Breast Implant Revision

Every woman has some natural degree of asymmetry in her breasts when carefully measured, though many patients are not aware of these differences prior to surgery. Every plastic surgeon seeks to minimize these innate differences at the time of initial breast augmentation. Most of the time, patients receive improvements in their overall symmetry, but on occasion initial asymmetries are incompletely corrected, or healing issues may yield more major unanticipated differences in breast enlargement results.

Whenever pre-operative breast size asymmetry is noted, adding identical implants to each breast will always decrease the percentage of perceived asymmetry. For example, if a woman starts with natural breast volumes of 90cc and 100cc, this is a 10% difference. Let’s say she and her surgeon decide to add 400cc identical implants on each side, for a final total volume of 490cc and 500cc. This reduces the percentage difference from 10% to 2%. Thus, for the minor breast asymmetries that most every woman has, identical breast implants will actually decrease the percentage of discrepancy between breasts.

For greater degrees of starting asymmetry—say natural breast volumes of 275cc and 300cc—implants are manufactured with small incremental volume differences, and we could choose a 325cc implant for the smaller breast, and a 300cc implant for the larger, yielding near-ideal symmetry. However, even identical-volume breasts may not swell, scar, contract, or settle the same way, so volume is not the only cause of asymmetry in post-operative results. Patients often ask if it is possible to see a visible difference between implants of 25cc discrepancy—for example, 400cc vs. 425cc. This difference is LESS than 2 tablespoons, and is NOT visible. For the woman of average height and weight, it takes a volume increase of 50-100cc to be barely visible, 100-125cc to equal about a ½ bra cup size increase, and 200-250cc (about 2/3 of a can of soda) to equal one bra cup size. Many surgeons disagree with these volumes, so it is no wonder that some patients are unhappy with their initial size choices, and many surgeons fail to adequately advise their patients regarding revision in size.

Size asymmetry can also be caused by incomplete development of breast tissue on one side, sometimes associated with pectoralis muscle or hand-shoulder maldevelopment (Poland’s syndrome) that can be improved by use of different size and profile breast implants (women) or custom solid silicone pec implants in men. Men with Poland’s syndrome may exhibit only absence of the lower 2/3 of the pectoralis major muscle on the affected side. This is frequently exacerbated by the patient striving to gain muscle bulk by weightlifting and work-outs to develop a muscle that is mostly absent—resulting in enlargement of the pectoralis muscle on the non-affected side that makes the discrepancy even more visible. In women with Poland’s syndrome, the breast on the affected side may be significantly smaller than the opposite normally-developed breast, often with a diminutive nipple areola complex (and partial absence of the pectoralis major muscle). Each patient’s anatomy will need individualized assessment and formulation of the appropriate surgical plan and necessary implants.

Constricted, tuberous, or tubular breasts typically refer to small (hypoplastic) breasts with enlarged “puffy” nipple areola complexes, wide cleavage, constricted breast base, often with sagging and a short inframammary crease (IMC) to nipple distance. Tuberous breasts are thought to be a congenital problem of breast development, but are viewed by insurance companies as “cosmetic” (non-covered) concerns. If sufficient breast tissue is present, breast feeding is still possible. There are many degrees of severity of tuberous breasts, and not all features of tuberous breasts are seen in each affected patient. More severe cases of tuberous breasts can be impossible to correct with implants alone, and in some cases periareolar or other breast lift procedures can improve symmetry between breasts with major differences. In some cases, unilateral surgery can deal with the problem breast, but absolute symmetry is both unrealistic and impossible, yet remains our goal.

Patients with saline implants, often used in the years from 1991 through 2006 because of the FDA restrictions on the use of silicone gel implants during this time period, may find their breasts feel less natural than they like, particularly if they have friends with silicone gel implants. Interestingly, saline implants can either feel “too soft” or “too firm” depending on fill volume, tension of overlying tissues, or the presence of capsular contracture in varying degrees. Visible or palpable rippling is more commonly seen with saline-filled implants, particularly if they are under-filled, and even more so if they are above the pectoralis muscles. Often, switching to the latest generation of cohesive silicone gel breast implants (by any of the 3 present USA implant manufacturers) will eliminate or significantly improve this rippling. Thin patients or those with very little breast tissue of their own may still have some degree of rippling or implant edge visibility, even with silicone gel implants below the muscle.

That being said, virtually every patient who switches their saline implants for silicone gel implants is pleased with her choice to undergo this revision. Of course, size change or other issues can be addressed at the time of implant exchange. Costs are always available at the time of no-charge consultation with our American Board of Plastic Surgery-certified plastic surgeons.

The most common reason for any re-operation in breast augmentation patients, however, is size change (usually to place larger implants), whether saline or silicone.

Capsular contracture can be the cause of pain or distortion in one or both breasts, and can occur from any number of causes (discussed in Breast Augmentation under Capsular Contracture). Every breast augmentation patient will form a scar around her breast implants; this scar capsule can be so thin, soft, and pliable that it is nearly translucent, or the capsule can thicken and tighten to an unyielding hard sheet of scar (or anything in-between). Obviously, the latter will cause a hard and unnatural “feel” to a woman’s augmented breasts, and can also be painful if sensory nerves are trapped and “pulled” within the thickened contracted scar capsule.

The most common causes of capsular contracture are bacterial biofilm on the surface of the implant(s) and/or bleeding. Bleeding in the absence of bacterial contamination may cause scar capsule thickening on its own, or collection of blood or seroma within the implant pocket can act as a sort of “culture broth” for any bacteria introduced at the time of surgery, or from breast ducts within the breast. Regardless of the cause, capsular contracture can cause unnatural firmness, distortion in appearance, and sometimes pain, all in varying degrees. The Baker scale grades capsular contracture:

• Baker Grade I — the breast is normally soft and appears natural in size and shape
• Baker Grade II — the breast is a little firm, but appears normal
• Baker Grade III — the breast is firm and appears abnormal
• Baker Grade IV — the breast is hard, may be painful to the touch, and appears quite abnormal (distorted)

Capsular contracture rates range from a low of about 3% to as high as 70% in various studies. Sub-muscular implant placement has been shown to decrease the capsular contracture rate, as have antibiotic or antiseptic (Betadine) irrigations of the surgical pockets. Prior to submuscular placement becoming the most common implant position, above-the-muscle (submammary) implants had higher capsular contracture rates; these reduced with use of antibiotic or Betadine irrigations, as well as use of textured implants. Textured implants do not move as naturally as smooth implants (because of their innate adherence), so submuscular smooth implants are generally superior to above-the-muscle textured implants, in most cases. Use of the Keller Funnel for a true “no-touch” implant insertion technique further reduces capsular contracture rates by preventing transfer of skin bacteria from the patient’s own skin or surgeon’s gloves to the implant surface. At Minneapolis Plastic Surgery, our American Board of Plastic Surgery-certified plastic surgeons utilize all of these techniques to minimize the risk of capsular contracture as much as possible, since we believe prevention is significantly better than subsequent surgical treatment.

Surgical correction of hard breasts due to capsular contracture involves removal and replacement of the implant on the affected side or sides after capsulotomy (division and release of the scar capsule) or capsulectomy (removal of part or the entire tight scar around the implants). Complete capsulectomy is often a difficult, tedious, and bloody operation, with a (relatively) higher risk of recurrent capsular contracture. If capsular contracture is mild and/or early, a trial of medical therapy with leukotriene inhibitors Singulair or Accolate plus Vitamin E orally may be advised. This can be helpful in about 50% of cases; otherwise, surgery is the only recourse.

Although leakage and deflation of saline implants occurs infrequently, there are 15 years’ worth of elective cosmetic breast augmentation patients with saline implants, some of which can fail. When this occurs, it is rarely sudden and visibly deforming; rather, it occurs when a tiny pinhole leak develops in a fold or ripple that flexes with each breath or movement and eventually wears through the silicone shell. Gradual deflation occurs, often so slowly that patients may not be aware of it until enough saline is lost to become visible. Textured saline implants leak and deflate much more commonly than smooth-shell implants. This is because the tiny peaks and valleys flex with each breath and movement, and can eventually weaken and fail. Once a leak occurs, eventual deflation is inevitable over a few hours to a few weeks. (The fluid that leaks out is IV saline and is harmlessly absorbed.) However, once a leak is noted, surgery to replace the implant is necessary. If it occurs in the first ten years after implantation, there may be partial reimbursement for the surgical costs; the implant cost is covered by the implant company.

Often, saline implant deflation is considered a “sign” that the other implant may also develop a leak, and since surgery is required to replace the leaking implant, the patient may elect to switch both implants to cohesive silicone gel implants that cannot leak. These patients are virtually universally pleased with their switch to silicone gel implants. Of course, simply replacing the deflated saline implant with a new saline implant is appropriate when this is the patient’s request.

The latest generation of silicone gel implants are cohesive and cannot leak or deflate. A very severe blow could potentially rupture a cohesive implant; this is so rare we have seen it only 4 times in the past decade and a half. Ruptured implants should be replaced, but cohesive gel implants cannot “leak” silicone throughout your body or adjacent tissues as seen with older types of silicone implants. Since (the latest generation of) cohesive silicone implants cannot “leak” or deflate, MRI scans “recommended” by the FDA every 2-3 years to check for “silent rupture” are nonsensical, in our opinion. They are also incorrect as high as 21% of the time, leading to unnecessary surgery for perfectly-intact implants.

The FDA makes this recommendation because physician examination has been shown to be unreliable in detecting silicone implant rupture, which could occur with older generations of silicone gel implants. If you are not having any kind of problem or concern with your implants, we feel it is ridiculous to perform a costly procedure (that may not be covered by your insurance) and an often-inaccurate test that would require an operation (erroneously) over 20 percent of the time. Rather, we believe that if you have any issue at all with your silicone breast implants (size, shape, position, firmness, or concern about possible implant damage), return to your breast surgeon. We will then perform the corrective surgery where we will be able to examine, and replace if necessary, the implants under direct vision. Our plastic surgeons can offer substantially better than 79 percent accuracy with direct implant examination!

Infection with breast augmentation is fortunately extremely rare. When it does occur, it can require removal of the implant on one or both sides. Superficial incision breakdown, stitch abscess, or cellulitis may be successfully treated with antibiotic therapy, but if infection occurs in the breast pocket around the implant, the implant is considered contaminated, and cannot be sterilized by antibiotic therapy, even strong IV antibiotics. Implant removal is necessary, but the initial implanting surgeon may be loathe to remove one or both implants even when infection seems a definitive diagnosis. Stronger and more expensive antibiotic therapy, IV antibiotics, and even infectious disease consultations are commonly recommended rather than “biting the bullet” and doing what should have been done earlier—remove the infected implant (or both), cure the infection, and replace the implant(s) when the tissues have softened and settled enough to re-operate. This can be several weeks to as long as a year after implant removal. Capsular contracture may be more likely even after successful treatment of infection.

Implants that fail to drop adequately (causing a “Snoopy” or “waterfall” deformity) or drop too far (“bottoming out”) as healing occurs after breast augmentation may require re-operation to correct the malposition. Implants that fail to drop into proper position may require a simple surgical revision to open the pocket up slightly, allowing the implant to drop into improved (lower) position. In cases where the implant ends up lower than desired, causing a “too-high nipple” position on the breast mound, the pocket will need to be opened surgically and the bottom of the pocket tightened with sutures. Some degree of overcorrection is generally advised as additional settling can be anticipated on the basis of the initial “bottoming-out.” Side-to-side malposition can also be corrected by opening up or tightening the implant pockets accordingly.

“Double-bubble” deformities occur when the new implant pockets create new inframammary creases (IMC) on the underside of the breasts, but when the previous IMCs are still visible. This may occur more commonly when the natural IMC is high or close to the nipple, or when small breasts with high IMCs are augmented to larger sizes. Surgical correction of this is sometimes challenging, as the original causes of double bubble are often anatomy-based rather than related to surgeon misjudgment.

In cases where the cleavage area tissues lose adherence to the breastbone (sternum) between the two breast pockets, “uni-boob” develops as the cleavage is lost. Another term for symmastia is “breadloafing.” Symmastia can occur when the implant pockets are surgically created too close to one another, causing loss of adequate central tissue attachment between pockets, and the resultant loss of cleavage. Large implants can also contribute to this issue, as they require a larger pocket with more surgical dissection. Another cause of symmastia is daily wearing of too-tight or push-up brassieres while the implant pockets are still healing, causing the lateral pockets to close down and the central tissues to stretch and thin. Allowing the pockets to heal adequately (6-12 months) before daily wearing of tight push-up brassieres that can distort the final pocket position is recommended.

Re-operation is required to correct symmastia, and involves suturing the internal capsular tissues back down to the central presternal tissues, usually on both sides. The lateral implant pockets are also re-opened to relieve pressure on the central tissue repairs from the implants, or smaller implants may be requested.

After surgical correction of symmastia is carried out, the patient will be asked to wear a special symmastia brassiere (often called a thong bra) that provides pressure centrally to aid in healing this area, while leaving the sides of the bra open to avoid inward pressure. This will need to be worn until the tissues are healed enough to allow a standard brassiere, which should still be supportive rather than compressive. Your surgeon will advise on proper aftercare and support garment recommendations to reduce the risk of recurrence.

Rippling in the surface of breast implants can sometimes be felt, and less commonly seen, in some augmentation patients. This is more common in saline implant patients who are thin or who have very little of their own breast tissue covering the implants; it is much less common with silicone gel implants, and in patients with submuscular implant placement. Thin patients with submammary saline implants are the most likely to see or feel implant ripples or wrinkles; often, switching to silicone gel implants (or using them in the first place) eliminates or improves this problem.

Saline implants that are under-filled increase visible or palpable rippling significantly. If saline implants are chosen, they should be placed into the submuscular position (in most patients), and adequately “over-filled” to minimize rippling. Proper “over-fill” (about 5-15%) does NOT invalidate any implant manufacturer’s warranty, and in fact decreases not only rippling, but risk of leak (persistent flexing of the implant shell wrinkle can led to a pinhole leak and deflation).

Of course, use of silicone gel implants beneath the muscle (dual-plane placement) offers the least chance of seeing or feeling implant ripples or wrinkles, regardless of the amount of tissue cover.

Scars are necessary for all breast augmentations, and may be in one of several locations. Placement is critical to minimizing the visibility of breast augmentation scars, and this should be discussed in detail with your surgeon. Around 3% of all patients have the genetics of excessive scar formation, and can develop thickened, raised, red scars that can also be painful or itchy. If mild to moderate in severity, these are called hypertrophic scars, and can be expected to eventually (1-2 years) fade and soften. The final scars are often wide and flat, but usually pale in color. If the thick, raised scar outgrows the bounds of the original wound, this is termed a keloid, and these scars can continue to grow and remain symptomatic. If excised in an effort to improve them, keloids usually recur even larger than the original keloids, making surgical revision ill-advised.

Scars that heal normally, but are more unsightly than others, may be successfully improved via scar revision. Some unsatisfactory scars are simply the result of bad surgical design or breast lift pattern.

Augmentation plus breast lift involves more skin incisions and scars in order to shape the skin brassiere, and any increase in tension on the wounds, inaccuracies in closure, stitch abscess, inadequate skin circulation, or superficial incision infections can cause poor or unsightly healing. Scar revision may involve surgical excision and resuturing areas of unsatisfactory scarring. Improvement is usually, but not always, achieved.

As many as 15-20% of breast lift plus implants patients who smoke even one cigarette, use nicotine gum or patches, “vape” with e-cigarettes, or are exposed to second-hand smoke can have enough loss of circulation (due to nicotine-caused vasoconstriction) to develop dead skin. This can lead to prolonged dressing changes, skin grafts, or revisionary surgery, and can cause exposure of implant(s) leading to removal.

After breast surgery, including scar revision, we will show you techniques and methods to minimize scarring as much as possible, within each patient’s own unique genetic scar tendencies.