Cornwall Breast Surgeon Iain Brown
Cornwall Breast Surgeon Iain Brown

Revisional Breast Augmentation

This is one of the most complex and challenging of all cosmetic breast procedures. In general terms, the reasons behind deterioration in what may originally have been a satisfactory result, are related to a loss of harmony between the natural tissues and the implant.


Reasons for Revisional Breast Augmentation

There are many reasons why women may require or choose to have revisional augmentation surgery:

1. Implant Problems

  • Failure– there is a small risk of implant rupture even with the best modern silicone implants. This may be related to fatigue of the implant shell over time (particularly in the presence of capsular contracture). It is rare however for all but the most exceptional trauma to cause a problem. Older historical implants (including Dow Corning, PIP, Saline, Hydrogel, Trilucent, etc.)  may have higher rates of rupture related to the chemical properties and strength of the implant shell or the physical interaction with the inner filler whether it be low cohesive silicone, saccharides, saline or lipid).
  • Implant Rotation
  • Implant Palpability/ Wrinkling

2. Soft Tissue Changes

The reason that many women undergo revisional surgery is related to the natural changes in their own tissues that occur around the otherwise healthy implants.

  • Capsular Contracture – one of the most common complications after augmentation occurs when the natural scar tissue that develops around all implants to a greater or lesser degree (the “capsule”) becomes problematic.   A contracture is when the existing capsule becomes thickened and tightens around the breast implant causing it to become "hard" and less natural looking. Pain may also be a feature of capsular contracture. Pain is most likely due to the pull of the scar tissue on the natural breast tissue, muscle or nerves.
  • Loss of elasticity/stretching of the breast skin and breast tissue - this is usually related to age, pregnancy changes, lactation, weight loss. This can also occur if the original implant size and volume chosen was too large and heavy for the patients tissues to be able to cope with long term, This problem can lead to an unpleasant appearance of the rest of the breast; either empty, unnatural or both. Sometimes it is simply that the natural tissues have thinned and stretched so much that normal implant wrinkles and folds are visible through the tissues or are unpleasant to feel. These changes maybe more pronounced if capsular contracture also exists.
  • Dissatisfaction with original choice of size, shape, volume,  augmentation technique

Removal (Explantation)

Removal (Explantation) – The simplest procedure (and the only one funded by the NHS) is to remove the existing implant through the old scar. This will return the breast to a natural state, but obviously a reduced volume. It can lead to an unfavourable shape and droop, particularly if the natural tissues have been stretched irreversibly by a large volume, heavy prosthesis. Often a patient’s natural breast tissues may have altered so much from when her implants were originally put in, that she actually has a very acceptable breast size/shape after simple removal. An experienced surgeon will be able to help a woman to have a better idea of what her “implant-free” appearance may be like after simple explantation.

NB: In cases where the capsule is very thickened and scarred, it may be necessary to remove it completely with the implant (Capsulectomy) to return the tissues back to normal.

NB: if an implant has ruptured and there is a large amount of ‘contamination’; free silicone, infection, calcification etc, it may be beneficial for the soft tissues to be left to heal for upto 6 months before a second procedure is carried out to reimplant new implants.

R & R - Removal And Simple Replacement

R & R - Removal And Simple Replacement – Although this procedure is technically a “Revision” augmentation, it is really just a simple substitution of an old with a new implant. It is not likely to allow a big change in the shape/size of the new implant. As a result there is not likely to be a big change in the cosmetic appearance of the breasts. The old scar (which may be in a sub-optimal position) is usually re-opened, the capsule opened and the old implant removed and replaced with a new one.

This has often been the procedure of choice in situations when PIP implants are removed and replaced (R & R). Simple R & R may however not be an acceptable option for a patient who is already unhappy with the cosmetic appearance of her breasts.

R & R - Removal And Replacement With Capsule Modification

R & R - Removal And Replacement With Capsule Modification (Capsulotomy/Capsulectomy) - To select a better shape/size/volume of implant and improve the cosmetic outcome, it is usually necessary to modify the capsule around the old implant.

 

Capsulotomy - involves splitting the scar tissue to release any tightness of the pocket for the new implant.

Capsulectomy – involves the removal of the old capsule completely. This will return the tissues to their “normal state”. Although a new capsule may re-form again, the objective is to use a better shape/size/volume implant to create a better harmony with the natural tissues; and therefore a more stable new result.  

Re-Implantation With New Pocket/New Plane

Re-Implantation With New Pocket/New Plane – Once the old implant has been removed (with Capsulectomy if necessary), the creation of a new implant pocket and placement of a new implant may produce a better cosmetic outcome and a more stable harmonious result.

Unlike R&R Removal and Simple Replacement, the choice for the new implant is not dependent upon the original implant shape/size and may be a very different shape/size or volume to better match the patient’s needs and thus produce a better and more stable aesthetic outcome.

Often a new incision will need to be made (usually lower down) to achieve a better result (and a lower, more natural fold under the breast).

It may be better sometimes to ignore an old scar, rather than using it anyway to avoid having any more scars but compromising the eventual shape and final appearance of the new breast.

Mastopexy Re-Augmentation

Mastopexy Re-Augmentation - Skin Envelope Reduction & Re-implantation - When a patients skin and soft tissues have been stretched irreversibly by the previous augmentation, it may be necessary to remove redundant skin and perhaps redistribute and sculpt some of the overlying breast tissue before placing the implant underneath in an improved pocket.

This procedure requires very careful planning and often refinement of implant choice during the operation itself. In certain situations a more reliable result may be achieved using a 2 stage approach; the first stage being a mastopexy and removal of implant, followed by a second stage re-implantation several months later once the tissues have recovered and settled down.

The skin envelope reduction required for mastopexy re-augmentation leads to extra scarring around the nipple and lower breast (see 2 stage mastopexy augmentation for further details).

In Conclusion:

  • Revisional Breast Augmentation is both complex and demanding surgery
  • The objective is to re-establish a lasting harmony between the implant and a patients own natural tissues.
  • Excellent results may be achieved, but the procedure should be considered to be more like a Breast Reconstruction with longer procedures, recovery times and with similar risks and potential complications to more complex breast reconstructive procedures. 
  • A successful outcome cannot be guaranteed and is strongly dependent upon having agreed & clear objectives, careful planning and meticulous technical surgery.
  • As with any surgical procedure, it is essential that patients are well informed, with a good understanding of the options available, the possible risks and complications of each technique and have  realistic expectations of what may or may not be achieved.
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