, or capsular contracture. Treatment may require surgical revision to lower the implant and remove the capsular contracture.
Synmastia occurs when the cleavage between the breasts is obliterated giving the appearance of a single breast. This is also known as uniboob. Synmastia can be caused by a number of factors including complete medial pectoral muscle release, placement of too large of an implant, and over dissection of the inner aspect of a subglandular breast pocket. Correction of synmastia requires recreating the medial fold and cleavage between the two breasts. This can be done with a pocket reassignment from the subglandular to submuscular pockets and suture placement.
Lateral displacement of implants occurs when the implant pockets are too far apart causing the implants to shift to the side of the chest wall or to the underarm areas when lying. This is usually caused by over-dissection of the outer aspect of the breast pocket during original implant placement. Treatment usually requires surgical reexploration and placing sutures in the outer aspect of the breast pocket to close down the lateral pocket causing the implant to shift centrally. Replacement with a smaller implant may also be necessary.
Low positioning of the implants, or bottoming out, is caused when the implants descend to an abnormally low position on the chest wall. Typically, the implant descends beneath the level of the inframammary fold. This shifts the volume of the implant lower. The lower hemisphere of the breast may appear stretched, and the nipple areola may appear abnormally high on the breast. Bottoming out may occur when the inframammary fold is lowered too aggressively in surgery or by stretching of the lower pole skin of the breast. It may occur in one or both breasts. Treatment usually requires surgical reexploration and raising the level of the inframammary crease with sutures.
Dr. Zemmel performs several newer techniques to correct implant malposition. These incorporate the older methods of capsulotomy and capsulectomy (removal of the breast capsule), capsulorraphy (suturing the capsule), and pocket reassignment from the subglandular to submuscular position. Dr. Zemmel combines these techniques with the use of aceullar dermal matrix (Alloderm) to reinforce the capsule repairs. This gives additional tissue thickness and soft tissue strength. The reformation of capsular contracture may also be reduced.