Breast Augmentation Revision

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The frustrating need for revisional surgery
The need for breast augmentation revision can be an emotional roller coaster. It is frustrating for any patient to seek out an aesthetic breast enhancement and end up with a result that does not meet preop expectations. In some cases the implant selection is appropriate and the breast augmentation procedure goes well, but over time the implant position changes, or implant contours become visible, or capsular contracture develops.

Additionally, there are some breast ‘starting points’ that are inherently more challenging and therefore more likely to require a secondary surgery. Examples of the more difficult breast augmentation preop scenarios are tubular breast, high inframammary fold / small lower pole, and major breast asymmetry. While it is certainly possible for a diligent plastic surgeon to keep their breast augmentation reoperation rate very low, there is no such thing as a breast augmentation surgeon who has no patients that require a secondary breast surgery to refine or improve the results.

In some cases, however, the surgical decisions that were made at the time of the initial breast augmentation surgery may not have been ideal for the patient. For example, the implant size and/or implant profile was not an appropriate choice for the patient (most commonly too large), or the implants were placed in a submammary position when they should have been subpectoral, or a breast lift (mastopexy) was needed in addition to augmentation – but instead large implants were used to ‘take up the excess skin’. Which, as you can imagine, is never ever a good idea.

The patients in this latter category almost always make the following statement about their initial surgery: “I should have done more research.” So if you have not yet had your breast augmentation surgery, please do your research and find a board-certified plastic surgeon who, based on their body of work and the connection you make with them at your consultation appointment, makes you feel confident that they understand your aesthetic goals and can meet your expectations.

If you have already had your breast augmentation and are unhappy with the outcome, then – once again – do your research. You need to find a board-certified plastic surgeon with significant experience in breast augmentation revision surgery, one who gives you a clear sense of confidence and competence regarding their ability to improve your situation. Make sure they have plenty of ‘before and after’ photographs of their breast augmentation revision patients – that are appealing to you – and that they can clearly describe to you the both the nature of your breast implant problem and their plan for improving the appearance of your augmented breasts.

Moving forward and improving breast appearance
In this practice we take breast augmentation revision very seriously, and we do our very best to not only provide patients with the enhanced breast appearance that they originally envisioned, 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 (breast implant ‘animation’), 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. In some cases the new implant is covered in the lower pole with a material that helps to further reduce the likelihood of capsular contracture occurring again.

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. In some cases implant positioning may need to be reinforced with a supportive material such as GalaFORM (a synthetic biodegradable polymer, Galatea Surgical) or Strattice (acellular porcine dermis, LifeCell Corporation).

Breast distortion with pectoralis major contraction is corrected by selective additional pec major release and occasionally by repair of the muscle origin. Another option is switching from subpectoral to submammary implant position, in cases where that is a practical choice. Visible implant folds and ripples may be corrected by a combination of changing the implant position (e.g. submammary to subpectoral), 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).

When two stages (two surgeries) are required
An example of a revisional breast augmentation revision scenario that sometime requires a two-stage approach is the patient with severe capsular contracture and ruptured liquid silicone gel breast implants – which fortunately have not been in use since 1992. The liquid gel material that leaks from a ruptured liquid silicone gel implant was a potent stimulus for capsular contracture in many patients. 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, or if the thickened capsule and adjacent breast tissue is highly inflamed, and I will not put in new implants during that surgery.

If the liquid gel material is indeed a stimulus for contracture, then it just doesn’t make sense to place new implants if there has been significant spillage of that material into the new implant space. I instead irrigate the pockets thoroughly with a high-pressure tissue irrigating system, place drains and close the incisions, and we then 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 one of these staged revision patients 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 augmented breasts.

In-office preop procedures
Some breast augmentation revision scenarios 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, and can make it difficult for the surgeon to decide if a lift will be needed with smaller implants.

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 in most cases under local anesthesia, with IV sedation if needed, through the incisions by which they were inserted.

Deflating or removing large implants gives the breast skin an opportunity to recover and shrink somewhat over a week or two, and then the patient returns for a post-deflation (saline) or post-removal (silicone gel) consultation appointment to refine the plan for the next procedure. Having the implants removed helps patients to see clearly what their natural breast appearance is, to understand whether or not a breast lift is required as part of their next procedure, and also gives them the opportunity to decide if they want to have implants again or not based on the amount of natural breast tissue that is present (it can be hard to tell with implants in place).

We have had plenty of patients express surprise at how much natural breast volume they had after implant deflation or removal, and who then decide to have a breast lift only without implant replacement. These are often patients in their 50s or 60s who have put on some weight with age, including in their breasts, and who now have enough natural tissue to have beautiful breasts by means of a breast lift alone.

Most younger patients, and certainly almost all of those with A-cup to small B-cup breasts following implant deflation or removal, elect to have their formerly larger implants replaced with smaller ones, and usually a lift is required as well. The switch from large to more reasonably-sized implants while simultaneously performing a breast lift is one of the most challenging cosmetic breast surgeries there is. Make sure that the surgeon you choose is highly experienced in the treatment of this challenging situation, and that they take the time to clearly explain to you their surgical plan.