Revision Breast Augmentation –Exchange With a Different Type of Implant

Introduction

Women who have undergone breast augmentation live with their breast implants for years and typically want to maintain their outcomes because it adds value to their lives. Revision breast augmentation provides patients an opportunity to maintain or improve their long-term outcomes with the latest in breast implant technology. Breast augmentation is not a one-time surgery, and maintenance surgery will be necessary. There are excellent options for breast augmentation maintenance surgery that will benefit patients for years to come.

For patients who have a good long-term outcome, without issues, a simple implant exchange within the same pocket to newer styles of gel devices is straightforward. For patients who have developed implant or soft tissue–related issues, planning must encompass steps to address both implant exchange and correction of the underlying disorder(s). Some patients opt for removal of their implants with or without adjunctive procedures such as mastopexy or autologous fat grafts that restore volume loss at explant. This topic, however, is outside of the scope of this chapter. Silicone gel–filled breast implants have become highly differentiated, with many options of high fill ratio gel devices that come in a variety of size and shape configurations and with different gel specifications.

Millions of women with aging breast implants will require maintenance surgery. This remains a great opportunity for plastic surgeons to help them enjoy the benefits of cosmetic breast augmentation for years in the future. Although surgery is part of the process, careful attention must be given to preoperative planning, management of patient expectations, and aftercare.

Indications and Contraindications

There are two primary indications for exchange of different type of breast implant: (1) patients with good to excellent outcomes seeking maintenance implant surgery; for those patients who have had a good long-term outcome, without issues, a simple implant exchange within the same pocket to newer styles of gel devices can be performed; (2) patients who have implant or soft tissue issues who seek implant maintenance surgery; for those patients who have developed implant or soft tissue–related issues, planning must encompass steps to address both implant exchange and correction of the underlying disorder.

Preoperative Evaluation and Special Considerations

The female breast is a dynamic structure, with changes that occur naturally during a woman’s life and secondary to the presence of breast implants placed for augmentation. Successful maintenance surgery should follow a similar process that the surgeon has for primary breast augmentation, with a few other considerations. Patient evaluation templates ( Fig. 8.1 ) are useful to record measurements, patient data, implant data, and planning.

For patients who have had a good long-term outcome without issues, a simple implant exchange within the same pocket to newer styles of gel devices is straightforward. For patients who have developed implant or soft tissue–related issues, planning must encompass steps to address both implant exchange and correction of the underlying disorder. This adds a degree of complexity and risk. Breast implants cannot last forever, and an understanding of their failure modes is needed. There are many different approaches to improving the quality of breast augmentation in patients who have soft tissue–related disorders, provided that both patient and surgeon understand the risks of operating on both the inside and outside of the breast.

Silicone gel–filled breast implants have become highly differentiated with many options of high fill ratio gel devices that come in a variety of size and shape configurations and with different gel specifications. If a patient has round implants, a straightforward implant exchange can be planned. Individuals who have the highly cohesive, anatomically shaped implants can either continue with shaped implants or be converted to round implants. Although a conversion from round to shaped implants is possible, this requires a total capsulectomy and a tight pocket for the shaped implants to avoid rotation.

The best of all situations is having one of your own patients who returns for maintenance surgery (elective or emergent, e.g., saline implant deflation), where you have important data regarding the date of surgery, implant type and location, and the patient’s clinical course. More challenging situations involve a patient from elsewhere, without implant information, lacking medical records.

Even in situations of a known patient, with known implants, diagnostic ultrasound (DUS) proves useful to determine implant integrity and the presence of periprosthetic fluid, capsular calcification, or extracapsular gel. There are still many women with implants filled with the more liquid gels found in the pre-1992 era who have gel bleed, capsular calcification, and gel migration and require a total capsulectomy with removal of extracapsular gel. DUS is a useful tool to help plan surgery because it helps minimize planning mistakes when there is a problem with the implant or implant capsule that requires more extensive revisionary surgery.

Fig. 8.1 is a useful planning template to record physical measurements, information about the patient’s breast surgery history, and plans for surgery.

Patients With Good to Excellent Outcomes Seeking Maintenance Implant Surgery

The best outcomes from maintenance surgery come from situations of good to excellent long-term clinical outcomes, such as a Baker I or II result where patients elect to place newer-generation gel-filled implants in an existing pocket where there is a mature capsule. This is certainly the most straightforward approach, where it comes down to an implant exchange. Minimal modification of the capsule is required.

If a patient with saline-filled implants has a deflation, prompt reoperation and replacement with newer-generation gel-filled implants offers a better aesthetic outcome, without the limitation of rippling and feel of liquid. The dimensions of the saline implant pocket can change with slow deflation over time. Be certain to measure the pocket dimensions and weigh the saline-filled implant to avoid inserting the replacement implant into a constricted pocket. The use of sizer implants is a useful strategy to verify that the pocket has adequate capacity for the replacement implant. The replacement implant should be inserted one time into the pocket. It should not be used as a sizer because this increases risk of biofilm contamination from repeated insertion.

A capsulotomy may be required if pocket capacity needs to be increased because of constriction or to accommodate a larger implant. One sign of a constricted pocket is found in measuring the base diameter (BD) of the breast with calipers. If the BD of the breast is less than the BD of the implant, constriction of the implant pocket has occurred due to deflation or capsular contracture. A capsulotomy will be required to open the pocket somewhat to add capacity.

It is straightforward to find replacement implant choices that match the engineering specifications of the patient’s existing implants. Subtle changes in volume (plus or minus) may be possible but may require a capsulotomy for larger size implants. The use of newer-generation, highly filled, round silicone gel implants permits correction of rippling and the unnatural feel of saline. The only caveat here is to be careful when planning surgery to have the replacement implant match the engineering specification of the BD to fill the width of the pocket and avoid a possible implant flip-over or mismatch between replacement implant size and pocket capacity. A “popcorn” capsulorrhaphy with the electrosurgical pencil may be useful to decrease pocket capacity somewhat if the patient requests replacement with a smaller implant ( Fig. 8.2 ).