Breast Augmentation Revision – Patient 297
A mother of 2 in her later 40’s with a left breast implant deflation 2 weeks before seeing mye and breast ptosis ( drooping)
She had had breast augmentation 20 years before by a plastic surgeon who is now retired and described herself as a 36 D cup. She was happy with her size. She has had 2 children and breast fed since her surgery, and her breasts have drooped in appearance. She had her intial implant card showing mentor textured 325 cc saline implants. She had a capsular contracture on her right breast. Her initial surgery was transaxillary ( through the axilla) and her implants were above the muscle. She is active at the gym, and liked the lack of animation deformity ( movement of the implants with activation of her muscles( that is the tradeoff of placement of the implants above the muscles. However, there is a higher incidence of capsular contractrue both with a transaxillary approach and with a subglandular placement. She was sized in the office and liked a slight increase in size. There is a high risk of recurrence of a capsular contracture which can be decreased by changing the position of the implant to underneath the muscle, in a “new pocket”
At the time of surgery she had 350 cc implants filled to the maximum suggested volume of 400 cc and placed in a subpectoral space through an inframammary incision, combined with a periareolar mastopexy. At 5 ½ months after surgery her breasts remain soft, and her mastopexy scars have already faded nicely.
Breast Augmentation Revision – Patient 296
A woman in her late 50’s who had a sudden deflation of her right breast saline implant. She was 9 ½ years after bilateral breast augmentation and right mastopexy with Dr. Hall. She noticed a “funny feeling” on her right breast and the next day noticed that the breast implant had completely deflated. This was at the very start of the Covid 19 quarantine and we were able to first see her virtually online and then as soon as we were able to return to the operating room a few months later, we were able to replace her implants. She is shown now, 5 months after bilateral implant replacement.
Discussion: She has smooth round saline implants with the right side 400 and the left side 375. She is 5’4 and 139 lbs and was pleased with the original size that we had selected so we replaced them with the same size. The implants are under the muscle. The original incision along the inframammary fold was used on each side to replace her implants.
She asks me if she should change her exercise routine to prevent another deflation. The best answer is no. All implants will fail eventually, and a general number is around 8% of implants will fail by 10 years. The advantage of a saline implant is that this failure is not “silent” as it is with a silicone gel filled implant, because the saline is absorbed by the body and the implant gets smaller or generally goes flat. The FDA now recommends with Silicone gel implants that a patient obtain and ultrasound 6 years after surgery and then every 1-2 year thereafter to be able to detect a rupture when it occurs. With a saline implant, ultrasound follow-up is not necessary. Most of the implant companies have a kind of a warranty that is in force for 10 years, one of the companies (Sientra) has 20 years, and Ideal implant company allows you to renew the warranty each year for your lifetime if you desire for a small fee. The warranties typically provide some financial assistance toward the cost of the surgery and a new set of implants. Although the left implant was intact, since is has been 9 1/2 years she made the decision to replace both.
Breast Augmentation Revision – Patient 295
A mother of 2 in her later 40’s who had a breast augmentation 20 years before by another physician who has since retired. Earlier this year when she noticed a sudden deflation of her left breast. Since her augmentation she has had 2 children and breast fed and her breasts have become droopier in appearance. She retrieved her old records and she was noted to have textured Mentor saline 325 cc implants placed in a subglandular space through a transaxillary incision.
She is shown before and again, 6 weeks after removal of her old implants and placement of 400 cc smooth round saline implants through and inframammary incision, combined with a periareolar mastopexy.
Discussion: She likes the lack of animation with the subglandular approach and elected to keep her implants in that space. A transaxillary incision is now known to have a higher risk of capsular contracture and a new inframammary incision was recommended. Although the implants could have been placed through the peri-areolar incision, that would involve splitting the breast tissue and can lead to some unusual puckering and visible retraction of the breast tissue with my preference being for the separate inframammary incision. Permanent Goretex sutures were used around the areola to prevent spreading of the incision.
She was sized in the office and liked a slight increase to 400 cc. The textured saline implant was no longer manufactured by the Mentor company and we changed to a smooth implant.
Texture is controversial: The allergan Texture had a higher risk of Breast implant associated ALCL, a rare kind of lymphoma around the implant. It has a lower incidence with the Mentor and Sientra texture and may decrease the risk of capsular contracture in a subglandular placement and may also decrease the risk of shifting of the implants. In her case, she wished to stay with the saline implants and there was not enough of a benefit to texture in her case to switch to a textured silicone gel implant. Scars are at their peak at 6 weeks and will continue to fade and improve over the next 2 years.
Breast Augmentation Revision – Patient 294
A woman who had a silent rupture of her right breast silicone implant 9 years after her original surgery. She originally had Allergan Natrelle style 15 smooth round 397 cc implants placed in a subpectoral position through an infra mammary incision. She has some mild ptosis of her left breast but not enough to warrant the scars of a mastopexy. She did well until 9 years later when she noticed a change in the feel of her right breast with more folds notices on the side. An MRI was ordered and showed a rupture of the implant.
She has elected to increase slightly in size and was changed to an Allergan 450 cc Inspira Soft Touch smooth round high profile implant on each side.
She is shown before her first surgery in her early 40’s 9 years ago and 6 months after, and then 9 years after surgery and again 4 months after replacing the implants on each side, now in her early 50’s. The higher profile has given her back a little more upper pole fullness.
Breast Augmentation Revision – Patient 293
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.
Breast Augmentation Revision – Patient 292
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
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.
Breast Augmentation Revision – Patient 260
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.
Breast Augmentation Revision – Patient 259
Breast Augmentation Revision – Patient 258
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.