Revisional surgery following breast augmentation

Capsular Contracture

A capsule is always formed around an implant, regardless of whether the implant has been used for breast augmentation or for breast reconstruction. Initially, the capsule is thin and flexible. Over time, the capsule may become thicker and eventually contract. The reasons for this remain unclear but the phenomenon is called capsular contracture.

Contraction of the capsule around an implant may cause it to become deformed and can lead to chronic pain and a feeling of tightness in the breast. Capsular contracture can occur just a few months after the placement of an implant, but equally it may occur later, even after 20 or 30 years.

Once capsular contracture becomes uncomfortable for the patient, she may wish to consider a revision. In most cases, either a capsulotomy or a capsulectomy is performed.

In a capsulotomy, the implant is removed through the existing scar and incisions are made in the capsule, in different directions, so that the surrounding tissue can re-expand. The breast implant may then be replaced.

In a capsulectomy, the entire capsule surrounding the breast implant and the implant itself are removed through an incision in the fold of the breast. Once again, the breast implant may be replaced or exchanged for a new one.

Implants may have to be removed if severe capsular contracture recurs in the same patient or if the patient chooses this option. In these cases, it may be necessary to perform a breast lift (mastopexy) because the overlying skin and breast tissue have been stretched over a long period of time. Otherwise, the breast support has been lost and the soft tissue droops.

Depending on the patient’s wishes, it is also possible to create a new breast using reconstruction techniques and the patients’ own tissue.

Fig. 1a	Fig. 1b
Fig. 1c	Fig. 1d
Fig. 1e	Fig. 1f

Figure 1: (a) unilateral capsular contracture with displacement and deformity of the left breast. (b, c, d) Postoperative images following capsulectomy and implant exchange. (e, f) The capsule compresses the implant causing rippling. After releasing the thick capsule, the implant shape is restored.

Rotation of an implant

Rotation of an implant most frequently occurs in the first post-operative week. This problem only affects anatomical implants. It is important to apply dressings to the upper part of the breast after surgery so that the implant integrates and becomes fixed in an ideal position. However, if the implant does become integrated, it may still move or rotate within its pocket for months or even years following surgery.

If rotation of the implant does occur, the breast will quickly develop an unnatural shape, with the upper pole gaining more projection than the lower pole. Contraction of the pectoralis major muscle can cause the implant to move. In the early postoperative period, it will primarily move upwards, whereas later in the post-operative period it tends to move downwards and outwards. This may result in significantly asymmetrical breasts.

Displacement or rotation of the breast implant can only be resolved surgically. After removal of the implant, the pocket must be corrected accordingly. In some cases it is necessary to remove or close part of the capsule. Frequently, the solution is to move the implant from in front to behind the pectoralis major muscle, or vice versa.
If an implant has migrated downwards due to surgical disruption of the inframammary fold, the fold has to be recreated and then the implant can be exchanged. 

Ruptured Implants

This complication is more common in women with saline-filled implants than with gel-filled implants. Late rupture usually occurs because of weakness of the outer layer of the implant. Small folds may form on the implant when it is inserted. The corners of the folds cause continuous friction as a result of everyday movement. After several years, the implant may then develop tears at the site of these folds.

Implants that have been in place for a long period of time can rupture spontaneously. Sudden external trauma can also damage an implant, although this is rare.

A ruptured saline implant deflates within 24 to 72 hours. This poses no threat to the patient because saline is completely removed by the kidneys. However, the aesthetic impact can be significant and prompt exchange of the implant is recommended. If one waits too long, the capsule will continue to contract and a more complex procedure will be required to re-insert a new breast implant.

Arrival of the new, cohesive, silicone gel-filled devices has resulted in much fewer serious complications following implant rupture. The liquid gel which was used in the past migrated into the surrounding tissues after rupture. Many patients developed serious complications as a result of this.

With the new gelatine-like silicone implants, the gel remains in situ even if the outer layer ruptures. As a result, with these new implants a rupture may remain asymptomatic for a long period of time, only becoming problematic when capsular contracture develops. A capsulotomy and implant exchange solves this problem.

Skin necrosis

This is rare but predominantly occurs in patients who opt for very large breast implants and have thin overlying skin. The constant pressure on the lower poles of the breasts due to the effect of gravity, leads to progressive narrowing of the blood vessels. This causes the skin to necrose and later perforate.

Once the skin perforates, the implant is exposed and there is a high risk of infection. The surgeon must therefore remove the implant, thoroughly disinfect the cavity, close the skin defect and insert a much smaller device. In some cases it may be advisable not to replace the implant.

Assymetry

The goal of breast surgery is to achieve symmetry. A patient should understand that a small amount of asymmetry is normal. Women do not naturally have perfectly symmetrical breasts. Breast asymmetry, therefore, also applies to women who have had breast surgery and in fact, breast asymmetry may be more pronounced following surgery. There may be a disparity in shape, volume, position or orientation of the breasts. If a patient has a degree of asymmetry pre-operatively, this asymmetry will still be present following breast augmentation, although it may be less noticeable. Patients who have a marked volume disparity prior to surgery may have two different sized implants inserted.

Exceptional differences in breast sizes must be corrected using very specific techniques. This will vary with each patient and is best discussed with one’s plastic surgeon.

Distance between breasts

The position and distance between breasts varies significantly amongst women who have not had breast surgery. Equally, nipples may also be far apart and it is difficult to perform a breast augmentation that will correct this. Placing an implant in front of the pectoralis major muscle often brings the nipples closer together. If both nipples are oriented outwards, it is sometimes necessary to use very large implants in order to achieve naturally looking breasts. In some cases, it is impossible to correct the distance between the breasts and a patient may have to accept this.

Lipofilling may be able to smoothen out the transition between both breasts.

Fig. 2a	Fig. 2b

Figure: Pre-operative image (a) and postoperative image (b) of a breast augmentation in a patient with an increased distance between the two breasts. This distance cannot be reduced unless very large implants are inserted.

Dissatisfaction

Before undergoing a breast augmentation, the patient and the plastic surgeon discuss the patients’ desired breast volume. The breast volume is estimated using a trial implant, chosen by the patient pre-operatively. Although this is routinely performed, occasionally a patient may feel that the augmented breasts are still too small following surgery. This problem can only be resolved surgically. If the patient wants larger breasts, the current implant is removed and a larger implant inserted. This is performed through the same incision. At the other extreme, a patient may feel that her implants are too large. This is very rare but again can only be resolved by exchanging for smaller implants.