Breast Implant Revision

Despite optimal pre-operative planning and a well-executed surgery, there are still occasions when breast implant revision procedures may be necessary. Since the breast has already undergone a previous surgery, a revision can be more complex than the primary procedure. Factors that can make revisional surgery more difficult include scar tissue, altered implant position, thinning of the tissue or skin, and distorted breast shape.

Our board-certified plastic surgeon in Richmond has performed hundreds of breast procedures, including breast augmentations, breast lifts, breast reductions, and complex breast reconstruction surgeries for breast cancer patients. For those in need of a breast revision, Neil J. Zemmel, MD, FACS utilizes his advanced surgical techniques to tailor surgery according to each patient’s unique needs.

• What Is Breast Implant Revision?
• Breast Implant Revision Timeline
• Breast Revision Consultation
• Implant Revision Without Replacement
• Reasons for Breast Revision
• Breast Implant Revision Procedures
• Implant Revision Surgery Risks
• Implant Revision Recovery
• Implant Revision Cost
• How to Choose a Surgeon

What Is Breast Implant Revision?

Breast implant revision surgery is a procedure to address cosmetic or medical concerns following a previous breast augmentation. Patients may choose to switch to a different breast implant material or size; correct implant irregularities that may develop from aging, weight changes, or hormones; or decide to completely remove their breast implants. Due to the more challenging nature of this surgery, breast implant revision should only be performed by a highly skilled surgeon experienced with this complex procedure.

During your consultation, our plastic surgeon will perform a physical exam and evaluate your complete medical and 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.

How Soon After Breast Augmentation Can I Get a Revision?

Patients are typically advised to wait at least six months to one year after their original surgery before undergoing a breast revision procedure. The exact timing will depend on your reason for a revision, overall health, individual healing rate, and other factors. To determine the best surgical plan and timing, Dr. Zemmel will complete a thorough examination and discussion of your needs and goals.

What Can I Expect During My Breast Revision Consultation?

During your consultation, our plastic surgeon will perform a physical exam and evaluate your complete medical and breast history. He will examine the position of your implants, the potential presence of capsular contracture, the thickness and quality of your overlying breast tissue, muscle, and skin, and the overall shape of your chest and torso.

Please bring all relevant information to the consultation, including implant cards, names and locations of your prior surgeons, and previous medical records such as operative reports and prior mammograms. This will assist Dr. Zemmel in diagnosing your concerns and formulating a comprehensive treatment plan. By the end of your consultation, you should have a full understanding of the reason revision is required, all aspects of the treatment plan, and what to expect during recovery.

What If I Don’t Want My Breast Implants Replaced?

Rather than having implants revised or replaced, some patients prefer to have them removed entirely. Patients may desire breast explantation surgery because they dislike the look or feel of their implants, or, in rarer cases, to correct a complication. If you believe explantation surgery is the best option for you, Dr. Zemmel can review your options during your consultation.

What Are Common Reasons for Breast Revision Surgery?

There are a number of reasons women seek breast implant revision surgery. Below are some of the most common causes for revision as well as the general approaches to treatment:

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Implant Rupture

All prosthetic body implants have a lifetime including breast implants. Today’s breast implants are considered safe and durable, but with many years of normal usage, rupture will occur.

Saline Implants

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 — typically within 24 to 48 hours, though a slower deflation may occur if the fill valve is faulty rather than the shell itself — alerting the patient of the need for replacement. The rupture rate for newer saline implants is approximately 1.8% per year. When rupture occurs, timely replacement is recommended to prevent collapse of the implant pocket and to ensure the best cosmetic result with minimal recovery.

Silicone Implants

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 re-exploration. Depending on the severity of leakage complete, capsulectomy may be required.

In the event of a saline or silicone rupture, Dr. Zemmel recommends replacement. He usually replaces both implants at the same time, and if applicable, our staff will discuss any warranty issued by the original manufacturer. These issues will be discussed at length with you during your consultation.

Breast Implant Exchange

A revision surgery to replace breast implants — known as breast implant exchange — is designed to replace current implants for a different size, material (silicone or saline), or profile (projection forward from the chest wall). One of the most common reasons for breast implant exchange tends to be switching from saline to silicone breast implants, as silicone is well-known for its more natural look, shape, and feel, and reduced chance of rippling. A breast implant exchange may also be performed if a complication with the current implants has occurred, such as an implant rupture.

Change Implant Size

Breast augmentation generally has a very high post-operative satisfaction rate. However, breasts may age and change in shape and consistency, and many women desire changes in their breast size over time, some wishing to go larger, others preferring a smaller result.

Increasing Breast Implant Size

For women that want to increase the size of their breasts, this can be achieved by increasing the size of the implant. Your surgeon will measure your breasts and help you decide the final size that is right for you. To get the most natural-looking result, Dr. Zemmel typically recommends an implant size that provides a well-proportioned, balanced outcome. Therefore, he 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 pre-operative 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 capsulorrhaphy, 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.

Implant Rippling

*Individual Results May Vary

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 the 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. Additionally, under-filling a saline implant can cause the edges of the implant to become wavy.

Implant Malposition

The optimal shape of the breast occurs when the breast implant is located directly beneath the breast and the nipple-areola position is directly over the most forward projecting part of the dome of the implant. Implant malposition occurs when the implant is not located in this position, such as the following circumstances:

• 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.
• Symmastia occurs when the cleavage between the breasts is obliterated, giving the appearance of a single breast. This is also known as a “uniboob.” Symmastia 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 symmastia 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 re-exploration 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 re-exploration 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), capsulorrhaphy (suturing the capsule), and pocket reassignment from the subglandular to submuscular position. Dr. Zemmel combines these techniques with the use of acellular 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.

Capsular Contracture

When a prosthetic implant is placed in the body, the surrounding tissue heals around it and forms a thin, soft interface called the capsule. In rare cases, this capsule becomes thickened and firm, causing distortion of the breast shape and tenderness. Capsular contracture is graded on a scale of 1 to 4, with grade 4 being the most severe. Over time, the forces of contracture can pull the implant upward and sideways, and the overlying skin and soft tissue may become thin and distressed.

Severe capsular contracture (Baker grade III and IV) is usually addressed surgically. The treatment plan may consist of one or more of the following:

*Individual Results May Vary

• 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 your surgeon will discuss all of the available options with you.

Additional Concerns

• Snoopy Deformity is named after Snoopy’s profile and occurs when breast tissue drops below the bottom hemisphere of the implant, giving the appearance of a high implant and a low, hanging nipple. It is typically caused by natural aging and sagging of the breast in a patient who received a breast augmentation but also needed a concurrent breast lift. Correction usually requires a mastopexy (breast lift) using a circumareolar, vertical, or full anchor incision.
• Areola Enlargement can occur after breast augmentation due to stretching of the breast and areola skin during implant healing. This is usually mild and may not require revision, but the possibility should be discussed prior to surgery. When revision is desired, an areolar reduction can be performed by making a circumferential incision around the border of the areola and using a purse-string suture to reduce the diameter.
• Tuberous Breasts are characterized by a deficiency of skin and breast tissue in the lower pole of the breast, a higher and narrower breast fold than normal, and a constricted breast shape. Herniation of breast tissue through the nipple-areola may also be present. Correction of tuberous breast deformity requires additional surgical techniques performed concurrently with breast augmentation, and your surgeon will discuss this in depth during your consultation.
• Atrophy of Breast Tissue refers to severe thinning of breast tissue, which can result from placement of very large implants, normal aging, sun exposure, smoking, or pregnancy and breastfeeding. This can lead to visibility or palpability of the implant, movement of the implant pocket, and distortion of breast shape.
• Double Bubble Deformity is caused by a round-appearing implant beneath round-appearing breast tissue, creating a visible step-off and the appearance of two distinct breast mounds. This may result from improper implant pocket selection, capsular contracture, or the need for a breast lift.
• Implant Visibility and Palpability may occur in patients with thin soft tissue covering the implant, with or without rippling. Subglandular placement may allow the implant to be visible around the upper portion of the breast, giving a “coconut shell” appearance. Patients with thin overlying tissue may also be able to feel the implant. The thickness of soft tissue covering is the key factor in both cases and should be discussed thoroughly during a pre-operative visit.
• Asymmetry may be identified during a physical examination before surgery or may develop over time. Small volume differences or variations in inframammary fold position may be correctable, but asymmetries arising from differences in the bony rib cage structure or scoliosis of the spine typically cannot be fully corrected. Some degree of natural asymmetry between the breasts is normal and expected.

What Does Breast Implant Revision Involve?

Implants can be replaced and complications can be corrected using a number of advanced techniques. Dr. Zemmel has extensive experience altering the positioning and placement of implants to improve upon the outcome of an original breast augmentation. If needed, he can also replace your implant with a different type, shape, or size for optimal results.

Your personalized implant revision surgery may involve one or more of the following techniques:

• Mastopexy (Breast Lift): Depending on the amount of lifting required, several incisional approaches may be used. For patients requiring a small amount of lifting and tightening, a Benelli lift (circumareolar or donut lift) may be offered. If the nipple-areola requires additional lifting and the breast needs horizontal tightening, a vertical lift (lollipop incision) may be necessary. If the nipple needs to be lifted most of the vertical distance of the breast with maximal tightening, a full breast lift using a periareolar, vertical, and inframammary incision (anchor or upside-down T incision) may be needed.
• Capsulectomy: Complete removal of the capsule surrounding the implant may be necessary to relieve capsular contracture. A pocket reassignment may also be performed to relocate the implant to fresh, unoperated tissue. Placement of acellular dermal matrix (Alloderm) within the pocket can also help prevent recurrence of capsular contracture.
• En Bloc Implant Removal: When a capsulectomy with implant removal is required, Dr. Zemmel prefers to utilize the en bloc technique when it is deemed safe. This entails removing the entire capsule, kept intact, while the implant remains inside. If the implant has ruptured, the saline or silicone material is often trapped within the capsule, and removing everything in one piece allows for more thorough removal of scar tissue and implant material.
• Capsulotomy: This refers to making incisions along the borders of the pocket to open and enlarge it. It is typically performed in conjunction with implant exchange when moving to a larger implant, or to reposition an implant.
• Implant Exchange: Replacing existing implants with a different size, material, or profile. Other maneuvers such as capsulotomy, capsulorrhaphy, or capsulectomy may be necessary in conjunction with the exchange.
• Areolar Reduction: Reducing the size of the areola by making a circumferential incision around its border and removing skin, then placing a purse-string suture to reduce the diameter. This is typically performed in conjunction with a circumareolar mastopexy.
• Pocket Change: Relocating the implant from a subglandular to a submuscular position, or vice versa. This is typically performed in cases of severe capsular contracture, to improve the appearance of a subglandular implant, or to place additional soft tissue coverage over the implant.
• Capsulorrhaphy: Altering the diameter of the pocket to adjust the height, width, or location of the implant. This is typically done by removing a crescent-shaped section of the capsule and suturing the remaining edges closed, and is commonly performed for lateral displacement, bottoming out, or symmastia.
• Symmastia Repair: A group of procedures used to recreate two distinct breast pockets, accomplished by suturing the skin overlying the sternum back down to the sternum and closing off the medial pockets.

What Are the Risks of Breast Implant Revision Surgery?

Breast revision surgery requires a surgeon to possess both comprehensive knowledge of anatomy and exceptional skill with breast augmentation techniques. Thinning breast tissue, implant ruptures, and scar tissue can all complicate the procedure. The risks of breast revision surgery are similar to those of a primary breast augmentation and may include bleeding, infection, implant rupture, or a change in nipple sensation. Patients who have already experienced capsular contracture may have an increased risk of recurrence.

During breast revision surgery, patient safety is our top priority. Dr. Zemmel performs breast revision surgery only in fully accredited facilities using board-certified anesthesiologists and nurse anesthetists. Detailed pre-operative and post-operative instructions help minimize risk and support results that look and feel natural. We recommend seeking a board-certified plastic surgeon who is experienced with the additional challenges this surgery presents.

What Can I Expect During My Breast Revision Recovery?

The recovery for breast revision surgery is typically similar to that of your initial breast augmentation, and in some cases may feel easier or faster. Follow-up appointments are scheduled during the first few days after the procedure to help ensure your recovery goes smoothly. During the first few weeks following surgery, Dr. Zemmel recommends limiting physical activity and refraining from lifting any significant amount of weight. During the third week of recovery, you can begin your surgeon’s recommended scar treatment regimen.

While changes after your breast revision surgery will be immediately noticeable, the final results will become gradually evident as your body continues to heal over the next three to six months. At Richmond Aesthetic Surgery, we are available at any point during your recovery to answer questions and address any concerns you may have.

How Much Does Breast Implant Revision Cost?

The breast implant revision procedure is highly customized to the individual and their specific concerns. On average, the surgery may cost anywhere from $9,000 to $12,000. Once a general treatment plan has been determined, your surgeon and our staff will provide you with a cost estimate, walking you through the fees associated with your procedure.

Since breast augmentation is a cosmetic procedure, revisional surgery is typically not covered by insurance. However, if you are in need of an implant exchange or removal due to rupture or deflation, most breast implant warranties offer extended coverage. Our staff will discuss applicable warranty options during your consultation.

How to Choose a Breast Revision Surgeon

Although similar to a primary breast augmentation, implant revision tends to be more complex due to the presence of scar tissue and other complications. It is important to seek a qualified plastic surgeon who has specific expertise not just in breast augmentation, but in revision procedures as well. These professionals are more skilled at handling the potential complications that may arise.

While breast implant revisions often require a more involved surgical process, the right surgeon can help alleviate the concerns you have from your original procedure and create an appearance that restores your confidence. Make sure you find a surgeon who is transparent about what you can expect from your revision, including any possible limitations.

Schedule Your Breast Revision Consultation

For more information on breast augmentation revision options, or if you would like to schedule a consultation here at our practice, please contact Richmond Aesthetic Surgery.