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Category: Breast Revision

Positive Evolutionary Changes In Shaped Gel Implants

Shaped gel implants have undergone a renaissance in the last year or so. In one of my first blogs I was particularly difficult on them. There were limited options of shapes and sizes. The manufacturer’s have implemented significant advances including many many new shapes and sizes which open up the use of Shaped Gel filled implants to augmentation and reconstruction patients. Lets make it clear, no one style implant fits all patients.

There are a multitude of body shapes, breast shapes, conditions and patient desires. There is no perfect device.

I have been using shaped gel implants more and more for certain characteristics with good results. It is not necessarily based on a patients desire to have a Shaped or “natural result”. Some of the most natural results come from round smooth surface gel implants!

It is a complex decision process that only an experienced Plastic Surgeon has a grasp of. (torso curvature, rib asymmetry, starting breast volume, internal tissue laxity or tightness, nipple to breast fold starting distance, existing asymmetries and goals for outcome just to name a few…).

…So don’t look at the website and try to guess who has what. You (along with other plastic surgeons) will be and have been statistically wrong in your guess nearly 50% of the time!

In the end it takes good listening, thoughtful examination, and planning to limit the innumerable variables the human body presents.

Revisionary Breast Surgery

I’m often called upon by patients, other breast doctors, and gynecologists to perform corrective breast surgery. Patients present from previous cosmetic breast augmentations or reduction and from previous mastectomy breast reconstruction. Over my eighteen years as a Plastic Surgeon I’ve developed a reputation as a thoughtful problem solver and solid technician. Many of my patients come to me having had three, four or up to seven previous surgeries. In nearly all instances, I can correct problems in one single surgery. I find that a common theme has been that past surgeries either lacked proper well thought out planning or did not go “the extra mile” in technical execution.

The most common problem I encounter is repeat failures to fix cosmetic implant malposition and shape appearance.

I use my extensive background as an artist to help guide me. To me, the female breasts, with an implant, are a living work of art and as such the surgeon needs to strive for the highest level of aesthetics. Great pride and care must be taken in the plans and execution. Proper implant selection, based on numerous features often missed by the original surgeon (such as rib torso shape) along with reconfiguring the implant space is critical to achieving lasting, desirable results. I call it “wizardry of the implant capsule space”. Working surgical magic is just tedious and time consuming, but the recoveries are (surprisingly to the patient) uneventful and relatively discomfort free. This holds true in post mastectomy reconstructions as well. Repositioning the original scar capsule and reshaping the entire space is tedious but very rewarding for both the patient and the surgeon.

Correction Congenital Breast Anomalies

The family of constricted breast malformations includes much variability. Among these are tuberous (or tubular) breast. It can be the same bilaterally but usually is asymmetric. Correction is very very challenging and is not at all like simple breast augmentation.

See recent web site additions for more photo details!

Revisions In Breast Implant Surgery

How Do We Rescue Your Breast?  Dealing With Capsular Contracture or Implant Malposition.  Well, You Needed A Lift!

Look, no one wants unwanted scars. But there’s a difference between unnecessary scars and needed. My experience over 20 years has been that the saggy flat breast which has an implant placed within it is generally looked upon as ugly and matronly and rejected by the patient as not ideal. Fixing this issue entails not only doing a lift usually, but also reconfiguring the implant space internally higher since it was likely originally placed too low in an effort to better match the existing breast. This requires another type of capsulectomy and capsuloplasty– read the previous recent blogs to get up to speed on these fancy terms–

After the lift and implant repositioning, even though there are scars now , and initially more visible, the patients universally accept this new breast as being far more aesthetic, and more attractive. They gladly trade the old aged look for a fresh young look. Instead of being a detractor to their appearance, their new breast helps to convey a youthful interpretation of body image and gives these women a new sense of confidence.

When I do this procedure the objective is to correct or eliminate the disconnect between natural breast gland, fat and skin and underlying implant. So,  I carefully sculpt overlying breast tissue, preserving an envelope of volume to help hide the implant while tangentially eliminating the most sagging breast. Under the muscle, I raise, recreate, or create  the implant space to coincide. The result is a high centrally positioned implant joined with overlying breast tissue in unison. Everything form fits. There are no loosely disconnected parts. Just an ideal feeling new breast !


Revisions in Breast Implant Surgery

How Do We Rescue Your Breast?  Dealing With Capsular Contracture or Implant Malposition

Capsule formation is a natural process of healing around any implant; not necessarily a breast implant. There is no true “normal” capsules; Just variations. Capsules  are a layer of scar tissue the body forms circumferentially around a breast implant. They may be ideally soft or unusually hard. To complicate matters, the timing of capsule formation, the type of breast implant getting encapsulated, as well as the chest wall shape that the encapsulation is occurring on, all influence breast  appearance outcome.

For the purposes of simplicity, capsule formation has classically been gradiated in four grades. Grade 1 being soft capsules not influencing breast implant shape. Grade 2 capsules are firmer and make the breast implant subtlety firmer. Most women don’t even realize they have this type of scar formation. Grade  3 and 4 scar capsules alter appearance of the implant and generally will necessitate revisionary surgery.

Interestingly, grade 1 capsules- not even palpable, and leaving implants ideally soft, may also have an implication in reoperation  for conditions known as implant malposition.

Here, for instance, if the chest wall is keel shaped or curved, and implants are saline filled, and negligible  scar essentially forms around the implant, then , the implants may insidiously migrate low and laterally. Not ideal, and not where surgeon or patient had envisioned for the outcome. This requires selective capsulectomy and capsuloplasty for management. This means tightening the lower and or lateral internal space so the implant can’t migrate as well as removing part, most, or all of the remaining capsule so allow for better projection or position of the new implant. If the muscle was incompletely divided medially, the forces exist which would tend to push the capsule laterally. Switching to silicone gel implants and properly dividing muscle often helps stabilizes and neutralize the physiologic dynamics associated with implants under muscle. Most often I see this incompletely done – in effect underestimating what it really takes to get a great outcome. Some of the best of the best beautiful breast outcomes come from rescues I’ve performed as secondary augmentation.


Revisions in Breast Implant Surgery

How Do We Rescue Your Breast?

As promised in previous blogs, we’ll review this challenging topic.

I would say revision breast implant surgery involves far more planning, better skill, and more of an artistic eye than even initial breast surgery. Patients often come to see me from around the world to tackle complicated cases which have caused them to have had in some instances multiple pervious surgeries. In effect, the initial issues and the anticipated management are too often underestimated and or taken for granted leading to additional failures.

First and foremost lets be clear on one thing- problems and problematic outcomes occur from many sources. First their is poorly planned surgery. If you don’t pick the right implant your going to end up with issues. An example of this would be to put too narrow of implants in a wider torso and then wonder why the breasts appear far apart? Next is poorly executed  surgery. An example of this would be to under or incompletely separate the pectoralis muscle leaving the implants pushed outward or upward. Also there is the poorly compliant patient who underestimates the subtle healing issues inside the tissues which require a period of time to settle predictably and injudiciously does not follow early post op instructions. Then there is human variability of healing and despite the best efforts of patient and surgeon, things just don’t heal ideally. Remember we are dealing with a unique area- implants placed bilaterally in a body in constant motion and asking it to heal predictably well in a bilateral setting essentially all the time- things are going to happen. It’s how you rescue these misguided events that I believe separate  plastic surgeons.

My evaluation looks at implant position, size and shape. I ask patients for their desired goals and map out a strategy. Sometimes the problem includes failure to recognize that a breast lift was really needed initially with the first surgery. Sometimes it was because the implant was placed over the muscle and has caused accelerated breast aging. Sometimes it is due to hard scar formation called capsular contracture . Sometimes it’s because these healing processes don’t happen symmetrically. Sometimes it’s because previous attempts at correction were ill conceived or incompletely addressed the problem. Read the next blog on dealing with capsular contracture, see the section on the web site with before and after photos, and read the patient testimonials.

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