Adjustable Breast Implants

By Hilton Becker, MD

The adjustable breast implant was first described in the early eighties. The original implant was a single lumen saline device with a detachable injection dome.

Subsequently a double lumen implant was developed. The implant was smooth walled and had 25% or 50% silicone gel in the outer chamber. Saline is added or removed from the inner chamber via the detachable injection dome.

The smooth double lumen device proved to be very versatile, easy to use and able to afford excellent results. The textured versions were later introduced with the belief that capsular contracture could be reduced. Textured implants became the vogue in the early nineties, at the time of the silicone crisis when the use of silicone breast implants was soon restricted by the FDA. The manufacturers were forced to limit production to a small variety of devices, only the textured adjustable were registered for the adjunct study. It was still realized that the textured adjustable implant did not function as well as the smooth implant. Texturing resulted in less elastic shells, thus decreasing volume versatility, and increasing rippling. Unfortunately, it took 10 years to reintroduce the smooth adjustable silicone gel implant.

Indications:
Adjustable implants are used for reconstruction, augmentation, and particularly for revisions and for the treatment of complications. I use almost exclusively smooth implants.

Reconstruction:
Ideally the 50% silicone gel, 50% saline (50/50) is used. However, in primary reconstruction where skin flap viability may be compromised for example: thin flaps, tight closures and patients having had prior radiation, the 25% silicone gel, 75% saline (25/75) is recommended

Augmentation:
Smooth adjustable implants are used in patients with asymmetry, tubular deformity or in patients who wish to have input with regard to volume, post operatively. The 50/50 silicone gel saline is used in patients with ptosis or Polands Syndrome.

Treatment of Complications:
The adjustable implant has its greatest benefit in the treatment of breast implant complications.

1. Conversion from sub glandular to submuscular position: When an implant is removed from the sub glandular position there is often scarring extending into the muscle. The muscle is often more rigid than normal. Placement of an adjustable implant in the submuscular position allows for postoperative expansion, which helps stretch the muscle and scar tissue. Over-expansion will allow for ironing out or irregularities. There is often a discrepancy of the volume of the sub glandular verses the submuscular space and this once again, can be compensated for postoperatively.

2. Treatment of capsular contracture: Following an open capsulectomy there is often asymmetry and irregularity of the pocket. Postoperative expansion allows for stretching and smoothing out of the pocket. In the treatment of capsular contracture, I will often over expand the implant and keep the newly formed capsule splinted at a larger volume for several months. On releasing of the implants, the newly formed over-expanded capsule tends to remain soft.

3. Treatment of symmastia and other pocket irregularities, such as double bubble deformity: In these situations, it is necessary to suture the capsule into its new position and then place the implant back into the pocket. The force of the implant in the pocket often results in rupturing of the sutures. In these situations, the use of the adjustable implant enables the implant to be placed with a very small volume thus allowing the sutures to heal, tension free for two to three weeks. The implant can then be slowly filled without placing excess tension on the sutures.

Complications following the use of adjustable implants:
These complications are mainly related to the injection dome. No complications have been seen as a result of expansion or implant volumes. The complications seen as a result of the injection dome are mainly technique related. There has been no increase leakage rate noted, as a result of the self-sealing valve. The valve is a very sophisticated having three valvular mechanisms in one. The few leakages that have been seen, as a result of valve failure were in the earlier design where the plug mechanism did not seal adequately due to insufficient length. The problems seen with the injection dome include rotation of the injection dome, kinking of the fill tube, irritation of the skin at the injection dome site, and exposure of the injection dome. Two cases of cellulitis following removal of the injection dome, have been seen and I have now started using prophylactic antibiotics at the time of injection dome removal.
A word of caution with regard to mammography and MRI: False, positive linguini signs can be seen with the double lumen implant as the inner lumen may result in a shadow appearing like a linguini sign. Radiologists may report this as rupture of the shell. Experienced radiologists are able to differentiate between these findings.

Technique:
I almost exclusively use smooth adjustable implants. Saline adjustable implants are used for breast augmentation patients or patients who do not wish to have silicone implants. I prefer the higher volume, silicone gel adjustable implants for most cases. However, the low-volume gel implant is used where skin flap viability may be a problem.

Another advantage of the adjustable implant is that it helps with the discrepancy of implant base diameter and implant volume selection. With a non-adjustable implant I am more concerned with the volume of the implant than with base diameter volume. With the adjustable implant I select my implant closer to the appropriate base diameter than implant volume as the implant volume can be adjusted postoperatively.

I place the majority of the implants in the submuscular pocket, which is partially release inferiorly. If the implant is placed in the sub glandular pocket, I always use the large volume silicone gel implant. Once the implant is placed in the pocket, the implant is filled to the appropriate volume using the closed filling system. I usually under fill the implant at the initial surgery as this will result in less tension on the skin flaps, particularly in reconstruction, and this will also decrease postoperative pain. Once filled to the appropriate volume the fill tube is shortened and attached to the injection dome.

I use the metal connecter and secure it with a 3-0 silk tie. The tubing on the injection dome is shortened so that on removal the full tube can be grasped beyond the metal connector to avoid disruption at the connector site. A large injection dome is usually selected in reconstructive patients and the mini dome used in augmentation patients.

Postoperative volume adjustments are started two to three days after surgery. The implants are expanded at increments of approximately 50 cc at a time, usually at two to three day intervals. I believe that it is important to expand the pocket early postoperatively as the capsule forms quite rapidly. Filling is done with a 23 gauge butterfly allowing fluid to flush through the fill tubing to clear any blood that may be in the needle. The implants are over expanded postoperatively if needed. If expansion is required above the manufactures recommended fill volume, the patients are informed of the theoretical risk of over filling, although this is not proven to be a clinical problem. The injection domes are removed anywhere between three to twelve months.

Removal is performed under local anesthetic, usually through the original incision.
In certain augmentation patients, the injection dome is exteriorized through a long subcutaneous tunnel, allowing for postoperative volume adjustments several days after surgery. The injection domes are then removed once the patient is satisfied with the implant volume.

Avoiding complications:
Kinking is usually a result of excess tubing length. This can be avoided by shortening the fill tube appropriately. Rotation of the injection dome can occur if it is placed in a pocket that is too loose allowing it to move around freely. This situation is avoided by placing the injection dome either in a snug subcutaneous pocket or suturing it to the surrounding tissues. Pain and extrusion can occur if the injection dome is placed too superficially or directly beneath the incision. The injection dome should therefore be placed close to the incision but not directly beneath it and in a sufficiently deep pocket to avoid exposure.

The inadvertent puncture of the fill tube or implant can occur. Therefore, filling should only be performed when the surgeon is sure that he can locate the dome.

Conclusion:
The return of the smooth adjustable gel implant is a welcome addition to our armamentarium. The smooth shell allows for greater volume manipulation and decreased the incidences of rippling that have been seen in the past with texture adjustable implants.

References:
1. Becker, H.: Breast reconstruction using an inflatable breast implant with detachable reservoir. Plastic & Reconstructive Surgery; 73, 678-683, 1984.
2. Becker, H.: Breast Reconstruction by inflatable implant. Surgical Practice News, 5, #11, November 1984.
3. Becker, H. and Maraist F.: Immediate breast reconstruction after mastectomy using a permanent tissue expander. Southern Medical Journal; Vol. 80, No.2, February 1987, pp. 154-160.
4. Becker, H.: Expansion augmentation. Clinics in Plastic Surgery; Vol. 15, No. 4, October 1988. Pp. 587-593.
5. Becker, H.: The Expandable Mammary Implant. An update; Perspectives in Plastic Surgery; Vol. 3, No. 1, 1989.
6. Becker, H.: The Correction of Breast Ptosis with the Expander Mammary Prosthesis, Annals of Plastic Surgery; Vol. 24, No. 6, June 1990.
7. TISSUE EXPANSION; Rolf E. Nordstrom, M.D.; Breast Expansion Augmentation, p. 145; The Expander Mammary Implant for Breast Reconstruction, p. 163, Hilton Becker, M.D., 1996.
8. Becker, H.: ADJUSTABLE BREAST IMPLANTS PROVIDE POSTOERATIVE VERSATILITY; Aesthetic Surgery Journal, July/August 2000 Vol. 20, No. 4 Pp. 332-334.