Breast Revision Procedure Newsletter - Beverly Hills

Dr. Linder performs hundreds of breast augmentations and revisions every year. He places well over 1000 implants annually. A very large percentage of our practice is associated with women who have had their breasts done from other places throughout the United States, some as far as England, Dubai, and other continents.

Breast revision surgery requires a tremendous amount of skill. Not only must the surgeon be absolutely familiar with the specific anatomy, but the doctor must be able to recreate a normal appearance to the breast, which can be very difficult after the breasts have already been operated on once. Similar to molding clay for a pot, once the mold has been set, it may be very difficult to completely change that mold to create an absolute normal appearance. When considering breast revision surgery, the patient must find a doctor who specializes in these procedures and has many years of experience.

In my Beverly Hills plastic surgical practice, breast revision surgery is an enormous component. We deal with patients that have multiple problems including capsular contractures, double-bubble deformities where the implants are too high, anatomical implants that have rotated and have an abnormal shape, bottoming out of the breasts where the nipple ends up too high and the implant too low, ruptured implants where the implants are deflated and there is ensuing scar tissue encapsulation, and finally implant volume change where women may decide to go smaller and/or larger and/or change from saline to silicone or vice versa.

Capsular contracture is associated with severe scar tissue hardening around the implant. A capsule forms around the implant after only four to six weeks and the capsule contains the body’s mechanism to wall-off the foreign object (the implant, silicone or saline). Capsules include collagen, fibroblast, or myofibroblast, and blood vessels. They are white and shiny in appearance and the thicker the contracture, the more painful the breasts may become and the more visibly distorted.

A Baker IV capsular contracture is associated with a painful, hard, and visibly distorted breast, which may even be cold to touch. These breasts will require open capsulectomies to remove scar tissue and capsulotomies to circumferentially release the scar tissue in order to reopen the volume space so that the implant can remain flat in its normal position unobstructed.

Double-bubble deformity is associated with usually superior elevation of the implant in the pocket with the skin over-draping it. This can also be associated with malposition, improper or poor position of the implant due to transaxillary approach (through the armpit) where the parasternal and inframammary attachments of the pectoralis major muscle were not adequately detached, thereby causing a catcher’s mitt-like phenomenon where the implant is constantly pushed upward and will never fall into proper position without surgical release of the muscle appropriately. The double-bubble deformity usually requires an open capsulectomy with lowering of the implant as well as often a breast lift in order to remove the extra skin around the nipple vertically and along the inframammary fold. Anatomical implants are almost never used in our practice because they form rotational deformities and even 5 to 10 degrees of rotation can cause an absolutely bizarre and horrific appearance to a woman’s chest. Usually, these implants should be removed and a round implant, either silicone or saline will be replaced and will help to fix that problem.

Bottoming out simply means that the implant pocket is lowered to a point where the implant is too low and the nipple is too high. Capsulorrhaphies can sometimes be performed suturing the internal capsule, but more often we will often perform an inframammary lift removing the skin along the inframammary fold, which will also help to tighten and elevate the crease line. This could be very difficult to repair. Bottoming out is a very difficult phenomenon.

Ruptured implants are extraordinarily common. We see patients every week with ruptured implants from all over the country. Sometimes the surgeons are no longer available to take care of their problem and/or the patients are no longer comfortable with their doctor. In any case, we are happy to see these patients and fix this problem. Ruptured implant requires removing and explanting the implant with a replacement implant. If it is a silicone gel implant, possibly an older one such as a Dow Corning, these will often be removed, completely exenterated of scar tissue with the implant and new silicone gel implants can be replaced. Remember that with silicone implants, MRI’s should be performed at least every three years, as the mammograms are not sensitive as to a rupture of a silicone implant and can be completely incorrect. In other words, the mammogram may state that a silicone implant is intact, when in fact it is ruptured. Therefore, MRIs are your best definitive tests. The longer you leave a ruptured implant, silicone or saline, the more scar that will form and the greater the closure of the pocket, which may make it more difficult for the plastic surgeon to recreate a normal appearance and shape to the breast. Therefore, ruptured implants should be treated as soon as possible with open capsulectomies and exchange of the implants.

Finally, women often desire to have the implant volume revised. Thereby, they may desire to go larger. If so, implants can be replaced and often the capsule will have to be released in order to allow for more tissue space and volume to create a natural appearance to the breast. If you desire to go smaller and you have laxity of skin, it may also require a breast lift, a mastopexy and that can be either a vertical mastopexy or a Wise-pattern technique where the skin is removed in an anchor-like fashion.

We very much enjoy the challenge of breast revision surgery. This is an enormous component of Dr. Linder’s practice. Revising breasts can be very challenging. Sometimes the blood supply may be poor and therefore we are limited as to what we can do safely to prevent any loss of skin or nipple areolar complexes.

It is absolutely essential in undergoing breast revision surgery that the patient see a Board Certified Plastic Surgeon who is a Diplomate with the American Board of Plastic Surgery, a member of the American Society of Plastic Surgeons and a Fellow of the American College of Surgeons and that that doctor super-specializes in breast augmentation and breast revision surgery. This will allow the patient to have the greatest chance of having an excellent final outcome.

Stuart A. Linder, M.D., F.A.C.S. is a Beverly Hills plastic and reconstructive surgeon specializing in breast augmentation, liposuction, tummy tuck, and more.

Dr. Linder is certified by the American Society of Plastic and Reconstructive Surgeons and is a diplomate of the American Board of Plastic Surgery.

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Skin Deep Magazine

"Reasons For Reoperation:
Breast Revision Surgery"

Contributing Writer:
Dr. Stuart A. Linder,
Board Certified Plastic Surgeon
January 2006

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Stuart A. Linder, M.D., F.A.C.S. Beverly Hills Breast Revision Specialist
9675 Brighton Way Suite 420 - Beverly Hills, CA 90210
Phone: (310) 275-4513 - Fax: (310) 275-4813