Breast Augmentation Revision

A significant portion of my practice is dedicated to breast augmentation revision. San Francisco Bay Area plastic surgery patients are fortunate to have many, excellent Board Certified Plastic Surgeons from which to choose. But even in the best of hands, as many as 25% of breast augmentation patients will have breast augmentation revision within 10 years of their original surgery. The most common reason breast augmentation is revised is to change size. Other common reasons include: breast implant deflation, capsular contracture, breast implant malposition and rippling. Rarely, breast implant infection and exposure can occur, but this is more common with revisions of breast reconstruction than for revision of cosmetic breast augmentation.

Breast Implant Revision Surgery to Change Size

The most common reason for breast augmentation revision is to change the breast implant size. Overwhelmingly, the desire is to increase the size of the breast implants; however, decreasing the breast implant volume is also requested. Since the breast implant pocket is already mature, the operation is usually quick and simple.

To change an implant, the incision is opened and the old implant removed. If the pocket is satisfactory, a new implant is inserted and the incision closed. Recovery is normally a few days, and there are minimal limitation on activities. Most patients feel well in one to two days, and can resume normally activities quickly.

If you do not currently have breast implants, or if you are looking to go larger, tips on how to select the best implant size are included on the breast augmentation page. Click here for a guide on choosing breast implant sizes.

This can help minimize the need for a second operation to change the breast implant volume. It is hard to imagine what a particular volume will look like, so normally a desired cup size is determined. Cup sizes are not exact, and will depend on who makes the bra, and how tight or loose you like the bra to fit. If you come to your consultation appointment with a good idea of your goal size, I will help you choose the implant best suited to your desired results.

Even with excellent planning, sometimes the goals change. If you you already have breast implants, and want to change breast implant size, it is very helpful to come to the office with your implant information, or the operative report, in hand. This provides a concrete starting point, and helps improve the predictability of any change in size.

Breast Implant Revision Surgery for Breast Implant Deflation

Another common reason for breast augmentation revision is breast implant deflation. Like everything else on the planet, breast implants can wear out. Sometimes there is an obvious reason for deflation, like severe chest trauma after a car accident. Sometimes it is an unexpected surprise. Treatment is similar to that described above for changing the breast implant size. If you desire a change in size, breast implant deflation provides the opportunity to make the change, but likely, both sides will need to be changes to keep the breast augmentation even.

The presentation of a deflated breast implant varies with the type of implant.

Deflated Saline Breast Implants:

Saline filled breast implants are "honest" implants. If you saline filled breast implants leak, the volume is lost quickly, and no special testing is required to make the determination. The saline safely is absorbed by your body, and the breast goes flat. Since the saline disappears quickly, your body does not react to the leak. The capsule around the implant will slowly close around the empty breast implant, so it is best to replace the implant promptly to reduce the need for a capsulotomy. Recovery is quick, similar to that experienced after a breast augmentation revision to change the breast implant size.

Deflated Silicone Gel Breast Implants:

If your breast implants are filled with liquid silicone gel (not form stable or gummy-bear style), determining if there is a leak is more difficult. The silicone is not absorbed by your body, instead, the silicone gel is walled off by a layer of scar tissue. This occurs if the gel leaks outside the original breast implant capsule. If it is contained by the original capsule, there may be no reaction, and this is what is called a "silent leak". Silent leaks are best investigated with a breast MRI. This is currently the best test available to determine if there is a leak in a silicone gel breast implant. The FDA currently recommends an MRI of the breasts at three years after breast augmentation, and every two years after that, to detect the presence of a silent leak.

Deflated Form-Stable Silicone Gel Breast Implants (Gummy Bear Implants, Highly Cohesive Silicone Gel Implants or 410's):

Form-Stable or Gummy Bear implants are solid. They are soft solids, like Jell-O, but since they are solid, they cannot leak. This is one of the biggest advantages of form stable implant. This class of implant has been available outside the US for a decade, and has a good track record. The FDA's subcommittee recommended approval for use in the US several years ago after the additional information requested was supplied. Since that time, the FDA has not made its final recommendation, and it is unclear what additional information they may be waiting for to make the decision.

Breast Implant Warranties

The two major breast implant manufactures in the US are Allergan and Mentor (a division of Johnson & Johnson). Both stand behind their breast implant product lines with generous warranties, including lifetime replacement of your implant should you experience a deflation. Breast implants leaks that occur within 10 years of surgery may also qualify for financial assistance towards the cost of your breast implant replacement surgery. Warranty details are available here. Breast Implant warranties are frequenly updated. Be certain to check your breast implant manufacturer's web site for the latest information.

Natrelle Breast Implants (Allergan)

Mentor Breast Implants (Johnson & Johnson)

Breast Implant Revision Surgery for Capsular Contracture

It is normal for your body to form a thin layer of scar around your breast implants. This is called the breast implant capsule, or capsule for short, and it is important in maintaining and protecting your breast implants. The capsule maintains the breast implants in the correct position within in the breasts, and it protect the implants from exposure and infection. If the capsular scar becomes too tight or thick, the condition is referred to as capsular contracture. Capsular contracture may occur any time from a few weeks after surgery to several years later.

Capsular contracture is classified into four grades. The softest is Grade I, while the firmest is Grade IV. What grade is determined by how the capsular contracture presents.

Grade I capsular contracture: The breast capsule is soft, thin and not detectable on physical examination. This is the most frequent result and requires no treatment.

Grade II capsular contracture: The breast capsule is still usually soft and thin; however it may be felt upon physical examination. This type of capsule causes no physical distortion of the breast, and also requires no treatment. This is the second most common result.

Grade III capsular contracture: The breast capsule is either tight, thick or both. The breast implant capsule in Grade III contracture causes distortion of the implant. This may result in breast implant malposition (see next section) and a firm, or even hard, breast. Grade III capsular contracture is usually treated with surgical release (capsulotomy) or removal (capsulectomy). Recovery is usually easier than that for the initial breast augmentation, but more sore than a breast implants replacement.

Grade IV capsular contracture: The breast capsule is the same as in Grade III capsular contracture, but Grade IV capsular contracture is also painful. Fortunately, Grade IV capsular contracture is the least common of all capsular contractures. The treatment is the same as as with Grade III.

Non-surgical Treatments for Capsular Contracture

Many treatments have been suggested for the non-surgical treatment of capsular contracture. A partial list is included below. While methods like massage, ultrasound, Vitamin E, Steroids and Herbal Medications are not scientifically proven to work, there are few risks associated with their use. I have had patient resolve their capsular contracture while trying these. Whether they improved because of the treatment, or because they were given enough time to resolve spontaneously, we will never know, but better is better.

LT inhibitors are also listed. LT inhibitors are asthma medications and include montelukast (Singlair) and zafirlukast (Accolate). Unfortunately, LT inhibitors have been associated with liver failure and death, so I cannot recommend their use for capsular contracture treatment.

Partial list of non-surgical capsular contracture treatments:

Massage
Medications

Vitamin E
Steroids
Herbal Medications
LT Inhibitors (Accolate, Singular)

Ultrasound

Surgical Treatments for Capsular Contracture - Capsulotomy and Capsulectomy

There are two surgical treatments for capsular contracture: releasing the capsule (capsulotomy) and removing the capsule (capsulotomy)

Open Capsulotomy - This treatment is best for tight, thin scar capsules. The scar is cut, allowing it to expand. This releases the restriction and compression of the breast implant and softens the breast. This treatment is better for patients with very thin breast implant coverage, as it does not further thin the tissues around the breast implant. The majority of the time this results in a softer result with improved implant position.

Open Capsulectomy - This treatment is best for thick capsules. The scar is removed, resulting in a new pocket for the implant. A new capsule will form, just like with the first breast augmentation surgery. The majority of the time this procedure also results in a softer result with improved implant position.

Closed Capsulotmy - This is an old technique which involves forcefully compressing the breast in order to release (tear) the breast capsule. It has fallen out of favor because it lacks the technical precision of the open techniques. The procedure can lead to breast implant deflation and bleeding (hematoma) at a higher rate than the other procedures. Performing closed capsulotomy also violates most breast implant warranties.

The cause of capsular contracture is still not completely understood. There is evidence pointing to bacterial contamination around the beast implant; however, the usual hallmarks of infection are absent. Washing the breast implant and the breast implant pocket with antibiotic solution has been shown to decrease the risk of capsular contracture. Oddly, if you already have capsular contracture, your risk of recurrence after surgery is approximately the same as for someone who has not had capsular contracture.

Breast Implant Revision Surgery for Breast Implant Malposition

Malposition, as the name implies, means the breast implants are in the wrong place. Since breasts come in many shapes, sizes and locations, it is not possible to always have "perfectly" positioned breasts. When the location strays too from for the ideal position, revision surgery may be necessary. It is normal for the breast to appear too high in the early post-operative period. During the first year after surgery, breast implants normally settle lower on the chest. Intervening too early will not only get you an extra surgery, but it may result in implants that then continue to drop to a lower than ideal position. If you are more than a year out, and the implants are in a less than ideal position, you may want to consider surgery to reposition your implants. At a year the implants are stable, and correction is more predictable.

Breast Implant Malposition - Implants Too High

The most common breast implant malposition is too high. Fortunately, this is also the breast implant malposition that is the easiest to correct. High malposition can be caused by creating a breast pocket which is too high on the chest, or it can be from a pocket that is formed correctly, but the breast implant has settled too high in the pocket.

Over supporting the breast implants in the early post operative period can contribute tp high malposition. Underwire bras are not recommended in the early post-operative period for this reason. Underwire bras push the implants up and compress the lower pocket closed. If the lower aspect of the pocket closes with the implant high, the implant will become stuck high in the pocket, resulting in high malposition.

For implants placed under the muscle, a tight muscle, or prolonged muscle spasm after surgery, can also lead to breast implant malposition. The tight or spasmed muscle will hold the breast implant high up in the pocket. If the lower aspect of the pocket closes before the implant drops back down, high malposition can result.

Capsular contracture is another cause of high malposition. Capsular contracture can cause malposition months to years after the original breast augmentation surgery. A capsule that tightens at the bottom of the pocket will push the implant up, and support it higher than a soft capsule, causing high breast implant malposition.

Treatment of high malposition shortly after surgery may include:

Massage to displace the implants down and stretch the lower pocket.
Wearing a bra without underwire or with your plastic surgeons guidance, going braless.
Use of a breast band worn over the top of the implants to push them down.
Avoidance of overhead reaching and heavy lifting to allow the muscles to relax.

Treatment of high malposition that has persisted more than a year may include all the above and:

Breast augmentation revision surgery to release the lower capsule and enlarge the lower aspect of the breast implant pocket.

Breast Implant Malposition - Implants Too Lateral

The second most common malposition is too lateral. With lateral malposition, the implants move away from each other, and may start heading under the arms. Lateral malposition can be from formation of a breast pocket which is too lateral, or it can be from a pocket that was formed correctly, but the implant pushes it way laterally. This can occur because there are no firm attachments in the lateral breast to keep the implants towards the middle. The shape of the underlying rib cage contributes also. Ribs curve around from the front to the back. The flatter the ribs are behind the implants, the better support the ribs give. If the ribs begin curving towards the back while they are still under the implant, the implant will tend to fall towards the armpit. Sleeping on your stomach after surgery also tends to push the implants to the sides. Once the medial (central) pocket closes, the implant will not move back to the middle, and the gap between the breasts will widen. Capsular contracture can also cause lateral malposition well after the original breast augmentation surgery.

Treatment of lateral malposition shortly after surgery may include:

Massage to push the implants together and stretch the inner pocket.
Wearing a bra that holds the implants towards the middle, with your plastic surgeons guidance sometimes this means bras with underwire.
Use of a breast band worn over the top and sides of the implants to push them together.
Avoidance stomach sleeping.

Treatment of lateral malposition that is not responsive to the above:

Breast augmentation revision surgery to release the inner capsule and enlarge the medial (inner) aspect of the breast implant pocket.
Capsulorrhaphy to close the lateral aspect of the pocket.

Breast Implant Malposition - Implants Too Low (Bottoming Out, Double Bubble)

Another type of malposition occurs when the implants are too low. Inferior malposition may present as bottoming out or as a double bubble. Inferior malposition can be from formation of a breast pocket which is too low, or it can be from a pocket that was formed correctly, but the implant pushes it way down. This can occur because there are no firm attachments to enforce the inframammary fold (IMF), or because the attachments have been released too much to support the weight of the breast implant. Larger implants are at greater risk of inferior malposition.

Treatment of inferior malposition shortly after surgery may include:

Wearing a supportive bra, with your plastic surgeons guidance sometimes this means an underwire bra that holds the implants above the ideal IMF.
Taping of the skin underneath the breast.

Treatment of inferior malposition that is not responsive to the above:

Breast augmentation revision surgery to repair the attachments at the IMF, and capsulorrhaphy to close the lower aspect of the breast implant pocket.
For the correction of a double bubble deformity, sometimes it is necessary to move the implant from the subpectoral pocket (behind the muscle) to a subglandular pocket (in front of the muscle)
ADM's (Acellular Dermal Matrix) can be used to create a sling to internally support the breast implant.
Downsizing - Sometimes smaller breast implants are needed to maintain the ideal position and decrease the risk of recurrent inferior malposition.

Breast Implant Malposition - Implants Too Medial (Symmastia)

The rarest, and at times the most difficult malpostion, occurs when the implants are too close together. In its most severe form, the two breast can become one. This is termed symmastia in the plastic surgery literature and uni-boob or breadloafing in the lay press. Symmastia can cause the skin between the breasts to lift. This gives the appearance of one large breast. Like the other malpositions, symmastia can result from the formation of a breast pockets which is are too close together (or even meet in the middle), or it can be from pockets that were formed correctly, but the implant pushes it way medially. The shape of the ribs can contribute, such as in cases of pectus excavatum. Breast implant selection also can contribute to the formation of symmastia, The bigger the breast implant and the higher the breast implant profile the easier it is for the implant to lift the central chest's skin and form symmastia.

Treatment of medial malposition (symmastia) shortly after surgery may include:

Avoiding breast compression.
Thong bra

Treatment of medial malposition (symmastia) that is not responsive to the above:

Breast augmentation revision surgery to repair the attachments at the edge of the sternum. Sometimes the capsule is sufficient for repair, sometimes a neosubpectoral pocket is formed, sometimes ADM's are needed.
Downsizing - Sometimes smaller breast implants are needed to maintain the ideal position and decrease the risk of recurrent symmastia.

Breast Implant Revision Surgery for Rippling

Rippling is wrinkling of the implants. To some extent, rippling occurs with every breast implant. This is more commonly noticed with saline filled breast implant, though it can occur with silicone gel filled breast implants too. Even form-stable, gummy bear, breast implants can have rippling.

Rippling is most often felt rather than seen, and the most common location is along the outer edge of the implant, below the armpit. When seen, especially when seen on the inner aspects of the breast, treatment is elective, but may be desired.

Treatment of rippling depends on its cause. If capsular contracture is present, correction of the capsular contracture usually helps. In cases without capsular contracture, the treatment of rippling may include:

Changing the type of implant. For example replacing saline implants with silicone gel filled breast implants may help reduce rippling.

Changing the profile of the implant. For example replacing lower profile implants with higher profile implants may help reduce rippling.

Changing the location of the implant. For patients with thin skin moving the implants from in front of to behind the muscle may help reduce rippling.

ADM's have also been used to thicken the breast implants soft tissue covering, though long term results are still pending.

Breast Implant Revision Surgery for Infection/Exposure

A rare complication of breast augmentation is breast implant infection or exposure. Breast implant infections are most common early, but can occur years after surgery. The rate of breast implant infection in the first year after breast augmentation is about 1%. This is the same number seen with any "clean" surgery. The rate of infection increases dramatically if you already have another infection at the time of surgery. This seems obvious when the infection is on the breast; however, the risk is also increased with infections remote from the breasts, like urinary tract infections and upper respiratory infections.

If you have a cold or infection, all elective surgery should be postponed until you are well. An ounce of prevention is worth a pound of cure. It is not worth increasing your risk of infection. While rescheduling surgery may be inconvenient, not rescheduling can be disastrous.

Infection and hematoma (bleeding around the implant) both increase the risk of implant exposure. If the implant is infected, antibiotics should be started without delay. You may need intravenous antibiotics. If the the infection will not resolve, or the implant becomes exposed, the best treatment is temporary removal of the implant to allow the chest to heal. After healing fully, usually months later, the implant can be safely replaced.

Breast Implant Removal

Sometimes breast implant removal is desired. The reasons for breast implant removal vary widely. Often it is because the breast enlarges and the volume of the implant is no longer necessary. This is why breast augmentation should be delayed until breast growth is stable, especially in younger patients. Here are a few of the more common scenarios:

The complications associated with breast implant infections and exposure are covered in the section above. While rare, this accounts for a good number of the breast implants removed.

Breast implants placed at a younger age tend to be larger. While the volume of the breast implant will not spontaneously increase, sometimes the breasts continue to enlarge with age or weight gain. If the breast become too large, symptoms may develop, like those seen prior to breast reduction surgery. While reducing the size of the implant is often the best plan, in some cases removing the breast implant entirely may be better.

Another time when breast can enlarge is with pregnancy. It is important to note, there is no contraindication to breast feeding after augmentation with breast implants. The current recommendations for breast feeding are the same as for women with and without breast implants. While unusual, some women feel more comfortable having their breast implants removed before becoming pregnant to decrease skin stretching. This may or may not help, and no large randomized studies are available on the subject.

Breast can also enlarge with menopause. Some women become uncomfortable with the size of there breasts at this time, and desire breast implant removal. Some women have told me they are done enjoying their larger size, and just want to be smaller again.

Breast implants are also used for breast reconstruction. Unfortunately, as a group, breast reconstruction patients have more complications with breast implants than cosmetic breast augmentation patents. The injury from a mastectomy with breast reconstruction is greater than the injury from simple breast augmentation. Often radiation is performed to decrease the risk of local recurrence of breast cancer, and this further increases the risk of capsular contracture and hardening of the breasts. Capsular contracture, breast implant deflation, breast implant infections and breast implant exposure are all higher in with breast reconstruction.

Reconstructed breasts tend to sit higher on the chest. Breast lifts are often performed on the opposite side to enhance symmetry. When breast implants become encapsulated, the implant may feel firm and rise up on the chest. This can cause discomfort and difficultly in finding suitable clothing to hide the asymmetry. Breast reconstruction surgery can be revised to try to soften and lower the implant. In difficult cases, some patients will instead opt to have the reconstructive breast implant removed and wear an external prosthesis.

Removal of the implant is technically quite simple, and has a relatively short recovery period. No matter the reason the breast implant is removed, the loss of volume may cause sagging (breast ptosis). A breast lift may be necessary to enhance the breasts' aesthetics. Sometimes, removing breast implants is more challenging psychologically than physically. In these cases counseling may be helpful. With careful preoperative consultation, and perioperative care, most patients will do well after breast implant removal.

Breast Scar Revision

The incisions used for breast augmentation heal well the vast majority of the time. With carefully placed incisions, scar massage and topical treatments, patients are happy with the appearance of their scars. A small percentage of scars heal raised or widepread, and may remain irritated and at times itchy. These scars may benifit from breast scar revision.

Above are breast scar revision before and after photos of periareolar scars.

Before: The upper picture is before the breast augmentation scar revision and reveals pale, widepsread scars, which were poorly placed. The incisions were made within the areola, instead of along the margins. The peripheral dark areola skin only helps to define the white scars and makes them more apparent.

After: The lower photo is after breast augmentation scar revision. The wide, white scar was excised, and the new scar was placed more peripherally, curving along the edge of the areola. The edges were carefully reapproximated in layers, reinforcing the skin margins and supporting the closure from inside out. Minimizing the tension across the repair reduces the tendency for the scar to spread. The result is a fine white scar, and a much more cosmetically acceptable scar. By placing the scar along the edge of the areola, the scar is camouflaged. This method works well for both light and dark scars. Lighter scars will hide in the skin, and darker scars will hide in the areola.