Nearly 350,000 women underwent breast enhancement during 2008, and a significant number of these women will require revision in the future. The popular media often times portrays breast augmentation as a simple, straightforward procedure, but it is actually a complex procedure and requires a high degree of expertise to provide patients with consistently excellent and reliable results. Proper execution requires meticulous preoperative planning, proper surgical technique, and closely monitored postoperative care. Even with all factors optimized, revisions in breast augmentation and augmentation with mastopexy are not uncommon.
Revisional surgery is always more technically complex than primary surgery. Altered anatomy, scar tissue, ruptured implants, and thinning of tissue make breast augmentation revision more complicated with less predicable results.
During your initial consultation, Dr. Zemmel will discuss your goals and desires. Dr. Zemmel will perform a complete medical and surgical history and physical examination focusing on your prior breast implant procedure. If you have any information regarding your prior procedure please bring this to your consultation. Your prior surgeon’s notes, operative reports, previous mammograms, and implant cards will greatly assist Dr. Zemmel in planning your revision. Dr. Zemmel will then examine the position of your implants, the presence of capsular contracture, the thickness and quality of your overlying breast tissue, muscle, and skin, and the overall shape of your chest and torso. Dr. Zemmel will then recommend a treatment plan. You will have a full understanding as to the reason revision is required, all aspects of the treatment plan, and recovery.
Through proper preoperative planning and meticulous surgical technique, Dr. Zemmel has minimized revisions in his practice while striving to achieve the highest level of patient safety and satisfaction. Dr. Zemmel believes that by focusing on the prevention of these problems, many revisions can be avoided. Patients must be aware that breast implants are not lifetime devices and have a lifespan similar to artificial joints and prosthetic heart valves. Some patients will require reoperation despite optimal treatment.
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Patients must be aware that breast implants are not lifetime devices and have a lifespan…. Some patients will require reoperation despite optimal treatment.
The most common reasons for surgical revision of breast implants are:
1. Changing the size of the implant
2. Improving the shape and appearance of the breasts
3. Improving the texture of the breasts
4. Correcting capsular contracture
5. Replacing ruptured implants
The reasons for revisional breast augmentation can be grouped in 3 broad areas:
1. Implant related problems
2. Implant position problems
3. Problems related to the patient’s soft tissue
Implant related problems:
1. Implant Rupture or deflation: this can occur with either saline or silicone implants. Saline implants have a rupture rate of approximately 1.8% per year, while silicone implants have a rupture rate of 1% at 6 years. When a saline rupture occurs, the implant typical deflates over a 24 to 48 hour period. Some women may experience a slower deflation of the implant if the fill valve is faulty rather than rupture of the shell. The saline solution is harmlessly absorbed and excreted. When rupture occurs replacement is necessary in a timely fashion to prevent collapse of the implant pocket. This will ensure an excellent cosmetic result with minimal recovery. Both Allergan and Mentor warranty their implants against rupture. Silicone implants may require an imaging study such as an MRI to further examine the integrity of the implant shell. If rupture is detected for a silicone implant replacement will also be recommended. Dr. Zemmel will discuss the warranty options at length during your consultation.
2. Capsular contracture: all prosthetic implants (artificial joints, screws, plates, etc…) form an interface with your natural tissues. This is your body’s way of separating the implant from your natural body tissues. Usually a thin layer of tissue surrounds the implants and allows your body to “accept” the prosthetic. In rare cases, patients may develop a thick layer of tissue around a breast implant call a capsular contracture. In severe cases this can distort the shape of the breast and become painful and harden. Severe cases (Baker grade III and IV) may require surgery to remove the scar tissue and reopen the breast implant pocket.
3. Dissatisfaction with implant size: patients may desire reaugmentation with a smaller or larger implants.
You will have a full understanding as to the reason revision is required, all aspects of the treatment plan, and recovery.
Implant Positional Problems
1. High implants: Implants that remain high in the initial months after surgery. These implants typically have not “dropped.” This is usually caused by incomplete muscle release and may require revision.
2. Symmastia (uniboob or breadloafing): the breast appears continuous across the chest with no definite cleavage between the breasts. This is usually caused by medial release of the pectoralis major muscle in an attempt to improve cleavage. However this creates one continuous pocket between the right and left breasts.
3. Lateral implants: implants that are wide apart may be caused by over dissection of the lateral (outside) aspect of the pocket. In worst-case scenarios this can cause the implants to sublux into the armpit area when lying.
4. Low implants (bottoming out): Implants that are appear low on the chest wall with abnormally high positioning of the nipple aerola on the breast are usually caused by over dissection of the inferior crease of the breast called the inframammary fold. This fold located at the bottom of the breast is a thick ligamentous structure that supports the breast and “locks” it in place on the chest wall. Dividing these ligaments can cause the implants to sublux in a downward direction.
Problems related to the patient’s soft tissue
1. Snoopy deformity: named after Snoopy’s profile, this scenario is caused by breast tissue dropping below the bottom hemisphere of the implant. It can give the appearance of an implant that is high and a nipple that is low, causing it to appear hanging off of the breast. This is typically caused by natural aging with additional sagging of the breast in a patient receiving a breast augmentation who also needed a concurrent breast lift.
2. Areola Enlargement: some patients experience enlargement of the diameter of the areola after breast augmentation. This is due to stretching of the breast skin and areola skin during implant healing. This situation is usually mild and does not require revision. The possibility of areola enlargement should be discussed prior to surgery.
3. Tuberous breasts: this breast shape is characterized by a deficiency of skin and breast tissue in the lower pole of the breast. The fold beneath the breast is higher and more narrow than normal. It gives a “constricted” shape to the breast. Herniation of breast tissue through the nipple areola is also seen. Correction of tuberous breast deformity requires additional surgical techniques done concurrently with breast augmentation. Dr. Zemmel will discuss this in depth during your consultation.
4. Atrophy of breast tissue: severe thinning of breast tissue results from placement of very large implants, normal aging, sun exposure, smoking, pregnancy and breast feeding. This can result in visibility of the implant, movement of the implant pocket, and distortion of breast shape.
5. Asymmetry: A proper physical examination of the breasts before surgery may reveal significant asymmetries. Asymmetries arising from small volume differences between breasts or position of the inframammary folds may be correctable. However, some asymmetries may not be corrected. Those that arise from differences in the boney structure of the rib cage or scoliosis of the spine typically cannot be corrected. Some asymmetries between the breasts are natural and expected.
1. Double Bubble deformity: this is caused by a round appearing implant beneath round appearing breast tissue. There is a visible step-off between the implant and breast tissue giving the appearance two distinct breast mounds. This may be a problem with selection of the proper implant pocket, capsular contracture, of the need for a breast lift.
2. Rippling: rippling is when folding irregularities of the breast implant are visible beneath the skin and breast tissue. Rippling may occur when a saline implant is under filled or leaking, when textured implants are used, or when the patients skin and breast tissue are extremely thin. Rippling is often most visible in the outer lower quadrant of the breast where the soft tissue is thinnest. Rippling often is exacerbated by subglandular implant placement.
3. Implant visibility: some implants maybe visible despite optimal placement. Implants may be visible with or without rippling. Subglandular placement of implants may allow the implants to be visible around the upper portion of the breast giving a “coconut shell appearance.” Other patients with thin soft tissue covering the implant may experience some implant visibility.
4. Implant palpability: Patients with thin soft tissue covering the breasts implant may be able to feel the implant. This is again a function of the thickness of soft tissue covering the implant and should be discussed during a pre-operative visit.
Dr. Zemmel believes that by focusing on the prevention of these problems, many revisions can be avoided.
Correction of Breast Augmentation Problems
1. Mastopexy (breast lift): depending on the amount of lifting required, several different incisional approaches can be used. For patients requiring a small amount of lifting and tightening of the breast a Benelli lift (circumareolar lift, donut lift) can be offered. If the nipple areola requires additional lifting and and the breast needs tightening in a horizontal direction, a vertical lift (lollipop incision) may be necessary. If the nipple needs to be lifted most of the vertical distance of the breast and maximal tightening is required a full breast lift with a periareolar, vertical, and inframammary incision (anchor or upside down “T” incision) may be needed.
2. Capsulectomy: complete removal is the capsule surrounding the implant may be necessary to relieve a capsular contracture. A pocket reassignment (pocket change) may also be necessary to relocate the implant to fresh, unoperated tissue. Placement of acellular dermal matrix (alloderm) within the pocket can also help prevent reoccurrence of capsular contracture.
3. Capsulotomy: refers to making incision around the boarders of the pockets to open and enlarge the pocket. Occasionally the inner front surface of the breast capsule can be incised in order to loosen the tissue and allow it to “accordion” open. The maneuver is typically done in conjunction with Capsulotomy. Capsulotomy is also done when exchanging a smaller implant for a larger one in order to make the pocket larger for the new implant, and to reposition an implant.
4. Implant Exchange: Refers to replacing your existing implants for a different size, silicone or saline, or changing the profile. Other maneuvers may be necessary when changing implants such as capsulotomy, capsulorraphy, and capsulectomy. Implants are also exchanged in the event of a saline or silicone breast implants rupture.
5. Areolar reduction: refers to reducing the size of the areola by making a circumferential incision around the boarder of the aerola and taking out skin. A “purse string” suture is then placed around the areola and tightened to reduce the diameter. This is done in conjunction with a circumareolar (donut, or Benelli) mastopexy (breast lift).
6. Pocket Change: A pocket change operation refers the relocation of an implant to either the submuscular position when originally subglandular or vise versa. Pocket change procedures are typically offered in the event of a severe capsular contracture, to improve the appearance of an subglandular implant, or to place additional soft tissue over the implant.
7. Capsulorraphy: refers to alerting the diameter of the pocket to move the location of the pocket or to adjust the height or width. This is typically done by removing a crescent shaped section of capsule and suturing the remaining edges closed. This can be accomplished through the original breast augmentation incision. This procedure is typically done for lateral subluxation, bottoming out, or symmastia.
8. Symmastia repair: refers to the group of procedures used to repair a symmastia. This is accomplished with suturing the skin overlying the sternum back down to the sternum and the closing off the medial pockets to create two discreet pockets.
9. “Snoopy” deformity correction: usually requires a breast lift (mastopexy) procedure to lift the hanging breast tissue directly over the implant. This can be done using a circumareolar, vertical (lollipop), or full mastopexy (anchor) incision
10. Tuberous breast deformity: this repair consists of the steps. Breast augmentation, releasing of breast tissue and circumareolar mastopexy.
Dr. Zemmel hopes this information will be useful in guiding you during your decision making process. Please schedule a consultation with our office for further information on your unique body needs.
Directions to Our Office
Dr. Zemmel is proud to provide his plastic surgery services to patients traveling from nearby cities. For your convenience, we have provided driving directions to our practice from the following locations: