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Breast Implant Revision

Breast Implant Revision

Breast augmentation surgery remains one of the most popular cosmetic procedures around the world with the vast majority of patients thrilled with their new proportions. With the millions of women who have had breast augmentation, there are many who require exchange of outdated silicone gel implants, some others with a ruptured implant in need of replacement and those who simply wish to change to a different size. There are also many women requiring additional surgery to correct any one of a number of breast implant problems or complications. Unsatisfactory results may be from one or more of several problems associated with breast augmentation including:

  • capsular contracture (thickening, firmness, contraction and/or calcification of the layer of tissue around the implant)
  • malpositioned or displaced breasts implants
  • poor or unnatural shape
  • asymmetry
  • synmastia (implants too close or joining in the midline)
  • obvious rippling or wrinkling
  • deflation
  • inappropriate size implant placed
  • poor scars
  • firmness from excessive overfilling of saline breast implants
  • Asymmetry or malposition of the inframammary crease

Breast implant revision expert, Dr. Sam Gershenbaum in Miami, Florida has developed a reputation for correcting breast implant problems and has achieved acclaim for his natural appearing breast augmentation results on first time patients.

It is important to understand that every plastic surgeon will have, from time to time, a patient who has a complication or a result that is less than satisfactory which requires a “touch up” or reversion surgery. Don’t be too quick to blame the surgeon. There are many factors and variables in surgery and in healing. It is important to realize that there is always some degree of unpredictability in the final outcome of the healing process.

It is usually beneficial and appropriate to follow-up and continue care with the plastic surgeon who performed the original surgery and work through any problems or complications. Obviously, anyone who experiences a complication or poor result wishes to have the problem resolved immediately. However, working through these problems may take extended periods and will require time and patience. Frequently, it is appropriate to wait any number of months after the problem or complication before moving ahead to correct the problem. Lack of confidence, obvious poor judgment, or failure after two or more procedures may encourage one to seek a second opinion or an alternate plastic surgeon.

Correction of Asymmetry

Dr Gershenbaum points out that large number of women have significantly asymmetric breasts, and it is important to take into account the original shape and symmetry prior to any surgery. Breast sizes and shapes vary, as well as position of the nipple-areolar complex on each breast. Some breasts may be higher or lower than the other, or the asymmetry may be due to posture or curvature of the spine. Most people also have differences in width, shape and projection of the boney rib cage from one side to the other which translates into asymmetry of the breasts.   Many women do not realize their asymmetries until discussed during their consultation. Conscientious and meticulous surgeons will make every effort to make the breasts as symmetrical as possible, however, original asymmetries will prevent perfect symmetry. At times, asymmetry can even become more noticeable/obvious following breast augmentation. If pre-operative asymmetry is significant, two different size breast implants may be used to accommodate two different size breasts, thereby improving the asymmetry.  If one’s asymmetry involves different amounts of breast projection or width from one side to the other, there are also options to use two different breast implant profiles from low to midrange to high. Fat grafting alone or in conjunction with two different size or profile implants may also be incorporated to improve symmetry. When asymmetry involves differences in shape or position of the nipple, it may be wise to choose smaller size breast implants, with a more conservative change in size so as not to accentuate the asymmetry. In those patients who have one nipple significantly lower than the other or one breast hanging or drooping more than the other, some type of lift for that particular side may be considered along with the breast augmentation. Careful planning before the initial surgery best helps to produce optimal results.

It is also important to understand that complete healing and the final result after breast augmentation surgery truly takes several months – approaching one year – and what may be unsatisfactory to a patient after surgery may be something that will improve or resolve over time. Do not be too quick to insist that the surgeon correct a problem or concern when more time is recommended. For example, a patient happy with the left breast noted the right breast implant placement appeared too high and requested it to be corrected. However, at just under one year the high riding right implant ended up in perfect position and the left implant ended up a little too low !  In reality, it was the left implant that needed to be raised rather than the right implant lowered. Patience in the healing process is very important.

Correcting implant problems may be relatively uncomplicated or they may require one or more surgical procedures. For some, it is possible that no satisfactory result can be obtained requiring living with and accepting the “best” that can be done or removing the breast implants altogether. If removed altogether, one should wait six months to one year allowing breast tissue recoil/contraction before deciding if any type of breast lift or any other procedure is desirable. If more obvious sagging (ptosis) is present, a breast lift may be performed at the same time.

Capsular Contracture

With breast augmentation, capsular contracture is one of the most common complications with a reported incidence of about 3% to10%. Other studies have reported that capsular contracture affects roughly 10% to 20% of breast augmentation patients. Even higher incidence of this complication has been reported. Capsular contracture can form in one or both breasts after breast augmentation with implants and typically will occur within the first several months after surgery.

What is capsular contracture ?

It is well known that the body always recognizes a foreign body or any type of implant and mounts a response to “wall off” or encapsulate this foreign entity. The breast implant capsule refers to the body’s natural healing process which forms a thin, soft, fibrous scar tissue layer around every breast implant. Capsular contracture occurs when this capsule abnormally becomes thickened, firm, and contracts around the implant causing varying degrees of firmness, distortion, and sometimes pain. The greater the capsular contracture, the rounder and harder the breasts become with implants that generally become too high as well. Capsular contracture is not dangerous, though, it can be uncomfortable and even painful along with unsatisfactory cosmetic results. It is important to understand that the possibility of capsular contracture exists each time breast implants are placed or changed or manipulated in any way regardless of the history of capsular contracture or not. Capsular contracture can occur with first time patients or in patients changing, revising, or repairing problems even if capsular contracture never occurred previously.

Correction Capsular Contracture

What causes capsular contracture ?

From the review of literature, the cause of capsular contracture is multifactoral, but involves an inflammatory process which causes a fibrotic reaction in the tissue surrounding the implant. This fibrotic reaction will cause thickening, firmness, contracture and even calcification of the capsule. This inflammatory process can vary greatly from mild to severe. Capsular contracture severity is labeled according to the Baker Classification System.

Grade I: The capsule is soft and normal, the breast looks natural and there are no symptoms

Grade II: The capsule I mildly thickened, the breast is slightly firm but looks normal

Grade III: The capsule is thickened and firm, the implant does not move freely, the breast is firm      and distorted with obvious cosmetic symptoms

Grade IV: The breast is hard, painful and greatly abnormal in appearance

The causes or “triggers” initiating this inflammatory reaction may be from one or more contributing factors including:

  1. It is believed that non-pathogenic bacteria (bacteria that typically don’t cause infections) are largely responsible for creating a subclinical infection or inflammatory response. These bacteria slowly adhere and thrive in a protective layer termed a biofilm, which is largely resistant to antibiotic therapy
  2. Hematoma or collection of blood around the implant that can produce an inflammatory response
  3. Inflammation caused from the “micro-bleed” of silicone gel through the shell of the implant especially noted from the older liquid silicone gel implants before 2006 in the US
  4. Silicone implant rupture, especially the liquid silicone gel used before 2006, can produce an inflammatory response
  5. Inflammation from talc powder that used to be present on surgeons sterile gloves. Careful surgeons used to have to specifically order gloves without talc powder. Now, all the sterile gloves to the US are made without talc powder
  6. It is also believed by some plastic surgeons that those people who have a genetic predisposition to develop hypertrophic scarring (thick raised scars) and keloids are more prone to develop capsular contracture
  7. Exposure to radiation therapy for treatment of breast cancer or other reasons before or after breast augmentation
  8. Other yet unknown causes

Ways to reduce the incidence of capsular contracture

There is no plastic surgeon that performs breast augmentation routinely that does not have some patients who develop capsular contracture. Depending on the surgeon, his staff and clinic and how they operate to reduce the incidence of capsular contracture is of the utmost importance. Breast implant expert, Dr.Gershenbaum is well known for his meticulous care and reputation for natural appearing breasts after breast implant surgery. He has an exceedingly low incidence of capsular contracture in his patients due to his strict protocol to reduce this complication which include:

  1. It is well known that placing breast implants under the muscle reduces the incidence of capsular contracture. Dr Gershenbaum routinely places the breast implants under the muscle.
  2. Maintaining a strict protocol for the operating room and instruments for a sterile procedure. Proper cleaning and sterilization of instruments. Routine sterilizer maintenance and spore checks to ensure the sterilization process
  3. Besides starting two types of prophylactic antibiotics the day before surgery, patients wash with an antiseptic solution the night before and the morning of surgery
  4. Many plastic surgeons believe that the off-label use of montelukast (brand name Singulair) or zafirlukast (brand name Accolate), a prescription medication for asthma and allergy that reduces the body’s inflammation causing leukotrienes can reduce the incidence of capsular contracture. Prescribed for 90 days after breast augmentation, it is believed that it may reduce the body’s immune response to a “foreign body” and therefore reduce the incidence of capsular contracture
  5. Patients are prepped with two different types of antiseptic solutions prior to surgery
  6. Nasal vestibules are swabbed with betadine. Studies have revealed that iodine swabs and decolonization of the nasal bacteria significantly reduces the incidence of post operative surgical site infections
  7. Maintaining strict sterile surgical protocol during surgery. Dr Gershenbaum routinely dips his retractors into antiseptic solution each time it is used during surgery. The irrigation of each breast pocket with antiseptic solution prior to placing the implants. Changing sterile gloves for each breast and before touching any implant. Minimal to no handling of the implant even with new sterile gloves. Using the Keller Funnel to place the implant, which significantly reduces contact with skin and potential for bacterial contaminants. Some refer to this as a “no touch technique” which greatly minimizes the risk of contamination during surgery. Use of the Keller funnel also allows the implant to be placed through a smaller incision as well as reduces the potential damage to the implant as compared to manually pushing the implant through a small incision.
  8. Strict hemostasis, which refers to minimizing any blood in the created pocket as blood around the implant creates inflammation. Blood around an implant is a high cause for capsular contracture

Keller Funnel

Treatment for Capsular Contracture

Even with the following of this strict protocol, breast augmentation patients still have to accept a small risk of capsular contracture. If capsular contracture occurs, surgical correction may be needed.

If textured implants were placed, they must be exchanged for new with any surgical treatment for capsular contracture. If smooth implants were placed, they may or may not be exchanged for new depending on factors such as how long ago they were placed and as decided by the patient and surgeon. Mentor and Allergan offer new implants for capsular contractures occurring within ten years of placement.

There are several options for more minor capsular contracture or firmness as in Baker II capsular contracture. One may choose to do nothing and live with a bit more firmness. Medical treatment with Singulair or Accolate and aggressive message has helped soften the capsule in some cases. At times, surgical treatment with opening or releasing the sides of the capsule (capsulotomy) may be performed. There is a chance that capsular contracture may recur. Some may chose to do a capsulectomy and Strattice ADM interposition as described below.

In more severe cases of firmness, hardness and breast distortion such as in Baker III or IV capsular contracture :

  1. With implants placed above the muscle, this may be treated by removing the capsule (capsulectomy) and replacing the implants under the muscle.
  2. With implants placed below the muscle, Dr Gershenbaum strongly recommends removing the firm and thickened capsule (capsulectomy), recreating an appropriate size submuscular pocket and interposition of Strattice. Strattice is an acellular porcine dermal graft that is attached/sewn to the lower border of the pectoralis muscle and wrapped over and around the implant, essentially replacing the older thickened and contracted capsule. Although the exact mechanism is not yet understood, Strattice, in replacing the sickened capsule, is incorporated as a non-reactive, non-allergic collagen cover that allows in-growth of blood vessels and tissue.

Some surgeons are not familiar with Strattice, or choose not to use Strattice for the treatment of Baker III and IV capsular contractures.  Capsulectomy alone in the treatment of capsular contracture has a high recurrence rate reported up to 50%. Dr Gershenbaum has been using Strattice in this manor for many years and has near 100% success in treating capsular contracture. With capsulectomy and Strattice interposition, Dr Gershenbaum has operated on women with distorted and rock hard breasts, who have failed prior surgical treatments, return to soft and natural appearing breasts. Strattice certainly adds cost to the surgical repair, but with up to a 50% recurrence rate without Strattice, it doesn’t make sense to attempt the repair without.

Stattice Reconstructive Tissue Matrix is FDA approved for soft tissue reinforcement and repair. Strattice for repair of capsular contracture, championed by many surgeons, is considered off label use.

Correction Capsular Contracture

Additional Breast Implant Deformities

Dr Sam Gershenbaum at the Brickell Riverfront Surgery Center, Miami Florida is truly an expert in correcting breast implant deformities from complications of prior surgery. With years of training and practice in reconstructive surgery, Dr Gershenbaum has the knowledge, experience and artistic skill to reshape and create a pleasing and aesthetic result from a poor result or complication. Whenever possible, Dr Gershenbaum uses the same incision location and excises the original scar leaving no trace of a second surgery.

There is a multitude of different types of breast implant deformities that can unfortunately result from previous surgeries. Improperly positioned, malpositioned or displaced implants can be corrected by adjusting the capsule around the implant. It is this capsule that forms the walls or boundaries of the implant pocket or space. If an implant is too low and/or too far out to the side, the capsule is repaired or closed down along the bottom and/or side to reposition the implant. Conversely, if the implant is too high or too close to the middle of the chest then the capsule would be opened at the base or side allow greater room and repositioning of the implant. Frequently, corrections call for both releasing the capsule in one or more areas to make more space along with repairing the capsule in the other areas to repair and prevent displacement. Depending on the quality of the patients tissues and capsules, as well as on the size of the implant, Dr Gershenbaum frequently uses GalaFLEX absorbable mesh to reinforce capsule repairs. It may also be desirable or necessary to change the size or type of implants used when both breasts are to be corrected.

Correction Bilateral Displacement

Synmastia occurs when the breast implants are too close or touching in the midline. This is repaired by repairing the capsules in the midline with sutures and GalaFLEX absorbable mesh preventing this medial displacement. This repair may also require opening the capsules lateral on the sides to make more room and may also include reducing the size of the implants if too large.

Correction Of Synmastia And Bottom Out

Poor shape may be due to the above problems of capsular contracture and/or malpositioned implants. Poor shape may also come from poor choices in implant size or implant shape. Was too large an implant used or an “anatomical” or teardrop shaped implant used that rotated and doesn’t look natural?  Perhaps two different size implants should have been used to improve asymmetry as described above. Sometimes, too large an implant accentuates problems in shape. For instance, in what is termed a “constricted breast”, the lower pole of the breast, that area of breast below the nipple, is insufficient as compared to the upper portion of the breast. If too large an implant is placed in a “constricted breast,”  the implant will tend to “ride” too high with the breast too full on top and the nipples will appear too low. A common mistake some surgeons make is to excessively over-dissect the natural inframammary crease to lower the implant which may create a “double-bubble” deformity. A “double-bubble” deformity is where the implant is excessively lowered in an attempt to make it fit, however, a portion of the implant bulges unnaturally below the inframammary crease creating a “double-bubble” effect. This deformity must be corrected surgically by suture repairing or reducing the overzealous pocket and may include reinforcing the repair with GalaFLEX absorbable mesh. Hence, there are certain breast sizes and shapes where conservative implant sizes produce more favorable results.

Poor shape after breast augmentation may also be due to the wrong choice of procedures or the failure to include necessary procedures with breast augmentation. For instance, was a breast augmentation performed when a breast lift was also needed producing a “snoopy-dog” or “waterfall deformity” appearance where the breast tissue and nipple slide down over the breast implant mound ?  In this case, a breast lift is also needed.

“Waterfall” or “Snoopy Dog” Deformity

Correction of “Waterfall” or “Snoopy Dog” Deformity

At times, especially in thinner patients, poor shape and a less natural appearance may be associated with implants placed on top of the muscle. Breast implants placed on top of the muscle are more likely to show waves or ripples made by the implant, especially with textured implants. A textured implant adheres to the overlying tissues and is much more likely to reveal noticeable rippling or waves on the breasts especially in thinner patients. Smooth implants, however, move inside the “pocket” or space and slide to the most dependent area within the capsule which also more closely mimics natural breast. Implants placed over the muscle may tend to sag more over time due to the weight of the implants in the breasts. The benefits of placing the implants under the muscle include a lower incidence of capsular contracture, a lower chance of obvious rippling or wrinkling, less ability to feel the implant, and a more natural slope to the breast because of the additional muscle coverage. Also, with the implants behind the muscle, mammograms are easier to review.

Breast implant revision also includes replacing ruptured silicone implants. The risk of implant rupture increases with implant age, and eventually all breast implants will rupture if not replaced prior. Modern cohesive silicone gel implants are reported to last up to 20 years or longer with a report of near 80 percent of implants intact after ten years and near 50 percent intact after fifteen years. A ruptured silicone implant maybe realized by a change in feel or a change in shape or only discovered by a mammogram or MRI. Ruptured silicone implants are the number one cause of latent capsular contracture. Ruptured silicone implants are not considered a medical emergency, but should be changed as soon as possible. Intracapsular rupture means the capsule is intact and the silicone is contained within the capsule. In this case, an en bloc capsulectomy or total intact capsulectomy may be performed that removes the ruptured implant and intact capsule together as a whole to reduce or prevent silicone exposure to the surrounding breast tissues. An extracapsular rupture means the capsule is no longer intact and the silicone has extended into the surrounding breast tissue. A capsulectomy would be performed here as well as exchanging the implants. Silicone implants are warranted for life and will be replaced by manufacturer if rupture occurs.

Other problems include deflation of saline implants, which typically last up to 20 years. Deflation can happen rapidly or slowly over weeks or months. The chances of deflation (leaking) can be increased by under-filling implants by the surgeon, which causes more creasing, and eventual wear and tear overtime leading to premature deflation. Over inflating a saline implant likewise can cause premature deflation by having excessive pressure inside over time. Saline implants are warranted for life and will be replaced by manufacturer if deflation occurs.

Sometimes an unsatisfactory result and request for breast implant revision can be due to size of the implant. There are times when simply too large of an implant was used to obtain a desirable result. Smaller implants may be all that is needed to improve overzealous attempts at breast augmentation. Significant reduction in the size of an implant may require a capsule space reduction or repair as well. Conversely, some may wish to increase their breast size to improve body symmetry and proportions. This will generally entail exchange to larger, but appropriate size implants and further opening of the capsule to accommodate larger implants.

At times, breast implant revision is a matter of fixing and revising unsatisfactory scars. There may also be times where by choice or by necessity, an implant may be removed altogether which may include a breast lift, fat grafting or just time to heal and realize if anything further needs to be done at all.

Breast Implant Scar Revision

Breast Implant Revision Complications

As with most surgical procedures complications are unlikely when performed by a skilled and competent surgeon. As can be realized by this lengthy discussion, correcting breast implant problems or complications often involves many decisions. It often requires time and patience during the healing process as well. Corrective or revision surgery, by nature, will always carry with it some degree of unpredictability, as well as the associated risks and expense. Complications include, but are not limited to anesthesia risks, bleeding, infection, poor cosmetic results, capsular contracture (firmness or hardening of the healing tissues around the implant), deflation, poor healing with prominent or obvious scars, soft tissue loss, numbness, altered nipple sensation, loss of nipple sensation, asymmetry in breasts and/or areolas, enlarged areolas, Breast Implant Associated Anaplastic Large Cell Lymphoma ( BIA-ALCL) predominantly associated with textured implants, Breast Implant Associated Squamous Cell Carinoma (BIA-SCC), and need for revision surgery or implant removal. Also rare, but possible are blood clots or emboli (blood clots which dislodge and travel in the blood stream to distant sites).

Venodyne calf compression devices are used for every breast augmentation surgery (as well as other surgeries). Venodynes are pressure cuffs that fit over each lower log from the ankle to the knee circulating every one to two minutes to reduce the pooling of blood in the lower extremities and further reduce the possibility of blood clots or emboli. Smoking seriously decreases blood circulation in the skin which increases the risks of complications and poor healing.

What Is The Cost For Breast Implant Revision

The cost for breast implant revision can only be determined after an in depth and careful evaluation. There are many options and variables in deciding on the best course of procedure(s) and the need for different material in determining the cost of breast implant revision surgery. The cost of breast implant revision in Miami will also vary depending on several factors including the practice, the surgeon, the surgery center and the anesthesia provider whether physician or nurse anesthetist.  Please check out the article on my website under patient education, What’s In A Surgical Fee to help better understand why prices vary.

Contact Dr Sam Gershenbaum in Miami, Florida for Breast Implant Revision

If you’re unhappy with the results of your previous breast augmentation or for breast augmentation revision or breast implant removal in Miami Florida  with award-winning and world renown Miami board certified plastic and reconstructive surgeon, Dr. Sam Gershenbaum servicing Miami, Aventura, Fort Lauderdale, Boca Raton and Palm Beach For more information on breast augmentation, or to schedule your appointment, click here to our Contact Form, or simply call 305-933-1838…….. Because YOU deserve the best!

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