Breast Augmentation Revision

• Breast Overview
• Rupture
• Breast Implant Size Changes
• Treatment of Rippling
• Treatment of Capsular Contracture
• Correction of Implant Malposition

Breast Implant Revision Overview

According the American Society of Plastic Surgeons, approximately 300,378 women underwent breast augmentation in 2017. This represents a 3% increase from 2016, 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.

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 an experienced 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 affect 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, one of our plastic surgeons 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 and Dr. Reddy 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.

Before

After

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Rupture

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 and Dr. Reddy recommend replacement. They usually replace both implants at the same time, and if applicable their staff will discuss any warranty issued by the original manufacturer. These issues will be discussed at length with you during your consultation.

Breast Implant Size Changes

Breast augmentation has a very high postoperative satisfaction rate. Over time, however, breasts 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 others 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. Your surgeon will measure your breasts and will help you decide what final size is right for you. Dr. Zemmel and Dr. Reddy desire their patients to have a well-proportioned, balanced result. They want their patients to have a natural breast augmentation result. Therefore, they do 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 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.

Treatment of 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 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.

*Individual Results May Vary

Severe capsular contracture is usually addressed surgically and is corrected in the most severe cases. The 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 your surgeon will discuss all of the available options with you.

En Bloc Removal Technique to Treat Capsular Contracture

For patients who require a capsulectomy to completely remove their implant capsule, Dr. Zemmel and Dr. Reddy will typically utilize the en bloc technique. This method involves removing the capsule with the implant still inside. To perform the en bloc technique, our surgeons will separate the scarred capsule from the surrounding tissue, and remove it through the small incision they havesur created. By keeping the capsule in one piece, any of its contents can also be cleanly removed, including potential material leaked from a ruptured implant. In some cases, the implant may need to be emptied before the entire capsule can be removed, as it may not fit through the small opening. Although en bloc is our surgeons’ preferred method of capsulectomy, they will perform whichever technique is the safest at the time of surgery.

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 and Dr. Reddy perform 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. Our surgeons combine 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.

Contact Richmond Aesthetic Surgery

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.