Breast Revision

BREAST REVISION SURGERY in NEWPORT BEACH


WHO IS A CANDIDATE?

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:

  • Patient Dissatisfaction with breast size, shape, spacing or symmetry.
  • Capsular contracture.
  • Rupture, leak, or deflation of implant.
  • Implant drop out, or loss of inframammary fold.
  • Excessive thinning of breast tissue.
  • Visible or palpable rippling or wrinkling.
  • Excessive space between breasts
  • Incomplete muscle release
  • Lower breast stretch or “bottoming out.”

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.

BREAST PROBLEMS REQUIRING REVISION

BOTTOMING OUT

This is the term given to implant displacement, where the implant drops down below the existing inframammary fold (natural crease beneath your breast). 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 restoring the crease beneath your breast to its normal position. This involves internal reconstruction including the capsule around your implant (capsulorrhaphy). Sometimes a biologic fabric (Acellular Dermal Matrix) 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 soft tissue inelasticity and/or the size or shape 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 as part of a mastopexy (breast lift/reshaping).
It may be necessary to use ADM to further support the breast tissue if too thin.


CAPSULAR CONTRACTURE

This is a condition where the capsule around the implant thickens and squeezes the implant making it hard and often changing the shape and position of the implant. It is more common in nicotine users (e.g. smoking or nicotine patches or gum). 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 (ADM) may be required to prevent continued problems. Although the published risk of capsular contracture is approximately 9-11%, in our practice it is somewhat lower after initial implant placement. Once capsular contracture occurs, the risk of problems with secondary surgery rises to between 25% and 40%. The use of Singulair and Vitamin E may be of benefit. If you had a Sientra Textured Implant placed as a primary procedure and a contracture occurs in the first two years after primary augmentation, then their implant warranty may apply.


DEFLATED OR RUPTURED IMPLANT

Deflated or Ruptured Implant: For silicone implants prior to 2006, ruptures occur at rates of approximately 1-2% per year for the first ten years then markedly increases after that time period. A rupture or deflation of the implant may be experienced at any point after the initial augmentation; this complication may be increased by an under-filling or overfilling of saline solution into the implant, excessive compression, trauma, and other causes. (If the implant shell if not filled with the correct amount of saline, there may be a crease or fold in the shell which often leads to a rupture). The patient will be able to self-diagnose the need for an implant exchange (if using a saline implant) because if the current implant ruptures, the breast will shrink to approximately its preoperative size. A silicone implant that has a rupture is usually noted on a routine mammogram or MRI scan. In either case although the situation needs to be corrected on a timely basis, it is not dangerous to your health from our current knowledge base. Silicone implants after 2006 are more cohesive and less likely to leak.


RIPPLING, WRINKLING, AND PALPABLE IMPLANTS

Implant 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; less commonly in the superior or top position. This occurs more frequently with saline implants and with saline implants.

In most cases 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 allowing the muscle to minimize their problem. Patients with extremely thin tissues may require Acellular Dermal Matrix or other biologic fabric. Patients with textured implants may require changing to silicone implants.

Palpable implants are implants that can be felt by the patient. It is common to feel the under edge of the implant and on the side where the breast tissue and skin is the thinnest outside the pectoralis muscle location. On occasion, a small “knuckle” or portion of the implant can be felt. This may happen with weight loss, pregnancy, traumatic injury, and at times there is no specific identifiable cause. Adjustment of the pocket size, changing the implant, and adding support with Acellular Dermis or other tissue substitutes can help with this.


DISPLACEMENT OF IMPLANTS

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 becomes 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) or other soft tissue substitutes would be used to further support this correction.


SYNMASTIA/SYMMASTIA

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 displacement noted above, but in this case the pocket(s) is/are too far towards the center.

Correction of this problem may involve using different implants such as textured, a smaller size, or a smaller base and placing the implants in a new pocket. 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 a dermal substitute may be required for additional support if the tissues are thin. The techniques of capsulorrhaphy and neopectoral pockets may apply here as well.


Breast Revision Before and Afters

INTENDED RESULTS

  • The over-all intention is the correction of the breast problems noted above which the patient is experiencing.
  • The goal is to provide breasts that look and feel natural to the best of the doctor’s ability.
  • The outcome will be limited by the existing anatomy, deformity, previous surgeries, underlying personal and family medical conditions, size of implant, nicotine use, and other factors.

PROCEDURE DESCRIPTION

The procedure is an outpatient operation performed under oral sedation, IV sedation, or general anesthesia depending upon the length and complexity of surgery

A list of potential procedures used for breast revision surgery follows below:

Capsulectomy/Capsulotomy

  • One of the most common problems is breast capsule contracture or the development of thickening, and contracture of the capsule that exists around the breast implants. Severe capsule 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 become calcified and thickened. As it thickens and shrinks, the patient may develop a feeling of firmness of the breasts and in its worst situation, the breast may become painful and abnormal in appearance, achieving a very round, hard, and uneven appearance. There may be distortion and possible breakage and leakage of an older implant, but may also include a newer implant. Nicotine users, such as smokers, have up to a 30x increased risk of capsular contracture.
  • Saline implants may deflate spontaneously. When the patient has significant symptoms, complete or partial 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 to ensure adequate pocket dimensions.

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.

NEOPECTORAL POCKET

This is sometimes used as a technique to provide a stronger more secure placement. In this case, the implant is removed and the capsule is dissected from the muscle, creating a new or “neo” pocket for the implant.

EXPLANTATION OF IMPLANTS

  • Explantation is the term that has been given to describe the removal of the breast implant.

What does explantation involve? Two choices exist for explantation:

1. Implant removal while leaving the capsule. This is a simple procedure and requires local
anesthesia, IV sedation, or (uncommonly) general anesthesia. It is relatively inexpensive. Microscopic amounts of gel may remain in the capsule.

2. Capsulectomy: This will enable the surgeon to remove as much silicone as reasonable without creating significant deformity. This operation may require a larger incision. The surgery and recovery time will be longer. General anesthesia is usually necessary and subsequently all of the costs associated with this operation will be higher.

  • Do silicone gel implants need to be removed? Currently, the medical research regarding “silicone-related disease” is not clear. Several recent studies and the FDA have concluded no increased risk in autoimmune or collagen vascular diseases. Silicone-antibody tests currently being utilized have not been proven to be specific or accurate. Direct cause and effect between a number of reported diseases in silicone gel have not been proven. On the other hand, there are ongoing research studies that may provide more conclusive information in the future. The Food and Drug Administration advises women who are not experiencing problems, need not have their implants removed.
  • The patient must weigh the risks of anesthesia, surgery and finances involved against current or potential problems that the implants may cause. Periodic check-ups are advised, and if an implant is found to be ruptured, it should be removed.

Leak and rupture and two terms that refer to loss of integrity of the implants shell. A small puncture in a silicone implant may result in the leak of varying amounts of silicone gel. This gel usually remains within the breast capsule. With a traumatic rupture or tear of the implant, the breast scar/capsule is sometimes torn resulting in “extra capsular” leak of silicone gel. This can be seen as distortion of the breast, sudden softness of a previously firm breast, or nodules close to the breast, chest or abdominal wall. These nodules are “granulomas”; the body has a natural response by forming scar tissue around the gel droplets in the same way it would make a scar around a splinter in a finger.

What about silicone that has spread beyond the capsule?
Silicone nodules in the breast should be removed as best as possible and biopsied if needed to confirm the lump to be silicone and not cancer. If silicone has spread in large amounts into the breast, chest muscles, arm pit, lymph nodes, or other sites, the patient and surgeon must decide on how “aggressive” the operation should be as there will likely be greater deformity and potential complications. The risks of trying to remove all silicone are generally worse than the benefit; so some silicone will remain. If silicone is in your lymph nodes then follow up with a general surgeon may be required.

What are the options regarding implant replacement?
The first possibility is simple replacement of the existing implant. If the implants are ruptured or more than 10 years old, consideration should be given to replacement. New implants are made from a highly cohesive gel. These “gummy bear” implants have less problems and retain their shape even when the outer shell breaks.

What is the best position for implant placement?
There are some studies that report a lesser incidence of firm capsules with placement behind the pectoralis muscle. If you developed firm capsules and your implants were submammary (behind the breast tissue) then conversion to a submuscular position should be considered. This placement is particularly better for the very thin patient who has little breast or fat in the upper part of their chest. In most circumstances, those patients with ptosis (sagging) require placement above the muscle in a submammary position or under the muscle combined with a mastopexy (breast lift) for contour purposes.

What if you choose to leave the implant out?
This is a consideration for women who have had repeated encapsulation of their implants, silicone related concerns, other chronic and recurrent problems related to their implants. The shape and size of the breast will be unpredictable after explantation. The breast will be smaller and possibly sag more. Patients who already have ptosis (drooping) should think about mastopexy at the time of explantation.

NATURAL Breast Augmentation can be performed with fat grafting. This requires liposuction to obtain the fat, and then the fat is transferred into the breast tissue. It is usually possible to achieve at least one half cup size increase. Additional fat transfer procedures to increase your volume can be done subsequently.

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.

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

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. In addition to ADM products, there are other newer tissue substitutes(e.g. SERI) which are used for similar purposes. The doctor will discuss which is the best product for your needs.

POST-OPERATIVE HEALING

Patients will feel sore and tired during the first 48 to 72 hours following surgery. During these first few days, the patient should engage in light activities, refraining from lifting or raising the arms above the head.

Swelling and bruising will subside during the first week after surgery and will be controlled by pain medication. The initial surgical tapes will be removed a few weeks after surgery during a post-operative visit. Patients typically may return to a work a few days after surgery (only a light workload during the first two weeks). Showers are permitted on post op day #3 if there are no drains.

Scars will progressively fade throughout the first year following surgery.

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