Revisional Breast Surgery

Although a plastic surgeon may have done all they can to ensure a successful breast surgery, complications and unsatisfactory results can occur. Some resolve over time without revisional surgery. Occasionally, the effects are permanent and may need additional surgery to improve the final appearance of the breasts. Unsatisfactory results can occur even with the most expert plastic surgical care, but occasionally the disappointing appearance may have been result of a surgeon trying to perform breast surgery beyond his or her skill or from an unqualified physician.  Many potential problems can be avoided by careful planning and thorough approach to breast surgery.  Whatever the cause, revisional breast surgery is exponentially more complicated requiring special skills and significant experience. Due to this complexity, it is especially important to choose a plastic surgeon with revisional experience.

I have had extensive experience with revisional breast surgery.  I have mastered the technique necessary to give you the best possible result and in most cases in one operation.  Revisional breast surgery can be one of the most challenging surgical procedures but it is also the most rewarding.

The need for breast augmentation revisions stem from a number of sources but fall into several broad categories:

• Problems with surgical placement or implant position
• Problems with the patient’s tissue characteristics
• Problems with the implants themselves

When a problem does arise, the proper correction focuses first and foremost on carefully diagnosing why the problem exists. Many patients have a problem that falls into more than one of the above categories, creating an even more challenging situation. 

Problems With Surgical Placement or Implant Position:

• Implant asymmetry with one implant higher than the other or located too far medially or laterally with respect to the other implant.
• Bottoming out occurs when implants are being positioned too low on the chest wall in relation to the nipple position.  This may represent over dissection in the region of the inframammary crease during surgery, cutting of the lower portion of the muscle, or may occur naturally with implants that are placed above the muscle.
• Synmastia (uni-boob) usually represents over dissection in the medial region of the breasts over the breastbone in an attempt to create better cleavage.
• High riding implants that remain too high postoperatively (and do not “drop” or “settle” into the correct position).
• Lack of Cleavage:  Implants that are too widely spaced apart, lacking desirable cleavage or falling into the armpits upon lying down.

Problems With The Patient’s Tissue Characteristics:

• Snoopy deformity occurs when the breast tissue droops over the implant.  This may be prevented by careful preoperative evaluation.
• Areolas that appear too large before or after augmentation- does not necessarily require revision, but should be addressed during the initial consultation and treated during the initial operation if it is of concern to the patient.
• Tuberous breasts are characterized by a narrow base of the breast, a widening of the breast near the nipple-areolar complex, and a short or deficient inframammary crease.  Tuberous breast deformity also has a prominence of the nipple-areolar complex characterized by herniation of some of the breast tissue into the nipple-areolar complex.  This deformity should be addressed during the initial operation because if overlooked or not treated properly will inevitably lead to an unsatisfactory outcome.
• Mondor’s cord represents a thrombophlebitis of the superficial vein(s) of the breast, typically between the nipple and the inframammary crease and usually causing significant discomfort.  This usually does not require a revisionary technique but is usually treated with anti-inflammatory medications and warm compresses until spontaneous resolution occurs.
• Thinning of the breast tissue as a result of aging, pregnancy, or breastfeeding (which may result in the implants becoming more visible and the appearance less natural).  An elongation of the skin and sagging of the breasts over time as tissue elasticity is lost as a result of aging, sun damage or smoking.
• Pre-existing natural asymmetry not corrected during the initial operation- most breasts differ from one another, sometimes greatly. This may be a difference in size, shape or position and is rarely perfectly corrected during surgery. However, asymmetries should be properly diagnosed and documented preoperatively in an attempt to correct the asymmetry as much as possible during surgery.

Problems With The Implants:

• Deflation (rupture of an implant)- with saline implants this is usually quite obvious because the augmentation effect is rapidly lost over the course of a day or two.  Although the saline is harmlessly absorbed by the body, replacement of the implant should be performed within a few weeks to keep the pocket from shrinking. With silicone implants, rupture may be less obvious and may require further testing to confirm, such as a MRI. Most implants used today have a full replacement warranty that will provide you with replacement implant(s) at no cost to you. Depending on how long it has been since your original operation, you may also be eligible for financial assistance towards the operating room costs as well.
• Capsular contracture is when your body forms a thick scar around the implant(s).  This may occur on one or both sides and may cause a shape change, discomfort, and may cause the breast to feel more firm.
• Dissatisfaction with the size of your implants either too small or too large

Combination Problems:

• Double Bubble (when there is the appearance of the round breast sitting on top of a round breast implant)-this may represent a problem with the tissue characteristics as well as a problem with the surgical placement of the implants and may occur on one or both sides.
• Rippling (when irregularities of the implant surface are felt or seen through the skin)-this may develop as a result of a thinning of the tissue covering the implants, may result from an implant that is underfilled or leaking, and may represent a placement problem such as an implant being placed above the muscle of the chest wall or some combination of these events.
• Implant visibility (being able to see the outline of the implants through the skin)-see rippling explanation.
• Implant palpability (being able to feel the implants beneath the skin)-see rippling explanation.

Solutions To Breast Augmentation Problems

Depending on your specific problem, a specific solution exists. These may include:

• Implant Exchange: replacing your present implants with new implants that may be smaller or larger, overfilling to change the appearance of the implants in an effort to reduce rippling, changing the present shape of your implants to a new shape such as High Profile, Smooth or Anatomical implants, changing the surface of the implants from smooth to textured or vice versa, or changing the filling of your implants from saline to silicone or vice versa.  Some may also be candidates for the new “gummy bear” implants.
• Capsulectomy: removing the entire capsule surrounding the implant is the definitive, state of the art treatment for capsular contracture and may be combined with moving the implants into a totally submuscular position and even an exchange to a textured surface implant may be performed to reduce recurrence rates.
• Capsulotomy: making incisions in the capsule surrounding the implants to change their position.
• Pocket Change: moving the implants from above the muscle to below the muscle can provide better soft tissue coverage of the implants, reducing a number of the potential complications described herein.
• Neopectoral pocket: an advanced technique to take advantage of the pre-existing capsule to create a new pocket for your implant.  This is an ideal method to correct lateral migration and synmastia.
• Mastopexy (breast lift surgery) depending on the amount of reshaping that is required, various techniques exist.
• Capsulorrhaphy: Internal pocket adjustment for inframmamry or lateral or medial control of implant placement.
• Areolar reduction
• Correction of natural asymmetry (which may require implants of different sizes or shapes as well as adjustment of the inframammary crease on one or both sides).
• Scar revison