Revisionary Breast Surgery

by Tom J. Pousti M.D., F.A.C.S.

As the desire of breast enlargement increases, so does the need for revisionary breast surgery. Breast Augmentation surgery is one of the most sought after "cosmetic procedures" performed today. Revisionary surgery is often times more complicated than the original surgery and it requires a surgeon with expertise in the area and excellent skill to achieve the patients desired results.

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 is a board certified Plastic and Reconstructive Surgeon who has corrected these problems for many patients.

"High-riding" breast implant deformities occur when the implant does not settle into the pocket. Sometimes the implant takes longer to settle down depending on whether the patient practices the downward exercises and massages to help implants fall into the pocket created. With time, the inframammary fold should stretch and allow the implant to fill in the dissected area.

"Double bubble" may give an appearance of two breasts on one side. The condition may be mild or obvious. This deformity may occur more so in women who have sagging breasts. The sagging causes the breast tissue to lump lower down and the breast implant then protrudes from the back of the chest muscle giving an impression of two bubbles. In most cases, a repeat surgery is required to correct this complication.

This patient traveled from Mexico to have Dr. Pousti perform her surgery. She is only 7 days post-op surgery and extremely happy with her results.

Implant "bottoming out" involves inferior migration of the implants. This causes the nipple areola complex to appear too high on the breasts. Over-dissection of implant pockets may cause bottoming out. It occurs more frequently when implants are placed over the muscle or the incision is placed at the inframammary fold due to tension. This is corrected by "raising" the inframammary fold using internal sutures. Careful measurements are made from the areola to the "new" inframammary fold to achieve improvement.

This patient had "bottoming out" of her left breast implant. Only one month out of surgery with excellent symmetry between the two breasts.

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 chestwall anatomy trying to increase cleavage in 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 submuscular implant placement allows the muscle to provide some softening of the transition to the cleavage area from the augmented breast mound.



The degree of medial displacement varies from patient to patient and the reconstructive technique therefore, also varies. Usually, the medial displacement of the breast implants cause the nipple-areola complex to appear off-center on the patient's breast mound. Other problems associated with symmastia include "bottoming out," rippling/palpability of breast implants and breast asymmetry.

Correction of symmastia involves careful planning and intra-operative reinforcement of the medial fold of the breasts. Reconstruction usually involves removal of the breast implants and internal suture reinforcement of the involved area. The use of dyes and needles through the skin surface assists the exact placement of permanent sutures. Often, it is necessary to "open" the breast implant pocket laterally (outer breast fold) to allow for positioning of the implant centrally behind the breast mound. This maneuver may also decrease the amount of implant pressure against the medial suture line. Use of a smaller breast implant, if possible, may serve the same purpose.

For correction of symmastia, the procedure can take from 2-3 hours depending on how much work is involved. Board Certified Plastic Surgeon, Dr. Pousti takes his time in the operating room to make sure that he does what he can to achieve the best result for the patient.

• An incision is made (usually under the areola) to expose the underlying tissue, muscle, and implant.

• The tissue that surrounds the implant is removed in the area of the planned repair.

• Tissue is sutured together to hold implant in place (with permanent sutures).

• The incision is then sutured close.
  
  

Intra-operatively, sitting the patient upright is imperative to assess the repair and degree of symmetry. Patience is important as multiple trials of suturing may be necessary to achieve satisfactory repair and symmetry.

Post-operatively, the use of tape is used to apply pressure on the previously elevated skin overlying the sternum. Compressive dressings and a pressure bra are also helpful.

This 21 year old patient from Bonita, California came to see Dr. Pousti for revisionary surgery. She had gone to Mexico for her first surgery and ended up with symmastia of the breasts.

This 26 year old patient from San Diego, CA had her first breast augmentation in 2005. She noticed mal-position of her breast implants and came to Dr. Pousti for a consult regarding symmastia repair in 2007. She is now post op surgery with saline implants filled to 330cc made by Inamed Corporation and pleased with her initial results.

Capsular Contracture (hardening of the breasts), breast implant rupture or deflation require the implants to be removed and replaced with fresh implants. If a capsulectomy is needed, that will require additional surgery.

What To Expect After Revisionary Surgery?

Bed rest, along with plenty of fluids, is necessary after surgery. Your chest will be sore. Pousti will prescribe appropriate pain management medications. Take your medication regularly and keep your office visits. Usually after a week, you will begin to feel back to normal.

A brassiere and bandeau will be fitted for you during your first week of recovery. These will need to be worn for a month. You will not be able to shower until your sutures are removed. Initially, breast implants will appear to be slightly higher than normal and your breasts will be swollen. Over time, the breast implants will descend to a more natural position.

The bra that is worn after repair is referred to as the "thong bra". It is used to stabilize the area. This will allow the sutured area between the breasts to heal properly without excessive pressure being applied to the area.