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Breast Augmentation Revision

Over 250,000 women in the U.S. will undergo breast enlargement this year. Although good initial results are anticipated in well over 95%, some women will have unsatisfactory results or will experience a subsequent implant-related problem. Dr. Friedman performs over 150 breast augmentations annually (compared to a national average of 35 among plastic surgeons). He also performs a large number of breast augmentation revision procedures. Many of these women are referred to him by other physicians.

The most common reasons for breast surgery revision are:

  1. Saline breast implant deflation.
  2. Silicone gel breast implant rupture.
  3. Capsular contracture.
  4. Desire for change in breast size (larger or smaller).
  5. Breast implant asymmetry/malposition.
  6. Excessive implant rippling.
  7. Sagging of the breasts.

We will explore each of these categories in detail with the recognition that many women fall into more than one category. For example, a woman who experiences saline breast implant deflation (1) may also be dissatisfied with loss of fullness of the breasts after subsequent childbearing (4) as well as excessive rippling of the implants (6). In this case, we may replace her saline implants with larger silicone gel implants, addressing all three of her concerns with a single operation.

Some of these procedures are quite straightforward. Many, however, are quite complex and require a great deal of surgical expertise and experience. Although Dr. Friedman approaches every surgery patiently and meticulously, please remember that not all breast implant-related problems have a perfect solution, and sometimes all that we can hope for is significant improvement.



1. Saline breast implant deflation

No manufactured device lasts forever. If you have saline breast implants, they will probably not last as long as you do. In fact, FDA-approved studies demonstrate that 20% of saline implants will deflate within 10 years of breast augmentation. Deflation of a saline breast implant does NOT pose any danger to you, since the contents are just intravenous salt water (obtained from an IV bag at the time of surgery).

Most saline breast implants deflations occur gradually over days or weeks. The breast will slowly feel softer and “squishier,” lose upper fullness, look smaller, and feel “ripply.” If you are reading this because your saline implant deflated recently, you should undergo removal and replacement of the implant as soon as possible. Why? As the implant deflates, the capsule of scar tissue around it may tighten to close the newly vacated space (i.e. capsular contracture). The longer the surgery is delayed, the greater the risk of capsular contracture--and the more difficult the replacement surgery.

Remember that both U.S. saline breast implant manufacturers, Allergan and Mentor, provide warranties on their implants. If you experience a deflation at any time, the manufacturer will provide a new breast implant for free. If you experience a deflation within 10 years of surgery, the manufacturer will also provide $1200 toward your implant replacement surgery. (We purchase a Platinum Plus Warranty for all of our primary breast augmentation patients. This provides $2400 toward replacement surgery.)


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This 25-year-old woman from Garland presented with a deflated right breast implant following augmentation with saline implants performed by Dr. Friedman 10 years ago. She was also interested in further enlargement of the breasts.

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She underwent placement of larger submuscular silicone gel implants (533 on the right and 457 cc on the left, due to preexisting size asymmetry). Her 6-week postoperative results demonstrate restoration of right breast volume and improved contour of both breasts.


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This 26-year-old woman from Lewisville presented with a deflated left saline implant following breast augmentation performed by Dr. Friedman 7 years ago. She was also interested in further enlargement of the breasts.

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She underwent placement of larger saline implants (450 cc) and left capsulotomy for a capsular contracture. Her 10-month postoperative photos demonstrate restoration of left breast volume and improved overall breast contour.



2. Silicone gel breast implant rupture

Like saline implants, silicone gel implants will not last forever. However, they do have greater average longevity than saline with a 15% rupture rate within 10 years of breast augmentation (versus 20% for saline). Silicone gel implant use was restricted by the FDA in 1992 due to concern regarding lupus, fibromyalgia, and other autoimmune diseases. However, subsequent studies failed to demonstrate any conclusive link between silicone gel and any autoimmune disease, and the FDA approved silicone gel for sale in the U.S. in November 2006. The FDA has stated that silicone gel implants are safe—as long as they are intact. However, the safety of ruptured silicone gel implants has not been established conclusively. Most silicone gel ruptures are undetectable by exam, mammogram, and sonogram. Periodic MRI evaluation of the breasts is the best screening tool for silicone gel implant rupture. If MRI demonstrates silicone gel rupture, the FDA recommends implant removal (with or without replacement).

Remember that all three U.S. silicone gel breast implant manufacturers (Sientra, Allergan, and Mentor) provide warranties on their implants. Like saline, there is a lifetime warranty for replacement of a ruptured implant. If the rupture occurs within 10 years of surgery, the manufacturer will also provide $3500 toward your implant replacement surgery. This will cover most, if not all, your surgical costs.


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This 28-year-old woman from University Park presented with a ruptured silicone gel implant following breast augmentation performed 5 years ago. She was also interested in further enlargement of the breasts and improvement in breast asymmetry.

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She underwent placement of larger silicone gel implants (616 cc) and elevation of the right breast implant (capsulorrhaphy). Intraoperative photos demonstrate rupture of the left silicone gel implant. Her 10-month postoperative photos demonstrate increased breast size with improved breast contour and symmetry.



3. Capsular contracture

Whenever a foreign object (i.e. breast implant) is placed in your body, your body will react by attempting to “wall it off” by forming a capsule of scar tissue around the implant. This capsule of scar tissue helps to provide long-term protection and support for your implant. However, like any other scar, the capsule may occasionally become too thick and hard. Capsular contracture refers to excessive tightness of the capsule around the breast implant.

Implant Feel Implant Look Breast Pain
Grade 1: Normal Normal No
Grade 2: Too firm Normal No
Grade 3: Too firm Too firm No
Grade 4: Too firm Too firm Yes
*Chart used with the permission of Ronald M. Friedman, M.D.

Grade 2 capsules are treated nonoperatively with implant massage and perhaps medication. Grade 3 and 4 capsular contractures generally require further surgery, which consists of releasing (capsulotomy) or partially removing (capsulectomy) the capsule to provide more room for the breast implant. This generally provides a softer, more natural-appearing breast.


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This 49-year-old woman from Highland Village complained of excessive firmness of her saline implants and elevation of her left implant following breast augmentation performed 12 years ago.

capsular-contractus-patient-4-front

She underwent capsulotomies and placement of 339 cc submuscular silicone gel breast implants. Her 5-month results demonstrate softer, more natural-appearing breasts.


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This 46-year-old woman from Westlake complained of asymmetry and “hard” implants after breast augmentation with subglandular (above muscle) saline implants 20 years ago.

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She underwent capsulectomies and placement of 378 cc subglandular silicone gel implants. Her 5-week postoperative photos demonstrate softer, more symmetric, and more natural-appearing breasts



4. Desire for change in breast size (larger or smaller)

Many women choose to further enlarge their breasts after an initial breast augmentation. This may be due to loss of breast volume from childbearing or aging, “settling” of the implants, or simply a change of mind regarding desired breast size. Regardless of the cause, further breast enlargement is generally a straightforward procedure with predictably improved size, upper breast fullness, and cleavage. This is assuming that you are not “going huge,” replacing textured implants, or attempting to correct some other concern besides size (breast shape, implant position, asymmetry), all of which entail more complex surgery.

Occasionally a woman will wish to reduce breast size following breast augmentation. This may be accomplished in one of two ways:

  1. If you DO NOT mind giving up some fullness of the upper and inner breasts, placement of smaller implants is the most straightforward procedure.
  2. If you DO mind giving up some fullness of the upper and inner breasts AND you have a reasonable amount of your own breast tissue, then liposuction of the breasts (if you are perky) or breast lift (if you are saggy) may be performed with or without modification of the breast implants. This better preserves the upper breast fullness and cleavage provided by the implants.

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This 26-year-old woman from Plano complained of loss of breast volume after breastfeeding two children. She had 300 cc saline breast implants placed by Dr. Friedman 8 years ago.

breast-aug-patient-6-front

She underwent further breast enlargement with 616 submuscular silicone gel implants. Her 6-month postoperative photos demonstrate improved size, upper breast fullness, and cleavage.


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This 51-year-old woman from Irving requested further enlargement of her breasts. She had 390 cc saline implants placed by Dr. Friedman 9 years ago.

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She underwent further breast enlargement with 659 cc submuscular silicone gel implants. Her 9-month postoperative photos show improved size, upper breast fullness, and cleavage.



5. Breast Implant Asymmetry/Malposition

Although most breast implants are in satisfactory position within 6 to 12 months of surgery, occasionally implants will settle too much or too little.

If an implant is too high or too close to the midline and exercises to “push it down and out” have been unsuccessful, then surgery to release (capsulotomy) or remove (capsulectomy) the scar tissue surrounding the implant will help to mobilize it into a better position. This is essentially the same procedure used to correct capsular contracture.

If an implant is too low or too far from the midline, then a procedure to tighten the implant capsule (capsulorrhaphy) is performed with a series of carefully placed permanent internal sutures. Tightening the capsule helps to lift the implant into a better position. In the unusual circumstance that the capsule appears to be thin and weak, the capsulorrhaphy may be reinforced with a biological matrix (SERI, Alloderm, Strattice), though these add complexity and expense to the procedure.

Occasionally capsulotomy may be performed to loosen one breast implant while capsulorrhaphy is performed to tighten the other, providing improved position and symmetry of the breast implants.


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This 58-year-old woman from McKinney complained of breast asymmetry with “sagging” of the left implant following augmentation with saline implants 15 years ago.

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She underwent placement of mildly smaller submuscular silicone gel breast implants (339 cc on the right, 371 cc on the left) with capsulorrhaphies (left greater than right). Her 3-month postoperative photos demonstrate “lifting” of both implants and improved symmetry of the breasts.


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This 50-year-old woman from Carrollton complained of breast asymmetry, “rock hard” implants, and desire for further breast enlargement and lifting. She had subglandular (above muscle) saline implants placed 24 years ago.

asymmetry-patient-9-front

She underwent staged subglandular capsulectomies, placement of larger submuscular 525 cc silicone gel implants, and breast lift. Her 18-month postoperative photos demonstrate improved size, shape, position, and symmetry of the breasts.

Note that Dr. Friedman addressed augmentation revision concerns #3 (capsular contracture), #4 (implant size change), #5 (asymmetry/malposition), and #7 (sagging) for this patient.



6. Excessive implant rippling

Excessive implant rippling (which may be felt, seen, or both) occurs most commonly when there is very little overlying breast tissue to camouflage the implants. This may be due to minimal preoperative breast tissues, weight loss after breast enlargement surgery, or placement of subglandular (above muscle) breast implants. It is also more common with saline implants than with silicone gel implants.

The usual treatment is weight gain to improve implant coverage (if feasible), placement of “overfilled” saline implants (rippling decreases as volume increases—up to a point), or conversion from saline implants to silicone gel implants. Occasionally fat grafting to the area of rippling may be helpful.


rippling-patient-10-front

This 31-year-old woman from Flower Mound complained of visible rippling of the inner breasts after placement of submuscular saline implants 8 years ago. She was also interested in further enlargement of the breasts.

rippling-patient-10-front

She underwent placement of larger, overfilled submuscular saline implants (550 cc implants inflated to 630 cc each). Her 2-month postoperative photos demonstrate resolution of the rippling and improved breast size, upper breast fullness, and cleavage.


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This 35-year-old woman from Celina complained of visible implant rippling after silicone gel breast augmentation 2 years ago. She had undergone two prior augmentation surgeries, and her pectoralis major muscle had been completely divided, leaving minimal tissue coverage for the implants.

rippling-patient-11-front

She underwent placement of mildly larger silicone gel implants (525 cc on the right and 495 cc on the left) and 10 cc of fat grafting to the right inner breast. Her 8-month postoperative results demonstrate significantly improved implant rippling.



7. Sagging of the breasts

After initial postoperative settling, most submuscular breast implants will remain in stable position for many years. However, subsequent childbirth, breastfeeding, and/or aging may cause long-term loss of volume and sagging of the natural overlying breast tissues. If the problem is simply a loss of breast volume, then further enlargement of the breasts may be beneficial. However, if there is fullness of the upper and inner breasts (good implant position) AND the overlying breast tissues appear to be “falling off” the breast implants (bad breast tissue position), then a formal breast lift may be a better option. Breast lift (mastopexy) is usually performed through incisions around the nipple-areola (to make it higher and perhaps smaller) and vertically along the lower breast.


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This 38-year-old woman from Frisco complained of sagging breasts and enlarged nipple-areolae. She had 350 cc submuscular saline implants placed 3 years ago and felt that her breasts were “falling off” her implants.

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She underwent breast lift to improve breast contour. Her 6-week postoperative results demonstrate improved breast position, reduced nipple-areolar size, and overall improved breast contour.


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This 54-year-old woman from Lubbock complained of extreme dissatisfaction with “hard and sagging” asymmetric breasts after augmentation with subglandular (above muscle) silicone gel implants placed 19 years ago. She requested larger, softer implants and a breast lift.

sagging-patient-13-front

She underwent subglandular capsulectomies, placement of larger submuscular 390 cc saline implants, and breast lift. Her 1-week postoperative photos demonstrate improved breast size, shape, position, and symmetry.

Note that Dr. Friedman addressed augmentation revision concerns #3 (capsular contracture), #4 (implant size change), #5 (asymmetry/malposition), and #7 (sagging) for this patient.

When you visit our office, we will be happy to show you a variety of “before and after” photos of breast augmentation revisions performed by Dr. Friedman. If you wish to speak to other women who have undergone similar procedures, we will be happy to provide phone numbers.

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© 2017 Ronald M. Friedman, M.D., P.A.

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