A mother in her later 50’s who was treated for bilateral ruptured silicone breast implants and bilateral nipple hypertrophy. She had had breast augmentation in the late 80’s by a plastic surgeon who had since retired. Her breasts had been hard since her surgery. She was also bothered by “long nipples” that were overly prominent in clothing and for which she would wear silicone nipple shields to hide them. The nipples were also very sensitive in the shower and in her clo6hing. I recommended an MRI to assess her implants which had been in place for 23 years, and it showed that bilateral subglandular silicones implants with intracapsular ruptured. Her original operative report was obtained and showed that she had 175 cc silicone gel implants. She wished to be a little fuller but still wanted a very natural look. She is petite at 5’2” and 115 lbs and is active at the gym, so did not want to appear unnatural in workout gear.
Sizing was performed in the office and she elected for a very modest increase in size to 250 cc moderate plus smooth round implants. Although there are benefits of placing the implant below the muscle, she did not want to worry about an animation deformity and elected to keep her implants in the subglandular space. She and family members have a history of easy bleeding and bruising and although a hematology workup was non-specific, I recommended against textured implants in her case which, although they may decrease the risk of capsular contracture in a subglandular position can have a potential problem with late bleeding and hematoma which I felt she was at more of a risk for.
She is shown before and again, 3 years after bilateral removal of her ruptured implants and creation of a new pocket below her breast capsule but above the muscle. A “top hat flap” nipple reduction was performed at the same time to reduce the projection and diameter or her nipples. She remains quite pleased with her new size. Her breasts have remained soft. And she no longer has nipple irritation in clothing or the shower, and no longer is embarrassed by excessive nipple projection.
A woman in her early 50’w with a 3 week history of a spontaneous deflation of her left breast implant. He had saline implants originally 22 year before and had a deflation 17 ½ years ago. She was pleased with her size although she had some rippling of the implants which are sub-glandular. Her initial implants had been placed through an axillary incision. Her replacement had been performed through an inframammary incision. She had her implant cards and operative report and was noted to have Siltex (micro-textured) mentor saline implants 325-375 filled to 375cc. She has had a remarkably stable result over the intervening years and after discussions the decision was made to replace her implants with the same implant style and shape and size, through her inframammary incision and keep them in the same sub-glandular ( above the muscle) plane. The capsule of tissue that forms around the implant does shrink and contract after the implant has deflated and a temporary breast sizer was used at the time of surgery to check the space and perform a precise capsulotomy ( release of the contracted capsule) to accommodate the new implant. She is shown before and again, 2 ½ months after replacement. All implants will fail eventually. The advantage of a saline implant is that this rupture is not “silent”- it is easy to detect on exam. A silicone gel implant will require an MRI or an ultrasound to check its integrity. A good rule of thumb is that about 8% of all implants whether silicone gel, saline, or even the highly cohesive “gummy bear” have leaked by 10 years. We do not yet have a number for the Ideal Structured saline implant but so far at 7 years it has an even lower failure rate compared to the numbers of other breast implants at 7 years
Breast Augmentation Revision/Ideal Implants – Patient 291
Breast Augmentation Revision/Ideal Implants – Patient 291
A mother of 3 in her early 30’s who had subglandular breast augmentation with saline implants 9 years before through a trans-axillary incision. She has had her 3 children since that time and would like her breasts to be fuller and more like they were before children. She is also bothered by visible and palpable wrinkles, especially in the cleavage area and upper breast when she leans forward. She is 5’5 and 127 lbs and wears a 32 cup bra.
She is shown before and again, 6 weeks after replacement of her saline implants with Ideal Structured Saline implants 370-415 filled to 415 cc total volume and placed in the original sub-glandular position though an inframammary incision.
Discussion: She already has some stretching of the lower part of her breast which is at 9.5 cm from the infra-mammary fold to the nipple. Her breast tissues are relatively thin with a caliper pinch of 2 cm. She had her implant card which showed Mentor moderate profile 275-300 cc implants filled to 300 cc. The base of this implant is 11.7 cm and it projects 4.3 cm She was sized in the office by adding Mentor sizing shells to her existing volume and she liked the addition of 125 cc but 150 cc started to look too full for her petite frame. In addition, the larger the implant, the more weight related stretching of the breast tissues so we elected for the 415 cc size Ideal structured saline implant, which is similar to a high profile silicone implant. In the case, the empty implant volume is 56 cc and the inner/back lumen is filled to 214 cc and the front/outer lumen is filled to 145 cc to give the total volume of 415 cc. This Ideal implant has a base of 11.7 when filled to 415 and has a projection of 5.3 cm. So is fits the space of her old implant but does not require any modification of the lower breast implant capsule- we can preserve the capsule to help support the new implant and help to protect her tissues from more stretching. She could have changed to a silicone gel implant to have less ripples and wrinkles but did not like the idea of a possible silent rupture- she liked being able to detect a leak with the saline implants on exam. She was changed to the Ideal structured saline implant and loves the new feel. She says that the wrinkles and ripples are nearly gone and do not feel like “a baggy filled with water” like her old implants. The higher profile gives a little more fullness in the upper breast.
A mother of 3 in her early 40’s who had a right breast saline implant deflation. She had had breast augmentation 10 years earlier in another state and noticed that her right breast deflated shortly after a recent mammogram. They were subpectoral and placed originally through an inframammary incision ( at the breast fold). She obtained her old records and had Mentor 300-325 cc implants filled to 325cc. She liked the fact that she could tell when the implant failed without an MRI, but was bothered by the ripples and “baggy filled with water” sensation when she touched her saline implants. She elected to have both implants replaced with the 335 cc Ideal Structured Saline implant. The posterior chamber was filled to 188cc, the anterior chamber to 95 cc and with the empty implant volume of 52 cc this gives her a total volume of 335 cc. They were replaced through the original inframammary incision. She is shown just before and again, 6 weeks after surgery. She likes the feel of the Ideal implants much better, which do not feel “like a baggy filled with water” and do not have the ripples on the sides.
Discussion: The Ideal structured saline implants are not the exact size of the mentor implants. The 300 cc mentor implant filled to 325 cc is 12.1 cm wide at the base and projects 4.3 cm. The Ideal Structured saline implant is 335-375 and filled to 335 has a base of 11.4 cm and a projection of 4.5 cm. The base measurements are not identical because the Ideal implant is curved at the base to sit on the curved chest wall and not flat on the base like the Mentor implant. This seemed to the the closest match in dimensions. She did not want to be significantly larger.
Her right nipple is lower than the left. It is not enough of a difference though to justify the scar of a mastopexy (breast lift) around the nipple. I typically wait until there is a least a 2.5 cm difference before a mastopexy is recommended. We tell women that breast are “sisters and not twins” and typically are not identical in appearance. No implants last forever and the typical statistics suggest that 8% of all breast implants have leaked by 10 years. This is true for the cohesive silicone implants, “gummy bear” implants and saline implants. The Ideal implants do not have 10 year numbers yet. But their 7 year numbers are actually better than the other implants at 7 years so we will have to wait and see if this holds true at 10 years as well.
A nurse in her early 70’s with Meme polyurethane covered implants from the early 80’s which have now ruptured. She had done well until her recent mammogram and had noted some pain since it was done. The mammogram suggested possible herniation of the implant shell or sub capsular rupture of sub glandular implants.
An MRI was obtained and confirmed bilateral implant rupture. She had a bilateral capsular contracture, with a firm, hard feel to each breast. The capsular contracture does help to hold the breasts up however and when is is corrected the breasts will drop, so a mastopexy (breast lift) is frequently needed at the time of implant replacement. Her original implant report and operative note was obtained, showing a “160 gm” implant. She was sized in the office by adding a sizing shell to the outside of her breasts and elected for a 300 cc smooth round moderate plus profile silicone gel implant. We performed a total capsulectomy with the removal of the entire capsule and implant, and a change of location for the new implant to under the muscle along with a mastopexy. She is shown just before surgery and again, 6 months after. Her breasts have remained soft.
A woman in her mid 40’s who had saline breast implants at the age of 28 to increase the size of her breasts and help to correct some asymmetry. Since her surgery she has had 2 children and her body has changed. She notes that both breasts are larger and more asymmetric as her left breast has increased proportionally more in size. She wished to be smaller in size. She was not sure if she wanted to have a breast lift at the same time as removal of her breast implants. This is a question that comes up and there is a novel solution for patients with saline implants-they can be drained in the office under local anesthesia a month or more before surgery. This allows the breasts to recover and gives the patient a better idea as to whether she wants to proceed with a breast lift, or simply remove the deflated shell of the implants later in the operating room. In her case, she was satisfied with the appearance of her breasts after they had recovered from the deflation and decided to proceed with implant removal only. She can always return later for a mastopexy (breast lift) if she changes her mind.
A woman in her late 20’s who had 350 cc high profile smooth round silicone implants placed by another plastic surgeon 7 years before. She felt that the implants were too large for her frame and also had “bottoming out”- placement of the larger implant evidently required releasing her infra mammary fold and it kept dropping to the point that her nipples would peak out of the top of her bathing suit. The breast fold is a ligament that supports the breast and the implant like a shelf. In her case when it was detached, this “shelf “collapsed and the implants dropped down too low. She also wished to have more cleavage.
Her implants were kept in the subglandular space and were exchanged for 255 cc round textured silicone moderate profile implants. Her infra-mammary folds were reconstructed and internal reinforcement was done with Strattice, which is a porcine dermal product that becomes part of the patients tissues and adds strength, and decreases the risk of recurrence. She is shown just before and again, 9 months after surgery. She is thrilled with her correction. The size is appropriate to her frame (5’9”/ 122lbs) and her fold is back and holding her implants in the proper position. This is a cautionary tale for patients that have an implant placed initially that is larger than their tissues can support. Lowering the breast fold should be done with caution, and the tradeoffs of an overly large implant may not be worth the potential problems that can develop.
UPDATE: Our patient is now seen 9 months after surgery. Her breast fold reconstruction has remained stable and her breasts have held their new shape.
A mother of 3 in her mid 40’s who had bilateral subglandular breast augmentation in another part of the country 17 years ago with textured round saline implants. She noted a sudden deflation of her left breast 6 months before seeing me. She was not able to obtain her old records but thought she had textured round implants of the 260-300 cc range. She wished to be slightly fully but still natural in appearance. She has an old breast biopsy scar on her right upper breast. She is not a good scar former and did not want to have the visible scars from a mastopexy (breast lift) The decision was made to replace her implants with a slightly fuller implant placed through her existing infra mammary scars ( at the breast fold).
So the question is what size implant to use? A nice option in a case like this is to drain her other implant in the office under local anesthesia, usually one month before surgery to allow the breast tissues to recover from the pressure of the implant. We can gain some information from the amount of fluid that we remove from the implant, and can then perform our sizing in the office with the Mentor sizing system, a set of silicone shells of different sizes that slip over the breast inside the bra and are excellent at simulating the final size in clothing. Based on this information she selected a 375 cc size, which is a 325-375 cc moderate profile saline implant filled to 375 cc. She is shown before and after deflating her right breast implant and again, 6 weeks after replacement with a smooth round saline implants under general anesthesia at the hospital in the same subglandular plane(above the muscle) through her existing infra mammary incision. A subglandular placement allows the implant to drop with the breast and can decrease the need for a breast lift in some patients who are on the borderline.
A 13 year followup on a patient with saline breast implants. Her case was made more complicated by having a history of Von Willebrand’s disease, which can increase the risk of bleeding. Clearance was obtained from her cardiologist she was given DDAVP ( STIMATE) just before and after her surgery. She had 325 cc smooth round saline implants placed through an inframmary incision and above the muscle (sub-glandular). She did not have any problems with bleeding after her surgery and is still doing well 13 years later. She was back for a routine check, One advantage of saline implants is that it is easy to tell if they have leaked ( the saline is absorbed and they go flat) so they are easy to evaluate without obtaining an MRI or ultrasound.