Implants Replacement, Removal, and Augmentation
Revision Surgery

Breast implant placement during surgery is followed by several months of gradual skin and soft tissue expansion to accommodate the devices. Following expansion of surrounding structures, tissue pressure drops and implants settle into their final shape and position. When a breast implant remains too high and firm instead of settling, this “superior” malposition may not resolve, and surgical re-positioning of the breast implant may be required.

Causes of superior malposition include:

• improper initial placement of the implant
• a capsular contracture immobilizing the implant
• or inordinate breast tissue stretching following implant placement with downward settling of the breast below the implant position.

In some cases, implant size exceeds the natural dimensions and borders of the breast. An implant may appear abnormally high relative to nipple position, rib configuration, native breast position, shape, and contour, or some combination of these elements. When capsular contracture is the cause, discomfort and un-natural firmness of the breast may exist.

Excessive expansion and/or elasticity of breast tissue and skin, a weak capsule, poorly placed implant pockets, inadequate implant support, a long distance running habit, aging, weight loss, and one or more pregnancies may cause breast implant descent over time to an abnormally low (“inferior”) position on the chest. Position of breast implants on the chest is judged in relation to nipple position, native breast position, and chest structure. Abnormally low implants may have a “bottomed out” appearance that is unnatural, unattractive, and uncomfortable.

Surgical replacement and repositioning of implants is usually the required correction. Because symmetry between right and left sides must be achieved with a naturally aesthetic lower breast crease and implant support must be physically reconstructed, these procedures are among the most technically demanding and challenging in aesthetic breast surgery.

Appealing cleavage between breasts in front of the central chest is an alluring feature of augmented breasts.  Implant width, implant position, breast size and position, chest anatomy, skin quality, and surgical soft tissue management all contribute to this aspect of the final result.  Lateral malposition refers to breast implants that are too widely separated from each other with little or no visible cleavage.  This may be related to angulation of the ribs, smooth implants in the sub-pectoral position, inadequate “pectoralis myotomies,” selected implants too narrow for breast base width, implants positioned too far laterally at surgery, excessive lateral breast pocket dissection, capsular contracture, and/or some combination of these factors.  If breast implants appear too widely separated from one another and space between the breasts is abnormally wide, surgical correction is usually required.  Breast augmentation revision, implant replacement, fat transfer, and/or a combination approach may be indicated. 

Symmastia refers to the appearance of breasts coming together in the midline, like excessive or disproportionately obvious cleavage all the time.  If midline chest skin is elevated due to one or both implants projecting across the midline, surgery may be indicated to normalize the appearance and restore implant position.  The most common cause of a symmastia appearance is pre-exisitng pectus excavatum, a situation of chest development characterized by ribs that curve around in front and terminate into a relatively depressed sternum (breast bone).  These curved ribs naturally orient breast tissue and nipple – areola complex to face centrally.  In the absence of pectus excavatum, implants uniting in the front central chest has been termed “uniboob,” a symmastia type implant malposition involving breast implants that have come together beneath chest skin. Sometimes one or the other implant crosses the center line, and sometimes both meet in the middle. Like other malpositions, implant location is judged based on symmetry between right and left and in relation to nipple position, native breast position, and other aesthetic elements. Causes of symmastia may be poorly placed implant pockets, excessive medial dissection of the pocket, capsular contracture,  excessive implant width, poor healing, chest trauma following surgery, or some combination of these.  Surgical breast revision is usually required for implant lateralization. 

Breast implants that are Food and Drug Administration (FDA) approved for use in the United States are manufactured by Abbvie (Allergan/Natrelle), Johnson & Johnson (Mentor), Sientra, or Ideal.  These companies are now producing the most durable long-lasting breast implants in history.  Still, the implants are subject to trauma and deformation over many years of use.  They are mechanical devices, and may at some time after implantation “fail” by developing a tiny shell defect through which contained content, either salt water or silicone, may leak.  If the implant contains salt water (saline), a tear or hole will visibly deflate the breast.  Silicone breast implant ruptures generally go undetected (“silent” rupture) because silicone gel is more viscous and cohesive.  The gel sticks to itself and doesn’t easily pour out through an opening in the implant shell. Signs of a possible silicone implant rupture include any breast change: swelling, soreness, shape difference, sensitivity, or a new breast sensation with movement. Causes of  implant rupture are a weakened area of the implant related to a fixed ripple or fold of the implant shell, normal implant aging and deterioration over decades, chest injury / trauma, seat belt / air bag trauma, damage by surgical instruments (during the implant procedure or other surgery), puncture by biopsy needle, or others.  Both the FDA and implant manufacturers strongly recommend removal with or without replacement of ruptured devices.  No cancer or other physical illness has been associated with breast implant failure, although widely distributed silicone can be difficult to completely remove from the chest.

Contemporary breast implants are more natural in consistency and appearance than past generations of devices, so visible implant rippling is therefore much less common than in the past.  Still, after swelling resolves, in certain positions and specific areas of the breast, an implant may be felt or seen through the skin to ripple, wrinkle, or demonstrate an un-natural irregularity.   This situation may be more common with saline implants, more common for women who are very lean or thin, who have implants that are disproportionately large that have stretched overlying skin, who have minimal native breast tissue, and who have implants placed superficially above the chest muscle.  Capsular contracture can ripple and distort implants.  In general, the larger proportion of the breast volume that is implant compared to natural breast, the more that breast will appear and perform artificially, and be more prone to visible rippling or wrinkling. Implant “edge visibility” is when the end of the implant at its interface with natural breast tissue is visible from certain angles, usually without a bra. This may occur when the native breast base width is narrow and a breast implant has been used not only to enlarge breast volume, but breast tissue distribution.  Breast implant revision surgery, implant replacement, fat transfer, use of surgical mesh or “allograft”, and other specific techniques may be indicated for smoother, more natural breast appearance. 

Natural breasts are soft, pliable, skin structures.  Although breasts are sensually attractive in many body positions, they are not naturally moved by any voluntary muscle contraction.  However,  breast implants positioned deep to the pectoralis major muscle are subject to movement and shape change with dynamic muscle contraction that occurs with shoulder movement.  This “breast animation” is often barely detectable.  Sometimes, depending on implant surface texturing, capsular ingrowth, pectoralis anatomy and surgical managment, patient physical fitness and other factors, excessive, objectionable, and abnormal breast movement and shape change accompanies chest muscle contraction.  Implant shifting and movement with contraction of chest muscles may distort breast contours.

Although the breast resumes its natural shape upon muscle relaxation, breast implant animation may be sufficiently distracting that surgical re-positioning of the implants above the chest muscle is indicated for relief.  At that surgery, the previously divided chest muscle is often reconstructed and repaired.