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 ).
Surgical Planning and Technique: Simple Implant Exchange
A simple implant exchange is a straightforward procedure, capable of being performed with intravenous (IV) sedation and local anesthesia. The existing inframammary fold (IMF) incision is used. My personal approach is to preinject the existing IMF incisions, use nipple shield covers, and excise the old IMF surgical scar. A stair-step dissection down to the capsule helps with the closure at the end of surgery. A capsulotomy can be easily made with the electrosurgery pencil to access the implants. For patients with transaxillary or periareolar incisions, I recommend a new incision in the inframammary region versus repeating the original incision that could produce a visible soft tissue deformity.
From that point, removal of the existing implants and replacement can be accomplished. Most implants have information on the patch that indicates manufacturer and style, which is potentially useful when medical records from earlier surgery are not available. In some cases, it may be necessary to measure the implant BD once the implant is outside the pocket and weigh the implant. Even in situations of ruptured gel implants, try to locate the patch on the implant shell for information.
Insertion of the new implants follows a standard technique designed to prevent biofilm contamination of implants (glove change, “no-touch” technique, use of anti-infectives [antibiotics and povidone-iodine [Betadine], and an insertion device). The replacement implants should go in one time only. If consideration for size change and possible capsulotomy are planned, use a sizer implant and measure the pocket dimensions internally. Wound closure with an absorbable monofilament suture and a skin glue finishes the procedure. Drains are not necessary, unless there has been extensive capsule work.
Surgical planning for a simple exchange is summarized in Boxes 8.1 and 8.2 .
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Obtain biodimensional measurements and a diagnostic ultrasound imaging study (implant, capsule, and parenchyma).
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Obtain the previous operative report or implant information for implant dimensions.
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Select replacement implants based on existing implant dimensions.
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Round-to-round may require minimal capsule modification.
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For shaped-to-round, plan on capsulotomy to enlarge the capsule.
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For round-to-shaped, plan on total capsulectomy and a larger implant that will have a tight fit (most complex; use anatomically shaped sizers to confirm tight pocket fit).
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Surgical planning: Use inframammary fold access.
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Surgical technique: Remove old implant and measure pocket dimensions; a trial size implant is required to verify pocket capacity.
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Insert the implant using the no-touch technique; irrigate the pocket with povidone-iodine (Betadine), change gloves, and insert the device.
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Drains are typically not required.
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Obtain biodimensional measurements and a diagnostic ultrasound imaging study (implant, capsule, and parenchyma).
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Obtain the previous operative report or implant information for implant dimensions.
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Select replacement implants based on existing implant dimensions: To go larger, pick a higher-projecting implant that will fit into the pocket; for smaller, select a lower-projecting implant.
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Round-to-round may require minimal capsule modification.
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For shaped-to-round, plan on capsulotomy to enlarge capsule for larger size.
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Round-to-shaped may not be feasible because of large pocket size and risk of rotation.
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Surgical planning: Use inframammary fold access.
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Surgical technique: Remove the old implant and measure pocket dimensions; a trial size implant is required to verify fit. Consider “popcorn” capsulorrhaphy to diminish pocket size when downsizing.
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Insert the implant using the no-touch technique; irrigate the pocket with povidone-iodine (Betadine), change gloves, and insert the device.
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Drains are typically not required.
Case Examples
Breast implant replacement surgery can vary from a simple implant exchange in the same pocket to more complex procedures where additional steps must be taken to correct implant or soft tissue problems. Five case studies are shown that have increasing complexity. Cases 8.1 and 8.2 are shown in a step-like fashion.
A 46-year-old woman presented 13 years after a biplanar saline breast augmentation with Inamed Style 68, 300–330 cc implant. She had experienced a partial deflation on the right side. She elected to replace with Allergan Inspira SRF 345 cc implants. This was a straightforward exchange without the need for capsular modification. Her surgery is shown in a stepwise fashion ( Case 8.1.1A–H ). This is a typical example of a saline deflation shown with a right-sided loss of volume. Her outcome after implant exchange is shown in Case 8.1.1I . The implant was found to have a valve failure with partial deflation (see 
).
A 34-year-old woman presented 8 years after a retromammary breast augmentation with Allergan Style 410, FM 350 cc implants. She experienced a buckling of her implants that was visible and annoying. Her goal was to have more upper breast roundness and a larger size. I selected the Allergan Inspira SSF 415 cc device with a more cohesive gel to enhance upper pole fullness. Her surgery was more complex because she needed a capsulotomy to increase pocket capacity from 350 to 415 cc. A trial implant of 415 cc was used to verify pocket capacity. The permanent implant should go in one time and not be used as a sizer. Her surgery is shown in a stepwise fashion ( Case 8.2.1A–J ). Her before and after photos are shown in Case 8.2.1K and 8.2.1L . The circles that are shown in the preoperative photo are the location of the implant buckling (see 
).
