Revisionary breast augmentation is an increasingly specialised field of breast surgery.With all breast reconstruction one must consider the patients wishes for improvement in terms of size, shape and symmetry. Both clinician and patient need to establish what can be achieved and whether all expectations can be met. The timing of revisionary breast augmentation must take into account the type of implants, the age of the implants, the associated changes of the implant, the capsule and the differences and changes of the breast.
Many patients will have experienced mild changes and often reassurance is all some patients require. For some patients changes to the implants may require a more immediate treatment. The majority of patients will have seen a gradual change in the aesthetics of their breast over a period of years and the timing of surgery can be based on the pros and cons of what can be achieved. Assessment of the implant for leak or rupture is imperative and may alter the timing of future surgery. It is uncommon for these complications to occur and occasionally if doubt remains and there is no immediate decision to perform surgery a diagnostic scan is warranted. It is rare for patients to have associated lymphadenopathy but again if present the pros and cons of managing this surgically need to be discussed. Often implants will develop creases or ripples and these need to be separated from the more troublesome changes mentioned above. The quality of the capsule needs to be assessed to determine whether the capsule should be removed in its entirity (en bloc resection – total capsulectomy), whether part of the capsule needs to be removed (partial capsulectomy) or whether the capsule needs to be released (capsulotomy). Capsules develop in all patients and are a protective barrier.
Over time however they can have a detrimental effect on the breast implant and can result in pain and visible changes. The visible changes are related to the squeezing of the implants in a confined space. This can compress the implants and make them feel hard and alter the position on the chest wall. Implants can move upwards creating an upper fullness or double bubble effect, downwards (bottoming out), outwards or inwards.
During surgery it may be necessary to place the implants in a different pocket ie where patients have implants above the muscle a new pocket can be made under the muscle.
Often with time the breast tissue will drop and one must determine whether a lift or mastopexy should be performed at the same time as implant replacement or whether it is advisable to perform the augmentation first and then a mastopexy at a second stage if needed. The need for mastopexy is dependent on both the quality of the skin and the breast tissue with particular importance taken to assess the height of the nipple areola complex on the breast and the breast’s position on the chest wall. Depending on the quality of the implant, the capsule, the skin and breast tissue one must consider the pros and cons of separating the removal of implant / surgery on the capsule with a second definitive operation. It is often possible to remove / replace implants at the same stage and mastopexy can often be performed at the same time. The pros and cons of each of these options needs to be addressed by a plastic surgeon with experience in revisionary breast augmentation. Patients often do not appreciate the complexity of the decision making process and what is involved in revisionary surgery. All patients should have the details of their previous implants available. From this information one can determine the width of the current pocket and adjust implant size and shape to improve any deformity that has occurred. There are pros and cons of using different implants, sizes and shapes in breast augment revisionary surgery and patients must be informed of the pros and cons of these and be part of the decision making process.