|
 Breast
augmentation is a procedure that is often assumed to
be simple in nature and execution but is actually quite
complex. Proper surgical technique and attention to
detail are essential to good results, and too often
these are overlooked.
There is no such thing as a simple breast
augmentation, and an attitude of "seen one, seen
them all," commonly held by many plastic surgeons,
simply will not suffice when dealing with the subtle
complexities and intricacies of breast augmentation.
As a similar example, twenty years ago
rhinoplasty was treated the same way, and the usual
result was that every nose done by the same plastic
surgeon turned out to look exactly the same, regardless
of the patient's facial proportions, preferences, ethnic
background, etc. Over the past twenty years, an evolution
in our thought processes has resulted in the realization
that rhinoplasty is a multidimensional, complex surgery
that must be individualized for each patient.
For instance, the notion that the surgeon
knows best in the selection of the implant size for
his or her patients is ridiculously outdated. We should
never presume to know what is best for our patients
in this regard. Our responsibility is to present the
facts to our patients and guide them in making their
own decision that is in their best interests. Similarly,
no one incision is right for every patient, and one
location for implant placement (be it above the muscle,
subpectoral, or totally submuscular) does not satisfy
every patient's needs.
Double Bubble/Capsular
Contracture
/Bottoming Out/Implant Asymmetry Repair
Procedure: Left Breast Capsulectomy,
"Internal Bra" with Implant Exchange
Age: 45, 5'7", Weight: 130, 34B
to 34C, Smooth, Round Saline Implants filled to 200cc
replaced with Mentor Smooth, Round Saline Implants filled
to 325cc, Incision: Periareolar, Placement: Subpectoral,
3 Months Postop (Note: Initial surgery performed elsewhere)
The three most common reasons for breast
implant revisions- changing implant size, improving
the natural feel and appearance of the breasts, and
correcting capsular contracture- should be minimized
by a careful and thorough approach to breast augmentation.
A systematic approach will minimize the need for revisions
while improving patient outcomes and satisfaction ratings.
The real focus should be in prevention
of these problems rather than in their treatment. However,
breast implants are like any other man-made implantable
medical device (such as heart valves and artificial
joints), and realistically some patients will require
revisionary procedures. Plastic surgeons must be aware
of the potential problems that may exist and be equipped
to properly diagnose and treat patients so that an acceptable
outcome is achieved.
In treating your specific complaint, one
must properly evaluate the problem and then recommend
one or more ways to correct the problem. The treatment
is individualized to your specific circumstances and
goals to ensure that you have an adequate understanding
of the issues involved. Then, you are able to make a
fully informed decision. This will help you achieve
the appearance you desire with the least invasive procedure
available, thus creating a mutually rewarding experience.
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. Within
the three broad categories mentioned above, specific
problems include:
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 (implants 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 or only subpectorally
and not totally submuscularly
-Synmastia (also known as bread-loafing) usually
represents over-dissection in the medial region of the
breasts over the sternum (also known as the breastbone)
in an attempt to create better cleavage
-Implants that remain too high postoperatively
(and do not "drop" or "settle" into
the correct position)
-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 (prominence of the nipple-areolar
complex characterized by herniation of some of the breast
tissue into the nipple-areolar complex, named after
its similarity to the cartoon character "Snoopy")
This condition should be addressed during the initial
operation but occasionally only becomes apparent postoperatively
-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 (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)-should be addressed during the initial operation
because if overlooked or not treated properly will inevitably
lead to an unsatisfactory outcome
-Mondor's cord (aka Mondor's disease, named after
French surgeon Henri Mondor, actually 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 mentioned here
for completeness. It 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 Themselves
-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 an ultrasound
or 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 (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. It may be
more common following infection or hematoma. Capsular
contracture is less common and less severe with saline
implants than with silicone implants.
There are four grades of capsular contracture - Baker
Grades I through IV:
Grade I - the breast is normally soft and looks natural
Grade II - the breast is more firm but looks normal
Grade III - the breast is firm and looks abnormal
Grade IV - the breast is hard, quite often painful,
and looks very abnormal
-Dissatisfaction with the size of your implants (either
too small or too large). The most common reason women
have a second operation is to change the size of their
implants (more commonly selecting a larger implant).
Dissatisfaction with your implant size should be totally
preventable by a thorough evaluation and decision-making
process.
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)
-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- in
Dr. Revis' opinion, this is an unsatisfactory solution
for capsular contracture but is very useful to reposition
implants)
-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)
-Mastopexy (breast lift surgery) depending on
the amount of reshaping that is required, a crescent
mastopexy (using an incision from 10 o'clock to 2 o'clock
around the top of the areolar border can raise the nipple
1-2 centimeters), a Binelli (aka donut) mastopexy (using
an incision around the outer border of the areola can
raise the nipple up to 4 centimeters), a vertical mastopexy
(creating a lollipop-shaped incision around the outer
border of the areola and extending downwards towards
the inframammary crease can lift the nipple up to 6
centimeters), or a full traditional mastopexy (creating
an anchor-shaped or inverted-T shaped incision around
the outer border of the areola and extending downwards
to the inframammary crease and then medially and laterally
along the inframammary crease can lift the nipple 8
centimeters or more) may be indicated.
-Internal pocket adjustment (for bottoming out
or other position problems- described more thoroughly
below)
-Synmastia repair (repairing the connection of
the overlying skin to the underlying breast bone or
sternum)
-Areolar reduction (using an incision placed
around the outer border of the areola)
-Correction of a "Snoopy" deformity
(using an incision around the outer border of the areola)
-Correction of a tuberous breast deformity (using
an incision around the outer border of the areola)
-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)
The "Internal Bra"
As a specific example of a problem requiring a thorough,
systematic approach and innovative techniques demonstrated
in photographs below, Dr. Revis has seen a dramatic
increase in the number of patients presenting from other
offices with bottoming out of one or both implants.
This means that the pocket, or capsule, surrounding
the implant has enlarged or stretched under the effects
of gravity and have become too low on the chest wall
or rests too far laterally when lying down. This may
cause the appearance to be unattractive and even uncomfortable
when wearing no bra. The implants may hang too low,
preventing you from being comfortable when braless.
You may also experience the implants falling far apart
and even into the armpits when lying down.
Dr. Revis has developed a special technique that has
the effect of creating an internal bra using strong,
permanent suture techniques. Using special lighted retractors,
Dr. Revis expands the implant pockets (capsulotomy)
superiorly and medially, creating room for the implants
to be repositioned at a higher level- creating better
cleavage, a more youthful shape, and improved fullness
in the upper pole of the breast. After expanding the
pockets in these directions, he then closes part of
the capsule that rests laterally and inferiorly (partial
capsulectomy), thus preventing the implants from resting
too low or falling too laterally to the sides. Dr. Revis
uses permanent sutures for a long-lasting result. These
sutures are carefully placed so that the suture material
is never in direct contact with the implants inside
the body.
The Results You Can Expect
After your breast implant revision surgery, you will
notice an improvement in your breast shape and size
immediately. You may experience soreness in your chest,
but this rapidly disappears. A very mild swelling usually
takes several weeks to subside. You should be able to
resume your normal daily activities the day after surgery,
and you should be able to resume all of your physical
activities (sports, aerobics, running, etc.) within
three weeks of surgery.
Dr. Don Revis is a board certified plastic surgeon
practicing in Fort Lauderdale, Florida. For more information,
see his specialist
page or visit his website at www.southfloridaplasticsurgery.com.
return to articles
index page
|
