Breast Surgery Revisions


Breast augmentation with implants is the second most popular surgery for women in America. Though rare, breast augmentation can result in problems that require a revision or re-surgery of the implants. Here is a list of reasons that you may consider breast implant revision surgery:

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It will comfort you to know after viewing the scary list above, that the #1 reason for breast implant revision is a desire for a larger size, not due to rupture or other complications.

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The patient here speaks of her experience with breast surgeon Dr. Jason Pozner, in Boca Raton, Florida. Dr. Pozner is an expert in revision plastic surgery as he often helps patients fix the wrongs of previous plastic surgery.

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Good candidates

If you are physically healthy, psychologically stable, and have realistic expectations, you will be a good candidate. It’s important to keep in mind that breast revision surgery is just a revision. There will be scar tissue present that must be addressed in order to create a positive outcome. The quality of the skin, including its thickness/thinness and elasticity, may also be an issue.

How the procedure is performed

Breast augmentation revision procedures are performed under general anesthesia in our Boca Raton accredited in-office surgery suite on an outpatient basis. Depending upon the reason for your revision surgery, the following procedures would be performed.

Change in implant size:

Changing the size of your implants is a fairly straightforward procedure. The previous incision will be reopened and the implants switched out. A smaller implant may require some tightening of the original pocket to fit snugly and conversely, a larger implant will require that the pocket be enlarged.

Change in position (implants 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 muscle fibers.

If the 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 the implants along with a portion of the capsule and creating a new, submuscular pocket. Alternatively, the subglandular pocket can be lowered if the patient does not want the implant placed behind the muscle. Correction of submuscular high riding implants involves first figuring out the cause – ie 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 capsulectomy. Surgical times vary from 1 to 4 hours and recovery is relatively quick for minor corrections and similar to primary augmentation for submuscular conversion or major capsule work.

If the 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 doing a layered closure or creating a new subpectoral pocket. Another way of dealing with this situation is to use a piece of human or animal dermis to help hold the implant higher. Our practice generally uses smooth implants but may use a textured implant for in situations such as these. Surgical time varies from 1 to 3 hours and recovery is usually quick. Postoperative taping and use of an underwire bra is essential for about 6 weeks.

If the implants are too lateral (too much to the sides of the 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 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 the consultation, a “tilt test” is performed in which the patient sits in an exam chair with her arms on the handles then tilts the table back to see the extent of sideways shift. This can happen with either subglandular or submuscular implants. Correction involves closing the lateral pocket (capsulorraphy) and taping the sides of the breast for six weeks or sometimes creating a completely new pocket under the muscle that is centered more towards the midline. Surgical time varies but is about 1 hour per breast and recovery is relatively quick.

If the implants are too medial (pushed too much to the center), this creates too much cleavage and in the extreme case, in which there is a connection of the pockets holding the implants, this is called synmastia or often referred to as “unaboob”. Causes of this vary from patient anatomy ,to too wide an implant, to 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 human or animal dermis may be used as a patch if the chest wall and/or breast skin is extremely thin. For patients who have had multiple breast procedures, we will occasionally use a post-operatively-adjustable saline or silicone  implant to avoid placing tension on the repair. Surgical and recovery times vary with degree of difficulty. Post operative taping and a supportive bra are essential.

Ruptured Implants are generally 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.

Capsular Contracture is a hardening of the breast which happens when the tissue surrounding the breast implant contracts around the implant. Data from large studies estimate the incidence to be up to 10%. 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, our procedure is to remove the entire capsule and reinsert a new implant underneath the muscle. Operative times vary but are generally about 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.

It’s our experience that other problems, such as ruptured implants or shape/position problems, often occur along with capsular contracture. We consider old, 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.

Rippling or dimpling of the breast skin can occur when there is not enough tissue over the implant and leads to a wavy appearance, usually noticed when a woman leans over. This can happen anywhere on the breast surface and occurs more often with saline implants than silicone and more often with textured implants than smooth implants. The worst rippling is seen with textured saline implants that are inserted under the breast gland rather than under the muscle. Our 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 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. Correction involves reinforcing the thin breast area with either capsule, muscle or human or animal 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.

The ability to feel the edges of the implant 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, as this is where the skin is thinnest. Sometimes changing to a smooth silicone implant will correct this. The more difficult problem is a visible knuckle of implant poking through the 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 the muscle initially and can feel the implant toward the center of the 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.

Infection following breast implant surgery is rare but can happen 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 resolve the infection; if not minor, the implant may need to be removed until the infection is cleared up and replaced at a later date.

What to expect during recovery

Following your breast implant revision procedure, recovery is generally similar to what you experienced when your implants were initially placed. We will recommend that you wear a supportive bra 24 hours a day until the surgery sites have healed completely, which may be up to a month. You will be sore at first, but after about a week you’ll feel well again and fully healed in about 6-8 weeks. Similar to your initial breast augmentation, the results are immediate, but due to swelling and settling the final appearance will not be apparent for about 3 months. After the procedure, we recommend that you avoid lifting your arms over your head as well as any exercise or activity that uses your chest muscles for a period of 8 weeks. If you have experienced a breast infection, we will give you a prescription for the appropriate antibiotics to address this. You’ll come back into the office within the first few days for your first postoperative visit at which time you’ll be examined to be sure everything is going as it should.