Revisionary Breast Surgery

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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