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Breast Revisions
Size Changes
Increase in Size - Most women with breast implants seeking a change size want larger implants. In fact, according to data from Mentor Corporation, the #1 reason for Revision Breast Augmentation is to increase breast size, not for any problems that have arisen.
In the absence of other problems, increasing breast size is usually straightforward. Normally, general anesthesia is used and surgical time is about 1 hour. The previous incision is usually used. The surgical procedure involves removing the old implants, scoring the old soft capsule and inserting larger saline or silicone implants. Depending upon chest wall diameter and degree of projection desired we may elect to use a moderate, moderate plus or high profile implant.
Most patients desiring breast size increases will need minor adjustments in breast shape. Usually, this involves making more cleavage or filling out the sides to create a more rounded breast shape. This will be discussed during your consultation.
If the breasts are not soft, the surrounding breast capsule may need removal (capsulectomy) – (please see section on capsular contracture). Implant malpositions such as an implant that has migrated too far laterally (to the side) may be corrected with a larger implant or may need capsule tightening (capsulorraphy) (please see section on positional problems).
Small increase in size to provide cleavage and circumareolar mastopexy to
correct areolar size.
Decrease in Size – Occasionally a smaller beast size is desired. General anesthesia or intravenous sedation (twilight anesthesia) is employed and surgical times can vary from 1 hour for a simple exchange to 5 hours for a difficult reconstruction.
If skin elasticity is good and size change is minor the procedure involves opening the old incision, removing the old implants and replacing them with smaller saline or silicone ones.
If skin elasticity is poor (many stretch marks) a breast lift (mastopexy) may be needed along with implant exchange. (please see section on breast lift).
Implant Leaks/Ruptures
Saline Leaks - In the case of a saline leak or rupture there is usually a rapid decrease in size much like a balloon deflating. The saline is absorbed by the body and breast appears flattened. Occasionally saline implants will have a partial leak with a gradual decrease in size over a few week period. It is usually necessary to change ruptured implants within a short time since waiting too long will cause a change in capsule shape and make the implant exchange more difficult.
Surgery may involve general anesthesia, IV sedation or in some cases local anesthesia. The old incision is opened, the deflated implant is removed and replaced with a new implant. Often patients choose to have a size change with an implant deflation and surgery is similar to that outlined in those sections.
Typical appearance of ruptured saline implant.
More complicated case - Ruptured right subglandular implant. Repair following bilateral capsulectomy and submuscular conversion. Note the shrunken right capsule indicating that this was ruptured for some time.
Silicone Leaks - Newer silicone implants have a lower leak rate than older implants. It is difficult to detect a silicone leak based upon physical exam. Mammograms and ultrasound examinations may detect a leak but MRI is currently the best way to detect a silicone rupture. However, MRI’s are not completely diagnostic and they may miss a leak or mistake a folded implant as one leaking. If someone is unhappy with breast shape, size or position and wishes to have this corrected, then preoperative exams to diagnose a ruptured implant are not indicated. Older implants that were soft and became firmer are considered ruptured until proven otherwise.
When to replace older silicone implants that are not problematic is the question that often arises. We used to counsel patients to leave them alone if they are asymptomatic but after having seen too many asymptomatic ruptures, we currently recommend replacement of older implants at 20 years. Current generations of implants should have a longer lifespan.
Old style silicone implants with capsule formation. Ruptured until proven otherwise.
Old silicone implant with capsule formation.
Calcified capsule and ruptured silicone implant were found at surgery.
Positional Problems - We consider positional problems those in which the implant is found out of its proper position, that is – too high, too high, too lateral (to the side) or too medial (to the center). The cause of these problems can be due to surgical error, poor healing and weakening or tearing of muscle fibers. We don’t include droopy breasts or capsular contracture in this category although similar problems can occur along with droopy breasts and with capsular contracture.
Too High
This can happen with either subglandular (over the muscle) placement or submuscular (under the muscle) placement. It may be due to poor pocket design, poor healing causing the implants not to fall into the “pocket” or inadequate muscle release. Correction of subglandular high riding implants involves removing the implants along with a portion of the capsule and creating a new, submuscular pocket. Alternatively, the subglandular pocket can be lowered if the patient does not want submuscular conversion. Correction of submuscular high riding implants involves first figuring out the cause – ie inadequate muscle release, poor pocket development or early capsule formation then treating the appropriate problem by either releasing muscle, increasing pocket size or partial or full capsulectomy. Surgical times vary from 1 to 4 hours and recovery is relatively quick for minor corrections and similar to primary augmentation for submuscular conversion or major capsule work.
Implant placed too high and following correction.
Too Low
This deformity is usually due to the surgical error of releasing the inframammary fold excessively. It can happen on one or both sides and with subglandular or submuscular implants. Correction involves excising a piece of the capsule and doing a layered closure. I usually use a smooth implants but may use a textured implant for recurrences. Surgical times vary from 1 to 3 hours and recovery is usually quick. Postoperative taping and use of an underwire bra is essential for about 6 weeks.
Before and after corrections for too low implants.
Too Lateral
Lateralized implants are usually caused by the surgical error of too much lateral dissection but may occur if there are excessive muscle forces pushing the implant out to the sides. Typical patient complaints are that the implants are in “my armpits” or that “I keep hitting the sides of the breast with my arms.” This is not to be confused with not enough cleavage due to too narrow an implant. In consultation I perform a “tilt test” in which I have the patient sit in an exam chair with her arms on the handles then tilt the table back to see the extent of lateral shift. This can happen with both subglandular or submuscular implants. Correction involves closing the lateral pocket (capsulorraphy) and taping the sides of the breast for six weeks. Surgical time varies but is about 1 hour per breast and recovery is relatively quick.
Tilt test is performed to see the lateral excursion.
Too Medial
This implies too much cleavage and in the extreme case in which there is a connection of the pockets is called symmastia or often referred to as “unaboob”. Causes of this vary from patients anatomy to too wide an implant to muscle tearing or to surgical error of too much medial dissection. This can happen with both subglandular or submuscular implants. For too medial subglandular implants – submuscular conversion usually corrects the problem. Correction of submuscular medial implants can be difficult and involves closing the central tissue in layers. Occasionally alloderm (human dermis) may be used as a patch if skin is extremely thin. For the multiply operated upon patient we will occasionally use a post operatively adjustable saline implant to avoid placing tension on the repair. Surgical and recovery times vary with degree of difficulty. Post operative taping and bra is essential.
Shape Problems
Capsular Contracture
Capsular contracture causes hardening of the breast and is due to the tissue surrounding the breast implant contracting around the breast implant. Data from large studies estimate the incidence to be about 6%. In general, there is slightly less capsular contracture with saline implants than silicone and with submuscular placement. Some studies show less contracture with textured implants but this is often offset by increased rippling and higher deflation rates. Current theories are that contracture occurs due to sub clinical infection. Cultures of capsules are only rarely positive but electron micrographs of the capsules often show signs of bacteria. We have seen capsular contracture from infections elsewhere, insect bites and teeth cleaning in which bacteria is leaked into the bloodstream. Other causes are previous hematoma or seroma that increase inflammation. Some people feel that smoking may increase the incidence. Capsular contracture is graded as to severity:
Baker Grade I - The breast is normally soft, and looks natural.
Baker Grade II - The breast is a little firm, but appears natural.
Baker Grade III - The breast is firm, and is beginning to appear distorted in shape.
Baker Grade IV - The breast is hard, and has become quite distorted in shape. Pain/discomfort may be associated with this level of capsule contracture.
Treatment of Grade I-II capsular contracture is often with adjunctive therapies such as massage, ultrasound, Vitamin E and with newer drugs such Accolate, a drug used in the treatment of Asthma. Accolate is usually given at a dose of 20 milligrams twice daily and may take several months before results are seen.
The most effective treatment of Grade III-IV capsular contracture is to remove the whole capsule (capsulectomy). Just scoring the capsule (capsulotomy) usually is ineffective. Other procedures such as closed capsulotomy in which the breast is squeezed until the capsule is broken is not recommended as it may cause implant rupture and in fact voids the implant warranty. Our usual procedure for subglandular capsular contracture is to remove the entire capsule and perform a submuscular conversion. For submuscular capsular contracture we will perform a capsulectomy. Operative times vary but usually are 1½ hours per side. Recovery is similar to a primary augmentation. Postoperatively, massage, Vitamin E and Accolate are often given to prevent recurrent contracture.
It is very common for other problems such as ruptured silicone implants or shape or positional problems to occur with capsular contracture. In fact, we consider old hard silicone implants to be ruptured until proven otherwise. Many times a mastopexy (breast lift) is needed along with capsulectomy for droopier hard breasts.
Left breast capsule and following capsulectomy
Ptotic (Droopy) Breasts
Ptotic or droopy breasts are a common problem following breast augmentation. The cause is gravity!!!! However, there are some situations that increase the incidence of breast ptosis. The most common situation we see is ptosis related to older subglandular implants. Submuscular placement appears to offer more support while subglandular placement appears to accelerate ptosis. In fact, some surgeons will place large subglandular implants in women with mild ptosis to create a little lift. Unfortunately, gravity from the large subglandular implants causes the breasts to sag more. Pregnancy may cause increased sag but may occur whether implants are present or not.
The treatment for breast ptosis is a breast lift (mastopexy) (please see section on breast lift/mastopexy). The type of mastopexy is determined by degree of breast ptosis.
Grade I - The nipple is above the inframammary crease.
Grade II - The nipple is at the inframammary crease
Grade III - The nipple is below the inframammary crease.
For women with subglandular implants a submuscular conversion is recommended in addition to mastopexy. For grade 1 ptosis sometimes placing a larger implant will correct the problem – otherwise a crescent lift or circumareolar mastopexy will be needed. For Grade 2 ptosis a vertical type mastopexy is usually needed while for grade 3 ptosis either a vertical or full anchor is used. Surgical times vary from 1 to 4 hours depending upon complexity of lift. Recovery is generally faster than breast augmentation unless submuscular conversion is needed, then recovery is similar to primary augmentation.
 2 patients with grade 1 ptosis corrected with submuscular augmentation. Note preoperative mild asymmetry that was corrected.
Small increase in size with circumareolar mastopexy for mild ptosis.
Subglandular implants with old mastopexy. Following submuscular conversion and
revision mastopexy.
Most often we perform mastopexy-augmentation in which an implant is placed at the same time as breast lift but as illustrated above augmentation can also be performed after breast reduction or breast lift to provide upper pole fullness.
Complicated revision in which we performed capsulectomy and mastopexy.
Texture Problems
Rippling
Rippling occurs when there is not enough tissue coverage over the implant and leads to a wavy appearance usually when a woman leans over. This can happen medially (towards the middle), superiorly (on top), or laterally (towards the sides). Rippling happens more frequently with saline implants than silicone and with textured implants than smooth. The worst rippling is seen with subglandular textured saline implants. Determining the cause of rippling is important to correction. Subglandular rippling is usually seen superiorly or medially and is corrected by submuscular conversion in which the implant is removed from the subglandular position, a portion of the capsule is removed, a new pocket is created under the muscle and the implant is replaced under the muscle. Most women will opt for new implants and smooth silicone or saline are chosen. Submuscular rippling due to textured implants is corrected by changing to smooth silicone or saline implants. Submuscular rippling with smooth saline implants is corrected with a change to silicone. The more difficult problem is rippling with a smooth silicone implant present. Correction involves reinforcing the thin breast area with either capsule, muscle or alloderm (human dermis). Surgical times for simple exchange are quick and recovery easy while more difficult problems and submuscular conversion lead to longer operative times and recovery similar to primary augmentation.
Rippling with subglandular implants. Corrected with submuscular conversion.
Palpable implants
Most women can feel the edge of the implants under the breast and laterally. This is where the skin is thinnest. Sometimes changing to a smooth silicone implant will correct this. The more difficult problem is a palpable or visible knuckle of implant poking through the skin. If subglandular, then submuscular conversion will correct this. Submuscular palpability especially if medially may be due to excessive muscle release or muscle tearing. Enhancing the coverage either through muscle advancement or alloderm placement may be necessary.
Other implant problems
Infection
Infection is rare following breast augmentation but may occur with wound breakdown, infection elsewhere in the body or with insect bites on the breast. Curiosly, we once saw a breast implant infection from an insect bite on a womans arm. If minor, antibiotics may correct a minor infection while if not minor the implant will need to be removed and replaced at a later date.
Extrusion of implant in a body builder. The implants were removed.
Infection and impending extrusion.
The implants were removed and replaced in 6 months.
Incomplete Muscle Release
Some patients present with muscle banding due to incomplete muscle release. Treatment is to divide the abnormal muscle bands.
Right medial banding (see arrow) after submuscular augmentation.
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