REVISION BREAST AUGMENTATION
Revision breast augmentation forms a significant and important part of Dr Huang’s breast augmentation practice. Such reoperations may be required to address complications or suboptimal results from previous breast augmentation surgery. The commonest complication requiring revision is capsular contracture, which occurs when the capsule of scar tissue surrounding the implant becomes thick and contracted. When the implant is compressed by the tight capsule, it feels too firm. The compressive effect of the capsule also causes the implant’s shape to become distorted and it then looks too round. In addition, capsular contracture also tends cause the implant to be displaced upwards, resulting in the implant sitting too high on the chest and above the level of the actual breast. When severe, capsular contracture can be uncomfortable or even painful for the patient.
The second commonest complication requiring reoperation is rupture and deflation of the implant. This was more prevalent with the older generations of breast implant which contained liquid silicone, and much less common with later generations of implant which contained high viscosity silicone gel that did not flow like a liquid. This complication is also not uncommon with saline implants, which have valves through which the saline solution is injected to fill the implant at the time of implantation. Postoperative failure of this valve would allow the saline to leak out of the implant, resulting in deflation and loss of volume.
As for suboptimal results, the commonest type of undesired result is where the implant is located too high up on the chest and is sitting above the level of the breast. This is usually due to total submuscular placement of the implant. The muscle is question, the pectoralis major muscle, is very powerful, and if an implant is placed completely under this muscle, there is high chance that after the surgery, the muscle will gradually pull the implant upwards and laterally, causing it to be malpositioned above the level of the breast. This creates an unnatural and excessive fullness in the upper part of the breast, and also causes the nipple to point downwards. The breast itself also looks and feels too empty in its lower pole.
Other less common types of suboptimal results include synmastia (implants to close to each other causing the breasts to join in the midline), bottoming out (implant too low) and lateral malposition (implant sitting too far to the side of the chest).
Although having to undergo another operation after a breast augmentation is never a positive outcome for the patient, the good news is these complications and suboptimal results can usually be corrected and an unhappy situation salvaged for the patient.
Revision breast augmentation requires explantation (removal of the existing implants), total or partial capsulectomy (removal of all or part of the capsule) if there is capsular contracture, and placement of new implants either in the same implant pocket or a new implant pocket that is surgically created during the same operation.
If the same implant pocket is used but it needs to be enlarged to accommodate a new bigger implant, then additional surgical dissection is required to enlarge the implant pocket. If the implant pocket needs to be reduced in size because the previous pocket was too big (an oversized pocket), the margins of the pocket need to be tightened (capsulorraphy).
If the problem being addressed is the implant sitting too high on the chest due to total submuscular placement, then conversion to a dual plane implant pocket is carried out. This involves detaching some of the muscle fibers of the pectoralis major from the ribs so that it can no longer pull the implant out of position.
The new implants are then placed in the implant pocket, surgical drains are inserted if necessary, and the wounds are meticulously closed.
As with primary breast augmentation, postoperative pain following revisionary surgery is mild and well controlled with oral pain medication. Bruising and swelling are also mild, and are reduced by appropriate medications. Normal activities can usually be resumed within one or two days. Downtime from work is usually three to four days or up to a week if surgical drains had been inserted. The drains can usually be removed within one week.
A compression band is usually worn around the upper chest above the breasts for the first one to four weeks. This helps to reduce swelling and keeps the implants in the correct position. The stitches are removed after two weeks. A proactive scar management program is then commenced to ensure the scar is inconspicuous.
Bras are usually to be avoided for the first one to two months so as not to push the implants upwards and allow them sufficient time to stabilize in the correct position. Exercise can be resumed after one month, but strenuous upper body exercise should be avoided for the first three months.
As with primary breast augmentation, the risks of surgical complications such as bleeding and infection are low. The main long term risk is still capsular contracture. However, if Motiva implants are used, this risk is low (less than one percent).
Furthermore, the risks of uncommon complications such as seromas (fluid collections around the implant), and ALCL (Anaplastic Large Cell Lymphoma) are zero with Motiva implants.
The risk of loss of nipple sensation can minimized by avoiding the need for surgical dissection beyond the lateral boundary of the breast, where the nerve responsible for nipple sensation is located.