Breast Revision Surgery in Beverly Hills

Capsular contracture is ruled in or out first, because its treatment is completely different. What people call a mild contracture is sometimes an implant sitting a little high in a slightly tight pocket, which is a position problem with a different fix (a "mild contracture" or an implant riding high).

If you have silicone implants that are a couple of years old or older, an ultrasound or MRI should check for rupture before any revision. A rupture can turn a simple exchange into a capsulectomy, and a documented rupture may open insurance coverage, even for cosmetic implants. Dr. Killeen can perform the ultrasound in her office.

Bring your operative notes and implant cards if you have them, but they are not always accurate: a patient may have kept the card from an earlier set, or may not know what size is in place. When the first surgery was done abroad, records are often hard to get and may need a medical translator.

What you see looking down at yourself can be very different from what she sees, so the first step is agreeing on exactly what bothers you: nipple position, areola size, the crease, volume, tilt, projection or the footprint of the breast (what to tell your surgeon). For implants under the muscle, the exam includes flexing your chest so she can see where the muscle sits.

The nipple sits where it should, but the implant has fallen below the crease. When it happens early, the cause is usually a thin, weak capsule that cannot hold the implant's weight. A crease that was lowered at the first surgery is never as strong as a natural one, and larger implants, weight swings, loose or sun-damaged tissue and high-impact exercise add to the risk. Her usual repair adds internal support so the capsule can hold the implant (see why removing skin doesn't fix a dropped implant).

Some movement when you lie flat is normal. Implants that slide toward the armpits usually have a stretched capsule, and under the muscle, the muscle's attachment to the breastbone and years of contraction can push implants farther apart (implants that drift to the sides). Once the capsule has stretched, a garment cannot fix it, so the repair is surgical, often reinforcing the side of the pocket. A supportive bra, even at night, helps prevent it.

An implant placed under the muscle can end up below it, usually because the lower capsule stretched or the muscle was released too far. Most women never notice the slip itself, only that the breast looks or moves differently. The repair either restores the pocket under the muscle or moves the implant over it, then supports the lower pocket (implants that slip out from under the muscle).

Right after surgery, implants often sit high because of a tight muscle or tight tissue, and for most people time brings them down. If one stays high without a contracture, the muscle may not have been released enough, or the pocket may be slightly tight. The fix is a further muscle release or cuts in the capsule (capsulotomy) so the implant can drop (implants sitting too high).

The implant turns over so its flat back faces forward, and the breast suddenly changes shape, which many women mistake for a rupture. It happens when the capsule has stretched larger than the implant, most often with high-profile, very large or under-the-muscle implants. A first flip can often be turned back and usually stays. If it keeps flipping, surgery tightens the pocket with stitches or a scaffold, sometimes with a smaller or lower-profile implant (why implants flip).

The breasts join across the breastbone and the cleavage disappears. When surgery caused it, the pocket was usually taken too far toward the middle, often by over-releasing the muscle. Dr. Killeen repairs what was harmed: if the muscle was over-released, she reattaches it to the chest wall and usually moves the implant over it, and she closes the inner pocket with heavy dissolvable stitches rather than stitches through the skin, followed by a symmastia bra. Symmastia that was not caused by surgery, often seen with very large breasts, generally cannot be corrected.

An implant under the chest muscle can make the breast move or distort whenever you flex or move your arm, and it is worse when the muscle was released too far. The fix is moving the implant over the muscle and repairing the muscle back to the chest wall (repairing the chest muscle).

Every implant ripples. It shows more with thin tissue and softer implants, and saline ripples the most. Rippling can also come from an implant that has dropped and is pulling on the tissue. It can be made less visible, but not eliminated, especially in thin patients (rippling causes and fixes).

Implants can come to feel too big or too small. Going smaller means making the pocket smaller so the new implant does not move around, and putting implants back after a removal means planning the pocket around the new implant (replacing or removing your implants). No surgeon can promise a cup size, so sizing is planned in volume.

Asymmetry can mean nipple position, areola size, crease height, volume, footprint, projection or tilt, and each has a different fix. Everyone starts out asymmetric, and fixing one difference can make another more noticeable. The goal is better, not flawless, and asymmetry you only see in certain positions cannot be operated away.

There is no set expiration date for implants, and ten years is not long for current ones. For implants placed many years ago, replacing them before they rupture is reasonable to consider even if they look fine, and she does this often. A ruptured silicone implant is a reason for surgery even when the breast looks fine. Swapping macro-textured implants is a reasonable choice, although it is not known whether it lowers the rare lymphoma risk, and saline implants can be changed to silicone for a more natural look and feel (when to consider replacing implants).

She uses only dissolvable mesh and absorbable stitches around implants, because permanent stitches can harbor bacterial biofilm (what a surgical scaffold is). For a dropped implant, dermal matrix is another option, but she finds it less consistent than mesh because it can stretch.

In her practice she has moved to placing implants over the muscle. When she moves an implant from under the muscle to over it, she reattaches the chest muscle to the chest wall whenever possible, stitching it down over a raw surface so it heals in place (recovery after moving an implant over the muscle).

When going smaller, including when implants go back in after a removal, she makes the pocket smaller, sometimes reinforced with a scaffold, so the new implant does not move around. She first works out why the previous implant was disliked so the same problem does not come back.

For rippling, a firmer, more cohesive implant ripples less but also feels firmer. In thin patients, as little as 10 to 20 cc of fat per side can soften a visible implant edge (hiding implant edges). For an implant over the muscle, moving it under the muscle is another option, with muscle movement as the trade-off.

If an earlier repair or lift has already failed, doing the same thing again rarely makes sense. That is when she adds internal support, such as a dissolvable scaffold, rather than repeating the first approach.

• Removing skin to prop up a bottomed-out implant, because the weak capsule is still there and the drop tends to return
• Placing dermal matrix over an implant to hide rippling, which in her experience is expensive and not very effective, although some surgeons get good results with it
• Stitches through the skin for a symmastia repair, which can leave unusual scars
• Permanent stitches around implants

A revision sometimes needs a lift added. As with any lift, the pattern is chosen by your anatomy and goal, not by scar preference, and the extra work can change how the scars heal (see breast lift).

If the nipple sits where it should and only the implant has dropped, the problem is a weak capsule, not extra skin. The fix is internal support for the implant rather than removing skin under the breast.

An internal bra adds support to a lift, a reduction or an implant operation, and a dissolvable scaffold is her preferred way to build it. She uses it when it is needed, for example when a breast has dropped again after an earlier lift (what an internal bra is).

When an implant is combined with lifting heavier breast tissue, the breast and the implant age differently, and the tissue can slide down off an implant that stays high. Expect this combination to need maintenance over time.

• Imaging: Any recent ultrasound or MRI of your implants, if you have one (silicone implants a couple of years old or older are imaged before surgery)
• Records: Operative notes and implant cards, if you have them
• Your goal: The specific thing that bothers you, in your own words
• Questions: Your surgeon's revision policy and what your insurance covers

Revision usually costs more than the original surgery. The cost depends on what the repair includes, such as new implants, a scaffold, a lift or muscle repair, along with anesthesia and facility fees. Dr. Killeen provides a personalized quote at your consultation.

Correcting position, rippling or size is usually self-pay. For cosmetic implants, a ruptured silicone implant or a severe contracture may qualify for partial coverage, but insurers generally do not pay for a new implant or a scaffold, and covered still means your deductible and coinsurance apply. It is easier to get approval before surgery than after, and Dr. Killeen's billing team submits pre-authorizations.

With a true contracture, the implant maker's warranty usually pays at least for the new implant (see capsular contracture treatment). Warranties can be harder to claim for implants placed abroad.