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Breast Revision
Before & After Gallery
 

Sanctuary Plastic Surgery surgeons specialize in the revision and correction of previous cosmetic surgery. This includes all facial revisions, body revisions and most commonly, breast surgery revisions.

Of the surgeries Dr. Pozner performs, almost eighty percent of them are corrections of previous cosmetic surgery performed somewhere else. He is particularly known for his work in correcting breast augmentation revisions. Dr. Pozner serves on the Mentor Advisory board and regularly conducts FDA studies on new breast surgery procedures.

Dr. Kurt Wagner’s work in plastic surgery was instrumental in the development of breast augmentation as you know it today. He was the original designer of the round version of the implant configuration that is still the most popular in use.

There are a variety of common problems that occur from primary breast augmentation:

Bottoming Out

This deformity is usually due to a surgical error of releasing the inframammary fold excessively. It can happen on one or both sides and with placement of implants over or under the muscle. The implants end up being placed too low on the chest wall and the nipples end up being positioned too high. This creates a loss of an internal support system for the implant.

Correction involves excising a piece of the capsule and doing a layered closure using a Strattice Reconstructive Tissue Matrix, an "internal bra" to provide additional support to the implant. This "internal bra" is an acellular reconstructive tissue matrix designed to support tissue regeneration.  It helps control the breast implant location, defines the breast shape and prevents bottoming out.

Dr. Pozner usually uses smooth implants but may use a textured implant for recurrences. Surgical times vary from 1 to 3 hours and recovery is usually quick. Postoperative taping and use of an underwire bra is essential for about 6 weeks. Refer to our postoperative recommendations for more details on recovery time.

 

Before: Implant placed too high
   
 

After: Implant is Repositioned

Implant Displacement

We consider positional problems those in which the implant is found out of its proper position, that is - too high, too high, too lateral (to the side) or too medial (to the center). The cause of these problems can be due to surgical error, poor healing and weakening or tearing of muscle fibers. We don’t include droopy breasts or capsular contracture in this category although similar problems can occur along with droopy breasts and with capsular contracture.

Placement is Too High

This can happen with either over the muscle or under the muscle placement. 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 over the muscle (subglandular) high with a portion of the capsule and creating a new, under the muscle (submuscular) pocket. Alternatively, the over the muscle pocket can be lowered if the patient does not want an under the muscle conversion. Correction of under the muscle high riding implants involves first figuring out the cause - i.e. inadequate muscle release, poor pocket development or early capsule formation then treating the appropriate problem by either releasing muscle, increasing pocket size or partial or full excision of the capsule.

Surgical times vary from 1 to 4 hours and recovery is relatively quick for minor corrections and similar to primary augmentation for under the muscle conversion or major capsule work.

Implant Displacement: Implant Position

Placement is Too Lateral.
Lateralized implants are usually caused by the surgical error of too much lateral dissection but may occur if there are excessive muscle forces pushing the implant out to the sides. Typical patient complaints are that the implants are in "my armpits" or that "I keep hitting the sides of the breast with my arms." This is not to be confused with not enough cleavage due to too narrow an implant.

In our consultation I perform a "tilt test" in which I have the patient sit in an exam chair with her arms on the handles then tilt the table back to see the extent of lateral shift. This can happen with both above the muscle or below the muscle implants. Correction involves closing the lateral pocket (capsulorraphy) and taping the sides of the breast for six weeks. Surgical time varies but is about 1 hour per breast and recovery is relatively quick.

Placement is Too Medial (Symmastia).

This implies that there is too much cleavage. In extreme cases, there is a connection of the pockets called Symmastia, often referred to as "uni-boob". The causes of this problem vary from patients anatomy, to too wide of an implant, to muscle tearing or surgical error of too much medial dissection. This can happen with both above the muscle or below the muscle implants.

For above the muscle implant that are too medial, conversion to below the muscle usually corrects the problem.

Correction of below the muscle implants that are too medial can be difficult and involves closing the central tissue in layers. Occasionally alloderm (human dermis) may be used as a patch if skin is extremely thin. For a patient that has been operated in multiple times, we will occasionally use a post operatively adjustable saline implant to avoid placing tension on the repair. Surgical and recovery times vary with degree of difficulty. Post operative taping and bra is essential.

Capsular Contracture


As a natural reaction to any device placed in the body, scar tissue will form around the breast implant surface creating a capsule.

Capsular contracture causes hardening of the breast and is due to the tissue surrounding the breast implant contracting around it. Data from large studies estimate the incidence to be about 6%. In general, there is slightly less capsular contracture with saline implants than silicone and with under the muscle placement. Some studies show less contracture with textured implants but this is often offset by increased rippling and higher deflation rates.

Current theories are that contracture occurs due to sub clinical 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, insect bites and teeth cleaning in which bacteria is leaked into the bloodstream. Other causes are previous hematoma or seroma that increase inflammation. Some people feel that smoking may increase the incidence. Capsular contracture is graded as to severity:

Baker Grade I - The breast is normally soft, and looks natural.
Baker Grade II - The breast is a little firm, but appears natural.
Baker Grade III - The breast is firm, and is beginning to appear distorted in

Baker Grade IV - The breast is hard, and has become quite distorted in shape. Pain/discomfort may be associated with this level of capsule contracture. 



Treatment of Grade I-II capsular contracture is often with adjunctive therapies such as massage, ultrasound, Vitamin E and with newer drugs such Accolate, a drug used in the treatment of Asthma. Accolate is usually given at a dose of 20 milligrams twice daily and may take several months before results are seen.

The most effective treatment of Grade III-IV capsular contracture is to remove the whole capsule (capsulectomy). Just scoring the capsule (capsulotomy) usually is ineffective. Other procedures such as closed capsulotomy in which the breast is squeezed until the capsule is broken is not recommended as it may cause implant rupture and in fact voids the implant warranty. Our usual procedure for subglandular capsular contracture is to remove the entire capsule and perform a submuscular conversion. For submuscular capsular contracture we will perform a capsulectomy. Operative times vary but usually are 1½ hours per side. Recovery is similar to a primary augmentation. Postoperatively, massage, Vitamin E and Accolate are often given to prevent recurrent contracture.

It is very common for other problems such as ruptured silicone implants or shape or positional problems to occur with capsular contracture. In fact, we consider old hard silicone implants to be ruptured until proven otherwise. Many times a mastopexy (breast lift) is needed along with capsulectomy for droopier hard breasts.

Implant Leak or Rupture

Saline Leak
In the case of a saline leak or rupture there is usually a rapid decrease in size much like a balloon deflating. The saline is absorbed by the body and breast appears flattened. Occasionally saline implants will have a partial leak with a gradual decrease in size over a few week period.  It is usually necessary to change ruptured implants within a short time since waiting too long will cause a change in capsule shape and make the implant exchange more difficult.

Surgery may involve general anesthesia, IV sedation or in some cases local anesthesia. The old incision is opened, the deflated implant is removed and replaced with a new implant. Often patients choose to have a size change with an implant deflation and surgery is similar to that outlined in those sections.

A more complicated case. Ruptured right subglandular implant. Repair following bilateral capsulectomy and submuscular conversion. Note the shrunken right capsule indicating that this was ruptured for some time.

SILICONE LEAK
Newer silicone implants have a lower leak rate than older implants. It is difficult to detect a silicone leak based upon physical exam. Mammograms and ultrasound examinations may detect a leak but MRI is currently the best way to detect a silicone rupture. However, MRI’s are not completely diagnostic and they may miss a leak, or mistake a folded implant as one leaking. If someone is unhappy with breast shape, size or position and wishes to have this corrected; preoperative exams to diagnose a ruptured implant are not indicated. Older implants that were soft and became firmer are considered ruptured until proven otherwise.

The question, "When do I replace older silicone implants that are not problematic?" often arises. We previously advised patients to leave them alone if they are asymptomatic but after having seen too many asymptomatic ruptures, we currently recommend replacement of older implants at 20 years. Current generations of implants should have a longer lifespan.


Calcified capsule and ruptured silicone implant were found at surgery.

Texture Problems

Rippling & Wrinkling
Rippling occurs when there is not enough tissue coverage over the implant and leads to a wavy appearance usually when a woman leans over. This can happen medially (towards the middle), superiorly (on top), or laterally (towards the sides).  Rippling happens more frequently with saline implants than silicone and with textured implants than smooth. The worst rippling is seen with subglandular textured saline implants.

Determining the cause of rippling is important to correction. Subglandular rippling is usually seen superiorly or medially and is corrected by submuscular conversion in which the implant is removed from the subglandular position, a portion of the capsule is removed, a new pocket is created under the muscle and the implant is replaced under the muscle. Most women will opt for new implants and smooth silicone or saline are 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 present. Correction involves reinforcing the thin breast area with either capsule, muscle or alloderm (human dermis). Surgical times for simple exchange are quick and recovery easy while more difficult problems and submuscular conversion lead to longer operative times and recovery similar to primary augmentation.


Rippling with subglandular implants. Corrected with submuscular conversion.

Palpable Implants

Most women can feel the edge of the implants under the breast and laterally. This is where the skin is thinnest. Sometimes changing to a smooth silicone implant will correct this. The more difficult problem is a palpable or visible knuckle of implant poking through the skin. If subglandular, then submuscular conversion will correct this. Submuscular palpability especially if medially may be due to excessive muscle release or muscle tearing. Enhancing the coverage either through muscle advancement or alloderm placement may be necessary.

Other Implant Issues

Infection
Infection is rare following breast augmentation but may occur with wound breakdown, infection elsewhere in the body or with insect bites on the breast. Curiously, we once saw a breast implant infection from an insect bite on a woman’s arm. If minor, antibiotics may correct a minor infection while if not minor the implant will need to be removed and replaced at a later date.

Incomplete Muscle Release
Some patients present with muscle banding due to incomplete muscle release. Treatment is to divide the abnormal muscle bands.


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