Breast implants are not expected to be lifetime devices. All of the implants sold in the United States today have an outer silicone elastomer covering (shell), and a filler material within the shell, which can be saline or silicone. Once an implant is placed into the body, the body naturally forms a tissue lining around the implant, called a capsule.
Both saline and silicone breast implants have the same outer shell that is designed to be as durable as possible. Current implant shells are able to withstand more than 25 times the force of a normal mammogram without failure. The manufacturers of breast implants warranty the shell for 10 years. That doesn’t mean you are committed to breast surgery every 10 years. If everything looks good and feels good and there is no evidence of rupture, you can keep your implants for many years. It is important to realize that the removal and replacement of breast implants is often desired for cosmetic reasons, rather than ruptures or other complications.
Whether you're unhappy with the outcome of a previous breast augmentation or an implant sustained a rupture, you have removal and replacement options. call (702) 260-7707 to discuss these options with our Las Vegas plastic surgeon today.
Surgical Procedures to Remove and Replace Breast Implants
Surgery to remove and replace implants ranges from straightforward and simple to complicated and expensive. It depends on the situation at hand, the patient’s goals and desires, her tissue characteristics, and basically what there is to work with. Secondary surgery in general is usually more complicated that primary breast augmentation surgery. Reasons for this include the presence of scar tissue, old pockets and capsules, thinning of overlying tissue, and changes in blood supply to the nipple and overlying skin envelope. These surgeries often take longer than the initial surgery, and being more complicated, they are more expensive. Patients need to anticipate these financial obligations associated with reoperation.
In general, I advise all patients with excellent results to avoid surgery unless truly indicated. I encourage them not to have surgery for frivolous desires and unrealistic expectations, and to think about long-term sequelae in addition to their short-term desires. I discourage surgery for small size changes, or in women who want to go with implants that are much too large for their frame.
I also do not recommend large sized implants in patients who are very saggy and think that a large enough implant will make the situation better, or those that have tissue characteristics that clearly will not support the weight of a large implant. In these cases, a larger, more ptotic (saggy), more matronly version of your breasts with implants visible through the skin is just not worth spending thousands of dollars on. Breast lift surgery may be the better option in these cases with or without implants. Larger implants have more complications and can create uncorrectable problems in the future. There are so many true surgical indications to have your breasts redone, it is important to make your initial investment last as long as possible.
All patients undergoing breast augmentation with implants need to expect implant maintenance surgery. The majority of patients have excellent short-term and long-term results with no complications. However, expect reoperation at some point in time, with the typical reason being cosmetic in nature.
With or without implants, all women age and their breasts look different from hormone fluctuations, weight fluctuations, gravity, and pregnancy. Breast implants, breast lifts, breast reductions, implant removal and replacement, and explantation are all common operations performed in women of all ages in order to maintain an attractive age-appropriate breast that complements their age and lifestyle.
Cosmetic Reasons for Breast Implant Removal and Replacement
The following are common cosmetic reasons for breast implant removal and replacement:
- Reoperation for a larger implant size is probably the most common yet unnecessary reason for secondary surgery. It is important to get the size right from the beginning to avoid an early reoperation for cup size desires. There is no way to guarantee bra cup size after surgery, as all bras fit differently and every implant size looks different from person to person depending on many individual traits. It is true that most women wish they went larger, simply as a normal emotional response to feeling better about themselves. It is part of our culture to “want more” of what is making you feel so good. By the same token, the implant has to fit within a person’s frame to prevent stretch deformities and problems. Naturalness and longevity in the result is also essential. Doing surgery for small increments of volume change such as 25-75 cc adds surgical risk and expense with little to no benefit, as the size increase will be too subtle to make it worth it. In women with saline implants, the practice of adding more volume to an existing implant is not advised, as it goes against the manufacturers’ labeling, risking implant damage and implant firmness. Approximately 200cc is needed to appreciate one-cup size increase. So in choosing to go larger, the new implant size ends up being quite large. Anything less than that is probably not worth the risks and expense of surgery. Surgery typically requires capsulotomies (opening the pocket in certain dimensions) to accommodate the larger volume. Remember, larger implants have higher risks of complications including more tissue stretch, more tissue thinning, rippling, increased heaviness and sagging over time.
- Reoperation for a smaller implant is less common, but does occur. Some implant sizes look large on small frames or women complain of difficulty buttoning tops or jackets after breast augmentation. Some women simply admit to making a poor choice of size, not realizing how big they would look, or they feel like they look heavy with larger breasts. Occasionally women complain of back pain, neck pain and shoulder pain from large implants. If a woman has good skin tone and no sagging issues, a conservative downsize may be appropriate. Going much smaller can lead to some skin redundancy and sagging. Surgery to downsize an implant may involve pocket tightening (capsulorrhaphy), usually at the bottom and sides of the pocket. In addition, the overlying breast tissue and skin envelope may need tightening in the form of a breast lift (mastopexy), if there has been a lot of tissue stretch, sagging, and looseness of skin.
- Saline to silicone switch involves removing saline implants for the more natural feel of silicone implants. There was a 14-year ban on silicone implants from 1992-2006 and many women who received saline implants during this time consider surgery to switch their device to the newer generation soft and natural feeling silicone implants. Patients who have the old leaky silicone devices may also opt to have their implants replaced with the newer generation cohesive devices.
- Augmentation mastopexy surgery is commonly performed when sagging becomes bothersome after a woman’s initial breast augmentation. Implants add volume to breasts; they do not treat sagging, defy gravity, or lift a breast. They add volume and the added weight can aggravate sagging over time especially in patients with poor skin tone and loose skin characterized by stretch marks. Many patients start with mild sagging and choose breast implants to improve their look and increase upper pole fullness. However, as time passes, the implant responds to gravity, and the upper pole fullness deteriorates. As the sagging becomes more pronounced, the tissue thins, and the implants tend to fall down and out to the sides and become perceptible. This is called lateral displacement. Surgery involves removal and replacement of implants, usage of the submuscular pocket when possible, lower and lateral capsulorrhaphies (pocket tightening) and simultaneous breast lift (mastopexy). Implant size can go up or down, depending on patient desires. Additional breast scars result from breast lift surgery, but they are hidden around the nipple and along the bottom of the breast. They are well worth the trade off for a beautiful and natural looking upper pole fullness and close central cleavage that you are confident showing off in all types of clothing styles.
- Explantation means implant removal. Some women are just ‘over’ having large breasts. Some women have regrets about their initial decision to undergo breast augmentation in the first place. A certain subset of women notice increases in bra size as they age. Hormones, weight gain, sagging and extra skin increase bra cup size over time. In these cases, it is remarkable that a patient once small breasted doesn’t need an implant for volume anymore. Another subgroup of patients has aged and they are simply unconcerned about their breast size or appearance. Surgery is straightforward to remove the implant. Sometimes part or all of the capsule (partial or complete capsulectomy) is removed when indicated. Explantation can be done with or without breast lift surgery. Simultaneous mastopexy reshapes the breast to a rounder, perkier and more youthful contour. Without mastopexy, expect a more mature looking, sagging breast. The degree of sagging after explantation varies and depends on many individual factors including breast tissue thickness, skin tone, patient age, the size of the implant, the capsule, and how long the implant was in place. Sometimes results after explantation are satisfactory, and other times the appearance of the breasts looks sad, saggy, deflated, with contour depressions.
Reoperations for Unacceptable Cosmetic Outcomes from Complications
- Capsular contractures (increased firmness of the breast capsule). A thin capsule or scar tissue sac is a normal response to any foreign object placed within the body. Usually the scar is not seen or felt. Everyone heals differently. Some patients form thicker capsules than others. Mildly thick symmetric capsules can be beneficial by keeping an implant in place and minimizing the look of sagging. Some patients admire a slight firmness to their breasts and a mild symmetric contracture is no problem for them. Moderate to severely thick capsules squeeze the implant, making it feel uncomfortably firm. In these cases it can change the breast contour or cause pain. The risks of capsular contracture increase with the age of the implant, and can be as high as 20-30% over time. Saline implants placed under the muscle using an inframammary crease incision have the lowest risk for capsular contractures. Risks are higher for implants placed over the muscle, and silicone implants have a slightly higher rate than saline implants. Textured implants placed over the muscle may have a lower rate than smooth implants placed over the muscle (subglandular or subfascial). Form stable “gummy bear” textured implants may also have a lower rate of contractures. Other potential risk factors for the development of capsular contracture include the way the surgery is performed, using a periareolar or transaxillary approach, spillage of blood in the pocket during the surgery, hematoma (bleeding), subclinical infection, or simply a patient’s inherent response to a foreign body. Surgery is indicated for moderate to severe capsular contractures. A complete capsulectomy is performed and the implant is changed. In this situation, although immediate softness and a natural contour is restored, the tissues get thinner from removing the thickened layer of scar tissue. There can be risks for increased implant perceptibility, sagging, and a 30% chance of recurrent contractures. With such a high incidence of recurrence, it makes no sense to perform the same operation and expect a different outcome. Reoperation for recurrent contractures needs to incorporate a change in surgical plan. For example, converting a subglandular implant into a new submuscular pocket will decrease the risk for recurrence. When all else fails, ADM is another option. ADM stands for acellular dermal matrix; Alloderm and Strattice are names of ADMs commonly used, although many other tissue substitutes are available. These are expensive tissue sheets that are surgically sewn into part of the implant pocket and may decrease risks for recurrent contractures.
- Implant malposition, including lateral displacement (implants falling out to the side, usually from gravitational forces), bottoming out (too low), one or both implants too high, symmastia (implants too close, “uniboob”), and sagging issues. The implant can drop too much, or the overlying breast tissue can sag over and above the healed implant pocket. Contour problems can occur from malposition. Implant malpositions typically require combinations of capsulotomies (pocket openings) and capsulorrhaphies (pocket tightening), pocket site changes, and mastopexy (breast lift or skin tightening procedures).
- Surrounding tissue thinning with skin wrinkling and rippling can be associated with thin patients or larger implants. Pressure-related thinning of surrounding breast tissue and flattening of the chest wall can occur over time, especially with larger implant sizes. Larger implants incite more tissue stretch, more thinning, more rippling, and more sagging issues over time. All of these issues are difficult to correct in the future, so choose your initial size wisely. Bigger isn’t always better. Common misconceptions about rippling abound. Rippling does not mean rupture, although increased folds can be a symptom of rupture. Patients often request more volume added to their saline implant bag or a switch to a large high profile silicone implant to decrease rippling. This does not solve the problem, and actually makes it worse over time. Rippling is from thinning. Any implant will show if your tissues are thin enough. If you loose any significant amount of weight and your ribs show, then guess what? Your implant can show. Gaining weight helps the problem, although for most patients in our community that is not an option. Going with a smaller implant or changing the implant from a subglandular to submuscular pocket helps. Simultaneous breast lift may also be required. Adding tissue with ADM or fat transfer are also options in certain candidates.
- Animation deformity means a distorted breast contour with pectoralis major muscle contraction. This can occur in any submuscular breast augmentation if a portion of the muscle is not released from the area near the lower breast fold. Because everyone’s muscular anatomy is different, the amount of muscle divided depends on many factors including the location of the muscle relative to the breast and the thinness of the patient’s tissue. Surgical options include a switch from the submuscular pocket to a new subglandular or subfascial (over-the-muscle) pocket, or lower pole capsulotomies with division of the responsible muscular bands.
- Contour irregularities can affect the lower breast fold called the inframammary crease. Inframammary crease deformities and “double bubble signs” can occur for several reasons. If the implant is placed under the muscle in the situation of sagging, you may be able see the lower round implant edge behind the breast, and the natural breast fold above it. It looks like a double crease. Surgery can involve switching the implant pocket from submuscular to subglandular, doing a mastopexy to tighten the sagging skin, or recreating the inframammary crease with sutures, also called capsulorrhaphy. Deformities of the inframammary crease can also occur from implant “bottoming out” if the inframammary crease attachments are divided during the initial augmentation. Additional breast contour depressions or areas of thinness can be treated with mastopexy techniques, tissue rearrangements, or fat injections. Contour problems can occur centrally if the pectoralis major muscle is cut from the medial sternal border in an attempt to get implants closer together in women with a wider bony cleavage. This problem is more difficult to correct.
- Early aggravated sagging can occur in breast augmentation patients whose tissues are loose, lax, and stretchable or compliant. This can occur in predisposed individuals with poor skin tone, where their tissues simply do not support the weight of the implant. Whether the implant is placed under or over the muscle is not always relevant. Surgery usually requires implant downsize and mastopexy.
- ADM or acellular dermal matrix is a tissue substitute used on complicated revisionary cases. When surgery is performed to treat a particular complication, and the problem recurs, something needs to be done differently. That’s where ADM comes in. ADM adds coverage and support to compromised tissues and can salvage difficult situations. Adding a tissue substitute becomes necessary when surgery to correct an issue fails, and the patient lacks healthy breast tissue and skin to support the presence of an implant. It adds implant coverage and implant support in situations of implant perceptibility and rippling. It can be used to treat recurrent capsular contractures and decreases risks for recurrence. It bolsters repairs when correcting implant malpositions. Strattice is the most commonly used ADM because it is the most affordable. These complicated cases get very expensive, as ADM costs thousands of dollars per sheet.
Complications That Require Breast Implant Removal
- Hematoma: Bleeding can occur with any surgical procedure. This is a treatable condition requiring surgery and usually has a satisfactory outcome.
- Infection is rare and usually requires implant removal, as antibiotics do not treat foreign bodies. Replacement is usually safe 6 months later.
- Seroma-a fluid accumulation around the implant. Reasons can be trauma, an irritant in the pocket, blood in the pocket, ALCL (see below), or infection.
- Lymphoma (ALCL): a very rare blood cancer has recently been linked to long-standing textured implants associated with a fluid collection. Usually curable with implant removal.
- Toxic shock syndrome: A rare infectious disease syndrome.
- Chronic breast pain or nerve pain for no apparent reason. Implant removal is advised in extreme circumstances.
- Wound separation or extrusion of the implant: These are treated similar to implant infections. If a simple early wound separation is treated emergently and there are no complicating factors, sometimes the augmentation can be saved. In other more prolonged situations, where the implant is contaminated and the tissues are damaged, the implant needs to be removed with consideration for implant replacement after 6 months of healing.
Nevada plastic surgeon Dr. Hayley Brown understands the changes a woman's body can go through and how a previously satisfactory breast augmentation might lose its effectiveness over time. Please contact Desert Hills Plastic Surgery Center online or call (702) 260-7707 to arrange a free breast implant removal consultation.