Revision of Breast Augmentation
No one wants to undergo surgery. It takes a certain amount of inner strength to undergo any surgical procedure that is not “medically necessary”, that is, required for you to maintain your good health. When undergoing cosmetic surgery, it is important to know that despite the fact that these procedures are designed to make us look younger, or as we did previously, or possibly even better than we did previously, there are factors out of our and our surgeon’s control. We cannot stop the aging process, we cannot change the biology of how we heal wounds and make scar tissue, we cannot make mechanical devices (i.e. breast implants) last forever and we cannot eliminate the ongoing effects of gravity upon our tissues. This is especially true when speaking of breast augmentation.
Breast augmentation is a wonderful procedure. I have performed thousands of them, and even my own daughters have undergone this procedure. I find it very rewarding to see how breast
augmentation can help a woman to improve her self-esteem and confidence. However, it is important to understand that these are not lifetime devices, and if you undergo this procedure, at some time in your lifetime, you will probably need to undergo an additional procedure for some reason or another.
I would like to discuss some of the more common reasons for revision of a prior breast augmentation and how these issues are managed.
Capsule contracture remains one of the most common reasons for a revision of a previous breast augmentation. In order to understand what “capsule contracture” is, lets first discuss what a “capsule” is.
If you implant any foreign body of any kind, including silicone, into the human body, the body will recognize that there is something foreign inside of it and try to “wall it off, “or isolate it. This is a process already programmed into our wound healing biology in our DNA and there is no way around it. This is not necessarily a bad thing either.
When a breast implant is placed, either between the breast and the pectoralis major muscle (“above the muscle”) or between the pectoralis major muscle and the bony chest wall (“below the muscle”), over the next several weeks, the body will slowly produce a scar tissue lining along the surface of the tissue surrounding the implant called a “capsule.” Normally, the capsule is thin, pliable and exists in harmony with the implant. You cannot see it or feel it. However, sometimes, there is stimulation of the scar tissue, possibly due to the presence of certain types of bacteria (but not always) around the implant, which causes the scar tissue to become thick, and contract, or try to shrink. Whereas a thin, pliable capsule does have any effect upon the look and feel of the breast, a thickened, contracting capsule will squeeze the implant and make if feel hard. As this process continues, the breast starts to take on a spherical shape, sometimes elevating itself on the chest wall, appearing higher up than it did previously. There are different degrees of capsule contracture:
- Grade I — the breast is normally soft and appears natural in size and shape
- Grade II — the breast is a little firm, but appears normal
- Grade III — the breast is firm and appears abnormal
- Grade IV — the breast is hard, painful to the touch, and appears abnormal
What causes capsule contracture?
While we do not have definitive proof, we do have some theories. One of these theories involves the formation of a “biofilm”, a thin membrane of proteins that coats the implant shortly after surgical implantation. The biofilm can then contain certain types of bacteria and protect them from the body’s defense systems. This can then result in a chronic inflammatory response which makes the capsular tissue thicken and the breast feels harder.
How do we prevent capsule contracture?
While we cannot reduce the risk to zero, there are several things the surgeon can do at the time of breast augmentation to reduce the risk of capsule contracture. Most likely, these things will probably have more effect on the early development of capsule contracture than on development of capsule contracture years later. Quite often we have no idea what causes the capsule contracture to occur. Sometimes, later development has been noted to follow an infectious process, such as a sinus infection. I am not aware of any connection to urinary infections.
Among the recommended things the surgeon can do to help prevent capsule contracture:
- Use prophylactic antibiotics to reduce the risk of infection
- Use an inframammary (breast crease) incision (armpit and nipple incisions are in areas of increased bacteria and may lead to contamination of the implant and resultant capsule contracture
- Use nipple shields – a clear, plastic adhesive dressing to keep nipple bacteria from encountering the implant, the surgeon’s hands or surgical instruments
- Careful surgical dissection with minimal bleeding – use electrocautery rather than blunt (“ripping tissue”) dissection to create the breast pocket
- No active bleeding or oozing present when implant is inserted
- Do not cut into the breast tissue – bacteria may be harbored in the milk ducts
- use submuscular (below the muscle) / dual plane pocket (I use this always for augmentation)
- Use Betadine/triple antibiotic irrigation – Betadine is an antiseptic that kills many types of bacteria on contact
- Use a funnel device (I use the Keller funnel) to minimize potential contamination of the implant as it is inserted into the breast pocket
- Change gloves before inserting the implant
- Close the wound in layers (I use a four-layer closure)
- Re-prep the skin with antiseptic prior to implant insertion
- Avoid the use of drains
- Prophylactic antibiotics with certain types of procedures (i.e. dental) after surgery
The above are excellent ways, but again do not guarantee, to prevent capsule contracture. In clinical studies, the use of Betadine has been a proven way to reduce the risk of capsule contracture.
How is Capsule Contracture treated?
There are no proven non-surgical treatments for capsule contracture. Some have tried Singulair, a drug used to treat asthma due to its effect on the inflammatory process, but results have not been impressive, and I do not recommend this form of treatment. Capsule contracture is not an emergency, and if it did not bother you, you could ignore it. Most women, however, do not want to have a hard, distorted looking breast.
Treatment for capsule contracture is surgical. Current recommendation is to first remove the breast implant, then remove the scar tissue capsule, and then replace the implant with a new one, as the previous one is presumed to have contaminated biofilm on it. All the same precautions used to prevent the formation of a capsule contracture during a primary (first) breast augmentation are again taken when a capsulectomy is performed. Drains are placed at the discretion of the operating surgeon based upon the findings at surgery. I personally rarely place drains during this procedure.
Can Capsule Contracture occur again?
Capsule contracture can occur again, however this is uncommon. Some women may be biologically prone to develop capsule contracture, although there is no way to test for this. If this is a repeat problem, then consideration should be given to using an acellular dermal barrier such as Strattice to reduce the risk of capsule contracture from occurring a third time. This product is also used in abdominal wall reconstruction and in some hernia repairs.
Examples of before and after case studies following surgery for capsule contracture can be found here.
Explantation (removal of implants without replacement)
There are several reasons why a woman might want to undergo removal of their implants:
- You have gained weight and now you have more than enough natural breast tissue and no longer need breast implants
- You no longer want your breast implants
- You have capsule contracture but do not want to replace your implants, you just want them out
- You have a ruptured/deflated implant and do not want to replace them
- You have systemic symptoms that you believe are related to your breast implants – understand that the existence of breast implant illness (BII) has not been substantiated – there is no guarantee that removing your implants will give you relief of your symptoms. You can learn more about this here.
These are all reasons why women ask me to remove their implants. The most frequent question I am asked is “what will my breasts look like after removal of the implants, will they look like they did before I got implants?” It is impossible to predict what the breasts will look like after implants are removed, although is some cases, you can make an educated estimation, but that is on a case by case basis. Consider that since your implants have been placed, your breasts have naturally aged and they have been lifted off the chest wall and stretched by the implant. Therefore, your breasts will in most cases not resemble the way you last remember them before your breast augmentation surgery.
There are surgical options that allow the surgeon to optimize the appearance of your breasts after removal of implants. The most common complaints are sagging of the breast and loss of upper breast fullness.
If your breasts have stretched significantly, a breast lift can be performed. This will involve a scar around your areola, and almost for certain a vertical one from the lower areola to the lower breast crease. Surprisingly, both scars usually heal quite nicely. The quality of the scar depends greatly upon your own tissue biology of healing. No one can change this. In rare cases, a scar will also be required in the lower crease of the breast, but this is usually not needed in explantation cases.
If you are lacking in upper breast fullness, fat can be taken from your abdomen flanks, and/or thighs and transferred to the upper portion of your breasts to restore some of the lost contour after explantation. This is a simple procedure to do and can greatly improve the overall appearance of your breasts. Not all the fat will survive, so more is put into the breast at surgery than is desired in the result.
Change of implant size
There are several scenarios that might lead you to change the size of your implants:
- YOU WANT LARGER IMPLANTS THAT YOU CURRENTLY HAVE. When you had undergone your breast implant surgery, you were not satisfied with the amount of increase in breast size and want to be larger. That said, it is possible that your surgeon used the largest implant that was able to fit into your breasts safely, but now that time has passed, and your breasts have relaxed (stretched), so there is now more room to replace your implants with larger ones. This is not an uncommon scenario. I find that depending upon the starting size of your initial implants, an increase of 70 – 100 cc can make a significant size difference. In some cases, I do make much more substantial size increases. This all depends upon the desires of the patient, and the tissue characteristics of the breasts.
- YOU NEED TO CHANGE YOUR IMPLANTS FOR A REASON OTHER THAN SIZE. If you are having surgery for capsule contracture where new implants are always placed anyway, change from textured to smooth implants, change in type of implant such as saline to silicone or change of firmness of silicone implant, replacement of a ruptured/deflated implant, you are getting a new pair of implants. Consider changing the size to one that you are more comfortable with if your surgeon agrees for technical reasons – that it will fit inside your breast pocket and will look good.
- CHANGE IN BODY WEIGHT. You may have gained or lost weight and now your breasts are not in proportion to the rest of your torso. If you have gained weight and now want larger implants to bring your breasts more into harmony with the rest of your torso, it is unlikely that you will require a breast lift. If you have lost weight and want to downsize your implants, there are two considerations. First, the pocket is now going to be too large for the implant. Sometimes, this pocked needs to be partially closed off to allow the implant to sit appropriately underneath the breast without shifting to the side. This is addressed by closing off part of the pocket with sutures, a “capsular flap” which is a section of scar tissue capsule that is elevated and shifted to decrease the size of the pocket and restrict movement of the implant within the pocket. I usually like to reinforce these capsular flaps with a piece of Galaflex mesh which adds strength to the repair and prevents disruption until the Galaflex eventually is absorbed by the body and replaced with a layer of scar tissue, which will maintain the integrity of the repair.
Exchange of Textured to Smooth implants
Textured implants are no longer available for use for breast augmentation. You can read more about this here.
All my patients with textured saline and textured silicone implants have been notified about the concerns relating to textured implants. I am happy to see anyone with textured implants who have concerns about them. The issue is the textured surface of the implant shell, not whether the implant is filled with saline or silicone.
While current recommendations do not include removal of textured implants in asymptomatic patients, there are patients who are concerned about having the textured implants inside their breasts and are just more comfortable with replacement with round, smooth silicone gel implants. For these patients, I believe that it is totally reasonable to remove their textured implants and replace them with smooth ones. I do believe that silicone gel-filled implants will look and feel more natural than saline implants, but either one is available, based upon the patient’s needs and desires. The actual surgery is quite easy and very fast recovery, even easier than a primary (first time) augmentation using the “One Day Recovery Breast Augmentation” technique. Currently, Allergan is offering those patients with Allergan Natrelle textured implants a replacement pair of implants at no cost to them until July 2021. This does not include surgeon, anesthesiologist and facility fees.
If you are also interested in changing the size of your implants and currently are concerned about your textured implants, this may be another reason to undergo the replacement surgery.
Adding a breast lift (mastopexy)
Implants don’t change with time. Unfortunately, breast tissue does. As we age, the effects of gravity combined with the loss of collagen and dermal support of the skin, softening of the breast fat and loss of firmness of the glandular component of the breast results in overall sagging of the breast with loss of firmness. Now, couple this with some weight gain, which results in an increase in breast tissue now sitting in front of the implant. This results in sagging of the breast in front of the implant, called a “waterfall deformity” and a breast lift is now needed. To achieve ideal breast aesthetics, it may also be worthwhile to replace with a larger or smaller sized implant. Maybe several years have passed and there are better types of silicone gel implants available now that better suit your breast tissues. All these concerns can be addressed in a single surgical procedure! A mastopexy is associated with surprisingly little post-operative discomfort in most cases. Sometimes, Galaflex mesh is also used to provide additional support (like an “internal bra”). Remember, this mesh will dissolve in a couple of years, and be replaced with a layer of new living scar tissue that will provide continued support to your breasts.
Exchange from Saline to Silicone gel implants
Many women have saline implants. For many years, there was no available alternative in the United States. Compared to silicone gel filled implants, saline implants are much firmer, and more likely to have palpable and sometimes visible rippling. If you are interested in having breasts that are softer, look and feel more natural, then an implant exchange from saline to silicone gel may be an option to consider. Sometimes a size change as well is indicated, which should not be a problem. With today’s options in silicone gel implants, an implant that best fits the tissue and contour characteristics of your breasts is easily attainable.
Most indications for revision of a breast augmentation are due to issues that evolve that are out of the control of the surgeon and the patient. While weight gain or loss is not intentional to affect the breasts, tissue stretching and thinning, implant malposition (usually), the ideal implant size for a given breast and the availability of newer, more suitable types of implants are all out of the control of both the surgeon and patient.
Synmastia is usually not something that happens due to unpredictable tissue stretching. It is usually a result of improper dissection of the surgical pocket for the implant. There are always exceptions to this, but this is usually the case.
First, lets discuss what synmastia is. Synmastia is a medial (inner) malposition of the breast implants. This will cause the breasts to lie too close together, to the point that that implants themselves are so close that the skin overlying the sternum (breastbone) lifts off the bone itself. Some people have nicknamed this condition a “uni-breast.” This is different from “cleavage.” Most women who undergo breast augmentation want cleavage. Cleavage is when the sides of the breasts are very close together, if not touching completely, but the skin over the sternum is still tightly affixed to the bone. This preserves the gentle curvature of the inner breast all the way down to where it meets the chest wall.
Breasts normally do not touch in their medial (inner) portion. The base of the breast is defined as the portion of the chest wall between the outer and inner borders of the breast. The inner borders can be close together, or further apart. I see variations of this all day long in my breast augmentation patients. When an unaugmented woman has cleavage, it is because the breasts are large enough and close enough to be squished together in a bra. The larger the breasts naturally are, the easier this happens. For smaller breasts, the breasts need to be relatively close together to achieve cleavage in a bra. Except for woman with very large breasts that naturally have a very narrow gap between the inner aspect of each breast, cleavage never happens naturally, that is breasts upright, and unsupported by a bra or other type of garment.
So how does synmastia occur? There are two scenarios to consider. Either one of them can lead to synmastia if the pocket is not dissected (created) carefully.
Subglandular augmentation: During a subglandular (implant lies above the pectoralis muscle and below the breast gland itself) augmentation, a pocket is created under the breast and above the muscle. As the pocket dissection approaches the periphery of the breast, the actual amount of breast tissue becomes very thin, until there is just about only skin overlying the muscle. When dissecting towards the sternum (breastbone), if one strays too far towards the midline, the pocket may then continue further towards the midline than the overlying breast is situated. This will result in the implant potentially displacing too far towards the midline. If the dissection occurs medial to the outer edge of the sternum, the skin can now lift off the sternum. Now, consider this occurring from both sides. Now both implants can lie too close to the midline. The inner aspects of the breasts will now touch, but at the expense of the skin lifting off the sternum as well. So now, the trough the deep crevasse that should lie between the breast and appear as a dark, vertical linear shadow now is a shallow, widened indent between the breasts, which is very unnatural in appearance. If the implant size chosen has a base diameter like, or slightly less that then natural breast, then there is a chance that the implants may still lie in the proper location directly under the breast itself. It takes force to push the breasts towards the midline and lift the skin over the sternum. If there is no force from the outside of the breasts, then this won’t happen. However, now consider if the surgeon places an implant that fills the now over dissected, oversized pocket, that implant has no where to go and is forced to push towards the midline and elevate the skin over the sternum. See the example below:
So now, the result is an unattractive synmastia and a very unhappy patient. The good news is that fixing this problem is relatively simple. We need to find some way to limit the inner border of the implant and keep it from moving any closer to the midline. Fortunately, there is a wonderful solution – the pectoralis muscle. This muscle lies along the entire sternum and when the implant is placed below it, its attachment to the sternum will maintain the inner border of the implant in the exact position you want it and prevent it from moving further towards the midline. So here, a “site change” where the implant is removed from the subglandular pocket above the muscle and placed into a new pocket created under the muscle solves the problem. That is what was done in the case shown above.
Submuscular augmentation: This is a little more complicated. In this case, the implant has been placed under the pectoralis muscle. This muscle, like all muscles, has an origin and an insertion. The origin is the fixed point the muscle is attached on one side, and the insertion is the point of attachment on another bone that is moved by the muscle. In the case of the pectoralis, the muscle is attached to the entire side of the sternum (breastbone) and the lower attachment to the sternum continues along the rib cage in a horizontal line for a few inches. The insertion of the pectoralis muscle is on the humerus (upper arm bone). When making an implant pocket under this muscle, only the horizontal portion of the muscle is separated from the underlying rib cage, never separate the muscle from the sternum (it is usually OK if the lower 1 -2 cm of sternal attachment is separated). If the sternal attachment of the muscle is detached during surgery, the implant can now push its way towards the midline, or as the implant normally drops when the breast stretches, can then move too close together.
The repair of this problem is much more complicated. There is now no natural barrier left intact to use to keep the implant in its normal position. In this case, the scar tissue capsule needs to be separated from the underside of the pectoralis muscle, but only so far towards the midline as where the muscle ends (where it was previously attached to the sternum) so that this new “neo-subpectoral” pocket can keep the implant in proper position. This is a much more tedious surgical procedure.
As you can see, the best chance you have at achieving a beautifully crafted breast augmentation is at the first surgery. After this, revisions can become difficult, complicated, expensive and occasionally fail. Anyone who believes that they can re-write the laws of nature and place implants that are too large, or dissect pockets incorrectly and still obtain a predictable, excellent result with a low complication and revision rate is only fooling themselves. It is up to the patient to exercise their due diligence and educate themselves, rather than be a passive participant in the consultation process.