Breast Revision
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.
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 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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