Revision Breast Surgery

Patients may find the need to have revision breast surgery due to breast implant deflation, capsular contracture over one or both implants, asymmetry, implant mal-position, rippling / palpability, wanting to change implant size and double bubble formation among many other complications.

One of the most common complications after breast augmentation surgery is implant mal-position. This occurs when the implant is in an incorrect position on the chest wall. This may include incorrect position of the implant superiorly (“riding high”), inferiorly (“bottoming out”), medially (“symmastia or uni-boob”) or laterally (falling outward into the axilla). Dr. Pousti, at Pousti Plastic Surgery, has corrected these problems for many patients.

Symmastia (or medial mal-position or “uni-boob”) occurs when the breast implants move too far toward the midline–the two implants may actually touch one another in the center of the chest. If the horizontal muscle that is connected to the sternum and goes across the implant is cut during surgery, then the implant can move toward the middle of the chest. Symmastia may result from overly aggressive attempts to alter chest wall anatomy trying to increase cleavage for patients. This outcome is made worse by use of larger implants in thin patients, and is a problem for implants over or under the muscle, though sub muscular implant placement allows the muscle to provide some softening of the transition to the cleavage area from the augmented breast mound. Correction involves use of internal sutures of the capsule around the breast implants. Often, it is necessary to expand the breast implant pocket laterally (outwardly) to allow for correct placement of the implants.

Dr. Pousti addresses another common issue with his patients and uses AlloDerm Regenerative Tissue to cover the implant in cases where the pectoralis muscle has been severed or damaged and therefore not providing enough coverage to the area. This assists with decreasing palpability of the breast implants.

Asymmetry: Patients may start with different sized breasts before surgery (most patients are not perfectly symmetrical). Adjustments can be made with the implants to try to get as much symmetry as possible after breast enhancement surgery. Different types of implants may be used, different volumes may be used to fill up the breast implants, or the pocket dissection may be different between the two sides. The Surgical Procedure for correction of asymmetry can take up to 1-2 hours depending on the amount of work involved to make the breasts as symmetrical as possible. Board Certified Plastic Surgeon, Dr. Pousti takes his time in the operating room to make sure he achieves the patient’s goals. If the patient doesn’t currently have breast implants and has asymmetric breasts, Dr. Pousti will use temporary sizers in the operating room and possibly use different size implants to achieve symmetry. If the patient currently has breast implant, usually an internal suturing technique is used to correct the pocket and therefore the implant placement on the chest.

Bottoming out involves inferior migration of the implants. This causes the nipple areola complex to appear too high on the breasts. Also, the distance from the areola to the inframammary fold is too great. It is the loss of internal implant support where implant placement with partial, or no, muscle coverage, allows slow downward migration of the implants. This is because support of the implant by the skin alone is not always enough to prevent downward migration of the implants. Also, over-dissection of implant pockets at the time of surgery may cause immediate bottoming out. This is corrected by “raising” the inframammary fold using internal sutures. This is done after careful measurements are made from the areola to the “new” inframammary fold.

Capsular Contracture: After breast augmentation with breast implants, excessive scar tissue may form around the breast implant which causes the breast implants to harden (similar to what a contracted muscle feels like). The cause of capsular contracture is not known but it is the most common complication with breast augmentation surgery. There are different grades of capsular contracture from mild to severe. The rate of capsular contracture has decreased from 20-30 years ago when all breast implants were placed above the muscle (sub-glandular). By placing the breast implants below the muscle (sub-muscular), the rate of capsular contracture has significantly decreased. Also, it is said the massage helps decrease the chance of capsular contracture. When a patient is starting to get breast hardness (capsular contracture), they may be placed on a medication called Accolate. This is an asthma medication that has shown to improve capsular contracture in patients at an early stage. When a patient develops severe capsular contracture, the treatment would be to return to the operating room and perform a capsulectomy on the patient. There is a chance that the capsular contracture may return after the revisionary breast surgery.

Change in Breast Size: Some patients choose to change their breast size after undergoing breast augmentation surgery. The most common “complaint” that patients have after breast augmentation surgery is that they “wish that they had gone bigger”. After a year or so, they may decide to remove their current implants and replace them with larger breast implants. Other patients may have gone larger when they were younger and are now ready to have a more natural look so they remove their larger implants and replace them with smaller implants. Depending on the reduction in size, the patient may need a breast lift to accommodate for the extra skin from when the breasts were larger – this is assessed on an individual basis.

Deflation: Due to a malfunction or defect in an implant, revisionary breast surgery may be necessary. If a saline-filled implant were to rupture or leak, the body would absorb the saline, causing the breast to deflate to the original size (prior to surgery). Patients may see this happen on one side or sometimes both breast implants may be involved. If a patient has silicone gel breast implants, and MRI has to be performed to detect an implant leak. Once a leak is detected (with either a saline or silicone implants), the patient would have to go back to the operating room and have the defective implant removed and replaced with a new implant. Dr. Pousti would most likely use the same incision that was used previously.

Double Bubble can occur when breast implants are placed behind the pectoral muscle, rather than in front of it, in women whose breasts have begun sagging naturally. While the implant remains in place, breast tissue sags bellow it, creating the appearance of two separate breast creases.

How the double bubble effect can be avoided: * Implant placement in front of the muscle fills out sagging skin and helps avoid this complication (although it can increase the occurrence of other aesthetic problems like the appearance of rippling) * A breast lift in conjunction with sub-muscular implant placement can help prevent inconsistent sagging.

If you are considering revision breast surgery and are located in or around La Jolla, Riverside or San Diego, we invite you to contact Dr Pousti and arrange for your personal, confidential consultation.

Tour our site to learn more about breast revision in San Diego, Riverside and La Jolla. Read testimonials from breast revision patients of Board Certified Plastic Surgeon Dr. Tom Pousti. View before and after photos of revisional breast surgery patients, and send your questions directly to the offices of Southern California Breast Revision Specialist Dr. Pousti through our contact form.