July 5, 2022
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By Dr. Andrew Campbell-Lloyd

Breast implant revision surgery

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Information

PROCEDURE:

Breast implant revision

  • to correct complications after previous breast augmentation surgery, including capsular contracture, pain, animation deformity
  • to correct for changes in the breast that occur after previous breast augmentation, including enlargement and stretching of the breast during pregnancy
*Note: much of this information will also be applicable to ladies who have had breast reconstruction using implants, after mastectomy for breast cancer.

COSTS:
Plastic surgeon’s fee: from $7,700 to $11,900

Total approximate cost (uninsured patient, day surgery only): from $TBC

Associated item number: item numbers for implant replacement ARE NOT typically applicable to patients with cosmetic breast implants. In rare circumstances, findings during surgery may allow for the use of an item number, but this cannot be determined pre-operatively.

May be performed with: MASTOPEXY
May be performed with: FAT TRANSFER

LENGTH OF PROCEDURE/HOSPITAL STAY:
2.5-4.5 hours

Day surgery

Breast augmentation surgery remains the most common cosmetic surgery procedure performed in Australia. Nearly every breast augmentation procedure performed each year is done in a similar way: the Pectoralis major muscle is cut and the implants are placed partly under the muscle in a "dual-plane" pocket. The rationale for placing implants under the muscle is largely historical, with very little evidence to support the practice, and yet few surgeons question this dogma.

In Dr Campbell-Lloyd's experience, placing breast implants under the muscle is associated with a range of problems, including implant animation, implant displacement and pain. Many patients will experience significant cosmetic and functional benefits from repairing the Pectoralis major muscle and replacing their implant in a pre-pectoral (on top of the muscle) pocket.

Dr Campbell-Lloyd's goal in all breast implant revision surgery is to restore the breast to a natural, aesthetically pleasing shape. In doing so, it is often possible to resolve functional complaints, including pain.

Breast augmentation is performed by a wide array of individuals, not all of whom are qualified or appropriately trained. The capability of the surgeon performing the original breast augmentation may have a substantial impact on the complexity of the revision procedure.

The key to revision surgery is being able to accurately determine what has been done in previous procedures. Dr Campbell-Lloyd needs to consider both what was done deliberately, and what mistakes may have been made by the previous surgeon. We must then work to restore the breast to as close to normal as possible before proceeding with the placement of a new implant.

Breast implant revision surgery has more in common with breast reconstruction than it does with primary breast augmentation.

Breast augmentation may be associated with thinning of the natural breast tissue over time. This compounds the fact that ladies who choose to have cosmetic breast augmentation normally do so due to having a relatively modest natural breast volume, or due to deflation of the breast after pregnancy. As a consequence, in some patients breast implant removal may lead to very poor aesthetic outcomes, even when performed with other procedures such as fat transfer. In these patients, breast implant replacement may be a consideration to avoid cosmetic deformity.

All breast implants are associated with a range of complications, the risk of which increase over time. All breast implants will require removal or replacement at some point in the future.

Key Features

"Plane change"

Two of the main reasons patients seek revision surgery with Dr Campbell-Lloyd are to address capsular contracture and its consequences, and to undo the functional limitations created by cutting the Pectoralis major muscle and placing an implant in a dual-plane pocket. Dr Campbell-Lloyd believes that the only way to achieve durable results after implant revision is by ensuring that a new implant is placed in a totally new pocket, after performing a complete capsulectomy.

Attempts to modify existing pockets are associated with the early recurrence of complications. In the past, and even now, many surgeons perform revision surgery by simply releasing the contracted scar tissue (capsulotomy) to allow it to expand, or tightening the capsule where necessary for support (using sutures or "heat shrinkage). These techniques fail to manage the basic processes which result in capsular contracture.

Dr Campbell-Lloyd recommends a complete capsulectomy, and conversion to a pre-pectoral pocket in most cases.

Total capsulectomy

Dr Campbell-Lloyd recommends removal of the entire scar capsule from the old implants. This minimises the risk of contracture recurrence, and facilitates other aspects of the surgery including muscle repair. When there is implant rupture, a "total intact" (often incorrectly referred to as "en-bloc") capsulectomy will be performed to contain the rupture during removal.

Pectoralis major muscle repair

Dr Campbell-Lloyd will always repair the Pectoralis major muscle following capsulectomy. Restoring the muscle to its natural position is a key step in creating a stable foundation for any breast implant revision procedure. The muscle repair offers a number of functional benefits.

Internal bra technique

An "internal bra" is the creation of strong supports for the breast using internal sutures to reconstruct or reinforce the natural boundaries of the breast.

The original breast augmentation procedure may have involved deliberate or accidental disruption of the boundaries of the breast. The most common example is the deliberate destruction of the natural crease under the breast (the inframammary fold) by dividing the supporting tissues. This manoeuvre may be a planned step in performing the augmentation surgery as it allows the surgeon to lower the level of the crease (in a properly selected patient) to accommodate a larger implant size. This can however lead to several problems including double-bubble deformity and "bottoming out". Another common example is the inadvertent over release of the inner and outer boundaries of the breast, which can lead to medial displacement/symmastia (effacement of the cleavage; sometimes referred to by patients as "mono-boob") or lateral displacement respectively.

Depending on the specific problems encountered, the internal bra, in conjunction with precise dissection techniques, allows for repair of the previous damage and strong control of the new implant pocket.

Drainless

Due to the techniques Dr Campbell-Lloyd uses, there is no need to use drains for breast implant revision procedures. This allows patients to go home on the day of surgery, and is associated with less pain, with no increase in the risk of fluid collections.

Associated procedures:

Fat transfer & Mastopexy (click for details) are commonly performed as part of breast implant revision procedures.

Reasons To Consider This Procedure

The reasons some patients consider breast implant revision are identical to the reasons other patients consider explant surgery.

The choice to revise and replace breast implants is deeply personal, as is the original decision to have a breast augmentation. It is vital that in choosing to replace their implants, patients are guided carefully through the complexities of revision surgery. Managing expectations in revision surgery can be difficult due to the enormous number of variables which can influence outcomes.

Implant revision surgery is far more challenging and extensive than primary breast augmentation.

There are 3 main reasons that patients ask Dr Campbell-Lloyd to perform breast implant revision surgery:

Capsular contracture

All breast implants are surrounding by a scar tissue capsule. If this scar tightens, it may shrink, gradually squeezing the breast implant. Often the implants become almost sperical under the deforming forces of the contracture.

Capsular contracture may be associated with pain, breast shape changes, and increasing firmness of the breast. Capsular contracture is frequently associated with implant rupture, although the relationship may not be causal.

Implant rupture  

Ruptured breast implants are common, and very frequently an implant rupture is a silent event. Most patients only find out they have a rupture when they seek investigation of some other complaint, like breast pain. The symptoms that lead to investigation are most commonly related to a capsular contracture, but once the rupture has been identified, many patients erroneously believe that it is the rupture that is the cause of their symptoms.

Patients who have had breast MRI or ultrasound scans will sometimes have findings of silicone in lymph glands. This can be seen in patients with, or without implant rupture. This is suggested to occur most commonly due to the accumulation in lymph glands of microscopic silicone fragments which may be shed by textured implants. This finding is typically of little signfiicance and does not require additional management. Dr Campbell-Lloyd does not support the removal of lymph nodes based on these findings.

In general, implant rupture does not represent a health risk. The ruptured implant is contained within the scar capsule, which prevents leakage of the silicone into the breast tissue. It is very likely that a rupture will have been present for a long time prior to being detected. Implant rupture is far more common with older implants.

More importantly, implant rupture does not represent an urgent indication for revision surgery. Feeling rushed into surgery is a likely cause for dissatisfaction with the outcome of revision procedures.

Changes in the breast over time

Many patients who have cosmetic breast augmentation do so prior to having children. Enlargement of the breast during pregnancy and breast-feeding may lead to stretching of the breast tissues and loss of elasticity, which results in a typical appearance referred to as the “waterfall” deformity. This is a way of describing the breast falling down over the front of the implant, whilst the implant is typically held up by its position under the muscle (and often capsular contracture), creating dissociation between the breast and the implant.

Revision breast surgery is focused on restoring a harmonious relationship between the breast and implant, and may involve mastopexy to elevate the breast, as well as correcting the capsular contracture that often holds the implant in an artificially high position.

The other common reasons that patients seek revision surgery include:

Painful implants – whilst often associated with capsular contracture, pain can also occur without any evidence of contracture. Pain may relate to pressure effects of breast implants on nerves, and this is nearly always associated with “under the muscle” or dual-plane placement. Ladies who present with implants that have "fallen" out to the side (typically seen when lying down) may be more likley to experience discomfort in the absence of contracture.

Some patients also experience discomfort, which is best described as a sense of tightness, relating to stretching of the Pectoralis major muscle by the breast implants. This can be a significant issue for physcially active women who play sports and engage in weight lifting or functional training.

Botched” breast augmentation procedures – unqualified or inexperienced surgeons may be responsible for implants which are incorrectly placed, incorrectly positioned & the wrong size. There may be progressive problems leading to pain and cosmetic deformity. Patients who have had poorly performed breast augmentation surgery will often present for correction early after their augmentation procedure.

Animation deformity ” – the movement of the implant (typically upwards, and outwards) due the effect of the Pectoralis major muscle on the implant is referred to as implant animation. Along with movement of the implant, animation can cause distortion of the breast, a widened and flattened cleavage, and pain.

A typical example of implant "animation"

Dual-plane implant placement requires deliberate release and weakening of a very important muscle.

Cutting the Pectoralis major muscle always creates a serious and permanent change. It may not be obvious at rest, but with movement of the upper body, minor contractions of the muscle can create visible distortion and movement of the implant.

Implant animation can feel very uncomfortable, and some patients will actively avoid movements which involve Pectoralis contraction.

What To Expect

Dr Campbell-Lloyd believes very strongly in performing surgery that leaves patients with natural, durable results. We recommend a conservative approach to selecting the size of the new implants, especially when revision surgery is performed with a mastopexy.

It is important to understand that using breast implants will always create an ongoing requirement for additional surgery at some stage in the future.

In spite of complete correction of capsular contracture or cosmetic distortion of the breast, patients who present with pain may not experience resolution of their discomfort after revision surgery.

All sutures are dissolving sutures, under the skin. A layer of glue is then applied to any incisions. There are no “sticky” dressings applied as this will tend to cause irritation and prevent showering.

After breast implant revision surgery, patients are discharged home with a surgical compression bra which must be worn at all times for the first 4-6 weeks.

Patients are discharged with antibiotic tablets, and pain-relief medications.

Patients are discharged home with detailed instructions. The instructions include emergency contact details for Campbell-Lloyd.

Routine follow-up appointments are made for (although patients may be seen more frequently):

  • 3-4 days post-op,
  • 4-6 weeks post-op,
  • and 3-4 months post-op

There will be some pain. Most patients will experience pain at the incision site in the crease under the breast for the first 7-10 days. Some patients will experience occasional discomforts relating to movement after that time as the healing process continues.

The nature of this surgery is such that patients should expect to require pain relief medication for at least the first 2-3 weeks. Some patients will require simple pain relief (such as Nurofen) for up to 6 weeks as they increase activity.

The internal bra technique may be associated with some additional discomfort. Patients may experience a tight, "band-like" sensation under the breast associated with the muscle repair and internal bra, which can persist for 2-3 months. This is improved with stretching and the resumption of full activity.

It is vital to maintain a decreased level of activity for 6 weeks after surgery to ensure that the muscle repair is not inflamed or aggravated.

It will take at least 3-4 months for full recovery. Final results can only be appreciated after that time, once scars have softened and relaxed. Scars may only fade after 6-12 months on the breast.

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