Breast Augmentation Revision
It can be quite an emotional roller coaster ride for a woman who, being self-conscious about her breast appearance, seeks out a surgical breast enhancement, chooses a surgeon, has a breast augmentation, and then ends up with a result that falls far short of her expectations – or even worse, results in a breast appearance about which she is even more self-conscious. I take this situation very seriously, and in my practice we do our very best to not only provide such patients with the enhanced breast appearance that they originally had in mind, but also to make the experience of consultation, surgery and recovery as positive and pleasant as possible.
The two most important aspects of correcting problems with prior breast augmentation are (1) taking the time to make an accurate diagnosis and to fully understand how the result falls short of the patient’s expectations, and (2) creating a surgical plan that has the highest likelihood of improving the situation and meeting those expectations. In most cases that can be accomplished in just one trip to the operating room, however there are a few problems that are best managed by a two-stage surgical approach. One surgical procedure is far preferable to two, but not if a two-stage approach has a much higher likelihood of success. I feel obliged to do the operation (and occasionally the operations) that will be the most likely to turn a disappointed and frustrated patient into a very satisfied one.
Problems that can usually can be corrected in a single procedure include most cases of capsular contracture, most problems with implant position, distortion of breast appearance with contraction of the pectoralis major muscle, and visible implant folds and ripples. Management of capsular contracture includes implant removal, total capsulectomy vs. total exclusion of the original capsular space, creation of a new implant space, and placement of a new implant. Implant position problems are corrected by means of capsulorrhaphy, which is the medical term that describes suturing closed the implant space in areas where the implant projects too far – which in some cases may need to be reinforced with an allograft material such as Strattice (acellular porcine dermis, Lifecell Corporation). Breast distortion with pectoralis major contraction is corrected by selective repair and release of the muscle origin. Visible implant folds and ripples may be corrected by a combination of changing the implant position (e.g. submammary to submuscular), changing the implant style (e.g. saline to cohesive silicone gel), and adding tissue to help conceal the implant (e.g. capsular flaps and/or Strattice grafts).
An example of a revisional breast augmentation procedure that sometime requires a two-stage approach is the patient with severe capsular contracture and ruptured, liquid silicone gel breast implants – which fortunately are no longer in use. I believe that the liquid gel material that leaks from a ruptured liquid silicone gel implant is a potent stimulus for capsular contracture in some patients, and if the old implants and thickened capsules cannot be removed without spillage of a significant amount of liquid silicone gel into the new implant pockets, I will not put in new implants during that surgery (this happens in about a third of cases, so the good news is that most patients get new implants inserted the same day). If the gel material is indeed a stimulus for contracture, it just doesn’t make sense to place new implants if there is significant spillage of that material into the new implant space. I instead irrigate the pockets thoroughly with a pressure irrigating system, place drains and close the incisions, and we give the body’s natural scavenger system three months to `clean’ up any remaining gel material. The re-augmentation is performed after three months, and in taking this approach I have yet to have a patient return with a recurrent capsular contracture. No patient is ever that excited about the possibility of going three months without breast implants, but most are willing if it gives them the highest likelihood of a lifetime of soft, supple, natural-appearing breasts.
Some breast augmentation revisions require a minor, in-office surgical procedure several weeks in advance of the main surgery which is performed in the operating room. One example is the deflation or removal of overly large implants. Large breast implants act as tissue expanders and stretch out the skin of the breast, which usually creates a droopy and unsatisfying appearance when the large implants are removed and replaced with natural-appearing implants of lesser volume in a single stage. If the excessively large implants are saline, they can be deflated in the office using a needle and sterile tubing. If they are gel implants and have not ruptured (which can be confirmed by means of an MRI scan), they can be removed under local anesthesia through the incisions by which they were inserted. Deflating or removing large implants gives the breast skin an opportunity to contract and shrink over several weeks, so that when implants of a more appropriate size are inserted the breast profile is perkier and more youthful. In many cases this minor office procedure can avoid the need for a breast lift (mastopexy) procedure. It also allows the internal implant space (capsule) to shrink, so that the new, lower-volume implants are not placed into capsular spaces that are too large – which would allow the implants too much mobility (often manifested by the implants appearing too far apart on the chest wall, and falling off the side of the chest when a patient lies down).