Patients often present to our office having had augmentation mammoplasty procedure and are unhappy with the symmetry of their breasts. As a result, it may be pertinent to undergo revision breast implant surgery in Las Vegas by changing the volume of the bags, replacing them with new implants, either saline or silicone, and modifying the volume in order to regain symmetry.
Scar tissue contracture includes the Baker classification. Baker I is a soft breast. Baker II is a palpable contracture. Baker III is palpable and visible and Baker IV is palpable, visible and hard, distorted and sometimes painful cold breast. Scar tissue contracture is associated with hardening around the implant which is associated with increased scar tissue, possibly associated with micro contamination of possible increased thickening of the collagen, myofibroblast and increased blood vessels around the prosthetic device. Painful Baker IV capsular contracture with severe distortion and pain requires open capsulectomies with release of scar tissue as well as circumferential open capsulotomies in order to regain increased volume space and reduce painful hardening.
Implants can rupture at any time. Saline and silicone implants can rupture associated with simply wear and tear over the years as well as due to blunt trauma. Implants that rupture can include tearing along the shell of the bag circumferentially or an implant valve leakage in a saline implant. Silicone gel implants can also rupture at any time and therefore MRIs should be performed every two to three years in order to determine the integrity of the shell of the implants. Silicone gel implants rupture is often referred to as a "silent rupture" in that you may not even notice the rupture for many years because the gel may remain within the implant and not migrate. Therefore, MRIs are very important. Ruptured implants should be replaced as soon as possible in order to reduce scar tissue, impingement and contracture around the implant which may lead to further deformity and distortion.
Below please see an example of Acute Rupture and examples of Chronic Rupture. Notice the Chronic Rupture photos which have a yellow color occurring due to an increase protein level.
This is associated with superior retroposition of the implant with skin over-draping the bag. The nipple is often found in an inferior low position and this is often seen in patients who have undergone transaxillary augmentation as well as transumbilical. These patients require both functionally open scar tissue release or capsulectomies, lower of the implants, often replacement of the bags and a breast lift of some sort in order to tighten up the skin and reposition the nipple areolar complex superiorly.
Cleavage is a significant concern to all of my patients who undergo augmentation mammoplasty procedure in Las Vegas. The cleavage can be determined preoperatively in some respects with respect to the anatomy of the female's chest. The attachments of the pectoralis muscle within the sternal and costochondral junction areas will have a significant effect on cleavage with each patient. Women who have laterally displaced and attached muscles will have more difficult medial cleavage to be obtained because complete release of the muscle may lead to visibility and palpability of the implant edge. So, anatomical distribution of the muscle attachments into the chest wall certainly is a significant factor on a woman's cleavage. Number two is the technical ability of the breast implant surgeon to appropriately release the muscle towards the midline as well as not to extend too much lateral dissection which could cause lateral displacement of the implant and allow for poor cleavage as well.
On primary augmentation mammoplasty procedure, each week Dr. Linder is extraordinarily careful in releasing the parasternal and the inframammary attachments of the pectoralis major muscle. The muscle is released from the chest wall, but not completely. Along the parasternal region, approximately 60% of the muscle is released in order to bring the implants towards the midline. In the majority of our subpectoral dual plane technique patients, the parasternal attachments are released of the muscle in order to allow the implant to be settled to an appropriate inferior position.
Cleavage can be obtained and enhanced. The muscle was released along the parasternal ridge, infraclavicular and the parasternal attachment of the pectoralis major muscle was completely taken off the chest wall. The implants were exchanged with moderate plus silicone gel implants. Notice, they were not larger. The pocket was not closed along the lateral breast. There was no capsulorraphy performed and the patient then had six weeks of compression garments in order to allow the pocket to settle and the implants to be placed towards the midline. As you can see, her postoperative view shows excellent cleavage of which the patient was very happy with the final result.
Malposition of the implant can either be due to technical error originally which may occur through transaxillary approach or any approach in which the muscles are not completely correctly released and the implants end up in a pocket that is not anatomically correct or it can be associated with over time simply scar tissue contracture causing the implant to be pushed up, down or in any specific direction.
Pregnancy and breast feeding may increase malpositioning of the implant with scar tissue contracture.
Bottoming out occurs when the implant is inferiorly displaced and the nipple ends up superiorly toward the top of the breast mound. This can be very difficult to fix. Capsulorrhaphies internally may not always work in that the capsule is often thin and suturing it together may not allow for a full tightening support of a significant size volumed implant. Breast mastopexy through an inframammary approach, removing skin along the fold, is often useful and I have performed this on many occasions allowing a nice tightening and repositioning of the implant superiorly.
The implants may require changing the volume in that many women as they get older actually desire to go smaller and downsize their implant sizes. On the other hand, younger patients may desire to go with a larger implant over a couple of years and implant volume changes with sizes as well as saline to silicone may be useful.
We do not use anatomical implants at this time because of the significant chance of rotational deformity which leads to bizarre and unattractive appearances to the breast. I do not use textured implants at this time nor do I like shaped or anatomical implants due to the unpredictability with rotational deformity.
Symmastia occurs when the implant pockets are made too aggressively along the medial sternal area and it crosses over to the midline. Implants should not cross over and when dual plane technique surgery is performed, the complete muscle attachment should not be performed. In other words, I release 60 to 70 percent at most of the muscle attachments down to the sternum, thereby preventing the implant from becoming medially displaced across the sternum.
Symmastia repair is extraordinarily difficult and requires Board Certified Plastic and Reconstructive Surgeons. Repairs can include capsulorrhaphies where the capsule is sutures down along the parasternal area to itself in order to bring the implant lateral. It may also require lateral open capsulotomies in order to allow lateral displacement and room for the implant to move to the side, as well as reduction in the size of the implant volume.
The cases below show severe symmastia patients presenting internationally. In fact, the implants have completely crossed over the midline and the repairs were made by 1) open capsulectomies along the superolateral breast pocket only, replacement with small high profile silicone implants and spacers placed for two months with large supportive brassieres. This has reduced the symmastia appearance of the breast. Capsulorrhaphies were not performed on these specific patients.
Some Las Vegas breast surgery patients may desire to simply remove their implants for their own personal reasons or they may have undergone multiple capsulectomies with continued scar tissue contracture and they are really not good candidates for an augmentation mammoplasty procedure and thereby the implants are removed. Implants can be removed with a JP drain placed for one week and a tightening procedure of the skin may be useful if there is enough breast volume in order to maintain blood supply to the nipple areolar complex.
Scarring on the breast mound. Patients who undergo breast lifts and breast reduction procedures may end up with widespread scarring, keloids or hypertrophic scarring. They may do well with scar revision as well as laser therapy, vitamin E, Kelo-Cote or other adjunct ointments.