By Donald Revis, MD
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. Dr. Revis’ systematic approach has minimized these revisions in his own practice while improving patient outcomes and satisfaction ratings. He feels that 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, our pledge to you is to properly evaluate the problem and to recommend one or more ways in which we can correct the problem. Breast augmentation revision surgery is certainly more complex than primary (initial) augmentation, and you should realize that the proper time for the correct operation to be performed is the first time. However, Dr. Revis has developed considerable experience with the correction of breast augmentation problems and may very well be able to improve your results.
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 (aka bread-loafing) usually represents over-dissection in the medial region of the breasts over the sternum (aka 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)-usually does not require a revisionary technique but is mentioned here for completeness- 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
- 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
Dr. Revis has developed a scientific approach to breast augmentation and the correction of 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.
During your initial consultation, Dr. Revis will inquire about your medical history, prior procedures, medications, allergies, and your motivations for seeking plastic surgery. It is very important that you be thorough when providing your medical history, as this information helps to prevent complications during your care. When asked about medications, be sure to include any vitamin or herbal preparations, as these can affect your blood pressure and clotting ability. Honesty regarding your use of tobacco and alcohol is also very important, as these may have a profound impact on your recovery period and your ability to heal following your procedure.
After reviewing your medical history, Dr. Revis will discuss your concerns, priorities and motivations for pursuing plastic surgery, as well as your fears. After examining you, Dr. Revis will be able to offer advice and options to help you achieve the appearance you desire. He will explain the advantages and disadvantages of the different options you have before you. You will also be shown the different types of breast implants.
At the completion of your consultation, you will be given a written estimate of the cost of your procedure. At this time, you will also have the option to schedule your procedure if you so choose. The decision to undergo surgery is a very important one, and the final decision should be given very careful consideration. Dr. Revis realizes the importance of this decision, and at no time will you be pressured to make a decision. You are also encouraged to bring your spouse, significant other, family member, or a friend to your consultation.
Breast implants come in many different types, and they may be placed through different incisions and in different locations. Once you have decided to undergo a revision of your augmentation, there are three main choices you must make- incision location (whether or not your prior incisions will allow the proper procedure to be performed or if you may need additional incisions), whether or not your implants will be replaced and if so then the new implant type and size, and whether or not the implant pockets will remain the same or be changed. This can be quite confusing, and the following information is to help you understand the various issues involved in making your decision.
Types of Implants: Silicone Gel vs. Saline Filled Implants
There are two basic types of implants, silicone gel and saline filled. ALL implants consist of a silicone shell. Silicone gel implants are filled with liquid silicone. The FDA has restricted the use of silicone gel implants to only a select group of plastic surgeons and only certain of their patients. Dr. Revis is among the group of plastic surgeons allowed to use silicone gel implants. If you are interested in having silicone gel implants, be sure to ask Dr. Revis if you might be eligible to participate in one of the FDA-approved protocols. To date, there have been numerous studies in the medical literature demonstrating no link between silicone gel implants and any type of disease.
Saline filled implants consist of an outer shell of silicone that is filled with saline, or salt water. Most breast implants used for breast augmentation are of this type. In addition, there is a new type of saline implant called a high profile saline implant. It is designed to give better breast projection and volume, because more of its volume is used in establishing projection rather than increasing the width of the implant. Please ask Dr. Revis for further information regarding which implant might be right for your individual needs.
New High-Profile Saline Implants
In our efforts to continually improve the products offered to our patients, Dr. Revis is pleased to announce the availability of a new saline filled breast implant. The high profile implant provides yet another option for those women considering breast augmentation to enhance their appearance. These new implants allow a higher volume to be achieved with a smaller diameter implant. Depending on the shape of your chest, you may be a candidate for these new implants and may achieve an improved shape and more natural appearance.
Types of Implants: Smooth vs. Textured Surfaces
Breast implants may have a smooth surface or may have a rough, textured surface. The textured implants were produced in the hopes that they would decrease the incidence of forming a scar around the implant, also known as a capsular contracture. This does appear to be effective, but only when the implant is placed beneath the breast but above the muscle of the chest wall (see Implant Placement Options, below). Textured implants have never been shown to provide any advantage over smooth implants when placed beneath the muscle of the chest wall.
Textured implants also have their own disadvantages. Textured implants are manufactured by taking a smooth implant shell and applying the texturing to the outer surface. This texturing process makes the shell slightly thicker and more stiff, which translates into an implant that is more visible through the skin and is more easily felt when the breast is touched.
Because of these disadvantages and because most implants are placed beneath the muscle, the great majority of breast implants used today are of the smooth variety. Dr. Revis believes that the smooth surfaced implants provide a much more natural look and feel when compared to textured implants.
Types of Implants: Round vs. Anatomical Shaped
Most breast implants used today are round. There are also implants which are teardrop shaped, called anatomical implants. These are in an attempt to better simulate the shape of the natural breast. In certain cases these may be recommended, but ALL anatomical implants are textured, with the accompanying disadvantages of textured implants.
The incision for breast augmentation may be placed underneath the breast, around the areola (the pigmented skin surrounding the nipple), in the armpit, or in the belly button. Dr. Revis performs all of these types of incisions, and he will discuss which might be the best for your specific situation at the time of your consultation.
Nationally as well as in Dr. Revis’ practice, most patients choose an incision around the nipple or in the crease underneath the breast for their initial operation. This provides the surgeon with the most precise control over implant placement, and when performed properly should in no way prevent breastfeeding or alter nipple sensitivity.
Revisions typically cannot be performed through an axillary incision or through a TUBA incision unless only a very simple procedure will be performed such as changing the size of the implants or replacing a deflated implant. Most revisions require a periareolar incision for adequate visualization to provide the most long-lasting results.
Implant Placement: Subglandular vs. Submuscular
Breast implants may be placed beneath the tissue of the breast (subglandular), or may be placed even deeper, beneath the muscle of the chest wall (totally submuscular). There is also a subpectoral (or partially submuscular) placement that some surgeons use. The decision is a very individual one, and it is determined by the natural shape of your breasts and chest wall muscles.
Whenever possible, Dr. Revis prefers to place the implants in a totally submuscular position. Dr. Revis believes that the advantages of placing the implants completely beneath the muscle of the chest wall greatly improves the long-term appearance of your breasts following augmentation.
This is for three main reasons. First, mammography is easier and the quality is better when the breast implant is separated from the breast tissue by the additional layer of muscle. Secondly, there is a lower incidence of capsular contracture when the implants are placed totally beneath the muscle. Capsular contracture occurs when the body produces scar tissue around the implant. This may change the shape of the implant and make the breasts asymmetric. Finally, placing the implants beneath the muscle of the chest wall makes your augmentation appear more natural because there is more of your own tissue covering the implant, making it less likely that you will be able to see or feel the implant.
Dr. Revis uses a special technique and instruments to place the implants 100% beneath the muscle of the chest wall without cutting any of the muscle tissue. This entirely submuscular placement will improve your long-term results and minimize your potential complications.
Choosing The Proper Implant Size
This is one of the most important decisions you will make. Because of this, we take several approaches to help you make the best decision based on your anatomy, personal preferences, and the appearance you wish to achieve. Interestingly, in a recent national survey, over 80% of patients undergoing breast augmentation stated that a C cup was their desired postoperative goal. A D cup was the second most popular request.
Dr. Revis will measure your natural breast and chest shape. This gives him an idea of what size implant will help you achieve the size you want postoperatively. As implant size increases, so does the diameter of the implant. There is an implant that will perfectly match the diameter of your natural breast. Choosing an implant smaller than your natural breast shape will not provide the proper cleavage and shape following the procedure. Similarly, choosing an implant too large for your natural chest shape is more likely to give you an unnatural appearance.
Unfortunately, implants do not come in cup sizes. Rather, they are categorized by the volume of saline (salt water) that they are designed to hold. There are several reasons for this. First, your final cup size will be partially determined by your preoperative breast size, and everyone is different in this regard. Secondly, a “C” cup from one bra manufacturer is not necessarily the same as a “C” cup from another manufacturer.
Although everyone is built differently and bras are not manufactured to a set standard, you can expect that a cup size is approximately 200cc in a person of average height and average build. If you are tall or have broad shoulders, you can expect that number to be slightly higher. Similarly, if you are shorter or have a more narrow chest, you can expect that number to be slightly lower. Although a desire for a certain cup size is helpful to Dr. Revis in guiding you in the selection of the proper implants, it is more helpful to focus on the shape and appearance that you wish to achieve.
Using these three approaches, you will be able to accurately select the implant that will give you the appearance you desire. When asked about size postoperatively, over ninety percent of our patients feel they chose the right size implant to achieve the appearance they envisioned. The remaining few state that they might have gone larger if they were to choose again. We almost never hear that a patient wishes they had chosen a smaller implant. Therefore, if you are debating between two sizes, it is probably a better decision to opt for the larger size.
Type(s) of Anesthesia
Anesthesia is an essential part of any surgical procedure and must be performed safely. General anesthesia is the deepest form of anesthesia. You are asleep, feel no pain, and will not remember the procedure. This form of anesthesia is usually not required for breast augmentation unless the patient specifically requests general anesthesia.
Intravenous sedation, called “twilight sleep,” is a combination of local anesthetic administered at the surgical site by Dr. Revis and intravenous sedation administered by the anesthesiologist. You breathe for yourself, but you are in a deep sleep throughout the procedure. You should feel no pain, and you will not remember the procedure.
An intermediate form of anesthesia, the laryngeal mask airway (LMA), is a relatively new technique. This technique is similar to twilight sleep in that you are breathing on your own, but the method of sedation differs. With an LMA, you actually breathe anesthetic gases administered by the anesthesiologist, rather than receive intravenous sedation via your intravenous line. These anesthetic gases cause you to sleep during the procedure. At the completion of the procedure, the gases are turned off and you wake up from your sleep. You will feel no pain, and you will not remember the procedure. This is the most common type of anesthesia used by Dr. Revis because he feels that the effects of this type of anesthesia leave your body the fastest, allowing you to feel better faster with very little likelihood of postoperative nausea.
The prevention of postoperative nausea and vomiting is also a focus of Dr. Revis’ approach to breast augmentation revision surgery. To improve your overall experience and ensure you feel better faster following your revision, he has developed a technique that has resulted in a very low incidence of postoperative nausea and vomiting. You will be given an intravenous dose of Zofran at the beginning of your operation. Zofran is a new drug which is currently the best medication available to prevent nausea and vomiting. Dr. Revis feels it is a very important component of his overall approach to make sure that your experience is as pleasant as possible.
Dr. Revis will discuss all of these options with you more thoroughly at the time of your consultation, and please ask him about anything you do not understand.
Details of the Procedure
Breast augmentation revisions vary greatly in the exact procedure to be performed and the length of time the operation will last. However, Dr. Revis will thoroughly describe the procedure he has proposed for you, and please ask questions about anything you do not understand.
After you are properly anesthetized in the operating room, Dr. Revis will inject a solution of local anesthetics along the borders of the breasts, underneath the intended incision site, and into the muscle under which the implants will be placed. This injection solution consists of a special combination of lidocaine (xylocaine), marcaine (sensorcaine, bupivicaine) and epinephrine. This accomplishes several objectives. First, the epinephrine causes vasoconstriction of the area, reducing your potential for bleeding and bruising. Secondly, the lidocaine provides a rapid numbing of the area.
Although you are asleep, this prevents the brain from registering any pain from the region during the operation. Studies have shown that this so-called preemptive analgesia actually decreases your sensation of pain postoperatively, decreases the amount and length of time you will need to take pain medication postoperatively, and also leads to a more rapid return to normal daily activities. Finally, the marcaine component of this local anesthetic mixture is a long-acting local anesthetic. This actually prolongs the numbness of the area, making you more comfortable following surgery and delaying the time at which you will begin to need any pain medications.
After allowing time for the local anesthetic mixture to take effect, Dr. Revis will make the incisions necessary for the procedure. Using the newest techniques and instruments, Dr. Revis will perform the procedure you have discussed.
After the revisionary steps have been taken, your new breast implants are inserted and filled with saline. (Silicone gel implants come pre-filled and do not require filling in the operating room). Dr. Revis uses a “no touch” technique when placing the implants into the pocket. This includes using new sterile towels to drape around the breasts, changing his gloves and washing the outer surface of these new gloves in sterile saline, and only opening the sterile implant packaging immediately prior to insertion.
Dr. Revis is the only person who ever touches the implants, and his goal is to minimize the time the implant is exposed to the air in the operating room prior to insertion into the pocket. Additionally, Dr. Revis does not allow the implant to come into contact with any instruments or the skin during the insertion process. He feels that this minimizes the possibility of any foreign material coming into contact with the implant and causing any inflammation.
During the filling process, Dr. Revis uses a “closed system” to fill the implants with saline. This means that the saline that enters the implant is never at any time exposed to the air in the operating room. The saline flows from a sterile bag through a sterile tubing directly into the implant. Dr. Revis feels this additional precaution prevents any foreign material from inadvertently being injected inside the implant.
After the implants have been filled properly and Dr. Revis has assessed your final shape and size, the incisions are carefully closed with absorbable sutures to minimize your scar. A sterile dressing is applied to the incisions, and a soft surgical bra is placed over your breasts. Dr. Revis uses a technique in which all of the sutures are placed beneath the skin and are absorbed by your body. Not having to undergo suture removal has improved patient comfort and satisfaction.
After Your Procedure
Breast augmentation revisions are performed as an outpatient procedure. After recovering in the recovery room for approximately one hour, you will be able to go home in the company of a friend or family member. Dr. Revis will also give you his cell phone number so that you may reach him directly at any time with any questions you might have.
When you wake up from your procedure, you will be in the recovery room and will be wearing a soft surgical bra or sports bra. You may remove this bra on the second day following surgery and begin showering daily. After showering, simply pat your incisions dry and replace your surgical bra or a sports bra.
The antibiotics that were prescribed during your preoperative visit (usually Augmentin) should be taken twice daily beginning on the evening prior to surgery. Continue this medication for five days postoperatively or until it is gone. The pain medication prescribed by Dr. Revis during your preoperative visit (usually Lortab or Vicodin) should be taken fairly regularly, every four hours or so, during the first twenty-four hours (when you are not asleep, of course). Most patients find that they are able to transition to Tylenol after three or four days. It is not safe to drive a car within twenty-four hours of taking pain medication, as your reflexes and alertness may be altered.
Dr. Revis may prescribe a muscle relaxant (usually Flexeril) for you if he suspects that your muscles may be tight and uncomfortable following surgery. If so, you may take one tablet every eight hours if needed for muscle tightness.
Alternatively, you may also be a candidate for a revolutionary new product for the management of postoperative pain, called the On-Q Post-Operative Pain Pump. Be sure to ask Dr. Revis about this during your consultation if you think you might be a good candidate for this system.
You should plan to take it easy following your surgery. No strenuous activities, heavy lifting (over 20 pounds), aerobic exercises, swimming, contact sports, tennis, or golf should be planned for the first three weeks. As Dr. Revis monitors your recovery, he will advise you when it is safe to resume specific activities.
Unlike many surgeons, Dr. Revis does not feel that you must follow any specific regimen of straps, massaging, etc., following your augmentation. His philosophy is that the time to place the implants properly and precisely is in the operating room through careful technique and attention to detail. In his opinion, there is very little manipulation that straps or massaging will accomplish in the postoperative period to change the position or shape of an improperly or hastily placed implant. Dr. Revis will, however, occasionally recommend gentle massaging as a way to relax the muscle under which the implant is placed. In select patients, this can lead to a more rapid relaxing of the muscle and a softening of the breasts. Dr. Revis will instruct you during your postoperative visits in the proper technique of massaging the implants if he feels this would be of benefit to you.
Dr. Revis will also discuss the use of Mederma with you following surgery. Beginning three weeks postoperatively, daily or twice daily use of Mederma (available over the counter at most drug stores) will stimulate rapid wound maturation and fading of your scar to a barely noticeable thin line.
The Results You Can Expect
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.