Lewis Plastic Surgery: Gordon Lewis, MD
2331-A Robious Station Circle
Midlothian, VA 23113
Breast augmentation is very popular and the majority of women who get breast implants are highly satisfied. In some cases, though, patients seek breast implant revision surgery at our Richmond, VA, practice. Revision breast surgery is typically more complicated than primary breast augmentation and requires the skills of an experienced plastic surgeon such as Dr. Gordon Lewis.
What Are The Most Common Reasons For Breast Implant Revision?
Over 300,000 women annually are getting surgery to enlarge their breasts in the Unites States. This is often thought of as a simple and straightforward procedure with no potential pitfalls. Achieving a great result requires meticulous attention to detail and proper surgical technique. Avoiding these principals can lead to less than desirable outcomes. There is no simple breast augmentation, and we pride ourselves on our attention to detail and surgical care. There is no question that careful attention to detail and meticulous surgical technique will keep the need for revision to a minimum.
Unfortunately, we do see many women who are dissatisfied with the appearance of their breasts after prior surgery from other surgeons. There are a variety of reasons for this and each patient needs to be evaluated individually.
In some cases, despite a well-executed procedure, implant revision may be necessary. The need for revision can be grouped into three categories.
- Implant related issues: Wrong size (too big or too small) or rupture
- Implant positional issues: Too high, too low, Synmastia (too close together) or too far apart
- Issues with the soft tissue: Capsular contracture, Rippling, Palpability of the implants, Ptosis (droop) of the breast over top of the implants, Thinning of the tissue, Enlarged areola, Tuberous breast deformity
Despite proper planning prior to a breast augmentation a small percentage of women will want a different size to their breasts at some point after a breast augmentation. This can be a change to a smaller or a larger implant. This may be immediately after surgery, or maybe at a later time.
An implant may rupture simply as a result of the amount of time it has been in your body. While technology has improved greatly, breast implants still cannot come with a lifetime promise. Current evidence suggests that Mentor silicone breast implants have a 1.1% chance of rupture after six years. There are other studies supporting a somewhat higher rate of rupture for silicone breast implants. Saline breast implants do have a higher rate of rupture. At 7 years, studies have shown a 7% cance of rupture of saline breast implants. When a rupture is detected, replacing the implants is usually a very easy, small procedure that is more cost effective than the original surgery and has an easier recovery.
- Saline implant ruptures are generally very easy to determine as the breast deflates and the breasts become uneven in appearance. If treated quickly, replacing the implants is a very simple and easy process. If there is a delay, the pocket (that the implant sits in) will shrink, and a slightly larger surgery may be necessary to recreate the appropriate space
- With silicone the rupture can be harder to detect. Whereas saline gets absorbed into the body, the silicone will not be absorbed. There is subsequently no change in volume of the breast. Often this is first seen on a mammogram. Because of this, the FDA recommends MRIs to evaluate for rupture after the placement of silicone breast implants. Once rupture is detected, we do recommend removal of the ruptured implants. Usually new implants are placed at the time of the removal
- A rupture may also occur due to an external factor such as a blow to the chest, but more commonly, there is no identifiable cause of the rupture
Issues With Tissue
Whenever a foreign body is placed within our tissues, our bodies react to that. This occurs with breast implants but also with orthopedic implants as well. Normally that capsule is a very soft, pliable, nearly see through film that surrounds any implants. In some cases, the capsule can become thickened and contract. If this occurs around a plate on a broken bone, the plate is stronger than the capsule and patients never know there is an issue. However, if this is around a soft breast implant, the breast can become less soft, even hard and painful in some circumstances. This often leads to further surgery for this problem.
Studies suggest that there is about a 5% chance of getting a capsular contracture that leads to another operation after breast augmentation; we do all we can to keep this number as low as possible in all cases involving breast implants.
In a small percentage of women who have breast implants, they may be able to see rippling in the underlying implants through their skin. This is rare in all patients, but is more common in thin skinned women, (particularly those who have saline breast implants) or thin women who have very large impants. There is usually an option to fix this issue, but it usually involves changing the implants. Usually a change from saline to silicone will resolve the problem. In women who have silicone implants, decreasing the size can help, or changing to a “gummy bear” cohesive gel implant can also help.
Palpability of the implants
In most cases after breast augmentation, the implants can not be felt by someone not trained to feel them. However, in some circumstances, the implant can be felt. If this is an issue, it is usually on the lower outer portion of the breast. This can usually be fixed, but may require a change in implants. The options depend on the type of implants that are present, and the soft tissue overlying the implant
A (droop) of the breast on top of an implant. (also called Snoopy deformity due to the profile) Over time, breast tissue will lose some of its elasticity, and most women as they get older, or after pregnancy, will develop some sagginess in their breasts. This can occur even if there is a properly place implant underneath a breast. Although breast implants can give a degree of lift to the shape of the breast, the breast tissue can droop over time. This can result in a breast that is sitting below a properly placed implants. This can be fixed by preforming a lift (mastopexy) of the breast tissue over top of the implants. Depending on the duration of time since the placement of your implants, we may recommend changing your implants to new implants at the same time.
Thinning of the tissue
Over time breast tissue in all women can thin. This can be more apparent in women with breast implants. There usually are options to help with this, but it will depend on your specific anatomy and goals.
No women’s breasts are perfectly symmetric. This can be due to inherent size differences in the two breasts, or could be due to more subtle asymmetry in the underlying chest wall. This all needs to be taken into consideration prior to a primary breast augmentation. We take great care in analyzing each patient’s breasts for asymmetry and therefore it is rare to have any significant asymmetry after breast augmentation. When asymmetry does exist after a breast augmentation, we strive to determine the cause. The asymmetry usually can be decreased once the cause is identified.
After a breast augmentation, the skin does need to stretch to accommodate the breast implant. This always involves a small amount of increased diameter to the nipple areolar diameter. In patients who are starting with a larger baseline areolar diameter, there is a risk that this may be more than what is desired. This can be preventively treated at the time of the original surgery if desired, or if a decision to decrease the diameter is made later, this can be done then.
Tuberous breast deformity
This is not a problem related to another surgery, but a developmental problem in the breast. This deformity can be mild to severe. This involves a constriction of the base of the breast and often a herniation of the breast tissue to just underneath the nipple. The treatment can be relatively straightforward for mild cases to very complex for severe cases.
There are several studies showing a strong link between bacterial contamination at the time of the original operation and capsular contracture. Dr. Lewis uses a “no-touch” technique to introduce to implants to the pocket. He also washes the implants and pockets with a triple anti-biotic solution. This will nearly eliminate the possibility of bacterial contamination. Saline breast implants are placed through small incisions and should not need to touch the skin. Silicone breast implants are prefilled and skin contact had been unavoidable until recently. We use the Keller Funnel (link) to place all silicone breast implants. This allows the implants to be placed through a smaller incision and eliminates the contact to the surrounding skin.
Increasingly we are realizing that bacterial contamination has a large role in capsular contracture. Implants placed either through the axilla or through peri-areolar incisions have been shown to have a higher rate of capsular contracture than those placed through inframammary incisions. It is thought that the skin in the armpit is more contaminated, and that the breast ducts near the peri-areolar incision contribute to contamination as well. For this reason, we prefer the use of the inframammary incision for primary and most revision breast augmentations.
Placement of the implants above the muscle
There are a number of studies supporting higher rates of capsular contracture when the implant is placed above the muscle. When the implant is underneath the muscle, it is mostly covered by the muscle. This brings more motion to the area and also better blood supply. This position has a lower rate of capsular contracture.
If there is a hematoma (blood collection) around the implant after surgery, it should be surgically removed. It will resolve if left in place, but will increase the chance of capsular contracture.
Smokers have a 3-fold increased rate of developing capsular contracture after breast augmentation. At 14 months one study found 1.9% of non-smokers had capsular contracture, where 5.5% of smokers had developed capsular contracture.
Grades of capsules around breast implants
Grade 1– soft pliable capsule, no change in shape to the breast. This is the normal capsule after a breast augmentation. This is what we want. This is a capsule, but is not capsular contracture.
Grade 2– breast shape is normal, but the implant feels more firm. This usually does not require operative intervention, but needs to be followed to make sure it does not worsen.
Grade 3-breast is more firm, and there is a change in the shape of the breast. The breast shape can not be fixed without removing the capsule. We thoroughly wash the pock with antibiotic and replace the implant as well.
Grade 4– the breast is hard, and can be painful as well. This also requires removal of the capsule, washing the pocket with antibiotic, and replacement with a new implant.
Options to fix capsular contracture?
Grade 1 capsules are normal and never require surgery. This is not contracture, but your bodies reaction to the implant.
Grade 2 capsules rarely require surgery, but may be treated with antibiotics and/ or a leukotriene inhibitior such as Singulair.
Grade 3 and 4 capsular contractures require surgery to fix. This can vary by person, but usually requires the removal of the implants, removal of the entire capsule, washout of the pocket with antibiotics, and replacement of the implants with new implants. If the original implants were above the muscle, they will likely be placed below the muscle at that time. Following surgery, you may be placed on antibiotics for a few weeks as well as a leukotriene inhibitor such as Singulair.
Issues With Position
Poor position of the implant
When implants are placed underneath the breast, there are several goals. The implant is ideally centered underneath the nipple areolar complex. The breast should have a smooth contour from the side. The breast tissue should be on the front of the implant. There should be a normal size and position of the cleavage, and the breasts should be reasonable symmetric. If the implants are not correctly placed at the original operation, or if a patients soft tissue does not react as expected, the implants can stay in positions the do not create a harmonious appearance to the breast.
Implants too high
When the implants are placed at the time of surgery, in most women, the tissue at the bottom of the breast needs to stretch to accommodate the implant. The implants usually sit a bit high after surgery. The implants the “drop” over the next few months. In some circumstances, the implant does not drop. This may require a small revision to release this tissue.
Implants too low
If the pocket underneath the breast is made too large at the time of surgery, or if large implants are placed and over time the soft tissue can not support them, and revision surgery may be needed to raise the implants on the chest and to recreate the inframammary fold. Often this can be done with an internal bra that will increase the strength of the tissue and prevent recurrence of the problem.
Synmastia (implants too close together)
This results from the creation of a pocket for an implant that gets too far to the middle of the chest. If all the medial fibers of the muscle and fascia are released, the implants can migrate centrally and sometimes can touch each other. This can create the appearance of a “uni-boob”. This can be a much more difficult problem to repair. This always requires surgery to repair and sometimes requires decreasing the size or temporarily removing the breast implants.
Implants too far apart
If the pocket created for the implants is too wide, the implants may sit farther out than wanted. This can be repaired by internally closing down the extra space bringing the implants closer together.
What is a breast implant?
Breast augmentation surgery involves the placement of custom-fitted saline breast implants or pre-filled silicone implants. This procedure allows women of all ages to select the bust line they have always desired or restore the youthful contour of the breasts they once had. In addition to enhancing the size and shape of the breasts, this procedure improves firmness. More on Breast Implants / Augmentation.
Do many of Dr. Lewis’s patients need revision?
Dr. Lewis has been very successful in guiding patient to implants that are the correct size and shape for each persons body. He is also meticulous in his surgical care. This has helped to keep the need for revision in his patients to a minimum.
Most of the revisions he has performed are in women who have originally had breast augmentation surgery through another surgeon. He has been very successful in helping these women resolve their issues.
The care needed for revision breast surgery can be very easy such as in cases of a recent saline breast implant rupture, however it can also be very challenging such as in cases of significant asymmetry, synmastia, or substantial implant malposition. We carefully individualize the plan for each person coming in for an evaluation and direct the plan based on the best options to fix the problem.
Your options include:
Placing new implants in the same pocket
Making openings in the capsula to allow the breast to stretch around the implant. This is very useful in minor cases of implant malposition.
Removing the entire capsule- This is most commonly performed in cases of significant capsular contracture. This usually also involves removal of the breast implant and replacement with another implant.
This involves removal of a portion of the capsule and suturing it to tighten the pocket. This is most commonly used as part of an operation to raise an implant to is too low, or too wide on the chest.
In some cases after breast augmentation, the areola can stretch to a larger diameter. This is usually a very mosest amount, but in rare cases it can be more than desired. The areolar diameter can be reduced with a very small surgical procedure and has minimal complications.
Repair of a tuberous breast
This can be a very complex process depending on the degree of tightening and herniation of breast tissue from the tuberous breast deformity. The repair can be as simple as opening the under surface of the breast, or can be a process that involves two to three steps to create a natural appearance.
Will anesthesia or pain relief be used during and after surgery?
You will be made comfortable throughout the whole procedure. Most women have a general anesthesia for this surgery. However, if a patient has a medical condition or concern that would preclude general anesthesia, monitored sedation can be used. After surgery, you will be given instructions on pain relief medication, if required.
What happens immediately after surgery?
Once the incisions are closed with sutures, surgical garments are wrapped around the chest to protect the treatment area. Our breast revision patients initially recover in the recovery room, observed by our licensed nurses. After a short period when you are awake and comfortable, you will be able to go home to rest.
How long will complete recovery take?
We suggest taking a week off of work, but some patients will return to work faster assuming that they do not have to perform any heavy lifting. Full recovery takes two to four weeks.
Your first post-operative visit will be scheduled about two to four days after the procedure and you are then seen a few more times during the recovery period. In the first few days patients often experience mild discomfort, bruising and swelling, all of which are considered normal and treated with prescription medicine. Patients are also asked to wear a special supportive garment for five to seven days after which they may resume wearing normal bras. Detailed instructions on how to care for the incisions, when to resume exercise and other pertinent facts are provided prior to surgery.
Your relationship with us will not end after the surgery. We will see you frequently after the surgery for the next weeks and months and will want to see you back one year after surgery as well. We will continue to advise you on activity, exercise, breast self-examination and the future need for mammography, as you require.
What are the risks of breast reduction surgery?
With any surgical procedure there are risks that you must be aware of. To minimize the risks, ensure your surgery is conducted in a safe and secure environment using the latest surgical techniques by checking the certifications and accreditation of your surgeon. Accreditation boards and bodies are there to protect you. Dr. Gordon Lewis has 9 years surgical experience and is affiliated to several important professional organizations.
- He is board certified by the American Society of Plastic Surgeons www.plasticsurgery.org
- Affiliated to the Richmond Academy of Medicine www.ramdocs.org and the Medical Society of Virginia www.msv.org
- He is also an associate member of the American Society for Aesthetic Plastic Surgery www.surgery.org and the American College of Surgeons www.facs.org
- A candidate member of the American Society for Surgery of the Hand www.assh.org
Although infrequent, breast implant surgery risks may include (but are not limited to);
- Numbness of the breast
- Leakage or Rupture
- Poor aesthetic scar healing
- Formation of scar tissue around the implant
- Changes in nipple / breast sensation
Post-operative complications are rare but may occur in some patients. If you experience any alarming symptoms, please contact us right away.
During a comprehensive one-on-one consultation at Lewis Plastic Surgery, we will assess the existing implant, determine any immediate dangers and discover your goals moving forwards:
- Assess reasons for implant revision
- Look at the options for new implants including the difference between saline and silicone breast implants
- Look at breast implant sizes and shapes
- Breast implant placement: behind, in front of or partially behind the pectoral muscle
- Incision types: under the breast, around the nipple or in the axilla (arm pit)
- Surgical facility and anesthesia
- Breast revision cost and financing options
Surgical procedures are performed at an accredited outpatient surgical center or a local hospital. Dr. Gordon Lewis is affiliated with several local medical centers where his patients undergo surgery. He primarily operates at these locations:
Stony Point Surgery Center
Parham Surgery Center
He also has privileges at St. Mary’s Hospital and Henrico Doctors Hospital, but he operates there less frequently.
Initial consultations, follow-up appointments, and all non-surgical treatments and minor surgical procedures are performed at Lewis Plastic Surgery practice, which is located on the grounds of Johnson-Willis Hospital in Richmond, Virginia.
Revision breast surgery is very difficult to price without a consultation because the needs are so individualized. If you email us with general concerns, we will attempt to give you a price estimate, but unfortunately, this may not be accurate. The only way for us to give you a accurate estimate of costs, is to have an in person consultation. At that time, you will be given a quote which includes all the costs of the surgery. This will include:
- Dr. Lewis’s Fee
- Operating room fee
- Anesthesia fee
- Cost of implants
- Cost for CosmetAssure®
Every patient is required to attend an initial consultation before a procedure can be booked. Once you decide to proceed with surgery, we will assist you in finalizing a date and getting everything ready for surgery. We try to be as flexible as possible and will make arrangements to see you at Lewis Plastic Surgery on the grounds of Johnston-Willis Hospital within a few days after you contact us.
Gordon Lewis, M.D.
Dr. Lewis, a native of Richmond, prioritizes building honest, trusting relationships and providing personalized care for his patients.Meet Dr. Lewis