Breast Implant Or Breast Revision Surgery (Revision Mammoplasty)

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WHAT IS BREAST REVISION SURGERY:

Breast revision surgery is performed for a number of reasons and factors related to the patient’s initial breast surgery.  Some of these reasons include the following:

    - Saline implant deflation.
    - Implant leak (gel)
    - Capsular contracture.
    - Dissatisfaction with breast size.
    - Asymmetric breasts.
    - Double bubble deformity.
    - Implant drop out (loss of inframommary fold).
    - Symmastia (synmastia).
    - Excessive thinning of breast tissue.
    - Visible or palpable rippling.
    - Excessive intermammary space between breasts.
    - Malposition of implants:  too high, too low, too far to the side.
    - Incomplete muscle release.
    - Ptosis or droopy breasts.
    - Poor shape.
    - Lower breast stretch

Correction of many of these problems will involve a combination of procedures from the following list below and your specific surgical plan will have to be detailed by the doctor.  One of the most common problems is capsular breast contracture or the development of firmness of the capsule that exists around the breasts. Severe capsulary contracture probably occurs in less than 15% of augmentation patients. Every woman has a breast capsule around their implant and this is a normal phenomenon.  The capsule itself could be as thin as Saran Wrap but may also be calcified and somewhat thickened.  As it becomes thicker or shrinks, the patient may develop a feeling a firmness of the breasts and in its worst situation, the breast may become painful and abnormal in appearance, achieving a very round hard appearance.  There may be distortion and possible breakage and leakage of an older implant and, on occasion, even a newer implant.

Saline implants may be deflated and at times the fluid is contained within the capsule, so that the breast still has the appearance of being intact.  When the patient has significant symptoms, complete leakage of their saline implant, or concerns regarding silicone leakage, it is recommended that the implant is removed and exchanged.  Frequently, this is performed on both sides depending upon the age of the implant.  Capsulotomy or opening of the capsule may be required or frequently capsulectomy, which is removal of the scarred capsule, is recommended.

New implants may then be placed in the same existing position or may undergo a change of placement frequently from submammary to subpectoral position and, on occasion, the other way around.

 

Acellular Dermis Matrix (ADM):

ADM materials have the potential advantage of providing increased coverage over a breast implant and decrease visible wrinkling, rippling or thinness. They may even decrease the occurrence of capsular contracture and hardness of the breasts.  These products do not change the potential risks of possible complications that are listed elsewhere in these papers and that have been discussed with the doctor and his staff. They may decrease the chance of further complications and the need of additional surgeries.

ADM products are soft tissue substitutes not unlike skin grafts, which are composed of collagen and other proteins, generally from human or porcine origin.  Common product companies at this time include the Strattice, AlloDerm, BellaDerm, and Flex HD .

These products have been treated to remove all harmful tissue cells and proteins that may have any harmful effect or transmit any diseases.  Components that your body may recognize as foreign material and subsequently result in rejection have also been carefully removed.

ADM has been used thousands of times for many different reconstructive purposes on many different parts of the body and have not been reported to transmit any disease or infection.

Ultimately, the goal is for these materials to be incorporated into your body tissues and establish their own circulation and then your body will replace the majority of these materials with its own natural tissue in the healing process.

Specific Risks:

_____  Although an attempt will be made to make your breasts the same size and more even than they are, the facts are that they will never match!!!

_____ There can be no promise or guarantee of the specific cup or bra size after your surgery.

_____ If one nipple/areola is higher than the other it will not be totally corrected even with a breast lift.

_____ Any asymmetries regarding the folds under your breasts will not be totally corrected.

_____ The gap between the breasts (intermammary space) can be reduced some, but patients with a large gap will always have some space between them.

_____ Capsulectomy or capsulotomy will change the projection and shape of the breast.

_____ Chest wall (rib and breast bone) and shoulder / back asymmetries that exist before will not be corrected from the surgery and will affect the breast shape and position.

_____ Capsular contracture may recur regardless of surgeries being performed at this time.  New capsular contracture may require additional surgeries which also will require additional fees.

_____ A thin or completely hidden scar is not guaranteed, especially in revision surgery.

_____ It is very likely that you will require additional breast surgery in your future.  Breast revision surgery is more difficult, complicated, and requires more time than primary surgery.  There is as much as a 40% chance!!! that revisional surgery will be needed following this operation.

_____ Thinner tissue on the underside of the breast and on the outside of the breast may result in implants that can be felt or are visible (rippling)

_____ Implants which are under the muscle or are placed in a new position under the muscle may change with shape on muscle contracture and may have “banding” and motion of the implants with muscle contracture.  If this is unsatisfactory, it may require additional surgery which will also require additional surgeon’s fees, Operating Room and anesthetic fees.

 

BOTTOMING OUT:

This is the term given to implant displacement, where the implant drops down below the existing inframammary fold.  This may occur when the fold has been released excessively during surgery or may be due to factors of the patient’s collagen and tissue integrity.  The implants end up sitting very low on the chest and there is lack of internal support for the implant itself.

Correction usually involves treating the internal capsule, by sewing this in place.  Currently, ADM can be used to attach to the breast tissue internally and support the implant.

This corrects the placement of the implant, redefines the breast shape and refines the internal fold.

STRETCH DEFORMITY:

This occurs when the breast fold is in the correct position, however, the length of the tissue between the nipple and the fold stretches. This may be due to the patient’s elasticity and/or the size of the implant that is used. Skin laxity can change with age, pregnancy, weight changes, or heredity.

Correction of this problem usually includes skin excision with a mastopexy or breast lift.

It may be necessary to use ADM again to further support the breast and breast tissue of the tissue is too thin.

 

IMPLANT DISPLACEMENT TO THE SIDE (LATERAL DISPLACEMENT):

During breast implant surgery a pocket is created carefully to maintain certain folds on the sides and bottom of the breast. On occasion, the space for the breast implant is made too large on the side of the chest or the tissue stretches and the implants fall too much to the side.  This is most easily seen when the patient is lying on her back.  On rare occasion, the implants can move towards the patient’s armpit.

Treatment will generally require closing the space with a procedure called a capsulorrhaphy.  In this case, the capsule is closed off internally much as we do when we are trying to raise the breast fold.  The capsule is closed with sutures and at times Acellular Dermis Matrix (ADM) would be used to further support this correction.

 

NEOPECTORAL POCKET:

This is sometimes used as a technique to provide a stronger better space.  In this case, the implant is removed and the capsule is dissected from the muscle, creating a new or neo pocket on top of the old capsule.

SYMMASTIA / SYNMASTIA:

This is a condition which can occur when the implants are too close together.  Patients often refer to this as a “uniboob.”  This can occur for the same reasons as lateral and displacement.

Correction of this problem may involve using implants of a smaller size or a smaller base.  On occasion, this may require surgery in more than one stage to allow the tissues to heal and then place the implants.  If the implants have been placed above the muscle, converting them under the muscle frequently will help and, again, the use of Acellular Dermal Matrix may be required for additional support if the tissues are thin.  The techniques of capsulorrhaphy and neopectoral pockets may apply here as well.

CAPSULAR CONTRACTURE:

Effective treatment of the capsule frequently involves completely removal of the capsule (capsulectomy), and occasional incisions in the capsule may be somewhat helpful (capsulotomy).  In the past, closed capsulotomy, in which the breast is squeezed until the capsule breaks, was used.  Currently, most doctors avoid this technique because of complications associated with the technique and because the implant companies will void their warranty if this technique is used.  At times it is necessary to change the position of the implant, either above or below the muscle, depending upon the initial position, changing the implants themselves and, on occasion, the use of Acellular Dermal Matrix may be required to prevent continued problems.  Although the risk of capsular contracture is approximately 9-11% in our practice or initial implant placement, the risk of problems with secondary surgery rises to between 25% and 40%. The use of singulair and vitamin E may be of benefit.

 

RIPPLING, WRINKLING AND PALPABLE IMPLANTS:

Rippling may be something that is felt by the patient or in very thin patients it may be visible.  This usually occurs when there is not enough tissue coverage or when the implants are excessively large, relative to the patient’s breast and breast tissues.  This commonly happens at the bottom but may also be seen towards the middle or on the sides; even more rarely in the superior or top position.  This does occur more frequently with saline implants and with textured implants.

Correction of this problem will not be completely possible, however, improvement can be achieved depending upon the original cause of the problem. Subglandular implants may require conversion to submuscular position with creation of a new pocket.  Patients with extremely thin tissues may require Acellular Dermal Matrix.  Patients with textured implants may require changing to smooth implants.

Palpable implants are implants that can be felt by the patient.  It is common to feel the under edge of the implant and to on the side where the breast tissue and skin is the thinnest.  On occasion, a small “knuckle” or portion of the implant can be felt. This may happen with implants that have been placed for a period of time, with weight loss, pregnancy, traumatic injury or, at times, there is no specific identifiable cause.  Adjustment of the pocket size, changing the implant, and adding support with

— Dr. Jed Horowitz, MD, FACS

Article by
Orange County Plastic Surgeon