Why is my Nipple Caving In?

Question

Hello, I am 9 weeks post op for breast augmentation revision for capsular contracture with dual plane silicon switched from 270cc down to 250cc. If the left breast is squeezed or flexed the nipple caves/folds in deeply at the incision line. Is this part of the healing process? It did not happen last surgery and it's very unattractive ;( The left breast is also significantly more painful

Gerald Minniti, MD, FACS · Answer

Hello,

	I am terribly sorry that you are having this problem after your revision surgery.  As difficult as it is for the plastic surgeon trying to remedy one problem, only to create a new one, it must be even worse as the patient having to personally experience these serial problems, wanting only to get a good, problem free result.

	Your description of the problem is clear, and I know what is happening to you. Unfortunately, this problem will unlikely improve with time, and is one that afflicts about 10% of women that get primary breast augmentation and about 15% of women who get revision breast augmentation via the periareolar route.  You have developed a tethering scar that connects the skin of the areola down to the muscle and/or scar capsule around the implant.  This deformity is made worse by anything that pulls on the scar, like the pectoralis muscle when it contracts.

	The good news is that this problem can be repaired under a local anesthetic to save on cost and inconvenience.   The procedure involves a combination of scar lysis and fat grafting through small incisions, utilizing specialized canulae. The combination of dividing the tethering scar fibers and filling the space with fat cells (and those precious stem cells the we are hearing about so much lately) will likely fix the problem entirely. 

	For the express purpose of utilizing your post as a means to educate women reading this, I would like to discuss this issue in more detail.  Periareolar incisions have become a very popular incision for breast augmentation for various reasons, and this is especially so in Southern California and Nevada, where a lot of breast augmentation is performed. Unfortunately, more than one study has shown that this incision is associated with higher rates of capsular contracture, and also other problems, like tethered and depressed scars, as well as long term problems like breast tissue thinning and palpable implants just under the nipple-areolar complex.

	Given what we know about the relationship between capsular contracture and bacterial contamination, it doesn't make sense to deliver the breast implant via the periareolar route, putting it in direct contact with breast tissue/milk ducts which contain bacteria. From the perspective of tissue preservation, it also doesn't make sense to surgically divide and traumatize the breast tissue, as it is the most important tissue that covers the implant and provides shape to the breast mound.  Although we have good evidence of the problems associated with the periareolar route, don't expect any medical, legal, or governmental board to ban it as a procedure, or declare it 'below the standard of care'.  Historically, it is a very common technique/incision, and many surgeons are 'just fine' with it. Additionally, as long as the consumer asks for it, surgeons are going to continue doing it.  So, as a potential breast augmentation patient, you should be informed that all incisions are not made equal, and there are higher risks associated with the periareolar route.  Choosing the inframammary route is associated with the least risk of capsular contracture, and has no risk of nipple-areolar complex scar tethering or thinning of the tissue below the complex.

	Best of luck!

Vincent N. Zubowicz, MD · Answer

Without a picture in physical examination it's hard to say what is going on. However, by nine weeks most significant swelling should be resolved. There may be some scar tissue retracting the areola which probably will require surgical release. This is just a guess however.

Vincent P. Marin, MD, FACS · Answer

Without a photo, it is difficult to tell, but it sounds as if you have a scar connection from the incision down to the capsule. When the muscle contracts, it pulls the capsule and then the scar resulting in an external deformity. This is difficult to correct, but may require anything from a simple release of the tissue to having to place some additional tissue as a barrier to prevent subsequent scarring in the future.

Continue to follow up with your surgeon to ensure that you progress as planned.

Best of luck,

Vincent Marin, MD
	San Diego Plastic Surgeon

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