Breast Implant Revision
Breast implant surgery is the most common cosmetic surgery procedure performed worldwide. While the vast majority of women after their breast augmentation surgery have an excellent outcome with long lasting results, some are unfortunate and require a breast implant revision. Some of these patient may require revision procedure after many years of enjoying the benefits of having breast implants, while for some this may occur soon after their procedure because they have suffered an early complication or are unhappy with their results.
A breast implant revision surgery involves removal and/or replacement of saline the silicone breast implants with a modern cohesive breast implant in a new breast pocket. It can be performed to change the size or shape of your implants and to correct any complications that has arisen from your primary breast augmentation. With the goal is to restore a youthful breast contour and appearance. It is important to highlight that breast implant revision surgery is much more complicated than the initial breast augmentation surgery and needs to be carefully performed by an experienced plastic surgeon.
While modern breast implants all have a lifetime warranty from the manufacturer’s, it is expected that they will fail at some stage and so most women who have breast implants will require a revision procedure after 10-20 years. Aside from this, a lot of the problems that we see with women seeking breast implant revision surgery could have been avoided by careful selection of the breast implant and the experience of the surgeon performing the procedure.
We have listed a few of the most common reasons why we see women seeking breast implant revision:
“I wish I would’ve gone larger the first time”
This is is a frequent comment we hear from patients who have already undergone breast augmentation and request a size change. However on occasions, it’s the opposite, where they feel uncomfortable with the shape of their new breasts from going too big. While it is possible to change your implant size and shape with a revision breast procedure, it’s often not a simple procedure. If you want to go larger, it can be helpful to think about what aspects of your look you want to change rather than simply opting for implants with greater volume:
Do you wish you had more cleavage?
Often a higher profile implant will help create more cleavage and upper breast fullness without changing the implant width or height.
Do you wish you had more lateral boob?
Changing the width of your implants can help to accentuate your shoulders, waist, and hips.
Times have changed, and for many women, bigger isn’t always better. If you want a considerable decrease in size, you may need to have a breast lift to take care of any excess skin that has stretched while having the larger implants. If you had your implants for a short period of time, your body will often shrink down to accommodate the new smaller implant. How well your skin will shrink down to the new size will depend on the quality of your skin.
BREAST IMPLANT RELATED COMPLICATIONS
Capsular contracture remains the most common complication after breast augmentation and can occur as early as 3 months after surgery and as late as 10-20 years. Unfortunately it is not possible to predict who will have this problem or when it will occur. When capsular contracture is present the breasts may become hard, change in shape or even be painful.
Capsular contraction frequently requires revision surgery. This may involves removal of the abnormal capsule – called a capsulectomy and replacement with a new implant, or the creation of a new breast implant pocket ‘neopocket formation’ leaving the old capsule behind with the new implant placed in a fresh breast implant pocket for a much quicker recovery. When the original breast implant had been placed under the breast tissue only (subglandular), the chance of capsular contracture recurring can be further reduced by moving it to a deeper position underneath the chest muscle (submuscular).
In women who undergo multiple breast implant revision surgeries for capsular contraction, the overlying soft tissue becomes increasingly thinner and results in more visibility of the implant, with risk of palpability and rippling. This can often be improved by the addition of fat grafting to the breast envelope at the time of a breast implant revision procedure.
Despite all the precautions taken to minimise the chance of capsular contracture recurring, it may not be possible to prevent it from happening again. In patients who have had significant capsular contraction or multiple revision procedures we often change the implant to a polyurethane implant as it has a low chance of recurrent capsular contraction. We recommend all patients to cease smoking as the rates of capsular contracture are twice as high in smokers as non-smokers.
If the shell of a breast implants ruptures, the implant may deflate or deform which will require revision breast implant surgery. With rupture of saline implants there is an obvious decrease in size of the breast like a deflating balloon, however with silicone implants this is more difficult to detect. Women may notice discomfort or pain in their breast or slight change in shape due to the underlying ruptured implant.
Diagnosis of silicone implant rupture requires an MRI or ultrasound, to determine the integrity of the implant shell (fold defects) and to look for the presence of silicone that may have leaked outside the breast implant. The risk of rupture with modern silicone breast implants is very low (<1%). With the latest form stable breast implants, due to the cohesive nature of the silicone you probably won’t notice when a silicone implant develops a tear as the silicone stays in the implant shell or the scar tissue layer around the implant (the capsule).
It is important to realize that breast implants don’t last forever. Eventually, all implants will develop a crack or tear in the outer shell (implant failure) which will require some form of revision breast implant surgery.
SOFT TISSUE RELATED COMPLICATIONS
Double Bubble Deformity
When you develop a crease across the lower half of your breast, between the nipple and the breast crease this may be due to double bubble deformity or window shading (dynamic crease).
Double bubble deformity is a static deformity and occurs when the implant settles below the natural breast fold creating a defined crease on the lower part of the breast implant giving an unattractive appearance.
Common causes of a double bubble include:
• Implant that is too large for the breast,
• Tight / constricted breast in the lower pole (tuberous breast anomaly)
• Short nipple to inframammary fold distance
• Well formed inframammary fold
• Capsular Contraction
Correction of double bubble deformity is both a challenging and rewarding exercise. There are many surgical techniques that can be implemented to alleviate double bubble deformity depending on the underlying cause.
Breast Implant Malposition
Breast implants may shift upward, downward, inward (symmastia) or outward (toward the armpit). Although occasionally unavoidable, meticulous surgical technique can help avoid implant displacement. As part of your breast augmentation surgery Dr Turner creates a very precise pocket for the implant in order to avoid implant displacement and malposition. Patients who request overly large implants are at greater risk of implant displacement.
• Implant size – Larger implants (500cc or more) are typically more prone to displace downward or outward
• Implant placement – Implants placed over the muscle (subglandular) are more likely to displace downward, while implants placed under the muscle (submuscular) are more likely to move outward
Lateral displacement occurs when breast implants shift towards the armpit resulting in lose of cleavage definition. Although it is natural for your breasts to naturally drift toward your armpits when you are lying down, implants should not remain in this position when you are seated or standing upright. When the breast implant pocket becomes too large either from over dissection or over time with expansion, the implants can fall off to the sides when the patient is lying down. In some patients with significant chest wall asymmetries ‘pectus carinatum’ this is unavoidable due to the extreme slope of the chest wall.
SYMMASTIA – KISSING IMPLANTS
Symmastia refers to breast implant displacement that has caused one or both implants to migrate inward toward the breastbone, resulting in development of a “uniboob.” This is more common with subglandular implant placement but can also happen from over dissection of the pectoralis muscle in submuscular placement and placement of too wide a breast implant.
While over-dissection of the breast pocket typically causes symmastia, women who have a depressed breastbone (pectus excavatum) are more likely to experience the condition. Surgical treatment is possible but needs complex re-adjustment of the pockets using permanent suture techniques and smaller size implant with narrower base.
When implants are placed in a submuscular pocket, sometimes patients may develop an animation deformity of the breasts. The implant can appear to move upward and toward the axilla and/or a dynamic ridge can sometimes be appreciated at the junction between the lower muscle border and the breast tissue ‘window shading’.
This can be the result of both under or over release of the muscle fibres along the sternum, or overtime with thin soft tissue coverage. This deformity can be treated by moving the implant into a subglandular pocket, changing the implant to a high cohesive, form stable breast implant or adding extra support to the lower border of the pectoralis muscle by the use of acellular dermis matrix (ADM).
Breast Implant Rippling
Implant rippling occurs when there is not enough tissue coverage over the implant and leads to a wavy appearance, usually when a woman leans over. Rippling is more common with subglandular than subpectoral placement. While low cohesive (softer) textured round implants have a higher risk of rippling than smooth implants, with the lowest risk is with modern high cohesive, form stable, anatomical textured breast implants.
With subglandular placement, rippling is frequently seen within the cleavage area and is often disturbing to women as it creates a stigmata of a ‘fake’ breast look. This is improved by creating a new subpectoral pocket and changing the implant to a high cohesive, form stable, anatomical textured breast implant.
While less frequent with submuscular placement, rippling can be seen on the lateral aspect of the breast as the cleavage area is protected by the coverage of the pectoralis muscle and so is often less concerning to women. Again the rippling can be improved by changing the implant to a high cohesive, form stable, anatomical textured implant.