Breast Revision Surgery

What Breast Revision Surgery Is, and Why It Can Be So Challenging

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When a woman undergoes breast augmentation surgery, it’s likely that the last thing on her mind is having a second surgery -- called breast revision surgery -- on her breasts. However, it’s important to understand that breast implants are not lifetime devices. In fact, the warranties on most breast implants are for a term of only 10 years. Due to the nature of implants, some secondary surgery is virtually given at some point in the patient’s lifetime.

Of course, implant deflation or rupture is not the only reason one might seek secondary surgery after augmentation. Breast revision surgery is performed when a woman is not happy with some aspect of the look and/or feel of her breasts. According to Maryland-based board certified plastic surgeon, Adam Tattelbaum, MD, the most common reason by far for breast revision surgery can be summed up in one sentence: “Gee, I wish I had gone bigger.”

According to FDA statistics, switching to a larger size implant is in fact estimated to account for approximately 37% of all breast revision surgeries in the United States. Dr. Tattelbaum says that when women come into his office for a consultation about breast augmentation, one of the biggest concerns is often that they don’t want their new breasts to be too big. After the post-op swelling goes down and they get used to their new breasts, however, they are often singing a different tune.

Other Common Reasons for Breast Revision Surgery

  • Capsular contracture – requires release of scar tissue through capsulectomy or capsulotomy
  • Switching from saline to silicone implants due to rippling problems or just a desire for a more softer, more natural feel
  • Breast changes after pregnancy, weight gain or weight loss, or age-related changes
  • Cosmetic concerns where the patient is unhappy with result of previous surgery due to poor implant placement or other problems such as double-bubble, symmastia, or bottoming out

Dr Tattelbaum says he also occasionally sees women who had breast augmentation surgery 20 to 30 years ago, and are now at a different place in their lives, so they want a removal of implants. Removal is then performed, usually in conjunction with a breast lift, although not always.

The Challenges of Breast Revision Surgery

Secondary surgery is always more difficult than primary breast augmentation, for several reasons. First, the presence of scar tissue makes it more difficult to predict a good result. In addition, the surgeon is dealing with the stretching of tissues or anatomical changes caused by previous implants. For these reasons, many surgeons may charge higher fees for breast revision than for primary breast augmentation.

Second, the breast revision patient may come into the surgeon’s office disillusioned and more fearful than a primary breast augmentation patient.

Often, the first surgeon has done nothing wrong to cause the problems that are bothering the patient. However, sometimes a lack of effective surgeon-patient communication is to blame for the patient’s insufficient understanding of the normal risks associated with breast implant surgery. This can create unrealistic expectations, which means the patient is more likely to be dissatisfied with the outcome of the primary surgery or the revision surgery.

The Secrets to Breast Revision Surgery Success

According to Dr. Tattelbaum, the biggest predictor of the success of breast revision surgery is the quality of communication between the doctor and the patient prior to the surgery. Patients who receive a full and honest explanation of what they can expect are likely to be much more satisfied in the end.

Another factor that determines the success of breast revision is the reason for which the surgery is desired. Early capsular contracture has a high success rate, although it is possible for contracture to recur, mostly due to a patient’s genetic pre-disposition.

Certain other types of revision are easier and thus generally more successful due to effects of gravity (and to the action of the pectoral muscle, when the implant is placed under the muscle). For instance, lowering an implant is easier than raising it, and moving implants toward the sides is easier than moving them toward the center of the body.

Many doctors also feel that the location of the incision is key to success in breast revision, with many breast revision specialists leaning toward the peri-areolar approach (incision follows the outer edge of the lower 1/3 - 1/2 of the areola). This approach allows the surgeon a 360-degree view of tissues inside the breast, allowing for more precision in releasing scar tissue and creation or modification of the pocket. Many surgeons feel it can be much harder to judge what you’re working with from incisions made in other locations.

In addition, Dr. Tattelbaum believes that breast revision can sometimes be more successful when the implant is placed on a different plane from the first surgery. (i.e., from over the muscle to under the muscle, or vice-versa). This is because operating on a different plane usually means there is less scar tissue and less tissue deformity due to the first surgery. Of course, this is highly variable, and the best course of action is always determined on an individual basis.

Don’t be afraid to ask your surgeon about his qualifications and experience. How many times has he performed procedures like yours? What is his complication rate with this procedure? Is he a board certified plastic surgeon?

Continue on to page 2 to learn what happens during breast revision surgery, and how to minimize your risk of needing breast revision surgery in the first place.

What Happens During Breast Revision Surgery?

Of course, the answer depends very much on the reason for the surgery. Breast revision usually involves swapping out the old implants for new ones, often with a size change. It can also include a breast lift, release of scar tissue, and change to the size, shape, and location of the “pocket” (the space inside the body where the implant sits).

With some cosmetic problems, additional surgery may be needed for the best and longest-lasting results.

For instance, repair of symmastia and bottoming out may be more successful when the implants remain out of the body for a period of at least 12 weeks after removing the old implants and strategically placing sutures to close off the pocket. Once proper healing and stabilization is achieved via the formation of new scar tissue, the final surgery can be done to replace the implants.

How to Minimize the Risk of Needing Breast Revision Surgery

Many cosmetic problems with implants (including double-bubble, symmastia, and bottoming out) are much more likely when putting very large implants in very small bodies. Placing the implant in a higher position rather than too low usually results in the most pleasing appearance, since the effects of gravity will cause the implant to drop over time. By the same token, a too-aggressive approach to creating cleavage is often partly to blame for symmastia. It is important to remember that dramatic cleavage is created by push-up bras, not by natural or enhanced breasts.

Since changing size is the number one reason for breast revision, it stands to reason that you would want to be sure about what size you want before having surgery. If you are considering breast augmentation, it is a great idea to “try before you buy.” The best way to accomplish this is to try on several different sizes and shapes of implants at your surgeon’s office.

With the range of shapes, types, and sizes of implants available today, this is the only way to accurately judge which implant will work best for your body.

Of course, your surgeon is not going to let you walk out of the office with a bunch of implants to wear in your bra at home. If you simply want to judge what cup size you’re most comfortable with and wish to spend some time getting used to a D cup before deciding if it’s right for you, there are commercially available sizing systems that allow you to try out different sizes on your own time. However, if you want to try several sizes, this can get expensive. A popular (and cheaper) way to try out and get comfortable with a variety of sizes is to do the rice test.

Ask a lot of questions in your consultation with your surgeon, and ask some more on the day of your surgery. (It may be helpful to write your questions down in one place as you think of them, then bring your list with you any time you see your surgeon.)

Do your research, and consult with more than one surgeon before making your decision.

An educated patient is much less likely to wind up needing a “do-over.” And don’t let price be your main determining factor when choosing a surgeon.

Finally, remember that it is of utmost importance to go into your surgery with realistic expectations. Perfection does not exist in nature or in plastic surgery. Your pre-surgery body is not completely symmetrical, and it won’t be perfectly symmetrical afterwards either.

If you do have breast revision surgery, be aware that you may still see some of the problem you came in to have fixed. It is not always possible to completely remove all hints of a double bubble, for instance. Keep in mind always that the goal of plastic surgery is to improve, not to perfect.


Interview with Adam Tattelbaum, MD, Rockville, MD; conducted on November 14, 2008

Saline-Filled Breast Implant Surgery: Making An Informed Decision, Mentor Corporation (information provided by the U.S. Food and Drug Administration)

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