Breast Revision

With the breast revision patient’s input, Dr. Cook will select an implant that relates well to the natural breast and body dimensions. If the original implant was salinefilled, he will often recommend conversion to a silicone gel implant. Together, the patients and Dr. Cook will plan the implant’s volume, projection, and shape.

There are several ways to help restore proper coverage to an implant via breast revision, so that there is a layer of natural tissue over the device. Options to consider include moving the implant to the plane under the pectoral muscle, adding thickness with acellular dermal matrix (a biological scaffold), and using fat transfer to restore missing volume in the plane over the remaining breast tissue.

Dr. Cook may recommend some form of breast lift as part of breast revision, both to bring the breast back to a proper position on the body and to reduce the excess stretched-out skin. The good news for patients with oversized implants is that the newer breast revision techniques provide a much better range of choices than used to be the case.

There are several reasons a breast revision patient might choose to downsize or remove an implant that is relatively good proportion to her body. Some patients gain additional breast structure, either because of hormonal influences or simple weight gain. The additional natural breast structure may simply make the breast larger than the patient desires. These breast revision patients can usually achieve a happy outcome with either a downsizing or a complete removal of the implants, sometimes accompanied by a lift.

A patient’s taste may also change over time. What seemed a perfect volume in her 20s now seems a bit too full, even though the rest of her body’s proportions haven’t changed. Over the years, Dr. Cook has seen a small number of patients who simply don’t like the way implants feel in their bodies. In some cases, it simply makes sense to remove the implants during breast revision surgery.

Sometimes implant malposition is related to the way the original pocket was created. Dr. Cook has also seen situations where patterns of activity, especially early after augmentation surgery, can move an implant. Structured bras, if worn almost continuously, can help to re-stabilize an implant’s position, but if a patient forms very little scar tissue, even these efforts may not work. For these patients, it is usually necessary to perform breast revision surgery in order to reduce the size of the pocket. This is traditionally done with surgical stitches, but for patients who don’t form much scar tissue, these stitches may pull through.

A variety of surgical scaffolds have increased the probability of success in breast revision surgery to re-position implants. The material can be anchored in place, so that it forms a secure buttress that defines the edge of the pocket and holds the implant in place.

Fortunately, plastic surgeons now have a wider range of tools to restore a nice, soft coverage of implants. Autologous fat transfer and acellular dermal matrix have allowed Dr. Cook to increase the thickness of coverage over implants. If the implant has been in the plane above the pec muscle, he will often shift it to the plane under the muscle, which softens what may have been a harsh transition at the upper border of the implant. For some breast revision patients, he uses aspects of the structural breast surgery technique to shift the breast structure to where it is needed.

Some surgeons try to prevent this problem by overfilling saline implants with saltwater, but this produces a hard, ball-like breast. It is also possible to see rippling with silicone gel implants, but this is much less common than with saline implants. The best implants from the standpoint of rippling are the filed with more cohesive gel. These are sometimes called “gummy bear” implants.

Sometimes, the problem driving a breast revision is that the pocket is too large for the implant it holds. This may allow the implant to slide out of position and to ripple, particularly with saline implants. A lack of adequate thickness in the tissue over an implant can also contribute to the problem by allowing irregularities to show through.

Oversized breast implants in effect sabotage their own results, since they tend to cause a thinning out of the natural breast structure. The correction of rippling via breast revision requires an accurate diagnosis of what is causing the problem, so that we can design a strategy for correction of the problem that has the best likelihood of success. Corrective strategies include changing to an implant that is less prone to ripple, controlling the dimensions of the implant pocket, and increasing the thickness over the implant with acellular dermal matrix, fat transfer, and shifting the implant to the space underneath the pectoral muscle.

If an implant deflation occurs, it is not an emergency. With a saline implant breakage, the salt water is simply absorbed by the body. With a gel implant breakage, the natural capsule of collagen that the body forms around the implant keeps everything in place. Also, silicone gel implants from recent years are filled with a cohesive gel that does not tend to drift. Although it is not necessary to rush to surgery, it is also not wise to delay the necessary breast revision procedure for a long period of time, especially with saline implants. If enough time passes, the space around the implant may tighten, making it more difficult for a new implant to create a look that matches the opposite breast.

One question that comes up with breast revision patients in this case is whether it makes sense to simultaneously replace the implant of the opposite breast, which has not deflated. In Dr. Cook’s opinion, if it is just a few years after the first surgery and everything is perfect with the opposite breast, it is reasonable to keep the original implant in place. If a longer period of time has passed—for example, more than 10 years—then it is probably wise to also replace the unruptured implant during breast revision surgery.

If the implant is soft and in a good position, a breast revision involving a lift will restore a proper balance between the breast and the implant by bringing the breast back to its proper position over the implant. Dr. Cook evaluates each breast revision patient in detail to determine which lift technique is best suited to her breast structure and her goals. Options include the periareolar lift, the classical (anchor) lift, and the structural lift.

The Consultation for Breast Revision After Reconstruction

The breast revision consultation is a sharing of information. Dr. Cook learns the patient’s general state of health, her priorities for the reconstruction, and her pattern of living and activity, since these elements may influence the choice of breast revision techniques.

Dr. Cook then makes a careful list of the issues he sees in the reconstructed breast and discusses potential improvements. Since he has a referral practice, he sees quite a few patients for breast revision surgery in a given year. For these patients, he emphasizes a practical, goal-oriented approach.

Above all, the patient must accept that although we can usually obtain a significant improvement, it is never possible to reach perfection. “Better, but not perfect” is a point that Dr. Cook repeatedly emphasizes with his breast revision patients.

Breast Revision for Correcting a Reconstructed Breast that Is Smaller and Higher than the Natural Breast

Asymmetry is a common pattern that Dr. Cook sees in patients who are referred to him for breast revision surgery after reconstruction. If the limiting factor is the tightness of the capsule around the reconstructive implant, but the skin of the breast is not tight, he can usually open up space for a larger implant by removing the capsule of scar tissue and placing acellular dermal matrix or other scaffolding between the bottom edge of the pectoral muscle and the fold under the breast.

He will typically place a cohesive gel implant and carry out fat transfer for this breast revision procedure and will modify the opposite natural breast so that it is lifted to a better position. If necessary, he will also reduce the volume of the breast to get the best possible match with the reconstructed side. If the skin of the reconstructed breast is too tight, there are two options.

Breast Revision for Correcting Reconstructed Breast Irregularities

There are several possible causes for visible irregularities, such as rippling in breasts that have been reconstructed with implants. In general, saline implants are more likely to show rippling and irregularity than silicone gel implants.

Sometimes, there is a mismatch between the implant and the space where the implant sits. If the pocket is too small relative to the base dimension of the implant, the proportions will cause the implant to fold and wrinkle. Too large a pocket can also allow the implant to shift out of alignment and develop wrinkles.

Patients who have very little structure over the implant also are more likely to show imperfection. Dr. Cook selects a breast revision strategy based upon his assessment of the most likely cause of the rippling, but he is prepared for extra measures in case he finds other causes once he explores the pocket where the implant lies.

In general, Dr. Cook has found that cohesive gel implants are less likely to wrinkle than other types of implants, and silicone gel implants are less likely to ripple than saline implants.

Adjustment of the implant pocket, which may require acellular dermal matrix or other scaffolding, is often an important step in breast revision. It is also possible to provide extra structure for breast revision patients who have extremely thin coverage over their implants. This can be accomplished either with a fat transfer procedure or by placing a sheet of acellular dermal matrix over the implant.

Breast Revision for Correcting Excessive Fullness in the Upper Portion of a Reconstructed Breast

Reconstructed breasts are more likely to be too full in their upper portions than natural breasts that have been augmented. There is less tissue to camouflage the upper border of the implant with mastectomy. The lower portion of the reconstructed breast can also be tight, which pushes the implant toward the upper portion of the breast.

Fortunately, several recent innovations in reconstruction surgery give us a better chance to use breast revision to restore a normal shape to reconstructed breasts so that there is a natural curve in the lower portion of the breast and an upper part of the breast that is not too full.

Form-stable implants are made of highly cohesive silicone gel so that they maintain a natural shape. For some patients, conversion to a form-stable implant may be helpful.

A breast revision procedure that includes fat transfer can add volume to the lower portion of the reconstructed breast and also soften the transition at the upper edge of the implant.

Acellular dermal matrix and other surgical scaffolding can open up the space at the lower portion of the reconstructed breast so that a form stable implant can achieve optimum fullness.

Breast Revision for Correcting Failed Breast Reconstruction

When a patient is referred to a plastic surgeon with a failed breast reconstruction, the first priority is to determine the cause of the failure. Once the surgeon understands this cause, he or she can devise a breast revision plan that provides the best chance of success.

One cause of failure is infection. If there is a skin-level infection of a reconstructed breast (cellulitis), the problem can usually be brought under control with antibiotics—no need to remove the implant. If there is an infection at the level of the implant, however, it is usually necessary to remove the device to bring the infection under control. Once the infection is cleared, it is usually possible to obtain a good quality reconstruction via breast revision surgery. There are many possible options, including the use of flaps, the placement of tissue expanders, and fat transfer.

Breakdown of the skin over an implant can also lead to the failure of reconstruction results. The breakdown usually occurs along an incision line, although it is possible for it to develop anywhere the skin is very thin. The likelihood of a breakdown increases significantly if the area has been radiated. If the implant has not yet been exposed and there is no sign of infection, it is usually possible to salvage the situation during breast revision. For most patients, this is best done by the original reconstructive surgeon. The specific strategy will be determined by the patient’s individual circumstances.

Breast revision options include flaps, reinforcing the area with acellular dermal matrix, fat transfer, and the placement of an expander to take pressure off of an area of weakness. If the previous surgeon had to remove an implant, all is not lost. Sometimes it is desirable to bring in additional tissue with a flap. Often, the disadvantages of a flap can be avoided with a series of fat transfers to restore quality and thickness to the breast skin. For some patients, tissue can be modified with a preliminary external skin-stretching device.

Once the surgeon has prepared the breast skin in this manner, he will place an expander and re-stretch the breast structures. When the expansion portion of the breast revision is complete, he will place an implant. Acellular dermal matrix frequently helps to provide additional internal protection of the implant.

Dr. Cook performs surgery for revision of breast reconstruction on an outpatient basis. If he sees a patient who will require methods such as microvascular free tissue transfer or flap surgery, he will refer to colleagues in the Division of Plastic Surgery at Rush University Medical Center.

Breast revision surgery taxes the ingenuity of the surgeon and may require several operations, but the newer techniques have significantly increased the odds of success. Breast revision surgery can provide significant improvement in a patient’s quality of life.

Breast Revision and Skin-Stretching Techniques

For years, tissue expanders have been key devices for breast reconstruction. The expander is placed under the skin and pec muscle, where it gradually expands with weekly injections of salt water through a valve. This prepares a space for the reconstructive implants.

As fat assumes a greater role in reconstruction, the preparation of a space to accommodate the fat becomes very important. There are external devices that allow the plastic surgeon to stretch the skin of the chest area, so that it is optimized to receive transferred fat. This may be helpful in complex reconstruction and breast revision surgeries.

Acellular Dermal Matrix for Breast Revision

Acellular dermal matrix and other surgical scaffoldings have several useful roles in breast revision surgery. For breasts that have become stretched out in their lower portion, these materials can help to support the breast structure in a new position. For implants that have moved out of position, they can help to stabilize the pocket for the implant.

Acellular dermal matrix can also be used in breast revision to help camouflage irregularities that sometimes occur with implants in thin patients, especially in breast reconstruction.

Acellular dermal matrix can also be very helpful for breast revision patients who have developed capsular contracture around their implants. The body sometimes develops a tight pocket of scar tissue around an implant, which can distort the breast shape and cause the breast to be unusually firm.

Like many surgeons who do breast revision surgery, Dr. Cook has been impressed by the ability of acellular dermal matrix to prevent the return of capsular contracture. The strategy is to cover a portion of the implant with the acellular dermal matrix, which seems to prevent the body from making scar tissue at this location. This “loosens the grip” of any capsule that may form.

Highly Cohesive Gel Implants for Breast Revision

Implants that contain highly cohesive silicone gel tend to maintain their shape and projection and are less prone to rippling than implants filled with thinner gel. They are sometimes referred to as “gummy bear” implants. Patients today are fortunate to have a wide variety of implant shapes, cohesivity and projection. Consideration of these factors is an important part of planning a revision procedure.

Autologous Fat Transfer for Breast Revision

Dr. Cook’s familiarity with techniques of fat transfer is extensive, since he has used the procedure to restore volume in his facial rejuvenation
patients for more than 15 years.

In recent years, he has employed fat transfer to the benefit of his breast reconstruction and breast revision patients. Fat is a remarkable tool, because it can be used restore or add volume to very specific areas.

It can help to camouflage implants, particularly in thin people. Fat can also be used to improve the quality of skin that has been irradiated.

Structural Breast Surgery for Breast Revision

The development of structural breast revision techniques has been a major project of Dr. Cook’s for many years. The rearrangement of breast structure to restore natural volume to the upper portion of the breast and the deep structural anchoring of the breast can be very useful in a variety of circumstances when he revises the results of previous breast surgery.