Westlake Plastic Surgery

Breast Revision

Age 37: Breast Revision

This is a 37 year old mother of two, 5’7” and 140 pounds who had a previous breast augmentation done elsewhere. She told me she wanted larger breasts and more cleavage.  On examination, she has laterally located breasts and a gap between her breasts. Her implants feel relatively soft and small in size. We discussed options at length. I felt that she would actually benefit from larger implants because they would fill out her dimensions better, and I would adjust the pockets so that her breasts would appear closer together.

I used her old incision beneath the breast and removed her submuscular saline implants that were 275cc in size. I adjusted the pockets on both sides and placed smooth moderate saline implants filled to 355cc on the right side and 420cc on the left side. I noted at the time of her surgery that her ribs were very sloped beneath her breasts and that there was significant differences in the size of her breasts.

She is seen in these pictures well over a year from her revision. You can see that her breasts are larger and fuller and they fit her dimensions much better. Her breasts are closer for sure, and her cleavage is more pronounced. She is wearing an excellent bra because this is mandatory because it will keep her breasts in the best position possible.

Learning points:

1. Sometimes you have to go larger with your implants so they actually work best for your particular anatomy. The whole idea is to get the size right from the beginning. This is where I spend a lot of time with my patients during the pre-surgery counseling.
2. I would have preferred silicone implants over the saline but she wanted saline.
3. Since her ribs are sloped under her implants, they will always want to move laterally and down as they did the first time. The only way to keep this from happening again is to use a very supportive bra more often than you can imagine.
4. Most surgeons talk about what beautiful breasts they make and how wonderful they are. What about talking about how my breasts will look five or ten years down the line? If this is a reasonable time line for you, then you need to know about choosing an implant size that is sustainable for the long term and you need to wear a great bra to provide long term support to protect your investment.
5. I can guarantee you that her breasts would not look this good if she didn’t wear the bra you see in the pictures.
6. Anatomically, some breast will get more cleavage after a breast augmentation than others. If your breasts are far off to the sides of your chest, you won’t be the patient who gets a lot of cleavage after an augmentation. However, you can expand the implant pocket towards the midline of your chest and this will allow you to move your implants towards the midline.

Age 40: Breast Revision

This is a 40 year old female, 5’3” and 115 pounds who had a previous breast augmentation many years ago above the muscle with saline implants and she developed a bilateral breast contracture. Her breasts were rock hard, did not move, and they were painful to her. It’s interesting that if you look at her pre surgery photos, they don’t look bad. The problem is that they are stuck on and rock hard and painful to touch.

We discussed options at length. She wanted larger implants and she wanted saline implants because they were less expensive than the silicone variety. At her surgery, I removed her contracted saline implants that were above the muscle. I removed the capsule around the implants at the same time. I put in 420cc saline implants beneath the muscle and used acellular dermal matrix to help support the muscle with the larger implants. She is seen here about 1.5 years after surgery. Her breasts are soft and certainly larger. You can see how she can move them to the midline. I can feel rippling around the perimeters of her implants as she has a very thin layer of skin on top of her implants. She is pleased. She wanted me to put in larger implants but I told her that I wouldn’t.

Lessons to learn:

1. Implant contracture is the most common problem associated with breast implants. It tends to happen (if it does) within five years of surgery, but it can occur at any time.
2. The use of ADM (acellular dermal matrix) is used in her case to help support her implants internally as she has very thin tissues and the implant would overwhelm the thin tissue with these larger implants in no time.
3. She wanted larger implants. I would have preferred smaller ones from an engineering perspective and from a potential complication perspective.
4. The rippling of her implants can’t be seen in her pictures—I can feel the ripples when I examine her breasts. This would no likely occur if she had silicone implants. She would do better with silicone implants but she didn’t want to pay the increased cost of the implants. I told her that anytime in the future if she wanted to exchange out the saline for silicone that this would be relatively easy.
5. It has been my experience that the submuscular location of an implant is better than when it is above the muscle.
6. Because of her thin tissues and larger implants, the use of a support bra is very important. I want the weight of her implants to be supported by the bra, and not her tissues.

Age 29: Breast Revision

This is a 29 year old mother of one, who is 5’2” and 119 pounds who had three previous breast surgeries and eventually presented to me because her breast implants have “bottomed out”. She said she developed a hematoma on the right breast after surgery then had two additional procedures to position the breast implants and they didn’t work.

She has 400cc high profile silicone implants in the submuscular position. You can clearly see that her breasts have bottomed out to some degree, right side much more than the left. It has resulted in her right nipple areola complex moving upwards and the scar on the right breast lifting off the crease on to the front aspect of the breast. Her right breast implant is a lot lower than the left side. The bottom of the breast feels very unsupported on examination (the skin is holding up her implant only).

I revised her breasts by keeping the same implants in the submuscular position and using ADM (acellular dermal matrix or pig skin) to help stabilize her chest muscle that was displaced and to help shore up the bottom of the breast. I adjusted the breast implant pockets so her implants don’t move off to the side like they did before surgery.

She is seen here about one year out from her procedure. Her breasts are soft and symmetrical. There is no longer bottoming out and her breasts are “front and center”. She wears a great supportive bra to keep them there day and night. Her right nipple areola complex has been lowered into a normal position and the scar on the right breast is now in her inframammary fold area where it belongs. Her scars are still red and will continue to lighten in color over the next year.

Lessons to learn:

1. Repeated attempts to raise a breast means failure of the technique to raise the breast implants and provide stability. In this case, the use of acellular dermal matrix is important to stabilize the chest muscle and support a new “floor” for the breast implant so it stays where I put it.
2. It is critical to wear a great bra to keep her breast in the best position. Gravity will still work on my repair to move the implants down and under her arms if not supported.
3. As of this writing (2012), acellular dermal matrix has been proven to be very effective and reliable in breast revision procedures with very few complications with its use next to a breast implant.
4. Unfortunately, the photos in her case don’t do her results justice. Her breast look more symmetrical and better positioned for sure, but they feel so much better, more stable than they did before her revision.
5. The use of acellular dermal matrix adds considerable cost to any breast procedure because it is not inexpensive—but it is very effective.

Breast Revision

This is a young mom who had a previous breast augmentation with us and was thinking that her implants were too large and heavy and that they settled to some degree off to the sides over time. She was augmented with 385cc moderate profile saline implants beneath the muscle through an incision at the bottom of the breast. Her figure is relatively thin and athletic.

I removed her saline implants and replaced them with 325cc high profile silicone implants in the same pocket. I did adjust the pocket so that it moved her implants to the midline. She is very pleased with her results, and finds her new size more comfortable and better proportioned. She really enjoys the “feel” of the silicone implants over the saline variety.

Lessons to learn:

1. Too much can sometimes be too much.
2. Change can be good.
3. Women who have had both saline and silicone implants almost always prefer the silicone variety. In her own words the difference between saline and silicone implants is “Night and day. The saline was like having water balloons on my chest. Silicone seems more natural and fits my sporty lifestyle much better!”
4. Shape is often more important than size.
5. To keep her implants “up front” she needs to wear a bra that keeps them there. Most women do not wear the correct fit for their breasts.
6. Like anything in life, moderation is key to success.
7. High profile implants appear “perkier” than the low or moderate profile in most patients, but not always.

Age 42: Breast Revision

This is a 42 year old mom, 5’5” and 149 pounds who presented to me complaining of a saline implant deflation. She had her original procedure done elsewhere. We discussed her options, including types of implants and above and below the muscle as well as a breast lift. Her breasts are sagging OFF her implants. Her implants are sitting a bit high relative to her breast tissue. This makes for the saggy appearance. I can clearly feel the implant and then the loose breast tissue falling off it.

She doesn’t want a lift. She is seen here after the removal of her old saline implants and the placement of new silicone high profile 325cc implants in the same subglandular pocket. I adjusted the pockets internally to move her implants more medially and lower. By lowering the implant this will “take up” some of the loose tissue at the bottom of the breast (or at least this is what we hope!)

There is a dramatic improvement in the appearance of her breasts. No longer is her breast tissue falling off her implant. The difference in the “feel” of her breasts from the saline variety of implants is very positive. They look and feel quite natural. Keeping her breasts to the midline of her chest is important so that they don’t fall off to the side over time. Yes, this means wearing a bra at night as well!

Lessons to learn:

1. Adjustments can be made to improve the appearance of almost all breasts as they change over time.
2. Most patients who have had both silicone and saline implants generally prefer the silicone variety.
3. Going larger on implant size will certainly fill out the breast more but sometimes too large and implant can ruin things. In her case, her original implants were the same size as the ones that I replaced.
4. She wishes that she had gone larger with her implants. This isn’t always the case, but you will hear this more often in patients that are very happy with their results. What they haven’t learned the hard way is that sometimes too much implant can cause problems that results in the wish for smaller ones.
5. My experience is that subglandular implants don’t fare as well as submuscular implants, but not always.
6. It’s requires great surgical judgment and experience to help a patient to make a decision on “what to do” given the various options. Ultimately, success is measured with a happy patient. Having excellent patient rapport is critical and patients need to have realistic expectations.
7. The key to her long term success is a great bra.

Age 53: Breast Revision

This is 53 year old mother of three who is 5’5” and 130 pounds who presented to me for a breast revision. She had breast implants placed twenty some years ago and now they are contracted and painful. You can see on her pre-operative photos that her breasts appear “stuck on” and unnatural. They were rock hard and non-mobile. They were very painful to her and her breasts looked distorted even in her clothing.

She is seen here after a bilateral breast revision. I removed her silicone/saline implants that were about 360cc in total volume each side. I removed the implant with the surrounding scar capsule from the position on top of the muscle and built a new home below the muscle and placed 350cc high profile implants. I removed about 70 grams of tissue from each breast and adjusted the skin of her breast through a vertical lift with resulting lollipop shaped scars.

Her breast are soft, natural looking and with excellent scars (even though she is only six months from her procedure). She has NO PAIN. She is wearing an excellent bra that shapes and supports her breasts. She couldn’t be happier, and we couldn’t be happier for her!

In her own words:

The reason for me writing this message is simple… I want to encourage the women that are out there second guessing themselves about having this type of surgery done.

I had silicone implants done over 20 years ago. Within the first few years they started to harden and year after year they continued to get worse. My boobs felt very heavy, hard and painful not to mention they looked like rocks in a sock. Seeing what they looked like after Dr. Caridi removed them I now understand why they felt that way.

It is amazing what we convince ourselves is okay and that it really isn’t that bad. I really didn’t like the way I looked without clothes and liked even less how my boobs felt.

I finally made an appointment with Dr. Caridi. My husband attended the appointment with me because he had questions and concerns of his own.

After the appointment driving home I decided that I  wanted to have this surgery and it would be with Dr. Caridi and his wonderful team that I would trust to do this surgery. This surgery not only was to remove the old implants but to do a lift as well. My old implants were on top of the muscle so my skin had stretched considerably over 20 years.

I went into this hoping to get softer, perkier and pain free boobs and I got all this and more. No more rocks in a sock looking boobs for this girl!

Thank you Dr. Caridi and your entire staff you all have made me feel like my best interest was your priority.

Sincerely,

So Glad I Did It

Age: 37 Breast Revision

This is a 37 year old mother of one, 5’7” and 170 pounds who had a previous augmentation/breast lift and was not satisfied with her results (it was performed elsewhere). She complained of loose skin and large areola diameters. She had saline implants 350cc in volume beneath the muscle. The procedure was performed with an incision only around the areola on both sides (sometimes referred to as a “Benelli lift”). The resulting scars are only around the areolas (which sounds attractive to patients).

We discussed options at length. Certainly you can argue that her breasts are fine (albeit imperfect according to her). In this case I recommended that she consider a revision of her previous work (secondary breast work—it’s already been worked on). I suggested she change out her existing saline implants for the silicone variety and adjust the skin of the breast with a vertical lift and the removal of a modest amount of tissue along the bottom of the breast that “hangs” a bit. The resulting scar would be lollipop shaped and the areolas can be made smaller.

She is seen here about five years after her procedure. Our goals have been met (sort of). Her breasts are tighter (you can’t necessarily appreciate this in a photo), her areolas are certainly smaller, and her breasts look perkier to some degree. The “trade off” is the new vertical scar which, in her case is very good but slightly hyperpigmented (darker) because she has dark colored skin and this is not uncommon. She absolutely gloats about the difference between her former saline implants and her new silicone variety—“my breasts feel more natural, I don’t even know that I have implants”. “Many of my friends have asked to feel my breasts and they are shocked that they have been enhanced and they can’t tell that by feeling them”.

Learning points:

1.     Trying to “lift” a loose breast with an incision solely around the areola (Benelli Lift), is usually not successful. You can’t remove enough of the skin and the resulting scar around the areola usually spreads and the areola diameter gets bigger with time (basically you are asking the skin around the areola to do too much work).

2.     As I have said again and again, patients who have experienced both saline and silicone implants almost universally prefer the silicone variety.

3.     I used smaller implants the second time around. This is common and certainly educational. As women get older they often prefer smaller implants because it makes them less matronly looking, less heavy, less wide and more perky. Enjoy fuller implants when you are younger and change them for smaller when you get older, or love them all the way, or choose a moderate size to begin with and enjoy for life.

4. The reason why she wasn’t completely satisfied with her original work is because her goals were not met because I’ll bet she chose to have the procedure done around the areola because there was less scarring. Indeed, there is less scarring, but her goals were unmet because it was impossible to achieve them without more scars. Is it better to get a little bit of the way with smaller scars or closer to all the way with more scars? If she was told this before her original procedure, do you think she would have chosen a lift only around the areola?

Age: 18 Breast Revision

This is an 18 year old young woman who is 5’5″ and 198 pounds. When she presented to me she had lost fifty pounds with diet and exercise. She says she has always had asymmetrical breasts.

You can clearly see on her pre-operative photos that she has marked differences between her breasts. Her right is larger and more ptotic than that on the left. Her breasts are not what the average 18 year old would be proud of–indeed, these breasts often result in significant psychological trauma that can adversely affect her development (and probably has to a significant degree already).

She is seen here after a bilateral breast enhancement. She was augmented with high profile silicone gel implants, 350cc on the right and 375cc on the left. I performed a BAR procedure (breast augmentation and reduction) on the right side and an augmentation and areola reduction on the left side. The BAR procedure was designed to reduce some breast tissue while the procedure on the left side was designed to make the areola smaller (she didn’t actually need a lift on the left side).

Her post-operative photos were taken eight months after her procedure. The result is good, but what is more impressive is how this procedure has improved this young women. She is a lifeguard at a pool and wears a bathing suit. She spends time in pools and enjoys all sorts of water activities that she NEVER did before her procedure. Her current weight is 160 pounds! She is a new woman in many ways, and it is truly heartwarming to this surgeon to have been able to make this possible.

Age: 49 Breast Revision

This is a 49 year old mom, who is 5’2″ and 129 pounds who had previous breast work done elsewhere three times. She says that her breasts are flatter, not youthful in appearance and a bit asymmetrical. She thinks larger breasts would look better.

On examination she has some breast asymmetries. They look somewhat “stuck on” because they are smaller than her chest wall and they are both mildly contracted (right more than the left). She says she has 325cc implants.

She is seen here after a breast revision. We increased her implant size to 450cc high profile silicone (beneath the muscle) and I adjusted the pockets and used  her implant capsule (normal layer of scar tissue that forms around all breast implants) as a “strap” to help secure the right chest muscle into a more “normal” position (it was displaced from her previous surgery).

She is very pleased with her results. She says that at times her breasts look large but that they are also very perky. Having larger and perky breasts is unusual. This can only be achieved with the use of a breast implant and a supportive bra to keep them where they need to be. They are soft. They are shaped better. The larger implants fill her out more so they don’t look “stuck on”. You can make an argument that the larger implants actually look more “natural”.

Age: 44 Breast Augmentation

This is a 44 year old patient who is 5’5″ and 114 pounds who was interested in a breast enhancement after her two children.  She has asymmetrical breasts and her ribs are also different side to side. The right breast is larger and it is placed more laterally than the left side. Her ribs are sloped more on the right than the left.

She was augmented with 325cc smooth silicone implants of moderate profile placed through an incision beneath the breast. I also reduced some breast tissue on the right side and did a breast biopsy for a suspicious lesion. The idea of reducing breast tissue on the right size and using the same size implants is to make the same size breasts.

In the second photograph taken after her augmentation, you can clearly see that the right breast is lower and lateral and the left one is sitting up a bit higher than is ideal. To make the situation better, I took her back for a revision. I moved the right breast implant up and medial by securing the pocket internally with sutures and I lowered the right implant a tad so it would drop to a better location.

In the third photo, you can clearly see that the situation is better. There is much better symmetry than the first procedure. This case is good because it helps illustrate that trying to get things perfect can be a challenge. She has different breasts left to right that are sitting on different foundations (her underlying ribs). The forces acting on her breast implants are different side to side because of her anatomy. I was able to “adjust” her result so that it is certainly much better but there will always be a tendency for her right breast implant to move down and to the side because of gravity and the fact that her ribs are more sloped on the right side. Think of it as a beach ball on a hill instead of level ground–the ball will always want to move down the hill because of gravity.

The key to her long term success with my revision is a supportive bra day and night that will keep her implants where they need to be. She is very proud of the appearance of her breasts. This is why I make adjustments when appropriate rather than tell a patient that a result is “normal.” What woman doesn’t want her breasts to be as good as possible?

Age: 58 Breast Revision

This is a 58 year old woman, 5’5″ and 118 pounds who presented to me with complaints of contracted implants. She had them placed thirty years ago. She told me they became contracted about six years ago.

On exam, she had near rock hard implants. The breast shape was distorted, and her breasts were somewhat cool and painful to the touch. Her implants were above the muscle and they were the silicone variety.

She is seen here after I removed her ruptured silicone implants in the space above the breast and I placed new moderate profile smooth silicone implants that were 350cc in size below the muscle. At the time of these photos, she lost twenty pounds from an illness. Her breasts are soft and natural in both feel and appearance. I removed the capsule at the time of her procedure (her capsule is the normal scar tissue that forms around all implants). I moved her implants beneath the muscle because I feel they are less likely to contract in this position.

Lessons to take away:

1. The contracture process can occur an anytime, but clearly is more common the longer you live with your implants. Pain and contracture are two symptoms of a possible rupture of your implants. If this occurs, it’s time to have them replaced. Getting tests like an MRI or CT scan is really not helpful because you have to have a procedure anyway, so save yourself from radiation exposure.

2. She will pass the “hug test.” A full frontal hug before her revision would feel like she has rocks on her chest. Now it feels very normal.

3. Implant capsules are not always removed. In her case, when it has been present for thirty years often times it is calcified. This can interfere with mammography which is the best reason to remove it.

4. There is no reason to be running around with implants that are contracted. A breast revision – in expert hands – can provide you with soft, natural feeling breasts.

5. Pictures only tell part of her story. If I were to video her before and after surgery breast exam, you would see that I couldn’t move her breasts before, but after surgery they are mobile and soft–like a natural breast.

Age: 29 Breast Revision

This is a 29 year old female, 5’4″ and 140 pounds who presented to me after having two previous breast procedures performed elsewhere. She said the first time her implants were too high and the second procedure was done to lower her implants. On examination, she had bottoming out of her implants, pectoral muscle “window shading“, enlarged nipple-areola complexes, saline implant rippling and thinning of the skin on the lower half of the breasts. Her breasts were low lying and heavy and certainly not appropriate for a young woman with no children. To learn more about bottoming out, window shading, rippling, and thinning of the skin, click here to go to The Breast Place.

We discussed the issues at hand, the complexity involved in “fixing” the problems and the risks and benefits. This is called informed consent (I tend to be very frank with patients regarding the reality of the situation–although the procedure is “complex,” I felt confident that she will do well).

I performed an extensive revision. I removed partially submuscular saline implants (390cc smooth), and replaced them with 275cc textured silicone implant and placed them beneath the muscle. In addition, I used Strattice (pig dermis) to help with the reconstruction (using the sheet of pig skin to help pull down the pectoral muscle that has moved upwards and to provide for more support to the lower part of the breast). I performed an extensive internal suturing technique of the capsule (scar layer around all implants) so that the implants would remain in an optimal position. I reduced about 50 grams of tissue on both sides, and adjusted the skin of the breast around the new breast implant so that the breast is now “higher, tighter, and perkier”.

Results to note/Lessons to learn:

1. Low heavy matronly breasts have been lifted, narrowed, and made perkier and lighter.

2. Her upper chest is shorter and her abdomen looks a lot longer. Use her freckles to note how much lift has occurred.

3. Strattice (also called Acellular Dermal Matrix or ADM) has been used in her case to support the result. It has been used for five or so years and has been found to be very beneficial with minimal complications to date. Its use in secondary breast surgery is becoming more frequent.

4. Larger saline implants that ripple to smaller silicone implants that ripple less was the reason for the implant change. In addition, silicone implants feel better, more natural and more comfortable than saline variety.

5. Thinning tissue at the bottom of her breasts was from the weight of the implants being supported by the breast skin. Retraction of the chest muscle can occur after your surgeon removes the muscle origin along the breast crease. The muscle “rolls up” like a window shade would move up. When this occurs, there is less support at the bottom of the breast and the implants can/will move down resulting in “bottoming out.” Less tissue coverage over the implant from muscle retraction means less coverage of the breast implant and greater implant palpability.

6. As I have said many times before, this is challenging surgery best left to experts who have extensive experience with these cases.

7. This could have all been avoided by better decision making on the part of the patient and surgeon the first time she decided to get implants.

Age: 57 Breast Revision/Liposuction

This is a 57 year old who is 5’6″ and 175 pounds who came to my office with concerns about a right breast contracture. She had two previous surgeries on her breast performed elsewhere. Upon examination, her breasts were both quite large, and her right implant was contracted and distorted. You could rest a tea cup on her right breast as it was like a shelf. The right breast was non mobile and quite firm. The left breast was large but relatively normal. The implants were in the subglandular position and they were saline.

I removed her saline implants and performed a complete capsulectomy (I removed the layer of scar tissue that forms around all implants.) I replaced her implants with the silicone variety and placed them in the same pocket. I removed 650cc saline implants and replaced them with 800cc silicone implants.

This is a rare instance when I would allow myself to place such large implants but this patient wanted larger implants and she was a very reasonable woman. She knew what she wanted, she trusted that I would take good care of her, and she wanted “that look.” I also felt I could perform this procedure with a high degree of certainty.

She is seen here about a year after surgery. Her breasts have done quite well with the revision. They are soft and symmetrical. Her abdomen looks smaller because I also did extensive liposuction on her abdomen and back. She was interested in this as well and I thought this would be a great opportunity to help her achieve her goal of really large breasts because by making her abdomen and trunk smaller, her breasts would appear bigger. It’s an illusion for sure, but this is a good way of keeping the implant size reasonable.

Age: 38 Breast Revision

This mother of two, Asian who is 5’2″ and 110 pounds was interested in a breast enhancement. She is small in stature and her breasts are small as well. She is seen here in sequence after a bilateral breast augmentation with 315cc smooth saline implants placed beneath the muscle from a small incision in the crease beneath the breast. She required a revision of her enhancement.

This is a case that I performed and I predicted that she would be more difficult and that this outcome was a distinct possibility. As she is quite small, choosing such a large implant simply doesn’t fit her dimensions. It’s like sitting two people on a seat for one. If the implants are too large for the “foundation” then the only place they can go is off to the side. If they don’t go off to the side the possibility of symmastia is a distinct possibility. This means that the breasts meet in the midline and the skin is lifted off the breast bone area and the breast cleavage becomes suspended. Essentially, the two implants meet each other across the midline!

In her case she developed asymmetry of her implant positioning. The right breast didn’t drop like that on the left. She has a mild form of symmastia. I took her back and adjusted the pockets. Which side do you think I adjusted? In other words, should I lower the right implant to match the left or raise the left to match the right? Note that the left breast has more of a natural appearance with less superior fullness and the right looks quite good and has more superior fullness (because the implant sits up higher). In her case, and many like hers, most women prefer the right breast with more superior fullness so in her case I elevated her left breast to match the right!

The moral of the story is that size selection is important because choosing an implant that is too large can lead to a number of problems that will result in issues that will eventually need to be dealt with. This is why I may choose not to offer a procedure to a patient if I feel there is a high possibility that the outcome will be compromised because they want something they don’t realize is not in their best interest.. It’s not always about giving a patient what they want. Oftentimes it’s about offering a patient a procedure that is best for them-even though they may not know it! Comprehensive education always helps to ensure that patients make the right decision. I help NUDGE them into making the right decision.

Breast Revision

This is a classic revision of malposition of breast implants. This woman had a bilateral breast augmentation with 275cc smooth saline implants placed through an incision beneath the breast in 2008. A few years later she voiced some concern about the lateral position of her implants when she lies on her back. She admits that she doesn’t wear a bra as much as she should and that it’s not a particularly supportive either.

This view is from the foot of the operating room table to show the movement of the implants up on top of the chest wall after I revised her pockets to close that portion of the pocket that extended under her arm and below her original breast fold. I exchanged out her saline implants for a 250cc smooth silicone variety. You can also clearly see that her ribs underlying her implants are very sloped (more on her right side than the left).

Implants that stay soft also tend to be mobile. This movement of the implants can put pressure on the pocket around the implant and expand it—typically laterally and inferiorly. This refers to displacement of the implant or implant malposition. Some patients are more prone to implant malposition because of several reasons, the most important being the shape of their underlying ribs and chest wall, the size of their implants, the position of the implant above or below the muscle and genetic factors. I have always stressed the importance of wearing a supportive bra day and night in order to minimize implant malposition. The “internal” bra that I make is done by making sure that I don’t disrupt the pectoralis muscle origin along the inframammary fold area. The “external” bra is the one you purchase at the store to support the implants.

ADM or Acellular Dermal Matrix is a new material that is being used more commonly in cosmetic breast revision procedures. It consists of dermis from pigs or humans that has been treated to make it acceptable for human implantation. It’s like an additional layer of support that is needed in some cases when the tissues are thin, the implants were too large and the surgeon stripped the muscle away from its normal origin and it retracted up towards the clavicle and no longer helps to cover or support the breast implants.

Breast Revision

This is a case of a 5’7″ and 140 pound mom who had previous gastric bypass surgery and lost over 100 pounds. We performed some contouring procedures about her body first, finally working on her breasts which she wanted smaller and lifted. She has loose skin throughout her body as you would expect in any individual who has lost over 100 pounds. Although the degree of skin retraction can vary considerably among individuals, most will have some degree of skin laxity, and in some cases it can be very severe.

She had a previous breast augmentation with 425cc textured high profile implants performed elsewhere. We decided that the best option is for her to consider a bilateral BAR procedure with the placement of smaller silicone implants (225cc) in the submuscular position. The goal is to make her breasts smaller as well as improve the shape and provide for some lift.

She is shown here about 2.5 years after her procedure. She has gained about 20 pounds. You can clearly see that her breasts are smaller and appear somewhat lifted. She has collapse of the skin lateral to her breast that takes away from the shape of her breasts. She still has skin laxity about her breasts that she wishes was tighter and she also wishes that her breasts were more lifted.

Working with very loose skin is a challenge. There is only so much we can achieve under the circumstances, particularly if you prefer a smaller implant that has less of an “impact” on her outcome. We considered excising the tissue lateral to her breasts (thoracoplasty) to flatten the area beneath her arms as well as retighten the skin of her breasts but considering the very lax tissues that I have to work with and the puny sized breast implant I don’t feel the benefit will be very significant. Sometimes you have to accept the fact that it might not be possible to achieve your desired goals. We as humans always want the best but sometimes prudence and reality get in the way.

Age: 46 Breast Revision

This mother is 5’6″ and 130 pounds and has had a previous breast “lift” performed by another surgeon. She says that initially her breasts looked good but after five months they began to sag. Her pictures reveal “bottoming out”. This happens when the breast tissue that was elevated initially fell victim to gravity. The nipple areola complexes ride high as the tissue sags below.

She is seen here after a BAR procedure (breast augmentation and reduction). She was enhanced with 200cc smooth walled silicone implants placed beneath the muscle. A horizontal wedge resection of tissue was removed on the lower part of the breast (tissue that hangs). A new inframammary crease was designed.

Photo number 1 is her initial picture. Photo 2 was taken at 4 months and photo 3 was taken at 26 months post operative. Note the dramatic shape improvement with less hang and more superior fullness. The shape even improved after four months as the swelling subsided over time. Her breasts are more rounded and perky. Also note the excellent bra that has helped to mold her breasts as well as support them so they are less likely to fall in the future.

A mastopexy or breast lift alone (without an implant) works well in selected cases, especially when the breasts are small and the skin and tissue is of good quality. Most plastic surgeons believe that recurrence of the sagging is inevitable. It will also provide little superior breast fullness. This is why the use of an implant as well as a lift or reduction is popular because it’s the best method to build a perky more youthful breast. It’s also what patients are demanding from their surgeons. A note of caution however is that an augmentation/mastopexy or breast augmentation reduction is inherently a more complex procedure with a greater potential for complications and a higher revision rate. The complications typically are minor and the increased tendency for revisions usually involve implant adjustments or skin manipulation. An expert surgeon is mandatory.

Age: 35 Breast Revision

This patient is 5’7″ and 140 pounds. She had a previous breast augmentation performed elsewhere and was not completely satisfied with the result. She didn’t like that her implants felt rock hard and that her nipple areola complexes were displaced down and to the outside of her breasts. She doesn’t like the overall shape and appearance of her breasts and thinks her implants are too high. She had her implants placed through the underarm area.

Indeed, on examination, she had rock hard implants and the overall shape of her breasts was not ideal. Her nipple areola complexes were not in a good position and they were different side to side. Her implants were high as they hadn’t dropped to the lower part of the breast. Her breasts are essentially “cockeyed.” She is seen in her post operative photos 5 years after her procedure. I removed her 300cc saline implants that were below the muscle and adjusted the pockets and replaced them with 350cc silicone implants and moved her nipple areola complexes to a more symmetrical, central position. I felt that the larger implant would actually fit her chest better (I always prefer the smallest implant that works to achieve our goal however). Her breasts are now very soft and natural. She has beautiful cleavage. Her breasts are shaped beautifully now and she couldn’t be happier or prouder. “You should put my case on your website to show people what can be done!” I can tell you that these pictures don’t do justice to what her breasts look like in person.

Of note is the darker scarring that she had from the surgery to move her nipple areola complexes. It actually looks worse in photos than in person. I told her that women of color can scar darker-and she has. For years I told her that I can treat this with mild acid peels and hydroquinones (bleaching agent used on the skin) but she told me she didn’t have a problem with these “blemishes.” Basically she was thrilled with the improvement from what she had before and this was a minor issue at best. I think I have finally convinced her to have the treatments to the area and see if we can lighten it up a bit. This case illustrates also that it is far more common to have problems “seating” breast implants through the transaxillary (armpit) approach than through the most recommended incision beneath the breast.

Age: 34 Breast Revision

This mother of two is 5’4″ and 152 pounds. She had a bilateral breast augmentation with 275cc smooth silicone implants placed beneath the muscle. She is seen before surgery, after four months and at one year. At the four month visit it was obvious that the right implant had moved superiorly because of the activity of the pectoralis muscle. I corrected this by lowering the implant pocket under local anesthesia in my facility.

The biggest issue by far with submuscular placement of breast implants is that the muscle can influence the position of the breast implant depending on the individual. This is often initially after your procedure for the first month or two before it all “settles”. She should have come back sooner and told me that the implant had moved upwards and it would have been possible to move the implant to the correct position with massage and a breast band alone.

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