Breast Augmentation Revision
Breast Augmentation Revision Patients Who Are Referred to Me for Surgery Have A Variety of Problems
These problems include oversize implants, implant pockets that are too large or in the wrong place, thinning of natural breast structure, overly visible or wrinkled implants, and implant deflation.
There are also patients whose overlying breast structure has gotten stretched out, usually from natural events such as pregnancy or significant weight loss and weight gain to where the implant sits at a relatively high position and the natural breast structure has settled to a lower level.
DOWNSIZING BREAST IMPLANTS
Breast implant surgery is at its best when it respects and enhances the natural breast structure. There are some patients and some doctors who choose breast implants that overwhelm the breast and are out of proportion to the body structure. Generally the long term fate of these implants is not good, particularly if they are saline implants placed in the subglandular plane. Over time very large implants produce a predictable set of consequences. The implant compresses the remaining natural breast structure and causes it to thin out. Because the implants are heavy the breast skin will stretch and the breast will settle to a low position. Often wrinkles and irregularities will show through the skin.
There are three main components to the correction of over-sized breast implants: reducing the implant to a proper size, profile and shape, restoring proper coverage to the implant, and restoring the breast to a proper position on the body. There usually is a trace of the original breast structure and whenever realistic and possible, I use this as a guide for breast restoration surgery.
I will select an implant, with the patient’s input, that relates well to the natural breast and body dimensions. If the original implant was saline-filled I will often recommend conversion to a silicone gel implant. We will plan the implant’s volume, projection and shape. There are several ways to help restore proper coverage to a breast implant, so that there is a layer of natural tissue over the breast implant.
We will consider a number of options that include moving the implant to the plane under the pectoral muscle, adding thickness with acellular dermal matrix, a biological scaffold, and using fat transfer to restore missing volume in the plane over the remaining breast tissue. Usually I will recommend some form of breast lift, both to bring the breast back to a proper position on the body and to reduce the excess stretched out skin. The good news for patients with over-sized implants is that the newer techniques of breast surgery provide a much better range of choices than used to be the case.
REDUCTION OR REMOVAL OF NORMAL SIZED IMPLANTS
At least in my practice, the vast majority of patients maintain a high degree of satisfaction with their implants, even decades after the original surgery. Occasionally we will see a patient who wants to reduce the size of her implants or even remove the implants altogether, even though the original implants respected her natural breast dimensions and body proportion.
There are several reasons which a patient might choose to downsize or remove an implant that is relatively good proportion to her body. Some patients gain additional breast structure, either because of hormonal influences or simple weight gain. The additional natural breast structure may simply make the breast larger than the patient desires. These patients can usually achieve a happy outcome with either a downsizing or a complete removal of the implants sometimes accompanied by a breast lift.
Sometimes a patient’s taste will change over time. What seemed a perfect volume in her 20′s now seems a bit too full, even though the rest of her body’s proportions haven’t changed. Over the years I have seen a small number of patients who simply don’t like the way implants feel in their bodies. In some cases it simply makes sense to remove the implants.
CONTROLLING THE SPACE AROUND BREAST IMPLANTS TO RETURN IMPLANTS TO THEIR PROPER POSITION
Implants can shift out of proper position for several reasons. Some patients form almost no scar tissue around breast implants. At first glance, this might seem to be desirable, but with no scar to hold the implant in place, the normal “wear and tear” of life may cause the implant to shift.
Sometimes implant malposition is related to the way the original pocket was created. I have also seen situations where patterns of activity, especially early after surgery can move an implant. Structured bras, if worn almost continuously, can help to re-stabilize an implant’s position. If a patient forms very little scar tissue, even these efforts probably won’t work. If stabilizing bras don’t work, it is usually necessary to perform surgery in order to reduce the size of the pocket. This is traditionally done with surgical stitches, but for patients who don’t form much scar tissue, these stitches may pull through.
Acellular dermal matrix has increased the probability of success in surgery to re-position breast implants. The material can be anchored in place, so that it forms a secure buttress that defines the edge of the pocket and holds the implant in place.
CORRECTION OF THIN BREAST STRUCTURE
If the natural breast structure is very thin, the imperfections of implants will reveal themselves. One of the worst things about over-sized breast implants is that they put pressure on the natural breast structure, which causes breast tissue to shrink. This increases the challenge for the surgeon whose mission is to restore the breast to beauty and harmony.
Fortunately we now have a wider range of tools to restore a nice soft coverage of breast implants. Autologous fat transfer and acellular dermal matrix have allowed me to increase the thickness of coverage over breast implants. If the implant has been in the plane above the pec muscle, I will often shift it to the plane under the muscle, which softens what may have been a harsh transition at the upper border of the implant. For some patients I use aspects of the structural technique of breast surgery to shift breast structure to where it is needed.
CORRECTION OF RIPPLING AND IRREGULARITY OF IMPLANTS
There are three main ways that an implant may have visible irregularities or rippling. These irregularities often become more noticeable when a person leans forward or turns on her side. Some irregularities are caused by the mechanical structure of the implant, others may be caused by the design of the implant pocket, which still others come about due to inadequate thickness of natural tissue over the implant. In general saline implants are more likely to ripple than silicone gel implant.
Some surgeons try to prevent this by overfilling the implant with salt water, but this produces a hard, ball-like breast. It is also possible to see rippling with silicone gel implants, but it is much less common than with saline implants. The best implants from the stand point of rippling are the form stable or “gummy bear” implants. Sometimes the problem is that the pocket is too large for the implant. This may allow the implant to slide out of position and to ripple, particularly with saline implants. A lack of adequate thickness of the tissue over a breast implant can also contribute to the problem by allowing irregularities to show through.
Oversize breast implants in effect sabotage their own results, since they tend to cause a thinning out of the natural breast structure. The correction of rippling requires an accurate diagnosis of what is causing the problem, so that we can design a strategy for correction of the problem that has the best likelihood of success. Corrective strategies include changing to an implant that is less prone to ripple, controlling the dimensions of the implant pocket, and increasing the thickness over the implant with acellular dermal matrix, fat transfer, and shifting the implant to the space underneath the pectoral muscle.
CORRECTION OF IMPLANT DEFLATION
If a saline implant deflates, it is readily apparent, since the breast will lose significant volume. With silicone gel implants the changes in the breast are more subtle. If there is a question of a shell disruption, the gold standard for diagnosis is an MRI study of the breast. High resolution ultrasound may also be useful. If an implant deflation occurs, it is not an emergency. With a saline implant breakage, the salt water is simply absorbed by the body.
With a gel implant breakage, the natural capsule of collagen that the body forms around the implant keeps everything in place. Silicone gel implants from recent years are filled with a cohesive gel that does not tend to drift. Although it is not necessary to rush to surgery, it is also not wise to delay implant for a long period of time, especially with saline implants. If enough time passes the space that is around the implant may tighten, and this will make it difficult to match the opposite breast.
One question that comes up is whether it makes sense to replace the implant of the opposite breast, which has not deflated. In my opinion if it is just a few years after the first surgery and everything is perfect with the opposite breast, it is reasonable to keep the original implant in place. If a longer period of time has passed, for example, greater than ten years, then it is probably wise to replace the unruptured implant as well.
RESTORING PROPER RELATIONS BETWEEN AN IMPLANT AND A BREAST THAT HAS SETTLED BELOW IT
Life events such as cycling up and down in weight and pregnancy may loosen the structure of a breast that sits over an implant. The breast may drift downward while the implant remains in its original position. This produces a breast that has a double contour with the curve of the implant in the upper area and a second curve formed by the settled breast.
If the implant is soft and in a good position, a breast lift will restore a proper balance between the breast and the implant by bringing the breast back to its proper position over the implant. We evaluate each patient in detail to determine which lift technique is best suited to her breast structure and her goals. Options include the periareolar breast lift, the classical (anchor) breast lift, and the structural breast lift.