Breast Revision – General Description
Even in the face of proper planning and execution of a breast implant surgery, changes can and do occur leading to the consideration of undergoing breast implant revision surgery. These changes can be implant-related or from natural changes in the breast tissue such as after childbirth and breast-feeding. The goal of the plastic surgeon with the first time breast implant surgery is to help the patient achieve their goal by choosing not only the right implant but the proper surgical procedure.
The more common reasons for seeking revision breast surgery are implant deflation, a desire to change implant (size or type), capsular contracture, implant malposition, double-bubble deformity, and combination issues. Many women are not good candidates for a breast augmentation alone at the time of their first implant surgery and should have undergone a breast lift alone or with an implant. A common example of this is a patient who has breast laxity or sagginess after having had children or losing weight. Every patient is an individual and should be evaluated and treated as such.
Am I a good candidate for breast revision surgery?
You may be a candidate for breast revision surgery if you have one or more of the following conditions:
Loss of saline implant volume – implant deflation
X-ray (MRI) suggesting a silicone implant with a shell leak
If you desire to change implant/breast size
Tightening of the scar tissue around the implant (capsular contracture)
Breast implants that have shifted in position
If your breast tissue has changed in shape or volume from skin stretch or weight loss/gain
Your Surgical Experience
During your consultation, you will be asked about your desired breast size and anything else related to the appearance of your breasts that you feel is important and would like to change. This will help your plastic surgeon understand your expectations and determine whether they realistically can be achieved. It will be very helpful in the evaluation and planning of your revision surgery if you are able to provide your plastic surgeon with information on your implants and surgery. This information can often be obtained with your permission from your last surgeon.
How will my ASAPS plastic surgeon evaluate me for breast revision surgery?
Your plastic surgeon will examine your breasts and perhaps take photographs for your medical record and planning. He or she will consider such factors as the size and shape of your breasts, the quality of your skin and breast tissue, the position of your nipples and areolas and all aspects of your current breast implants. If your breasts are sagging, a breast lift may be recommended in conjunction with breast implant revision surgery.
You should come to the consultation prepared to discuss your past medical history. This will include information about any medical conditions, drug allergies, medical treatments you have received, previous surgeries including breast biopsies, and medications that you currently take. You will be asked whether you have a family history of breast cancer and about results of any mammograms. It is important for you to provide complete information.
If you are planning to lose a significant amount of weight, be sure to tell your plastic surgeon at your consultation. He or she will recommend that you stabilize your weight prior to undergoing breast revision surgery.
If you think that you may want to become pregnant in the future, you should mention this to your plastic surgeon. Pregnancy can alter breast size in an unpredictable way and could affect the long-term results of your breast revision surgery. There is no evidence that breast implants will affect pregnancy or your ability to breast-feed, but if you have questions about these matters, you should ask your plastic surgeon.
Description of Issues Possibly Needing Breast Revision Surgery
Breast Implant Deflation
Saline implants can leak or “rupture” leading to a distressing situation for the patient. Although it is helpful to evaluate and treat these patients as soon as possible a carefully planned approach can be taken to alleviate anxieties. Most implants placed in the US now come with an implant warranty where the implant manufacturer may replace the implant(s). The same is true of silicone implants except you would not know if your silicone implant had a structural defect, aka crack, unless you had surgery or an MRI to tell you that there was a chance that the implant was defective. Treatment may be as simple as removing the deflated implant and replacing with the same size or you may have decided that you would like to change your implant size. If you have a capsular contracture or thin tissues covering your implants, there may be good options to improve on your breast aesthetics. If it has been awhile since your primary surgery, your breasts may be different from changes in your weight or with pregnancy. IIf this is the case you may need to entertain having a breast lift in addition to tighten your breast tissue and move your nipple to a position more at the apex of your breast.
Desire to Change Implants
A Desire to Have Larger Breasts
The goal with your primary breast implant surgery is to choose an implant that both fits your body frame and tissue characteristics. If you choose to have a breast implant revision to change to larger implants, it is very helpful to have the information about your current implants so that an intelligent decision can be made about the change you would like to make. This surgery as well can be relatively simple or require more tissue release to make room for the larger implants. It is important to realize that the larger the implants you have, the more stress there is that is exerted on your tissues.
A Desire to Have Smaller Implants
Just as with changing to a larger implant size, some patients choose to decrease their implant size after their initial surgery. The choice of a breast implant should be based by questioning the patient’s desired outcome, a careful analysis of the dimensions of the breast and chest, tissue characteristics, and a good dose of common sense. If you choose to decrease the size of your implants, it may not be as simple as placing a new implant. The capsule that surrounds the implant may need to be tightened with internal suturing (capsulorrhaphy) and the skin may need to be tightened or lifted.
It is not known precisely what causes the capsule or scar that surrounds an implant to tighten. Trauma or bleeding around the implant, an infection either of the breast or even elsewhere on the body or just plain idiopathic (unknown cause) are the reasons felt to be causative in nature. Once a capsular contracture has declared itself and become symptomatic it will most likely require surgery to repair. Other more conservative modalities that can be tried include aggressive massage, Vitamin E, Accolate or Singulair (prostaglandin inhibitors) and even therapeutic ultrasound. There are mixed reports of success, most of which are anecdotal in nature. Surgical treatment can involve either removing the entire capsule (capsulectomy) or opening the capsule by making cuts in it (open capsulotomy). Other options can involve placing the new implant partially under the muscle to decrease exposure to breast tissue where there can be bacteria to cause recurrence of the capsule. The decision will depend on many factors including the type of implant, how old they are, covering tissues, etc.
The capsule that surrounds the implant ideally allows enough room for a soft and natural feeling breast but if it is too large it will allow the implant to move farther than is desired leading to implant malposition. Treatment revolves around properly diagnosing the problem and repairing it with either internal sutures alone or what ever other external technique is required, such as a breast lift. There are also newer described techniques that allow use of the existing capsule in a very creative way to support the new implant position. More information is being published about the use of acellular dermal matrix which can be suggested by your plastic surgeon as a part of your surgery.
Synmastia, so called uni-boob or bread-loafing, occurs when the pockets that the implants are in communicate with each other across the midline. This is a difficult problem but with proper planning can be corrected. This is not a common occurrence but can happen to various levels in women with chest wall concavity as well as with the use of larger wider implants. Repair can be accomplished with internal suturing with or without the use of acellular dermal matrix which may help to bolster the repair.
This finding can occur when an attempt is made to lower the infra-mammary fold with the primary breast augmentation. The look is that the implant is there and the patient’s breast is almost stacked on top of it. This may also be seen when an implant is placed under the muscle in a patient who probably should have a breast lift as well. The treatment required depends on the cause. Treatment may involve releasing the muscle inside, repairing the capsule repaired inside or moving the implant from below to above the muscle.
Implant Coverage Problems
If the breast tissue covering the implant is too thin you may see rippling of the implant through the skin. In the upper breast these are referred to as traction ripples and are classically seen in implants placed above the muscle. Treatment is focused on trying to provide a thicker coverage and that can be best attained by moving above muscle implants to partially below the muscle, called a site change. Some hope exists with pending approval of the more cohesive or form stable silicone implants, aka gummy bear implants, which ripple less and may function better in thinner women. Other options are to use a sheet of acellular dermal matrix to line the pocket and provide more thickness. Fat grafting to provide increased cover is being researched but this is not yet mainstream in aesthetic surgery. Your plastic surgeon will be able to review your options with you after examining you and reviewing your surgical history.
Changes in Your Breast Tissue
It is not uncommon for a patient’s breasts to go though changes after you have breast augmentation. This can occur as a result of the patient undergoing fluctuations in weight, changes in the breast from pregnancy and breast feeding, and changes or shifting of implant position. Surgical correction starts with a through evaluation and careful planning. Your surgery may involve changing implants, altering the capsules, changing the position of the implant and tightening the breast tissues in the form of a breast lift.
Your Surgical Experience
How Should I Prepare for Breast Revision Surgery?
In some instances, your plastic surgeon may recommend a mammogram before revision surgery. Following breast revision surgery, you will still be able to perform breast self-examination.
These are elective procedures and your safety is the most important factor to consider. If you are a smoker, you will be asked to stop smoking well in advance of surgery and for a period of time after to minimize the chance of complications. Aspirin and certain anti-inflammatory drugs can cause increased bleeding and bruising, so you should avoid taking these medications for a period of time before surgery. You may be asked to undergo medical clearance depending on your age and your overall health.
Breast revision surgery is usually performed on an outpatient basis. If this is the case, be sure to arrange for someone to drive you home after surgery and to stay with you at least the first few nights following surgery.
Where are the incisions placed?
The incision(s) used will depend on how much change is needed. For straight forward implant or capsule surgery your plastic surgeon may be able to use your original scar from your previous surgery. If there is a need to elevate the position of your nipple and areola, there will be a need for breast lift scars. One incision will be around the areola in the simpler cases where not much elevation is needed. For times when more lifting and tightening will help, another incision will run vertically from the bottom edge of the areola to the crease underneath the breast. The third incision is horizontal beneath the breast and follows the natural curve of the breast crease. If the nipples need to be lifted, the nipples and areolas remain attached to underlying mounds of tissue, and this usually allows for the preservation of sensation and the ability to breast-feed.
What will the day of breast revision surgery be like?
Your breast revision surgery may be performed in a hospital, free-standing ambulatory facility or office-based surgical suite. Like your previous breast surgery, medications are administered for your comfort during the surgical procedure. Occasionally, local anesthesia and intravenous sedation may be used for patients undergoing some revision surgery, although general anesthesia may be more desirable in most instances. When surgery is completed, you will be taken into a recovery area where you will continue to be closely monitored. Your breasts will be wrapped in gauze dressings or a surgical bra depending on your plastic surgeon’s preference. You may be permitted to go home after a few hours, unless you and your plastic surgeon have determined that you will stay in the hospital or surgical facility overnight.
How will my breasts look and feel after the revision surgery has been performed?
You should be up and walking on the day of surgery. Depending on your plastic surgeons’ preference, your dressings will be removed within a few days after surgery. You may be instructed to wear a support bra during your early healing period. Your plastic surgeon will probably permit you to shower between one to three days following surgery but you should not immerse your breasts under water in a tub, spa or Jacuzzi for at least 4 weeks after surgery as long as you are healing well. Stitches that don’t dissolve on their own will be removed in about a week.
Some discoloration and swelling may occur initially, but this will resolve as you heal. Most residual swelling will resolve within a month. Healing in revision surgery will take a little longer that your first breast surgery.
It is important to follow all patient care instructions as directed and stay in close touch with your plastic surgeon’s office as you heal.
When can I expect to resume my normal activities after my breast revision surgery?
While it will take several days to return to more normal activities after your breast revision surgery, it is important to your recovery that you get up and move around. After breast revision surgery, it is often possible to return to work within 7 to 10 days, depending on the type of activities that are required at your job. Heavy physical activity should be avoided for at least the first couple of weeks following surgery. After that, care must be taken to be gentle with your breasts for at least the next month. Your plastic surgeon will give you specific instructions and restrictions in terms of physical activity.
How long will the results last?
Unless you gain or lose a significant amount of weight or become pregnant, your new breast shape should remain fairly stable. However, gravity and the effects of aging will eventually alter the size and shape of virtually every woman’s breasts. It is important to realize that the weight of the implant used will also effect how your breasts appear as time goes on. The goal of revision breast surgery it to help restore a more youthful contour and appearance.
Will my insurance help cover the cost of surgery?
Breast revision surgery, as an aesthetic (cosmetic) procedure, generally is not covered by insurance. Under certain circumstances, however, insurance coverage may be available. For example, if a breast implant revision after breast cancer reconstruction is performed, the opposite breast may need to be modified for symmetry. Many factors determine your eligibility for coverage, including the specific terms of your insurance policy. A letter of predetermination may be required by your insurance company prior to surgery. Your plastic surgeon or a staff member in your surgeon’s office will discuss these matters with you.
Every year, many women undergo successful breast revision surgery; however, anyone considering surgery should be aware of both the benefits and risks.
The subject of risks and potential complications of surgery is best discussed on a personal basis between you and your plastic surgeon.
Some of the potential complications that should be discussed with you include reactions to anesthesia, blood accumulation that may need to be drained surgically and infection. Although rare, an infection that does not subside with appropriate treatment may require temporary removal of the implant. Changes in nipple or breast sensation may result from breast revision surgery, although they are usually temporary.
When a breast implant is inserted, a scar forms around it as part of the natural healing process, called a capsule. The capsule may sometimes tighten and compress the implant, causing the breast to feel firmer than normal. Capsular contracture can occur to varying degrees. If it is severe, it can cause discomfort or changes in the breast’s appearance. In such cases, more surgery may be needed to modify or remove the scar tissue, or perhaps remove or replace the implant.
Breast implants are not lifetime devices and cannot be expected to last forever. If a saline-filled implant breaks, its contents are harmlessly absorbed by the body. A definite change in the size of the breast is clearly noticed. Implant deflation can occur as a result of trauma to the chest, but more commonly it occurs spontaneously with no apparent cause. Surgery will be required to replace the implant, if desired.
If you are at an age when mammographic examinations should be conducted on a periodic basis, it will be important for you to select a radiology technician who is experienced in taking x-rays of augmented breasts. Additional views of your breasts may be required. Your plastic surgeon, in some instances, may recommend other types of examinations such as ultrasound or magnetic resonance imaging (MRI). It is possible that the presence of breast implants could delay or hinder the early detection of breast cancer.
In the past some women with breast implants have reported problems including certain connective tissue and immune-related diseases. Women without implants also have these disorders, so the key question is whether breast implants increase the risk of developing the conditions. Several large studies have been completed that provide reassurance that women with breast implants do not have a significantly increased risk for these diseases. Silicone implants were approved by the FDA in Nov 2006 and 14 years of investigation in thousands of women.
Maintaining a Relationship with Your Plastic Surgeon
You will return to your plastic surgeon’s office for follow-up care at prescribed intervals, at which time your progress will be evaluated. Your plastic surgeon will encourage you to schedule routine mammographic evaluations at the frequency recommended for your age group after you have recovered. Please remember that the relationship with your plastic surgeon does not end when you leave the operating room. If you have questions or concerns during your recovery, or need additional information at a later time, you should contact your surgeon.