Revisional breast augmentation surgery

There are four main reasons for reoperation in breast augmentation patients (the medical terms we use are listed in parentheses):

1. The augmented breasts become firm and less movable (capsular contracture)
2. The implants don’t remain in an aesthetically ideal position (implant malposition)
3. You can see the implants through the skin and breast tissue (implant shell visibility)
4. The patients thinks that their augmented breasts are too big or too small (implant size dissatisfaction)

Our plastic surgery practice in Raleigh NC treats a significant number of patients who schedule a consultation with us because they are dissatisfied in some way with the results of a breast augmentation they have had in the past. If you are one of these patients, the good news is that the results of your surgery can almost always be improved, and in most cases quite dramatically.

Capsular contracture
Traditionally, one of the most common and most frustrating to patients and surgeons has been capsular contracture, which is addressed in detail in a section above. If you have a contracture, you are at a somewhat higher risk for contracture following a second or third surgery, so it is of utmost importance that a number of things be done differently from your first surgery to minimize the risk of developing capsular contracture again.

Implant malposition
Another potential problem is an unfavorable change in implant position, which can be related to a number of issues: the dimensions of the implant pockets may not be ideal or symmetrical, the pectoralis major muscle may be inadequately released and thus holds the implants too high (and can cause them to ‘jump’ upward and outward when the muscle contracts), and one or both implants may even shift in position over time which results in positional asymmetry.

Examples of position problems include ‘bottoming out’ (the implants stretch out the lower poles, or descend below the inframammary folds), ‘lateral drift’ (implants that fall too far to the side when the patient lies flat), and synmastia (aka symmastia, which means the breast implants meet in the cleavage area and there is no longer a clear separation between the breasts).

If the implant pockets are dissected too far laterally, the implants may appear too far apart on the chest wall, and may fall off to the side of the chest when a patient is in supine position (lying on their back). It is important to understand, however, that many patients have a chest wall shape which slopes steeply in a lateral direction, and in these patients some lateral drift in supine position is essentially impossible to prevent.

If the pockets are not dissected far enough laterally, the implants appear too close together and do not project enough to the side to create the upper third of an ‘hourglass figure’. Again, this may be impacted by the underlying shape of the chest wall, for in some patients the chest wall slopes steeply inward towards the sternum, and in these patients the implants will always tend to sit medially towards the cleavage area and under-project laterally.

‘Bottoming out’ can mean one of two things: that the weight of the implants has stretched out the lower pole skin and breast tissue, allowing the implants to sit too low and sometimes making the nipples appear to be too high on the breasts; or that the implants have broken past the inframammary fold (IMF) and now a portion of one or both implants is below the IMF.

Treating malposition often involves temporarily removing the implants and making adjustments to the capsular space that tightens it (called capsulorrhaphy) or that releases it (called capsulotomy). Implants of a different size and dimension may be required. The inframammary fold may need to be repaired, and in some cases an additional biocompatible (meaning ‘accepted by the body) material may need to be added to help support and maintain implant position over time. Examples include GalaFORM and GalaSHAPE surgical scaffolds, and Strattice.

One additional form of implant malposition applies to shaped breast implants only, and that is shaped implant rotation. Shaped implants that have rotated should be removed and replaced with round implants. For a number of reasons that are outlined elsewhere on the website, this practice no longer places shaped implants for any first-time or revisional breast augmentation surgery.

Implant shell visibility
If the implant shell is visible through a patient’s breast skin, or the thinner skin adjacent to the breast, then a breast augmentation never appears truly natural. Avoiding implant shell visibility is primarily a matter of not using implants that are too large for a patient’s natural breast tissue to conceal. In most cases of implant shell visibility, the breast implant volume, implant projection or implant base diameter (and oftentimes all three of these implant measurements) are too large for the patient’s natural breasts.

In slender patients with small breasts (and really for the vast majority of our patients), subpectoral augmentation is the only appropriate choice. In some cases, the implant shell is visible because the implant – even if it is of an appropriate volume – was placed in a submammary (on top of the pec major muscle) position. In these patients, moving the implant from a submammary to a subpectoral position is usually effective in concealing the implant shell in the cleavage area.

Structural fat grafting can also be effective in helping to conceal visible implant contours in any area of the breast, particularly in the cleavage area, the upper pole and along the outer edge of the breast. Fat can easily be harvested from the abdomen, flanks or thighs and grafted into areas where the soft tissue coverage of an implant is not adequate.

There are many implant factors that must be taken into consideration when managing visible implant folds and ripples. Whether or not an implant is likely to develop ‘folds’ or ‘ripples’ that are visible through the skin is impacted by the nature of the implant fill material and the percentage fill of the implant shell. So correcting implant shell visibility may also involve removing the existing implants and switching to a different implant option.

Some silicone gel implants are easily deformable, which makes them very soft to the touch when implanted, but which also has the disadvantage of making them more likely to fold at the surface and not fully maintain their round shape. The higher the percentage of gel implant fill (and they are filled at the factory, of course), the less likely they are to fold or show ripples at the surface, but the more firm they will feel.

The same is true of saline implants, which are filled with saline in the operating room. Likewise, the more ‘cohesive’ the gel in a silicone gel breast implant, the more it will tend to maintain its shape – but the firmer it will feel. So there are pros and cons to implant fill percentage and the degree of gel implant ‘cohesivity’. All three US gel implant manufacturers offer implants with different degrees of cohesivity, so many options are available when planning implant removal and replacement.

Implant size dissatisfaction
Some postop breast augmentation patients feel that their implants are too big and make them feel very self-conscious, while others feel that their implants are too small and that their expectations for a shapelier figure have not been met. Increasing breast implant volume is one of the more straightforward breast augmentation revisional procedures, as long as the implant volume selection produces a plausibly natural position. Reducing implant volume can be more challenging, as in these cases the pockets must be tightened to accommodate smaller implants.

Keys to success in primary and secondary breast augmentation
The keys to achieving an aesthetically beautiful and natural-appearing breast augmentation result are the same, whether the surgery is the initial placement of breast implants or a secondary procedure to correct any of the potential breast implant problems outlined above:

1. Thorough preoperative assessment including measurements made in standing position and sometimes in supine position as well.
2. Examination of a wide variety of samples implants and breast forms, both in a bra and while wearing a form-fitting shirt over the bra (for patients that do not currently have implants in place).
3. Adherence to biodimensional planning principles – the concept that the measurements of the natural breast and chest wall directly impact the implant size and profile that are appropriate for each patient.
4. The willingness to take a staged approach to breast enhancement in instances where that is beneficial.
5. The willingness to deflate existing saline implants or remove existing silicone gel implants in some cases, and to re-evaluate the patient a week or two later to confirm the ideal plan for secondary breast enhancement. This is not required in all cases, but is extremely helpful in some.
6. The use of supportive / protective materials (GalaFORM, GalaSHAPE, Strattice, etc) when indicated.
7. Adherence to surgical principles and practices that have been demonstrated as effective in scientific studies published in peer-reviewed scientific journals (the practice of ‘evidence-based’ medicine).
8. Meticulous attention to detail in the operating room. The surgeon should never be in a rush, and should never leave the O.R. until the breast appearance is the best it can possibly be.
9. Frequent follow-up in the early postoperative phase, and intermittent evaluation over the course of one year. For travelling patients, some of this follow-up can be conducted by phone with postop digital photographs and video submitted securely by the patient.
10. Rigorous attention to a postoperative recovery protocol that includes a gradual, logical return to full-effort exercise over 12 weeks.

Regarding the issue of reoperation, these three things you ABSOLUTELY must know before your breast augmentation surgery…

1. There is no way around the fact that ALL breast augmentation surgeons, even the most meticulous and experienced ones, have some patients who return with a breast implant problem that requires surgical correction.
2. By following the principles outlined above, it is possible to avoid the need for reoperation in the vast majority of breast augmentation patients.
3. Because the need for reoperation is a possibility, although ideally a remote one, make sure that your breast augmentation surgeon can clearly describe to you the approaches that they use to minimize the likelihood that you will require a return trip to the O.R. to fix a problem with your breast implants. And, just as importantly, make sure that the practice policy for reoperation in breast augmentation patients is clearly explained to you – including any expenses that will be your responsibility.

Read DR. LAW’S PHILOSOPHY on BREAST AUGMENTATION REVISION SURGERY

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Breast augmentation after pregnancy, major weight loss and in naturally droopy breasts

Quite a number of the breast augmentation patients in our practice are moms. After one or more pregnancies, most women experience a loss of breast volume combined with some ‘stretching out’ of the breast skin. In many of these patients, a breast implant of moderate size will restore a very pleasing breast contour. These patients are not looking to raise eyebrows at work or around the neighborhood – they just want to discard their padded bras, to have more options when selecting clothing and swimsuits, and to feel better about their appearance in private.

When there is mild to moderate laxity of breast skin and/or loss of breast volume that makes the breasts appear somewhat droopy or ‘deflated’, the addition of a breast implant can ‘fill up’ the excess skin and create the appearance of a breast lift (although this is not truly a breast lift or ‘mastopexy’). This situation often is a result of pregnancy and lactation, but we also see many patients with significant breast skin laxity who have never been pregnant. Breasts are often droopy and lax at the time that they first develop, and can also have this appearance in patients who have never been pregnant but who have experienced major weight loss.

In patients with more advanced drooping of the breasts (the medical term is breast ptosis – the ‘p’ is silent so ptosis is pronounced TOE-sis), particularly when the nipples are pointing downwards, a mastopexy (breast lift) needs to be combined with the breast augmentation surgery to tighten the skin envelope around the implants. In these patients adding a mastopexy to the augmentation plan allows the surgeon to achieve a result that is truly youthful and aesthetically ideal. The result of this surgery is truly liberating for most patients, as most no longer feel the need to wear a bra to bed at night, and can go bra-less in some forms of clothing if they wish to do so.

Mastopexy may also be required when the nipples are still pointing forward or slightly upwards, but much of the lower pole breast volume has dropped below the level of the inframammary folds. This preoperative condition is referred to as ‘glandular ptosis’, meaning that the nipples are not down-pointing but a significant proportion of the glandular tissue of the breasts has ‘bottomed out’ and now resides below the level of the inframammary folds.

Simultaneous breast augmentation and breast lift (mastopexy) is called an augmentation mastopexy, and the results of this operation can be dramatic and absolutely transforming. An augmentation mastopexy is required when the surgeon’s preoperative assessment is that without a lift, the likely postoperative appearance is that of a breast drooping off of an implant – which is a distinctly unnatural and unappealing breast profile. If you need a bra to hold your breasts up preoperatively, it is quite likely that you will need a mastopexy in addition to your breast augmentation procedure.

Read DR. LAW’S PHILOSOPHY on AUGMENTATION ALONE vs. AUGMENTATION MASTOPEXY