Sometimes, despite the best efforts and intentions of the primary plastic surgeon, the outcome of a breast enhancement surgery may not be what the patient had expected. Breast implants are one of the most commonly performed plastic surgery procedures in the US and, although rare, sometimes the surgery may need to be re-done and new, different size or type of breast implants may need to be placed.
Dr. Salzman is often consulted in these situations to re-do and improve upon the outcome of a prior breast implant procedure. Some examples of reasons that patients may want to have their breast implants re-done include:
- Location: Implants that have migrated too low, remained too high, or are too close together or too far apart
- Feel: Breast implants that feel too firm secondary to rupture or capsular contracture
- Misalignment of the breast implant and the natural breast tissue
Breast implant revision procedures are done under general anesthetic at our own AAAASF Certified surgery center on-site. Dr. Salzman will consider the condition of your skin, the size of the implant, and the desired breast size of the patient. The thickness of the breast and the amount of scar tissue currently present will also be evaluated to plan a breast revision that will be successful in correcting the underlying problem. Depending on the reason for the revision, some of the possible surgical corrections will be explained below.
Change in Breast Implant Size
If the breast implant needs to be enlarged to make for a larger breast or to fill volume loss after weight loss or childbirth, it is quite simple to expand the pocket, sometimes cutting only capsule scar tissue. Placing a smaller implant may require a beefing up of the extra capsule (capsulorraphy) to keep the new implant in a more snug position, thus enhancing the shape of the breast.
Implants that have migrated too low
Breast implants that are very large in a small framed woman may migrate lower on the chest wall causing the nipple/areola complex to appear pointing upward with excess breast skin below the nipple. Commonly, we see this when an attempt by the first surgeon to place an excessively large implant necessitated a lowering of the infra-mammary crease. The repair of this condition usually involves adding some type of extra support in the bottom of the breast implant pocket and returning the excess breast skin back to the chest wall. Simple suturing of the bottom of the capsule (capsulorraphy) is sometimes insufficient in fixing this condition. If the capsule tissues are sufficiently strong, a flap of the undersurface of the capsule combined with the lining (fascia) of the surrounding muscles can be used to add support to the bottom of the breast pocket. Sometimes, a smaller implant will help in reducing the weight placed on this new repair. In cases where insufficient capsule tissue exists, we will add an acellular dermal matrix such as Strattice™ (ADM). These ADM’s are tissues from pig or human source, in which the cells have been removed in a manner that they will not provoke a rejection response from the patient. The patient’s own cells grow into the ADM making it appear to be normal human tissue only of better strength and thickness than the native capsule.
During the recovery from this procedure, some tape may be placed at the bottom of the breast for a week or so and the patient wears an underwire bra for the first six weeks post-operatively to take the weight off of the repair.
Breasts that are too close together
The cleavage area can be too narrow or in extreme cases, the pockets for the breast implants may connect across the sternum area. This is sometimes referred to as “uniboob” by the patient. This situation can be seen after sub-glandular or sub-muscular breast implant placement. Wide implants and over dissection by the first surgeon in an attempt to narrow a wide inter-breast space can sometimes contribute to this condition.
We repair this in several ways. If the breast implants are in the sub-glandular position, we will move them into a new pocket under the muscle. Sub-muscular implants that are too close can sometimes be moved into a new pocket called the “neo-submuscular pocket”. Here, the new pocket is made above the top part of the old breast capsule but below the muscle. The attachment of this new pocket to the chest wall prevents the breast implant from migrating too far to the center. If insufficient local tissues are present or if wrinkles in the cleavage area are present as well, we would then add an ADM like Strattice™.
Breasts that are too lateral (off to the side)
Breast implants over time may migrate out to the sides where the patient may say they fall outward while laying down or are “up in the armpit”. Several causes of this condition are known. First, most women’s chest walls are angulated outward rather than flat. Thus, as gravity acts upon the breast implants, they naturally fall away from the sternum and fall outward. Also, incomplete muscle release during the first breast implant surgery may disallow the implant from moving inward towards the cleavage area and repeated muscle contraction of the pectoralis may aggravate this condition by increasing the space between the breasts. Correction often involves releasing the proper amount of muscle on the sternal side of the pocket and capsulorraphy of the outside. Occasionally, we can make a new pocket in a place where the implant has not been previously placed as described above. In severe cases, we may place an ADM like Strattice™. to buttress the repair done with local capsule tissues out to the side.
Wrinkling, dimpling, or edge visibility of implants
Saline implants, especially textured saline implants will wrinkle more than gel filled implants. Implants placed above the muscle in the sub-glandular pocket will have less overlying natural tissue coverage and one can see more of the inconsistencies of the implant shell such as wrinkles or a prominence of the edge of the implants. If these problems are due to a textured saline device, we would change the implant to a smooth gel breast implant and try to increase the tissue coverage by moving a sub-glandular implant to the sub-muscular pocket. If the pocket is already under the muscle, and still wrinkles or edges are visible, then an ADM such as Strattice™ will need to be placed.
A new sub-muscular placement of a previously sub-glandular implant will take longer to have a pleasing shape than the initial breast augmentation procedure. Here, the new implant must push out the muscle and fill the overlying sub-glandular pocket.
Capsular Contracture is the inordinate tightening of the natural scar tissue that forms around a breast implant. In the normal post-operative healing, a thin, pliable scar tissue envelope surrounds and anchors the breast implant in the pocket. It allows for movement and compression of the implant such that the implanted breast has a normal breast-like feel. Infrequently, this scar capsule becomes thicker and less distensible, making the breast feel hard to the touch. The breast shape may be distorted as well. The absolute cause of capsular contracture of breast implants is not completely understood. Present concepts include the formation of a Biofilm. A Biofilm is caused by the bacterial presence in the capsule tissues or the fluid around a breast implant. Tiny amounts of common skin bacteria can gain access to this space and change their configuration such that the body cannot recognize them as such, and antibiotics have difficulty in eradicating them as well. These bacteria can gain access to the implant space months to years after the original breast implantation from innocuous sources like a tooth infection or bacteria in the bloodstream from some other focus of infection. If caught early, capsular contracture can be treated non-surgically with Vitamin E, massage, Ultrasound, and a drug called Accolate. Several months are often required to see the results of non-invasive treatments. Should the capsular contracture not respond, then the surgical approach is warranted. The easiest treatment involves cutting into and releasing the capsule (capsulotomy). Since only scar tissue is being cut, recovery is quite rapid and no new scars on the breast are necessary. With extensive capsular contracture or capsular contracture that returns after smaller procedures like capsulotomy, we will likely recommend a procedure to remove the capsule tissue (capsulectomy) and/or move a new implant to a new space like described above. In extreme cases, not only can the scar tissue be removed but an ADM may also need by placed to separate the implant from the old pocket. It seems that these ADMs are resistant to having capsular contracture happen within them.
Ruptured or Leaking Silicone Gel Implants
Early generations of silicone gel implants were made with a less consistent and more fluid-like gel and a thinner silicone shell. Over time, these implants could rupture or leak such that the liquid silicone would come out of the shell of the implant but remain within the natural scar tissue capsule. It has been well established by multiple peer-reviewed journal articles and by the FDA that systemic disease from these gel implant ruptures does not occur. (See website for more info.) If older silicone gel implants have changed in shape or feel or if routine mammography suggests a rupture or leak of the implant then a surgical approach is the best course of action. We recommend removing all of the implant material and surrounding capsule at the very least. After that, there are many choices. Sometimes we will beef up space to better fit a new, more modern cohesive silicone gel implant and place it in the old sub-glandular pocket. This will improve the look more quickly than other choices but may have a slightly higher risk that the capsular contracture surrounding the old ruptured implant may recur. A better choice is to move the implant under the muscle and sometimes add an ADM sewn from the bottom of the pectoralis muscle to the bottom of the implant pocket to isolate the new implant from the old pocket. Like moving implants from the sub-glandular to the sub-muscular pocket for other treatments, this procedure takes the longest for the breast to have a pleasing shape. If over time, the breasts have begun to sag in a way that they hang over the implant, which has stayed up in the chest wall, it may be necessary to add a breast lift as well.
Recuperation and Healing
The patient returns home in a light dressing sometimes with a stretchy tape supporting the area of repair. All the sutures melt away on their own. Drains are infrequently used. Postoperative instructions about the type of bra and duration of limited activity vary tremendously depending on what is being revised. Explicit instructions are given at the time of preoperative teaching.
Breast implants may be removed and not replaced or replaced with a different size or type of implant. Breast lifts may be done to even out the nipple location and/or elevate the breast to a more youthful chest wall position.
The specific risks and the suitability of this procedure for a given individual can be determined only at the time of consultation. All surgical procedures have some degree of risk. Minor complications that do not affect the outcome occur occasionally. Major complications are unusual.