Breast Implant revision surgery & why "downsizing" matters
December 20, 2022
September 10, 2023
By Dr. Andrew Campbell-Lloyd

Breast Implant revision surgery & why "downsizing" matters

Breast implant revision surgery is not something that every surgeon does. More importantly, I think a lot of breast implant revision surgery is not done well. It's complex, and to get really nice outcomes takes time and effort, and an understanding of what to fix and how. I can't pretend that my results are perfect and I am constantly trying to do it better, but I like to think that I know what generally works and what doesn't

Breast implant revision involves more than just dealing with what you see on "Botched", and the other outlandish stuff that you might see online. Fortunately this isn't California and we don't see the porn stars or the disasters coming back from Colombia. We do however see our share of medical tourists and of course (and rather topically) there are plenty of unqualified doctors doing cosmetic procedures in Australia, so I think it is safe to say that we have a reasonable amount of work to do.

Most people know that breast implants don't last forever. Most people have some idea of needing their breast implants either replaced, or removed, at some point. But the general assumption that I encounter (from speaking with patients) is that revision surgery might involve nothing more than taking one set of implants out and popping a new set in. Whilst sometimes that may be true, I would suggest that it represents a minority of cases.

Most of the time, when patients present for implant revision, it is because something has changed. That might mean a change in the breast, a change in the implant, or both. One of the most common changes that occurs is in women who have breast implants when they are younger, and then have children a few years later. The changes in the breast during pregnancy and breast feeding are commonly associated with the breast "falling over the front of the implant" (what is commonly referred to as a waterfall deformity). The other very common complication we encounter is capsular contracture, with the associated distortion of the breast and pain.

Now, the main reason I thought it would be useful to write something about this is because the advice that women typically receive (from other surgeons) and what I tell them seem to be very different.

On the one hand, when the breast may have enlarged or stretched after pregnancy (for example), many surgeons propose that they simply remove the old implants and put in bigger implants which will then more completely "fill" the stretched breast, as though the breast is just some balloon that needs a bit more air to fill it up. They recommend this "upsizing" to "inflate" the breast which has started to droop. Similarly, for women with capsular contracture and distortion of the breast shape, they recommend making a few releases in the capsule to allow it to re-expand, and then using a larger implant to supposedly hold the capsule in that expanded shape over time.

When I see the same patients, I will normally tell them the exact opposite: I recommend a capsulectomy and a plane change, generally using a smaller implant, often in conjunction with a mastopexy.

So, why the difference? Let's explore the issue so I can explain why I am right and everyone else is wrong (just kidding - this is all opinion!).

Breast implant revision

Breast implant revision surgery is tricky. Typically we are doing our best to alter the shape of the breast or the position of the implant (often both) to address whatever has changed over time.

The goal of breast implant revision surgery is control. Control of the shape, control of the implant position, and most importantly, control that is present over time. In other words, we are seeking to create a durable, stable, aesthetically improved appearance by performing revision surgery. It's a correction; we aren't working from a blank slate. So it is totally different to a primary breast augmentation.

If a surgeon chooses to revise a previous breast augmentation with a bigger implant (as so many surgeons suggest, and seemingly boast about online), they run into significant problems. The temptation to "go bigger" is obvious. The apparent simplicity of this approach is appealing, and the impression that women are given is that, with a bigger implant, there is less required to achieve the desired "fix".

The problem is that none of this works...and the bigger implants substantially increase the risk of complications.

Surgeons are approaching revision work as though it is the same beast as a primary breast augmentation. This is a fundamental error, and represents a total misunderstanding of the necessary goals of revision procedures.

Let's go back to the idea of control.

There are a few basic concepts that are integral to how we can establish and maintain control of the breast in implant revision surgery.

  1. Soft tissue support
  2. Considering the weight (ie. the volume/size) of implants
  3. Additional "prosthetic" supports (meshes) as part of an "internal bra"
  4. Mastopexy / breast lift procedures

Of course, on top of these concepts, we have to remember the principles of implant revision surgery, which are to correct the presenting issue (whether that be pain, capsular contracture, animation, implant malposition, "waterfall deformity", or anything else), and for me this involves:

  1. Neopocket formation
  2. Muscle repair (where applicable)
  3. Total capsulectomy
  4. Breast reshaping and nipple repositioning
  5. and careful reconstruction of the breast footprint with an internal bra (which then ties back into the points above).

So there you have the most important parts of any revision plan but that is all preface. The main thrust of this article really comes back to the problem with "upsizing" in revision surgery, and why I always recommend a reduction in implant volume for the best results. What I really want to focus on are those first 4 points relating to long-term control, because that is where I think other surgeons get it so very wrong.

Upsizing is typically bad. And it won't fix anything.

Breast implants are, to put it bluntly, a dead weight. They have no intrinsic ability to support themselves. Yeah yeah, I know, what about textured anatomical implants going under the muscle blah blah blah. I am perfectly aware that there are certain surgeons who claim that their "patent-pending-totally-unique" surgical technique results in the implant being magically "suspended" because of the "pinching" force between the Pec muscles. But let's be honest - the only way that most textured implants stay UP, is either becuase the muscle scoops them up (which is super unnatural) or becuase of the scar capsule holding them up, and the progressive tendency for the capsule to tighten resulting in superior malposition of the implant. Which we see a lot. If the surgeon putting a textured, anatomical implant in, prevents the Pec muscle from scooping that implant upwards, and if there is not capsule tightening, then those textured implants DROP just like any other implant without additional supports - which really means, without an internal bra.

Unless we do something meaningful to control implant position during breast implant revision surgery, they will always end up somewhere apart from where you want them over time. Those meaningful somethings generally involve careful control of the implant pocket, strong support at the breast crease (the internal bra stitches), in selected cases supporting the implant further with meshes, and of course, utilising the mastopexy to help with all of that whilst reshaping the breast over the implant.

The issue therefore with "upsizing" is that by increasing the weight of the implant, there are additional strains placed on any of those techniques...because gravity always wins. Bigger, heavier implants are more likely to drop, more likely to fall out to the side, into your armpits, when you lie down, more likely to stretch the breast tissue, and more likely to cause pain.

We also have reasonable long term data to support the general assertion that complications associated with breast implants (all causes) go up with implant size over 400cc.

So attempting to "reinflate" the breast with a bigger implant, and attempting to prevent capsular contracture by "stretching" the old capsule with a bigger implant, are invariably doomed to failure. Quickly.

Now because most surgeons, in spite of what they actually do (for large sums of money), know the difference between right and wrong, good and bad, they probably realise that shoving 700cc implants into the breast is a terrible idea, and so they have started doing something really curious - they are now pushing the idea of permanent, synthetic meshes in cosmetic implant revision surgery.

Small tangent: permanent, synthetic "internal bra" prostheses to support giant implants are an absolutely awful idea in cosmetic patients. Let's talk about this.

Meshes in the breast are not new. We have used them for quite a long time in a variety of ways. I have used them myself. Extensively. But we need to understand how and why they can be useful, and in what context.

The history of mesh use in the breast is for ladies who have had mastectomies for breast cancer. Because a mastectomy removes the breast tissue (which is the stuff that actually allows the breast to support an implant) leaving behind just the skin (which cannot support an implant) we started using various meshes and ADMs years ago to try to hold the implant up. Now, that does work, to an extent. Generally it involves wrapping (or partly wrapping) an implant with whatever "stuff" the surgeon had to hand, and the suturing that "stuff" in various ways onto things like the muscle, the ribs and any bit of supportive tissue we could find really. Because the "stuff" was quite resilient and tended not to give way much over time this then allowed us to vastly improve breast reconstruction with implants without having to put them under the muscle (because that looks horrible).

In the context of breast reconstruction, I am a very big proponent of, and user of meshes. Personally, I only ever use dissolving products - that is, things that will either be incorporated into your body naturally, or which will break down over time and be replaced with scar tissue. My experience would suggest that they work well, and have a low rate of complications.

However, those various meshes and ADMs come with problems. Number 1, they are all foreign bodies. Which not everyone will respond well to. Number 2, for the meshes that dissolve, they can lose support over time as they are replaced with scar tissue, but to be honest this is better than the alternative which involves permanent meshes (which are basically woven bags of something like fishing line). Which brings us to number 3, the permanent meshes, which are stiff, associated with chronic pain, create chronic irritation, and then when it comes down to it, they are an absolute nightmare to remove. I have spent far too many hours of my life digging out this stuff.

So, back to what I was talking about before: some of my uber-competitive colleagues in Sydney have suddenly cropped up on socials spruiking the use of these permanent meshes (one in particular, which I hate, called Ti-loop) for patients with breast implants, and even worse, they are pushing this stuff because it allows them to use truly awful, MASSIVE implants (like, 700cc massive) in cosmetic revision cases. So the whole thing is a perverse circular logic - big implants are dumb, and they need extra support. So use a permanent mesh, which has a higher complication rate, which is dumb, to support the big implant, which is dumb. Good lord.

I'll throw one life-line here to the use of meshes for cosmetic breast implants, and that is for ladies who have experienced substantial weight loss, with significant losss of breast volume and breast ptosis. For those ladies, where an augmentation-mastopexy (or revision surgery) is performed, I will sometimes recommend the use of a specific mesh (in my hands, the recommendation is for a dissolving product called Galaflex). Something to discuss, but I am very careful about how I use it cosmetically. It definitely isn't to allow me to use a big implants. It is only ever to overcome the natural limitations of soft tissue support in that specific patient group.

Let's get back to downsizing

From what I have said already, it should be no surprise then that for ladies who want to have their breast implants revised, I recommend staying the same size (where the implant isn't too large already), or more commonly a downsize (where the implant is big). Less weight means better implant position control, the internal bra has less work to do, there is far less need for any additional support from things like meshes. What I find really interesting is that a downsized implant will often look just as "big" as the larger, original implant, simply by putting it in the right place and addressing the other issues in the breast.

Downsize from 300cc (on the left) to 200cc (on the right) implants, combined with a mastopexy.
In this case, the implants are the same size (350cc) before and after surgery, but the correct positioning of the implant creates a very different appearance.

So, if we deal with the capsular contracture, if we get the implant out from under the muscle, if we reshape the breast appropriately, and if we set the crease position properly, a smaller implant has an outsized effect. We don't need a bigger implant. And the smaller implant can do that with a lower risk of complications. Most importantly, a smaller implant means longer term stability with a lower rate of re-operation in the short term.

So there you have it - a whirlwind tour of a complex surgical problem.

I say it all the time, but it bears repeating - breast implant revision surgery is hard. My preference, as a surgeon, is to optimise durable, and natural results. Of course, everything I say is just my opinion. Whilst my opinions are underpinned by fact, and data, it doesn't necessarily mean I am right.

If someone wants to look like a porn star, they better jump on the plane to Sydney though.

As always, please get in touch with any questions, or fill out an appointment request to see if we can help.