The request for breast revision surgery is usually based on dissatisfaction or flaws with breast implants, including:
It should comfort you to know that after viewing the intimidating list above, the number one reason for breast implant revision is a desire for a larger size: not due to other complications.
Deflation: Saline implant deflation or rupture is typically very noticeable, as the saline implants deflate quickly causing your breasts to change in size and shape. The saline is usually harmless, and easily absorbed by your body. Because silicone implants tend to leak more slowly than saline, initial rupture or deflation may go unnoticed. If you are concerned that your silicone implant may have ruptured, contact Dr. Moelleken and will conduct an MRI to detect a leak. If a leak has occurred, he will address the impending deflation as necessary to provide you with the highest level of safety possible.
Breast implant deflation can occur as a result of many reason which include:
Double Bubble or High Riding Implant: When tissue hangs beneath an implant that has been placed submuscular, this is referred to as a double bubble or high riding implant. This usually occurs in an individual who has sagging breasts before their breast augmentation surgery. Double-bubble deformity is associated with superior elevation of the implant in the pocket with the skin over-draping it. This can also be associated with malposition, improper or poor position of the implant, due to a transaxillary approach (through the armpit) where the parasternal and inframammary attachments of the pectoralis major muscle were not adequately detached. This causes a phenomenon where the implant is constantly pushed upward and will never fall into proper position without surgical release of the muscle appropriately. The double-bubble deformity usually requires an open capsulectomy with lowering of the implant as well as a breast lift in order to remove the extra skin around the nipple vertically and along the inframammary fold. In summary, this deformity can occur when an attempt is made to lower the infra-mammary fold with the primary breast augmentation. The look is that the breast is stacked on top of their implant. This may also occur when an implant is placed under the muscle in a patient who probably should have had a breast lift as well. The treatment required depends on the cause and may involve releasing the muscle inside, repairing the capsule repaired inside, or moving the implant from below to above the muscle.
Asymmetry Implants: Although uncommon, there is a chance that breast implants, if they do not have enough support from surrounding muscle, can shift or rotate causing asymmetry implants. Teardrop implants must be textured so that they will less likely shift or rotate and cause very noticeable asymmetry. Round breast implants can be smooth or textured because the shape of the breast will not change even if implant(s) shift or rotate. Whether you desire a larger or smaller implant or an implant has shifted and resulted in an asymmetrical appearance, Dr. Moelleken will address any and all of your goals and help you achieve the results you originally expected. Every woman has some degree of natural asymmetry in their breasts, which can be magnified once the breasts are enlarged by an implant. Cases where there is more asymmetry than usual do not occur often but if they do, there is a solution. In such cases, the implants can be either individually or together displaced from where they should be lying. To correct the abnormal implant position(s), a surgery is required to modify the implant pocket or even reconstruct some of the anatomical structures, which may have been weakened during surgery. If the cause for the uneven implants is firmness in one or both breasts, the treatment involves removing the scar tissue around the affected implants and replacing the implant. As a surgical complication, uneven breasts are rare but have successful outcomes in carefully planned cases.
Ruptured Implants: Decreased breast size, uneven breasts, pain, or swelling are possible indicators for a ruptured implant in either saline or silicone breast implants. Breast implants rupture for various reasons, including trauma to the breast, injury from surgical instruments, normal wear and tear, or simply from wearing out over time. Ruptures can occur at any time after surgery but they are more likely to rupture the longer an implant has been in use. The procedure is similar to a breast augmentation, as ruptured implants require removing and explanting the implant with a replacement implant. If it is an older silicone gel implant, it will be removed, completely exenterated of scar tissue, then a new silicone gel implants will be inserted. The longer you leave a ruptured implant inside your body, the more scar tissue will form resulting in a greater closure of the pocket. This makes it more difficult for Dr. Moelleken to recreate a normal appearance and shape to your breast so it is important that ruptured implants be treated as soon as possible with open capsulectomies and an exchange of the implants. Ruptured implants are usually simply replaced, assuming there are no other problems with the placement or size. This is rather straightforward and similar in time and recovery to exchanging implants for another size.
Bottoming Out: Bottoming out can occur when the inframmary fold loses its adhesion to the chest wall and the implant begins to move past the natural boundaries of the breast. Skin laxity plays a part in this however; attempts by the original surgeon to move or modify the inframmary fold could also be a reason for bottoming out. Bottoming Out simply means that the implant pocket is lowered to a point where the implant is too low and your nipple is too high. Capsulorrhaphies can sometimes be performed suturing the internal capsule but more often, Dr. Moelleken will perform an inframammary lift removing the skin along the inframammary fold, which will also help to tighten and elevate the crease line. Breast implants that have bottomed out can have nipples that appear too high or an inframammary fold that appears unnaturally low.
Infection or Allergy: Infection following breast implant surgery is very uncommon but can happen with wound breakdown, infection elsewhere in your body, or with insect bites on your breast. Rarely, a woman’s body may reject a breast implant, causing an infection as well. In the instance of infection, some antibiotics will resolve a minor infection however if the infection is not minor, your implant may need to be removed until your infection is cleared up and replaced at a later date.
Change in Implant Size: Changing the size of your implants is usually a straightforward procedure. Your previous incision will be reopened and your implants will be switched out for the new ones. A smaller implant may require some tightening of the original pocket to fit conversely while a larger implant will require that the pocket be enlarged.
Rippling or Dimpling of Your Breast Skin: Rippling or dimpling can occur when there is not enough tissue over your implant thus leading to a wavy appearance. This is usually noticeable when a woman leans over and it can occur anywhere on your breast surface. Rippling or dimpling of breast skin usually happens more often with saline implants than silicone and more often with textured implants than smooth. The worst rippling is seen with textured saline implants that are inserted under the breast gland rather than under the muscle. Dr. Moelleken’s focus is determining the cause of the problem. Subglandular rippling is usually seen on the top or sides of the breast and is corrected by placing the implant under the muscle instead of underneath the breast tissue alone. Most patients will opt for new implants and smooth silicone or saline will be chosen. Submuscular rippling due to textured implants is corrected by changing to smooth silicone or saline implants. Submuscular rippling with smooth saline implants is corrected with a change to silicone. The more difficult problem is rippling with a smooth silicone implant. Correction involves reinforcing the thin breast area with either capsule, muscle, or human dermis. Surgical times for simple exchange are quick and recovery is easy, while more difficult problems and switching to a submuscular implant placement can lead to longer operative times and recovery similar to that of your initial breast augmentation.
If you can visualize some ripples on your breast, odds are you do not have much breast tissue over the ripples. In women with adequate breast tissue, your natural breast tissue will cover and camouflage the ripples in the implants making them invisible. To treat visible ripples, implants that are over the muscle should be switched to under the muscle, as the chest muscle (pectoralis) will act as an extra layer covering your implant. If your implants are already under the muscle and you still have visible ripples, surgical options include insertion of Alloderm (human skin) over the area of ripples.
The Ability to Feel the Edges of the Implant: This situation is not uncommon, as most women can feel the edge of their implants where the breast meets the chest wall (the inframmary fold) and on the outer edges near the armpit. This is possible because this is where your skin is the thinnest and sometimes changing to a smooth silicone implant will correct this problem. The more difficult complication is a visible knuckle of implant poking through your skin. If the implant was placed beneath the breast rather than beneath the muscle, relocating the implant beneath the muscle will correct this. If you had the implant placed under your muscle initially and you can feel the implant towards the center of your chest wall, it may be due to excessive muscle release or muscle tearing. Boosting the amount of tissue coverage either through muscle advancement or AlloDerm placement may be necessary
Capsular Contracture: This is a hardening of your breast, which happens when the tissue surrounding your breast implant contracts around the implant. In general, there is slightly less capsular contracture with saline implants than silicone and with submuscular placement than with placement under the breast tissue. Current theories are that contracture happens as a result of a very low level infection. Cultures of capsules are only rarely positive but electron micrographs of the capsules often show signs of bacteria. We have seen capsular contracture from infections elsewhere, such as insect bites and teeth cleaning in which bacteria has leaked into the bloodstream. Other causes are previous hematoma (a pocket of blood) or seroma (a pocket of clear fluid) that increases inflammation.
Capsular contracture is actually graded by severity. The least severe levels, in which the breast is still soft or slightly firm but appears natural, is normally treated with massage, ultrasound, Vitamin E, and some asthma drugs such as Accolate. It may take several months before results are seen. If the breast is firm or hard and is either beginning to appear distorted or is quite distorted in terms of its shape, Dr. Moelleken will remove the entire capsule and reinsert a new implant underneath the muscle. Operative times vary but are usually approximately 90 minutes per side. Recovery is about the same as your initial augmentation. Afterwards, the use of massage, Vitamin E, and Accolate are often used to prevent a recurrence of contracture. Additional complications, such as ruptured implants or shape and position problems, often occur along with capsular contracture. Dr. Moelleken considers aged, hard silicone implants to be ruptured until proven otherwise. Sometimes a breast lift is needed along with the repair if the hard breasts have begun to droop.
Change in position—Implants that are too high, too low, too far inward or too far apart: The cause of positional problems can be due to surgical error, poor healing, or weakening or tearing of the muscle fibers.
Implants too High: If your implants are too high, it may be due to poor pocket design, poor healing causing the implants not to fall into the pocket, or inadequate muscle release. Correction of subglandular, high-riding implants involves removing your implants along with a portion of the capsule and creating a new, submuscular pocket. Alternatively, the subglandular pocket can be lowered if you do not want the implant placed behind the muscle. Correction of submuscular high riding implants involves first figuring out the cause, which could result from inadequate muscle release, poor pocket development. or early capsule formation. Once this is determined, treating the appropriate problem will be accomplished by either releasing muscle, increasing pocket size, or by partial or full capsulectomy. Surgical times vary from one to four hours and recovery is relatively quick for minor corrections and similar to primary augmentation for submuscular conversion or major capsule work.
Implants too Low: If your implants are too low, it is usually due to the surgical error of excessively releasing the inframammary fold (the spot where the breast meets the chest wall). It can happen on one or both sides and with either subglandular or submuscular implants. Correction involves excising a piece of the capsule and performing a layered closure or creating a new subpectoral pocket. Surgical time varies from one to three hours and recovery is usually quick. Postoperative taping and use of an underwire bra is essential for approximately six weeks.
Implants too Lateral: If your implants are too lateral or too much to the sides of your chest wall, this may be a result of surgical error of too much lateral dissection but may occur if there are excessive muscle forces pushing the implant out to the sides. Typical patients complain that they feel like the implants are in their armpits and they hit the sides of their breasts with their arms. This can happen with either subglandular or submuscular implants. Correction involves closing the lateral pocket (capsulorraphy) and taping the sides of your breasts for six weeks. In some cases, it may be necessary to create a completely new pocket under your muscle that is centered more towards the midline. Surgical time varies but is approximately one hour per breast and recovery is relatively quick.
Implants too Medial: If your implants are too medial or pushed too much to the center, this creates too much cleavage and in the extreme case where there is a connection of the pockets holding the implants, this is called synmastia or often referred to as “unaboob.” Synmastia occurs when the pockets that the implants are in communicate with each other across the midline. This is a difficult problem but with proper planning, it can be corrected. This is not a common occurrence but can happen to various levels in women with chest wall concavity as well as with the use of larger wider implants. Repair can be accomplished with internal suturing with or without the use of acellular dermal matrix, which may help to bolster the repair. Causes of this vary from patient anatomy, an implant that is too wide, muscle tearing, or to surgical error. This can happen with either subglandular or submuscular implants. For implants placed under the breast tissue, switching the implant placement to beneath the muscle usually corrects the problem. If the implants were already placed beneath the muscle in the original surgery, repair involves closing the central tissue in layers or creating a completely new pocket under the muscle and closing off the old pocket. Occasionally dermis may be used as a patch if the chest wall or breast skin is extremely thin. For patients who have had multiple breast procedures, Dr. Moelleken will occasionally use a post-operatively-adjustable saline or silicone implant to avoid placing tension on the repair. Surgical and recovery times vary with the degree of difficulty and postoperative taping and a supportive bra are essential.
Unsatisfied with Prior Augmentation Results: In some cases, a woman may not be pleased with the outcome of her breast enhancement and different implants may need to be used. These reasons are cosmetic.
Correction of Aesthetic Issues: Sometimes a breast lift may be required to improve your breast appearance. Dr. Moelleken will help determine which lift is best suited for you. Sometimes, minor pocket adjustments are required to help give the breast a more natural appearance.
Breast Volume and/or Shape Change: Weight fluctuation is natural with or without cosmetic surgery, so chances are breast augmentation patients are likely to experience weight gain or loss at some point post-op. Breast revision surgery may be necessary to maintain overall body proportion depending on the significance of the weight change. Some women struggle to choose a size that they will be happy with. Sometimes breast implants may be larger than desired, and other times they may not have been a big enough change. In either case, implants can be exchanged. Surgical correction starts with a thorough evaluation and careful planning. Your surgery may involve changing implants, altering the capsules, changing the position of the implant and tightening the breast tissues in the form of a breast lift.
A Desire to Have Larger Breasts: The goal with your primary breast implant surgery is to choose an implant that both compliment your body frame and tissue characteristics. If you choose to have a breast implant revision to change to larger implants, it is very helpful to have the information about your current implants so that an intelligent decision can be made about the change you would like to make. This surgery as well can be relatively simple or require more tissue release to make room for the larger implants. It is important to realize that the larger the implants you have, the more stress there is that is exerted on your tissues.
A Desire to Have Smaller Implants: Just as with changing to a larger implant size, some patients choose to decrease their implant size after their initial surgery. Questioning the patient’s desired outcome, a careful analysis of the dimensions of the breast and chest, tissue characteristics, and realistic expectations, should base the choice of a breast implant. If you choose to decrease the size of your implants, it may not be as simple as placing a new implant. The capsule that surrounds your implant may need to be tightened with internal suturing (capsulorrhaphy) and the skin may need to be tightened or lifted.
Implant Malposition: The capsule that surrounds the implant ideally allows enough room for a soft and natural feeling breast but if it is too large, it will allow the implant to move farther than is desired leading to implant malposition. Treatment revolves around properly diagnosing the problem and repairing it with either internal sutures alone or other external techniques such as a breast lift. There are also newer described techniques that allow use of the existing capsule in a very creative way to support the new implant position. Dr. Moelleken will determine which method is best for your situation.
Breast Implant Exchange: There are two types of breast implants: saline and silicone. Saline breast implants are made of a soft silicone shell that is inflated with the desired amount of sterile liquid saline solution. Conversely, silicone breast implants are made of a similar silicone shell manufactured with specific amounts of silicone gel inside and inserted (already full) during breast augmentation. Given the various viscosities of the implants’ filling, sometimes breast enhancement patients request a breast implant exchange; switching their saline implants for silicone or changing their silicone implants for saline to meet their personal cosmetic concerns.
Implant Coverage Problems: If the breast tissue covering your implant is too thin, you may see rippling of the implant through your skin. In the upper breast, these are referred to as traction ripples and are classically seen in implants placed above the muscle. Treatment is focused on trying to provide a thicker coverage and moving above muscle implants to partially below the muscle. This is known as a site change and it will successfully treat the condition. Dr. Moelleken will be able to review your options after examining you and reviewing your surgical history.
Correction of Implant Pocket: Many patients seek Dr. Moelleken’s expertise to adjust their breast pocket. If your implants are too low or fall to your side, especially when lying down, Dr Moelleken can place internal stitches to adjust the breast pocket. Some women report pain when their breast implants stretch the skin. With his technique, he can close off the lateral or outside pocket to help position the implants closer together for better cleavage. These supporting stitches may improve the pain from breast implant poor positioning. Sometimes, if the implant folds are different, he can adjust the folds by lowering or raising the fold. With internal stitches and sometimes an external device, the implants can be corrected to look more natural.
Droopy Breasts: The most common cause for droopy breasts after a breast implant surgery is not wearing a supportive bra. Gravity exerts a regular downward force on all structures in our body and your breasts are the most affected if you calculate the exact volume of tissue that actually droops down. To counteract the force of gravity, a supportive bra is extremely important, even if you do not have breast implants. A supportive bra does not have to be thick or padded, nor does it have to have an under-wire. To support your breasts, an effective bra only has to lift your breasts upward and keep them supported throughout the day.
Once your breasts become droopy with implants, a breast lift is necessary. You can choose to stay the same size or take this surgical opportunity to change your breasts to your ideal size during your breast lift. Be prepared for more scarring as breast lifts involve three types of scars. The mildest surgery to lift your breast will leave a circumferential scar around your areolas (dark skin around your nipples). A vertical or minimal scar breast lift will have a scar around your areola and another from the areola to under your breast like a lollipop. The most traditional breast lift, which is still being performed regularly by all surgeons, is a standard breast lift leading to an anchor scar.
Soft versus Firm: Firm breasts are the most common complication after breast implant surgery. After the implants are placed inside your breast, the body forms a film or capsule around your breasts. This is your body’s way of protecting you from a foreign material. As time goes on, your body may tighten the capsule around the implants for unknown causes. Some physicians believe it is due to the leaking of your implants while others believe the tightening may be caused by a mild infection. If caught early, there are medications that can be prescribed to reverse the tightening. Once your implants are uncomfortably firm however, it is too late for conservative management and a surgical revision is necessary.
During the revision, Dr. Molleken will remove the tight capsule and your breast implant will be replaced. Close follow-up is tremendously important after a breast implant surgery to be sure this problem is prevented before it begins and at Neo Surgery Center, we will follow your care at close intervals after your surgery.