Breast augmentation is the operation I have done the most over the 28 years I have been in practice. When I first started practice in the ’90s, I did saline implants—that was all that was available. Then, beginning in 2000, I was one of the surgeons doing silicone gel implants under the guidelines of the FDA research on the implants. When silicone gel implants were released for sale in 2006, these implants quickly became the most popular choice due to the superior natural feel.
Since I have done so many thousands of these, I’m now seeing my patients back for breast augmentation revisions. And, of course, I see patients who had their implants placed by other surgeons, both here in Columbus and in other cities. When I am teaching plastic surgery residents about revision surgery, I like to group the types of revisions into 6 categories, from the simple change-out of implants to the most complex implant and capsule removal and mastopexy to lift the sagging breasts.
This blog will run through these categories of breast implant revisions and the common questions related to each.
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Easy Revision
Simple saline or gel implant change out, no capsule intervention
The easiest revision is when the only intervention is changing the implants from either saline or gel. This typical patient has usually had her implants for a decade and is ready to do the required update—either with the same size or a new size but with the new and improved implants. In this scenario, the capsule around the implant is soft and pliable, so it does not need to be removed at all. This patient can expect an easy postoperative course with very mild pain and can be back to most jobs in just a few days.
Medium Revision
Saline/gel change out, some capsule work
The next category of revisions in the degree of complexity is the case where some capsule work needs to be done. The typical patient has had implants for quite some time, but gravity has been working on them and takes the implant lower and laterally—toward the armpit side. Due to this, the capsule needs to be tightened up along the lower and outer aspects. This is done with a row of quilting-type sutures internally. Due to this extra work on the inside, there can be drains placed and a slight increase in post-op discomfort. Even with this, most patients only need ibuprofen to manage discomfort and are back to work in just a few days.
Medium Plus
Implant change, capsule work, other adjustments
Moving up the ladder of complexity, the next category is similar to the previous but has added complexity due to the capsule work. They can be a patient with one side that is normal but one side that has had a saline deflation. The longer the patient waits to do the surgery, the more the capsule will shrink or contract, requiring multiple patterns of capsulotomy. This side will naturally have more post-op discomfort, but again, it is typically not too painful. My routine is to use a drain for patients who need this level of capsule work.
Complex Type 1
Lots of capsule work, total/sub-total cap
In my revision framework, the complex category is broken into 3 categories to describe the nuances of this most difficult type. In the first level, these revisions need extensive work on the capsule, with either complete or almost complete removal, called sub-total, with new implants placed after this is done.
The typical patient in this group has had her implants for a decade or longer and has noticed the gradual hardening of the capsule over many years. Some of these patients are symptom-free, except for the hard-as-rocks breast implants, but some of these women do have discomfort related to the implants. This can be an achiness or a heavy feeling, and they complain that sleeping is uncomfortable.
This operation entails removing the implant and the capsule around it, which is a much bigger operation. My surgical routine is to use drains postoperatively for 24 to 72 hours, requiring the patient to take a few more days off work.
Complex Type 2
Type 1 plus add mastopexy
Within the complex category, the next step is basically all of the previous level but with the addition of a breast lift or mastopexy. Doing this together is complex because there are competing priorities—on the one hand, the skin envelope is being made smaller and higher, and on the other hand, the addition of an implant is stretching the skin envelope in the upper pole. This can lead to wound healing problems, as the post-op swelling can strain the incisions. Quite honestly, my goal is to hit a home run, but with the complexity of doing both of these together, I will sometimes recommend a staged approach. In other words, it can be safer, with a more predictable result, to do this in stages.
Complex Type 3
Total cap, bad capsular contracture, large mastopexy with large, low breasts
The final category in my personal framework is doing all of the previous and adding a very large mastopexy to the list of procedures. This adds to the difficulty due to the large amount of surgery needed to lift the larger breasts. Also, this typical patient has skin that is not as elastic and can have stretch marks. The implant is added to give upper pole fullness, but due to the overall larger size of the patient, the result is not the Barbie/torpedo contour they desire, but a very large, still flat and square breast. Naturally, with this much surgery, more time off work is needed if the patient needs to go into work. Those who can work from home will usually need 3 days off work.
Revision Complexity Affects Recovery & Cost
Having these categories for revisions is helpful as it sets the overall level of complexity and also helps me explain to the patient why their surgery will be easy, medium or complex. And from this discussion, I can lay out their own typical recuperation and time off work usually needed. Finally, when it comes to the fees, this framework helps us explain why the cost goes up as the complexity increases.
Because I have been in practice since 1996 and have placed thousands of saline and silicone gel implants, I routinely see patients for revision surgery. I have this conversation many times a week, and guiding each patient on their own journey is our specialty at Aesthetica. If you have breast implants and would like to learn more about your revision options, call the office at (614) 569-2649 to schedule your personal consultation or use our online form to get in touch.
Breast Wishes.
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