Breast Implant Correction

Many women who have breast implants look great for a few years, but as time passes, their look can change, and problems can gradually arise. Capsular contracture is fairly common; tightening of the pocket that holds the implant in place can occur in up to 30% of women who have had breast implants. Implant migration can also occur, and is fairly common in women who have saline implants. Frequently, this occurs only on one side, so asymmetry or unevenness is another acquired problem that can trouble women who have implants. Saline implants can deflate, and implants that are placed under the breast tissue instead of under the muscle can develop an “orange in a sock” look. Silicone implants can also rupture; old gel implants can become calcified and the silicone can migrate. Combinations of these problems lead to even more mental distress; many women who have had implant surgery originally believed their implants would remain in good condition for a lifetime. However, like most things in life, breast implants require maintenance, including occasional repair or replacement.

The aging process can contribute to the problem as well. As we age, soft tissue tends to “go south” or slide down, due to a loss of integrity of the skin’s underlying support system. This support system can be moderately tightened with radiofrequency energy (a slight breast lift without scars), but if the drooping requires more than a 30% skin surface area reduction, surgical excision of skin may be required.

Saline implant deflation, capsular contracture
The 47 year old woman below originally had saline implants placed in the subglandular position, under the breast tissue instead of under the pectoral muscle. This location has a high risk of capsular contracture, or “hardening” of the breast, caused by inflammation of the capsule or scar tissue around the implant. Two hallmarks of a contracture are a misshapen upper pole bulge as the implant sits too high, and an overly firm breast as the pocket tightens up.

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Before treatment, she has a right saline deflation and a left capsular contracture.
After corrective surgery, with implant relocation under the pectoral muscle, her appearance is greatly improved.

Capsular contracture occurs in almost a third of women undergoing breast implant surgery. This can happen when there is bleeding into the pocket, or if inflammation occurs. In some cases, a sudden delayed contracture can occur with a serious local or systemic infection, such as a dental abscess or urinary tract infection. The 52 year old woman below had a hematoma due to trauma, and developed a very tight pocket on the left.

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The photograph on the left shows her pre-operative appearance. Surgical correction required opening up of the pocket and evacuation of the hematoma. She had quite a good result at six weeks postop (right) and has not required any further revisions.

Saline implant deflation
Saline implants have a relatively short life statistically as compared to cohesive gel implants. The average lifespan of a saline implant is about ten years. Deflation results in a sudden loss of volume, which feels like an emergency to many women when it occurs. While most patients are aware of this risk at the time of surgery, ten years can pass very quickly. The risk of deflation, implant migration, rippling, and lack of upper pole fullness are several reasons why I tend to use cohesive gel implants instead of saline.

The woman below had her saline implants for many years. One day she noticed a funny sensation on her left side, and over the next 24 hours lost all of the volume from that side’s implant.

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I removed her saline implants on both sides and opened up her tight pockets. Capsular contracture can contribute to deflation, as it can cause a peripheral fold with a weak point—the “fold flaw phenomenon” — which then creates a pinpoint hole causing the fluid to leak out. Her saline implants were replaced with “gummy bear” implants. Her new implants should last 20- 25 years unless there is severe trauma to the implants.

A size change is not an infrequent request from my patients. The woman below wanted smaller implants. When she was younger, having larger breasts was important to her. As she aged, she noted that her implants made her look a little thick around the midsection; she wanted to look more slender. She opted to have her old implants removed and smaller implants placed.

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The photos above show the patient before (left), and after replacement with a smaller gel implant (right). Note that while she is smaller after surgery, she also is less droopy. Normally, going down in size causes more, not less, droopiness, because larger implants fill out the skin more. Internal tightening with radiofrequency was needed on order to shrink her skin envelope. This minor to moderate lift can be done without adding additional scars.

In some cases, the problem can be caused by poor placement of the original implants. This can be corrected by switching the position of implants from subglandular to subpectoral, and by enlarging the pocket. The woman pictured below had implants put in by a physician who was not a plastic surgeon. The implants were under the soft tissue only, and her pockets were quite tight. They were saline implants, and were overfilled so they resembled a ball. This is not a natural appearance for anyone.

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Her photo above left shows her preoperative appearance. I removed her saline implants and the surrounding scar tissue, and replaced them with “gummy bear” implants using a “dual plane” approach—under the pectoral muscle above, under breast tissue below. I corrected the pocket position so that a more natural appearance could be achieved. It is difficult, once surgery has been done and a problem occurs, to entirely correct the appearance, but in most cases, dramatic improvement in appearance can be achieved. The result, right, shows a much more natural and tasteful look.

Another common problem with saline implants is “bottoming out”, or migration of the implants out into the axillary region or down towards the belly button. This can result in upper pole flatness, a poor implant position with a central gap between the implants, rippling, and sometimes the areola peeking out of the swimsuit.

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47 year old 9 years after saline implant placement in the subpectoral position. Implant migration has occurred; they sit way too low.
Lower crease fixation was needed to close the excess pocket space. Gel implants have better upper pole fullness.

At first this patient’s implants looked good, but over time, the weight of the saline implant caused the lower outer pocket to enlarge. This effect is potentiated by lack of support garments such as not wearing a bra. Very thin patients without much soft tissue support are prone to developing this problem as well. Correction can include removal of the saline implants and replacement with cohesive gel, or “gummy bear” implants, and a capsulorrhaphy, or tightening of the lower outer pocket.

When implants are placed under breast tissue alone, the implant tends to “ball up” and fall forward into the tube of skin that surrounds it. A torpedo-like look is not uncommon in patients who have had their implants done this way. The result, over time, is overprojecting breasts that also droop.

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44 year old had silicone implants placed within the breast tissue 22 years ago.
Change of implant profile: a moderate profile implant converted to subpectoral position solved the shape problem.

While top training and many years of experience are the basis for these excellent results, all of the staff’s caring attitude and high level of attention to detail also contribute to the consistently good outcomes that patients have come to expect.

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48 year old with left saline deflation and right bottoming out, before surgery.
After surgery, a beautiful rounded shape was achieved with gel implants.

We hope you will find this information helpful. All plastic surgeons have their own style; mine tends towards classic beauty and tasteful proportions. Perfection is never achievable with any artistic endeavor; we strive for dramatic improvement and results that appear natural yet dramatic. All of us at Plastic Surgical Associates hope that our patients will be part of our family for a lifetime; top results and a warm and friendly staff are our trademark!