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Breast Implant Revision Surgery ~ Breast Augmentation Redos

Breast Implant Revision Surgery

Almost 250,000 women underwent breast augmentation during 2002, and a significant number of these women will, at some point in the future, require another operation related to her breast implants. Breast augmentation is a procedure that is often assumed to be simple in nature and execution but is actually quite complex. Proper surgical technique and attention to detail are essential to good results, and too often these are overlooked.

As a similar example, twenty years ago rhinoplasty was treated the same way, and the usual result was that every nose done by the same plastic surgeon turned out to look exactly the same, regardless of the patient's facial proportions, preferences, ethnic background, etc. Over the past twenty years an evolution in our thought processes has resulted in the realization that rhinoplasty is a multidimensional, complex surgery that must be individualized for each patient. Breast augmentation is long overdue for such an evolution (revolution) as well. For instance, the notion that the surgeon knows best in the selection of the implant size for his or her patients is ridiculously outdated. We should never presume to know what is best for our patients in this regard. Our responsibility is to present the facts to our patients and guide them in making their own decision that is in their best interests. Similarly, no one incision is right for every patient, and one location for implant placement (be it above the muscle, subpectoral, or totally submuscular) does not satisfy every patient's needs.

The three most common reasons for breast implant revisions- changing implant size, improving the natural feel and appearance of the breasts, and correcting capsular contracture- should be minimized by a careful and thorough approach to breast augmentation. Dr. Revis has developed a systematic approach that has minimized these revisions in his own practice while improving patient outcomes and satisfaction ratings. He feels that the real focus should be in prevention of these problems rather than in their treatment. However, breast implants are like any other man-made implantable medical device (such as heart valves and artificial joints), and realistically some patients will require revisionary procedures. Plastic surgeons must be aware of the potential problems that may exist and be equipped to properly diagnose and treat patients so that an acceptable outcome is achieved.

The role of the plastic surgeon in approaching breast augmentation revisions should be to properly evaluate the problem and to recommend one or more ways in which the problem can be corrected. Breast augmentation revision surgery is certainly more complex than primary (initial) augmentation, and you should realize that the proper time for the correct operation to be performed is the first time.

The cornerstone of your plastic surgeon’s approach should be to individualize your treatment to your specific circumstances and goals and to ensure that you have an adequate understanding of the issues involved so that you are able to make a fully informed decision. This will help you achieve the appearance you desire with the least invasive procedure available, thus creating a mutually rewarding experience.

Surgeon Selection
As you consider plastic surgery, one of the most important decisions you will make is choosing your surgeon. Patients should seek a plastic surgeon who provides the latest, state of the art cosmetic plastic surgery in a safe and professional environment. Your surgeon should be board certified by the American Board of Plastic Surgery, the only plastic surgery board recognized by the American Board of Medical Specialties, and a member of The American Society of Plastic Surgeons, the national governing body representing almost 98% of all board certified plastic surgeons in this country. For more on researching a surgeon click here. To locate a breast surgeon in your area click here.

Should you entrust your revision to your original plastic surgeon? As you will read, many revisions are not related to a technical problem with the technique employed by your original plastic surgeon. If you maintain a good relationship and confidence in your original plastic surgeon’s abilities, then by all means he or she is a good starting point to discuss possible solutions for your situation. However, breast augmentation revisions are typically much more complex than the original operation, and you should seek several opinions and entrust your safety and your appearance only in the surgeon in whom you have the most confidence to achieve your desired results.

The need for breast augmentation revisions stem from a number of sources but fall into several broad categories:

When a problem does arise, the proper correction focuses first and foremost on carefully diagnosing why the problem exists. Many patients have a problem that falls into more than one of the above categories, creating an even more challenging situation. Within the three broad categories mentioned above, specific problems include:

Problems With Surgical Placement or Implant Position:

Problems With The Patient's Tissue Characteristics:

Problems With The Implants Themselves

Combination Problems

Solutions To Breast Augmentation Problems

Depending on your specific problem, a specific solution exists. These may include:

The "Internal Bra"

In recent years, there has been a dramatic increase in the number of patients presenting with bottoming out of one or both implants. This means that the pocket, or capsule, surrounding the implant has enlarged or stretched under the effects of gravity and have become too low on the chest wall or rests too far laterally when lying down. This may cause the appearance to be unattractive and even uncomfortable when wearing no bra. The implants may hang too low, preventing you from being comfortable when braless. You may also experience the implants falling far apart and even into the armpits when lying down.

The “internal bra” technique has the effect of creating an internal bra using strong, permanent suture techniques. Using special lighted retractors, the implant pockets are expanded (capsulotomy) superiorly and medially, creating room for the implants to be repositioned at a higher level and closer together- creating better cleavage, a more youthful shape, and improved fullness in the upper pole of the breast. After expanding the pockets in these directions, the part of the capsule that rests laterally and inferiorly (partial capsulectomy) is permanently removed and sutured closed, thus preventing the implants from resting too low or falling too laterally to the sides. Permanent sutures are used for a long-lasting result. These sutures are carefully placed so that the suture material is never in direct contact with the implants inside the body.

Decisions regarding your revision

Breast implants come in many different types, and they may be placed through different incisions and in different locations. Once you have decided to undergo a revision of your augmentation, there are three main choices you must make- incision location (whether or not your prior incisions will allow the proper procedure to be performed or if you may need additional incisions), whether or not your implants will be replaced and if so then the new implant type and size, and whether or not the implant pockets will remain the same or be changed. This can be quite confusing, and the following information is to help you understand the various issues involved in making your decision.

Types of Implants- Silicone Gel vs. Saline Filled Implants
There are two basic types of implants, silicone gel and saline filled. ALL implants consist of a silicone shell. Silicone gel implants are filled with liquid silicone. The FDA has restricted the use of silicone gel implants to only a select group of plastic surgeons and only certain of their patients. If you are interested in having silicone gel implants, be sure to ask your plastic surgeon if you might be eligible to participate in one of the FDA-approved protocols. To date, there have been numerous studies in the medical literature demonstrating no link between silicone gel implants and any type of disease.

Saline filled implants consist of an outer shell of silicone that is filled with saline, or salt water. Most breast implants used for breast augmentation are of this type. In addition, there is a new type of saline implant called a "high profile" saline implant. It is designed to give better breast projection and volume, because more of its volume is used in establishing projection rather than increasing the width of the implant.

New High Profile Saline Implants

We now have a new implant type to offer our patients, a new saline filled breast implant called a high profile implant. The high profile implant provides yet another option for those women considering breast augmentation to enhance their appearance. These new implants allow a higher volume to be achieved with a smaller diameter implant. Depending on the shape of your chest, you may be a candidate for these new implants and may achieve an improved shape and more natural appearance.

Types of Implants- Smooth vs. Textured Surfaces

Breast implants may have a smooth surface or may have a rough, textured surface. The textured implants were produced in the hopes that they would decrease the incidence of forming a scar around the implant, also known as a capsular contracture. This does appear to be effective, but only when the implant is placed beneath the breast but above the muscle of the chest wall (see Implant Placement Options, below). Textured implants have never been shown to provide any advantage over smooth implants when placed beneath the muscle of the chest wall.

Textured implants also have their own disadvantages. Textured implants are manufactured by taking a smooth implant shell and applying the texturing to the outer surface. This texturing process makes the shell slightly thicker and more stiff, which translates into an implant that is more visible through the skin and is more easily felt when the breast is touched.

Because of these disadvantages and because most implants are placed beneath the muscle, the great majority of breast implants used today are of the smooth variety. Dr. Revis believes that the smooth surfaced implants provide a much more natural look and feel when compared to textured implants.

Types of Implants- Round vs. Anatomical Shaped

Most breast implants used today are round. There are also implants which are teardrop shaped, called anatomical implants. These are in an attempt to better simulate the shape of the natural breast. In certain cases these may be recommended, but ALL anatomical implants are textured, with the accompanying disadvantages of textured implants. Please ask your plastic surgeon if you think you might be a candidate for anatomical implants.

Incision Placement

The incision for breast augmentation may be placed underneath the breast, around the areola (the pigmented skin surrounding the nipple), in the armpit, or in the belly button (TUBA approach). Your plastic surgeon will discuss which might be the best for your specific situation at the time of your consultation.

Nationally, most patients choose an incision around the nipple or in the crease underneath the breast for their initial operation. When performed properly should in no way prevent breastfeeding or alter nipple sensitivity.

Revisions typically cannot be performed through an axillary incision or through a TUBA incision unless only a very simple procedure will be performed such as changing the size of the implants or replacing a deflated implant. Most revisions require a periareolar incision for adequate visualization to provide the most long-lasting results.

Implant Placement- Subglandular vs. Submuscular

Breast implants may be placed beneath the tissue of the breast (subglandular), or may be placed even deeper, beneath the muscle of the chest wall (totally submuscular). There is also a subpectoral (or partially submuscular) placement that some surgeons use. The decision is a very individual one, and it is determined by the natural shape of your breasts and chest wall muscles.

Whenever possible, Dr. Revis prefers to place the implants in a totally submuscular position. Dr. Revis believes that the advantages of placing the implants completely beneath the muscle of the chest wall greatly improves the long-term appearance of your breasts following augmentation. This is for three main reasons. First, mammography is easier and the quality is better when the breast implant is separated from the breast tissue by the additional layer of muscle. Secondly, there is a lower incidence of capsular contracture when the implants are placed totally beneath the muscle. Capsular contracture occurs when the body produces scar tissue around the implant. This may change the shape of the implant and make the breasts asymmetric. Finally, placing the implants beneath the muscle of the chest wall makes your augmentation appear more natural because there is more of your own tissue covering the implant, making it less likely that you will be able to see or feel the implant.

Dr. Revis believes that an entirely submuscular placement will improve your long-term results and minimize your potential complications.

Choosing The Proper Implant Size

This is one of the most important decisions you will make. Because of this, your plastic surgeon should take several approaches to help you make the best decision based on your anatomy, personal preferences, and the appearance you wish to achieve. Interestingly, in a recent national survey, over 80% of patients undergoing breast augmentation stated that a “C” cup was their desired postoperative goal. A “D” cup was the second most popular request.

Your plastic surgeon should measure your natural breast and chest shape. This provides an idea of what size implant will help you achieve the size you want postoperatively. As implant size increases, so does the diameter of the implant. There is an implant that will perfectly match the diameter of your natural breast. Choosing an implant smaller than your natural breast shape will not provide the proper cleavage and shape following the procedure. Similarly, choosing an implant too large for your natural chest shape is more likely to give you an unnatural appearance.

Unfortunately, implants do not come in cup sizes. Rather, they are categorized by the volume of saline (salt water) that they are designed to hold. There are several reasons for this. First, your final cup size will be partially determined by your preoperative breast size, and everyone is different in this regard. Secondly, a "C" cup from one bra manufacturer is not necessarily the same as a "C" cup from another manufacturer. Although everyone is built differently and bras are not manufactured to a set standard, you can expect that a cup size is approximately 200cc in a person of average height and average build. If you are tall or have broad shoulders, you can expect that number to be slightly higher. Similarly, if you are shorter or have a more narrow chest, you can expect that number to be slightly lower. Although a desire for a certain cup size is helpful to your plastic surgeon in guiding you in the selection of the proper implants, it is more helpful to focus on the shape and appearance that you wish to achieve.

Using these three approaches, you will be able to accurately select the implant that will give you the appearance you desire. When asked about size postoperatively, over ninety percent of our patients feel they chose the right size implant to achieve the appearance they envisioned. The remaining few state that they might have gone larger if they were to choose again. We almost never hear that a patient wishes they had chosen a smaller implant. Therefore, if you are debating between two sizes, it is probably a better decision to opt for the larger size.

Hopefully the above information has helped to clarify some of the issues surrounding breast augmentation. The following information will help prepare you for your procedure.

Type(s) of Anesthesia

Anesthesia is an essential part of any surgical procedure and must be performed safely. General anesthesia is the deepest form of anesthesia. You are asleep, feel no pain, and will not remember the procedure. This form of anesthesia is usually not required for breast augmentation unless the patient specifically requests general anesthesia.

Intravenous sedation, called “twilight sleep,” is a combination of local anesthetic administered at the surgical site by your plastic surgeon and intravenous sedation administered by your anesthesiologist. You breathe for yourself, but you are in a deep sleep throughout the procedure. You should feel no pain, and you will not remember the procedure.

An intermediate form of anesthesia, the laryngeal mask airway (LMA), is a relatively new technique. This technique is similar to twilight sleep in that you are breathing on your own, but the method of sedation differs. With an LMA, you actually breathe anesthetic gases administered by the anesthesiologist, rather than receive intravenous sedation via your intravenous line. These anesthetic gases cause you to sleep during the procedure. At the completion of the procedure, the gases are turned off and you wake up from your sleep. You will feel no pain, and you will not remember the procedure.

The prevention of postoperative nausea and vomiting is also an important consideration in our approach to breast augmentation revision surgery. Zofran is a new drug which is currently the best medication available to prevent nausea and vomiting. Ask your plastic surgeon about this medication to make sure that your experience is as pleasant as possible.

Your plastic surgeon should discuss all of these options with you more thoroughly at the time of your consultation, and please ask him about anything you do not understand.

Details of the Procedure

Breast augmentation revisions vary greatly in the exact procedure to be performed and the length of time the operation will last. Your plastic surgeon should thoroughly describe the procedure he or she has proposed for you, and please ask questions about anything you do not understand.

After you are properly anesthetized in the operating room, Dr. Revis injects a solution of local anesthetics along the borders of the breasts, underneath the intended incision site, and into the muscle under which the implants will be placed. This injection solution consists of a special combination of lidocaine (xylocaine), marcaine (sensorcaine, bupivicaine) and epinephrine. This accomplishes several objectives. First, the epinephrine causes vasoconstriction of the area, reducing your potential for bleeding and bruising. Secondly, the lidocaine provides a rapid numbing of the area. Although you are asleep, this prevents the brain from registering any pain from the region during the operation. Studies have shown that this so-called preemptive analgesia actually decreases your sensation of pain postoperatively, decreases the amount and length of time you will need to take pain medication postoperatively, and also leads to a more rapid return to normal daily activities. Finally, the marcaine component of this local anesthetic mixture is a long-acting local anesthetic. This actually prolongs the numbness of the area, making you more comfortable following surgery and delaying the time at which you will begin to need any pain medications.

After the revisionary steps needed in your case have been performed, your new breast implants are inserted and filled with saline. (Silicone gel implants come pre-filled and do not require filling in the operating room). Dr. Revis advocates a “no touch” technique when placing the implants into the pocket. This includes using new sterile towels to drape around the breasts, changing his gloves and washing the outer surface of these new gloves in sterile saline, and only opening the sterile implant packaging immediately prior to insertion. Dr. Revis is the only person who ever touches the implants, and his goal is to minimize the time the implant is exposed to the air in the operating room prior to insertion into the pocket. Additionally, Dr. Revis does not allow the implant to come into contact with any instruments or the skin during the insertion process. He feels that this minimizes the possibility of any foreign material coming into contact with the implant and causing any inflammation.

During the filling process, Dr. Revis advocates the use of a "closed system" to fill the implants with saline. This means that the saline that enters the implant is never at any time exposed to the air in the operating room. The saline flows from a sterile bag through a sterile tubing directly into the implant. This additional precaution prevents any foreign material from inadvertently being injected inside the implant.

After the implants have been filled properly and your plastic surgeon has assessed your final shape and size, the incisions are carefully closed to minimize your scar. A sterile dressing is applied to the incisions, and a soft surgical bra is placed over your breasts.

After Your Procedure

Breast augmentation revisions are typically performed as an outpatient procedure. After recovering in the recovery room for approximately one hour, you will be able to go home in the company of a friend or family member.

Ask your plastic surgeon about his or her recommendations regarding showering, activity levels, massaging and the use of Mederma (a topical cream to improve the appearance of your scars) and antibiotics.

You may also be a candidate for a revolutionary new product for the management of postoperative pain, called the On-Q Post-Operative Pain Pump. Be sure to ask your plastic surgeon about this during your consultation if you think you might be a good candidate for this system.

You should plan to take it easy following your surgery. No strenuous activities, heavy lifting (over 20 pounds), aerobic exercises, swimming, contact sports, tennis, or golf should be planned for the first three weeks. As your plastic surgeon monitors your recovery, he or she will advise you when it is safe to resume specific activities.

The Results You Can Expect

You will notice an improvement in your breast shape and size immediately. You may experience soreness in your chest, but this should rapidly disappear. Any swelling usually takes several weeks to subside. You should be able to resume your normal daily activities the day after surgery, and you should be able to resume all of your physical activities (sports, aerobics, running, etc.) within three to six weeks of surgery.

For more information visit SouthFloridaPlasticSurgery.com

Email Dr. Revis with your questions DrRevis@SouthFloridaPlasticSurgery.com

Breast Implant Revision Photos

Breast Redo Surgery/Problem Cases - The Wall Center for Plastic Surgery, Shreveport, Louisiana
Breast Revisional Surgery - Dr. Joseph Cruise, Cruise Plastic Surgery, Newport Beach, CA

Breast Implant Exchange - Dr. Strock, Ft. Worth, Texas
Breast Revision Surgery - Dr. Win Pound, Atlanta, GA

Breast Revision - Calobrace Plastic Surgery Center, Louisville, KY
Breast Surgery Revision Photos - Cosmetic Surgery Center of Maryland, Baltimore, MD
Breast Revision Surgery - Dr. Campanile, La Bellezza Cosmetic Center, Ft. Myers, FL
Breast Implant Revision - Dr. Bazell, IL
Breast Implant Revision - Dr. Chapin, PA
Breast Implant Revision - Dr. Ciaravino
Breast Implant Revision - Dr. Revis, FL
Breast Implant Revision - Dr. Ferraro, NJ
Breast Implant Revision - Dr. Hunstad, NC
Breast Implant Revision - Dr. Hasen, FL
Breast Implant Revision - Dr. Sorokin, NJ

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