Breast Revision

The Procedures


Anatomical Implants

Anatomical implants are not recommended.

Oftentimes they are positioned correctly in the operating room, but will become malpositioned after the surgery. Anatomical implants come in saline, silicone and gummy bear round implants which can increase the odds of having a rotational deformity. Even as little as 5° shift in the implant can lead to a misshapen breast.

Any of these problems can lead to a double bubble deformity, bottoming out of the implant or rotational problems.

Risk: 5-10%
Top Symptoms
  • Rotational Deformity
  • Postoperative Implant Movement
  • Misshapen Breast
View Before & After Photos

Bottoming Out

Bottoming out can occur through technical surgical problems or overtime.

Correction of bottoming out can be difficult, especially in patients who have had multiple revisions or reconstruction. In order to repair bottoming out, it may require suturing the inframammary fold capsule upward, strips of capsule can be taken and the capsule can then be plicated superiorly.

Larger implants may lead to bottoming out more quickly.

Risk: 1-2%
Top Symptoms
  • Upward elevation of nipple and areola
  • Lower inframammary fold
  • Collapse of the upper pocket with pain
View Before & After Photos

Capsular Contracture

Capsular contractures are one of the most common causes of patients requiring breast revision surgery.

The Capsule

The capsule is formed with three elements - collagen, fibroblast and blood vessels. The capsular contracture may be associated with micro contamination and staphylococcus aures or staphylococcus epidermis. Removal of the capsule often will occur with the replacement of the implant concurrently. Patients with Baker IV capsular contracture may require open capsulectomy and circumferential open capsulotomy.

Capsulectomy

A capsulectomy is removal of the scar tissue around the implant, either above or below the muscle. A capsulotomy is simply circumferential release of the capsule, allowing more space and volume for the implant to occupy, reducing the pincushioning effect of the constriction. All capsule specimen tissue should be sent to Pathology for diagnostic purposes in order to investigate possible cancer. Patients who have had capsular contracture are at a higher rate for recurrent capsular contracture, both with silicone and saline implants. Silicone implants have a higher incidence of capsular contracture than saline due to micro porous silicone leakage and calcification.

Risk: Saline: 5-8%
Silicone: 10-15%
Top Symptoms
  • Painful scar tissue
  • Visible distortion
  • Cold and hardness to the breast
View Before & After Photos
Grade I
A soft capsule around the implant without scar tissue or visible distortion
Grade II
Palpable hardening around the implant
Grade III
Able to be felt and visible distortion of the implant
Grade IV
Palpable, visible distortion, with hardness and coldness to the breast with a deformity.

Double Bubble Deformity

Double bubble deformity occurs when the implant has risen and the skin now over-drapes the breast.

Correction requires three elements:

  • An open capsulectomy with an inferior open capsulotomy, releasing of scar tissue and lowering of the pocket
  • Removal and replacement of the implant
  • Tightening of the breast, usually performing a formal mastopexy using the inferior pedicle Wise-pattern technique or the anchor scar

This will allow for complete correction of a double-bubble deformity. Double bubbles are often associated with severe encapsulation, most often Baker III or Baker IV capsular contractures. There is deformity of the implant with malpositioning of the implant.

The transaxillary approach may lead to inaccurate release of the parasternal and the inframammary attachment of the pectoralis major muscle which automatically sets you up for a pincushioning effect of superior retro positioning of the implant right from the start and a double-bubble deformity.

Risk: 2-4%
Top Symptoms
  • Elevated implant
  • Skin looseness of the lower breast
  • Often painful scar tissue
View Before & After Photos

Positioning Issues

Our practice sees a lot of issues with malpositioning of their implants. These surgeries in general require either capsulectomies, capsulotomies or capsulorrhaphies with retightening of the capsule internally in order to reshape the pocket. This may require an AlloDerm or a Strattice Graft material if there is an inadequate amount of thinned out capsule.

Cleavage is often a problem with patients who have undergone surgery to transaxillary and transumbilical approach. Without precise release of the parasternal muscles or over-resection of the lateral breast pocket, the implants may be laterally displaced, patients present desiring cleavage and therefore the implants are changed to high profile and the capsule laterally may need to be tightened.

Risk: 10-15%
Top Symptoms
  • Inadequate cleavage
  • Inferiorly displaced with bottoming out
  • Superiorly displaced with severe double-bubble breast deformity
View Before & After Photos

Ruptured Implant

Ruptured implants are extremely common as Dr. Stuart Linder specializes in breast revision procedures.

Any patient with a ruptured implant should undergo surgery as soon as possible, as scar tissue contracture will continue and can progressively constrict the entire pocket with increased scar tissue in order to close the space.

We recommend our patients have surgery within 14 days of detection.

How To Detect

Saline
  • MRI Required: No
  • Average Implant Lifespan: 10 Years
  • FDA Approved
Symptoms Of A Silicone Implant Rupture
  • Clinical
  • Obvious asymmetry
Silicone
  • MRI Required: Yes
  • Average Implant Lifespan: 10-12 Years
  • FDA Approved
Symptoms Of A Silicone Implant Rupture
  • Questionable clinical diagnosis
  • Positive MRI
  • Mushy breast
Polyurethane
Symptoms Of A Silicone Implant Rupture

These implants were taken off the market by the FDA several decades ago due to the risk of breakdown product of toluenediamine in laboratory animals shown to be carcinogenic with sarcoma formation.

Any patient with polyurethane implants should have them removed as soon as possible.


Size Change

Size change is dependant upon the volume. High volume saline implants are tapered implants that will give you more AP projection and volume and less lateral fullness which is very, very useful for patients of all ages, especially women in their 40s and 50s.

These patients often may have been ectomorphic in build with thick breast tissue and muscle and therefore they were limited as to how large they can go on the original augmentation; however, after stretching out over one to two years, tissue expansion is allowed for now more occupied space and a larger implant can now be placed safely.

Implant exchange is associated with patients desiring larger or smaller volume implants. As patients age into their late 40s and 50s, they often desire smaller implants in order to feel less heavy and matronly. Saline exchange or silicone exchange may require a secondary procedure with the skin in order to tighten it if there is significant volume and skin laxity has occurred.

Concurrent implant exchange and mastopexy is a very frequent operation in my surgical practice. Patients may desire to change saline implants to silicone of silicone implants to saline. This is user-friendly and also depends upon the amount of breast tissue that the woman has to start with.

Risk: 12-15%
Top Symptoms
  • As people age they often downsize to feel less heavy, more feminine, and less matronly
  • Younger individuals often desire to have larger implants placed
View Before & After Photos

Symmastia

Symmastia is one of the most difficult problems to correct.

It is when the implant is crossed over the sternum. This is usually associated with a technical error of the original surgeon. The midline should never be crossed in any patient. Symmastia repair may require capsulorrhaphies and/or inlay grafting of Strattice or AlloDerm. Using a high profile saline and a spacer which narrows the implant diameter and opening the lateral pocket, may also be useful for reduction of symmastia.

The low profile implants are the most difficult to use with symmastia due to the wide diameter and changing to high profile saline and silicone will help to reduce the effect of symmastia.

Risk: 1-2%
Top Symptoms
  • Implant migration across the sternum
  • Painful scar tissue
  • Possible visibility of inner implant

Cost

Breast revision costs will vary per patient.

This includes surgeon’s fee, operating room fees, implant cost and anesthesia fees. The surgeon fee can include cosmetic and reconstructive revisions, and may be covered by insurance.

*Final cost will be determined by your plastic surgeon

  Saline Silicone
Allergan $ $$$
Mentor $ $$$
Sientra n/a $$$

Covered By Insurance*

Anatomical
Rarely
Bottoming Out
Rarely
Capsular Contracture
Occasionally this may be covered if the following criteria exist. Consult with your doctor to determine if this can be covered.
  • Baker Grade IV
  • Painful
  • Distorted breast
Double Bubble Deformity
Occasionally this may be covered if the following criteria exist. Consult with your doctor to determine if this can be covered.
  • Painful capsule
Positioning Issues
Rarely
Size Change
Never
Symmastia
Rarely
Ruptured Implants
While oftentimes this can be coveraged under your insurance policy - please consult with your doctor for your specific case

*This differs per policy and state. Consult with your surgeon.


Anesthetic

Breast revisions should be performed under general anesthesia with a board certified anesthesiologist.

All anesthesia is performed by Dr. Charles Hoffman.

Laryngeal mask airways can be used in the majority of the patients. However, those who have a history of reflux or gastroesophageal disease are usually better candidates for endotracheal tube intubation. This should be discussed with your Board Certified Anesthesiologist.


Recovery Time

Preoperative
Patient is started on an intervenous antibiotic (Ancef, Cipro and Vancomycin).
Surgery
A typical revision surgery takes between 90 - 120 minutes.
Recovery Room
At least one hour. This is a requirement of federal law in Medicare.
After Surgery
Patient is sent home with a Bias wrap and gauze in place. No heavy lifting or raising the arm above the shoulder for three weeks.
Postoperative Visit
All dressings are removed and replaced with a Linder Bra.
Day 5 (up to Day 14)
Patient returns to work depending upon the extent of the revision.
Day 7 Follow Up
Dressings are then changed two to three times a day.
Day 14 Follow Up
Patient returns for suture removal.
Day 21 Follow Up
Position of implant evaluated.
6 - 8 Weeks
Resuming regular exercise usually occurs.
10 - 16 Weeks
Photographs of postoperative results.
Continued Treatment
Incision sites are often treated with Vitamin E or Bio corneum silicone gel spray. In order to reduce scarring use twice a day for three to six months.