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by Don Revis, M.D.
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implant size for his or her patients is ridiculously outdated.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.
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.
Source :
http://www.beautysurg.com/learn/articles_breast_revisions.html