Breast Augmentation Revision Gallery

A woman in her early 40s who had breast augmentation elsewhere in 2016. She noticed a change in the shape of her left breast a year ago, and  An ultrasound suggested a left implant rupture, which was confirmed on a subsequent MRI.  She originally had Mentor moderate profile plus 350 cc smooth round silicone gel implants placed through an inframammary incision in a partial subpectoral position.  Her left implant fold was 2 cm higher than her right.  She liked the implant size that she had and wished to have it replaced with the same size.   She is shown before and again, 6 weeks after the removal of her left ruptured silicone implants, and replacement with new implants of the same size and manufacture on each side.  Her left fold was lowered to match the right. Because she had her original implant cards and it had been less than 10 years since her original procedure, we were able to open a case with Mentor for a warranty claim which will help to cover some of the costs of surgery.  We also were able to prior approval from her insurance company to cover the removal of her left ruptured silicone breast implant.  At 6 weeks she is healed well and has better symmetry.

A 12-year follow-up on a woman in her early 70s with a history of capsular contracture who comes in for a routine implant check.  She initially saw us after a partial deflation of saline implants as well as a left capsular contracture.  We treated her by removing the implants and performing a left partial capsulectomy and then waiting 3 months to allow the body to clear bacteria and biofilm which is often a cause of capsular contracture and may account for a recurrence rate of as high as 70% if the implants are replaced immediately.  3 months later we returned and placed smooth round silicone gel implants of 339 cc size.  She is now seen nearly 12 years later.  Her breasts remain soft and she asks about how to follow up on her silicone gel breast implants.

Discussion:

Breast implants are not meant to last your lifetime.  If you are like many of my patients, it has been a few years since your breast augmentation and you are wondering “What should a thoughtful patient be doing now?

There has been a little confusion because the FDA shook things up a little bit with new recommendations that they released in 2022.

These recommendations are for patients who do not have any symptoms and are doing well after their breast augmentation.  If a breast augmentation patient is having symptoms, they should call their plastic surgeon and make an appointment to be examined.

If a patient has had saline-filled implants, such as the traditional saline filler implant or the newer multi-lumen Ideal Structured saline implant, then they do not require any special screening for rupture.  The breast will get visibly smaller as a saline implant leaks and you will be able to tell if you have a full or partial deflation by looking in the mirror.  The saline is harmlessly absorbed like an IV.  They will typically not need an implant study such as an MRI or an ultrasound. ( photos of saline and ideal structured saline implants)

90% of breast implants used in the US for breast augmentation now are smooth, round silicone gel filler implants.  Rupture rates with breast augmentation vary depending on the implant study but around 10% of silicone breast implants have failed by 10 years.

I mentioned that the FDA changed things in 2022.  BEFORE 2022 the recommendation from the FDA in breast augmentation patients with no symptoms was to get a non-contrast  MRI every 2-3 years.  And a non-contrast  MRI is still thought to be the gold standard for detecting breast implant rupture.  However patients weren’t generally getting routine screening done— it was expensive, insurance companies often didn’t cover the cost in patients with no symptoms, and many patients didn’t like being in an MRI scanner.

In 2022 the FDA changed to recommend MRI or ultrasound starting 5 -6 years after the initial surgery.  Why 5-6 years? Waiting 5-6 years was recommended because the chance of having a rupture in less than that time was very low and they didn’t feel that it made sense to screen before then.

Studies have been done showing that diagnostic ultrasound is very good at screening asymptomatic patients, as well as being more widely available and lower cost.

So the current FDA recommendation is ultrasound or MRI starting 5-6 years after breast implant placement and then repeating this every 2-3 years to monitor for asymptomatic silent rupture. Our patient will obtain a screening ultrasound.

A woman in her mid-30s developed secondary fullness of her breasts after an initial breast reduction with us 14 years before.  She is very petite at 5 feet tall and 119 lbs.  She initially saw us in her early 20’s and was reduced from a DD to a “c” cup.  She did well after her first surgery.  Since that time her weight has fluctuated up and down and although she is back to her normal weight, her breasts are back to a 32 DD cup and she feels they are out of proportion to her frame.  She has bulging of the upper breast/ axilla (“axillary lipodystrophy”). She is shown before and again, just 6 weeks after a secondary breast reduction with the removal of 160 grams of breast tissue from each breast along with liposuction of 150 cc from each breast.

Discussion:

An article in the Plastic Surgery Journal in June 2018 showed a retrospective review of patients undergoing a re-reduction by a single surgeon in Canada.  The article was very similar to our experience here.  The surgeon had Ninety patients who underwent breast re-reduction surgery using a random pattern blood supply to the nipple. ( which is what we did here)  The average interval between the first and second surgery was 14 years  ) the same here) with a range of 0-42 years.  The majority of patients had undergone a primary reduction with an inferior pedicle technique. ( the same here)   The nipple-areolar complex was repositioned in 60% of patients. (same here)  The average volume of tissue resected was 250 grams with a range of 22-758 grams. ( our volume here was 160 grams of breast tissue and 150 ml of lipoaspirate from each breast )  Liposuction was used in all cases. ( as we did here)

The four key principles were:

1: the nipple-areolar complex can get elevated by deep laicization rather than recreating or developing a new pedicle

2. Breast tissue is removed where it is in excess, usually inferiorly and laterally ( which was done here)

3. The resection is complemented with liposuction to elevate the bottomed-out inframammary fold ( done here)

4. Skin should not be excised horizontally below the inframammary fold.

Our patient is thrilled with her 6-week result following the re-reduction of the breasts and will now start topical silicone to help with scar maturation.  She is thrilled to be back to a C-cup

A woman in her mid 40’s with a deflation of her left implant. She initially had bilateral sub pectoral breast implants placed by another plastic surgeon in 2004. Her records shown McGhan (now Allergan) style 68 330cc saline implants filled to 360 cc on each side. She describes herself as a 36 C cup and was otherwise been happy with the results. She has a minor “waterfall” effect where the breast drops off of the implant mound with a sub pectoral placement. This could be corrected by changing to a sub-glandular placement of the implants but she likes the other potential benefits of sub-pectoral placement (decreased risk of capsular contracture, easier to perform a mammogram)

She noted a sudden decrease in the size of her left breast in 2019 but then “covid happened” and she was not able to get in for treatment. She decided to switch to the Ideal Structured Saline breast implants, and is shown before and again, 6 months after implant replacement.

Discussion: She has a minor “waterfall” effect where the breast drops off of the implant mound with a sub pectoral placement. This could be corrected by changing to a sub-glandular placement of the implants but she likes the other potential benefits of sub-pectoral placement (decreased risk of capsular contracture, easier to perform a mammogram)

There is no problem waiting for treatment after a saline implant deflation- If the implants can be replaced in the months after and before the tissues tighten around the deflated implant it can be slightly easier but a capsulotomy or release of the implant capsule is typically performed at the time of implant placement. The Ideal structured saline implants may have a lower deflation rate and are closer in feel to the silicone gel implants but filled with saline so they have the same “peace of mind” of avoiding a silent rupture. If they leak it can be detected without obtaining an ultrasound because the breast gets smaller. It is therefore not “silent”

She liked her size so the closest match is the Ideal structured saline implant size 335 cc with the back lumen filled to 188 and the front lumen filled to 135 cc, which, together with the empty implant volume of 52 cc gives a total implant volume of 375 cc.

A woman in her mid 30’s with partial deflation of her left breast ideal structured saline implant after 2 years.  She is shown before and again, 6 weeks after replacement of the implant.

Discussion: Although the Ideal structured saline implant has a low failure rate, they do deflate on occasion.  When this happens it is typically one of the two chambers and presents as a partial deflation.  It has been easier to replace because the still intact second chamber tends to hold the shape of the base and makes it less likely that a full capsulotomy ( release of the contracted capsule) is required.

A woman in her mid 50’s who had breast augmentation done 19 years before  when she was in her mid 30’s and when she was a 36 “C” cup, making her a “D” cup after surgery.  Since that time she has gained some weight an is now a 38 DD cup.  She is having problems with neck pain, and feels that the size of her breasts are a trigger fo migraines and are too big now for her frame. She originally had Saline implants placed through an infra-mammary incision (at the breast fold) and below the muscle.  She did not have her old records.

The saline implants were sterily drained in the office and I removed 420 cc of saline from her left breast and 345 cc from her right.  This was done a month before her surgery to allow her tissues to recover and allow us to judge how much volume she had to recreate a breast with her own tissue

She is shown again, 4 weeks after draining the implants and then 7 ½ months after removal of the deflated saline implants combined with bilateral breast reduction with a superior pedicle technique.  She no longer has symptoms and is thrilled with the new size and more youthful  appearance of her breasts.

A woman in her later 40’s with breast ptosis and deflation of her left breast implant.
She had breast augmentation 20 year before by a different plastic surgeon and noticed a sudden decrease in the size of her left breast 2 weeks before seeing me. She describes herself as a 36 D cup an d wa happy with the size. Since her breast augmentation she has had 2 children, which she breast fed, and her breasts have become “droopier” in appearance. Her implant information was obtained and she had Mentor 300 cc textured implants placed through a transaxillary incision and in a subglandular space. She is active at the gym and likes the lack of animation with a subglandular placement.

She is 5’9” and 167 lbs Sizing was done in the office and she elecdted for a slight increase in size. She is shown 11 months after bilateral implant removal, capsulotomy, and replacement with Mentor Smooth round moderate profile saline 400 cc implants ( 350-400 filled to 400) combined with a periareolar mastopexy using a Round- block Goretex suture. A separate inframammay incision was used to remove her old implants and place the new implants.
Mentor no longer makes a textured saline implant and the smooth surface was used.

A mother of one in her early 50’s who has a long standing deflation of her left saline implant. She originally had 275 cc smooth round mentor saline implants placed in a partial sub-pectoral position through an infra-mammary incision in 2007. She did well but 3 years ago had a spontaneous deflation of her left breast implant.

She is petite at 5’2” and 118 lbs and elected for a small increase in size. She is now 6 weeks after removal of her ruptured left implant and intact right implant, using the same incisions and replacing with Ideal Structured Saline implants 300 filled to the top recommended total volume of 340.

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.

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.