COSTS:
Plastic surgeon’s fee: from $12,100 (implant revision with capsulectomy and plane change) - $15,400 (with mastopexy)
Total approximate cost (uninsured patient, day surgery only, including hospital and anaesthetic costs): from $19,700 - $26,900
Associated item number: item numbers for implant replacement ARE NOT typically applicable to patients with cosmetic breast implants. In rare circumstances, findings during surgery may allow for the use of an item number, but this cannot be determined pre-operatively.
LENGTH OF PROCEDURE/HOSPITAL STAY:
2.5-4.5 hours
Day surgery
Breast augmentation surgery remains the most common cosmetic surgery procedure performed in Australia. Nearly every breast augmentation procedure performed each year is done in a similar way: the Pectoralis major muscle is cut and the implants are placed partly under the muscle in a "dual-plane" pocket. The rationale for placing implants under the muscle is largely historical, with very little evidence to support the practice, and yet few surgeons question this dogma.
In Dr Campbell-Lloyd's experience, placing breast implants under the muscle is associated with a range of problems, including implant animation, implant displacement and pain. Many patients will experience significant cosmetic and functional benefits from repairing the Pectoralis major muscle and replacing their implant in a pre-pectoral (on top of the muscle) pocket.
Dr Campbell-Lloyd's goal in all breast implant revision surgery is to restore the breast to a natural, aesthetically pleasing shape. In doing so, it is often possible to resolve functional complaints, including pain.
Breast augmentation is performed by a wide array of individuals, not all of whom are qualified or appropriately trained. The capability of the surgeon performing the original breast augmentation may have a substantial impact on the complexity of the revision procedure.
The key to revision surgery is being able to accurately determine what has been done in previous procedures. Dr Campbell-Lloyd needs to consider both what was done deliberately, and what mistakes may have been made by the previous surgeon. We must then work to restore the breast to as close to normal as possible before proceeding with the placement of a new implant.
Breast implant revision surgery has more in common with breast reconstruction than it does with primary breast augmentation.
Breast augmentation may be associated with thinning of the natural breast tissue over time. This compounds the fact that ladies who choose to have cosmetic breast augmentation normally do so due to having a relatively modest natural breast volume, or due to deflation of the breast after pregnancy. As a consequence, in some patients breast implant removal may lead to very poor aesthetic outcomes, even when performed with other procedures such as fat transfer. In these patients, breast implant replacement may be a consideration to avoid cosmetic deformity.
All breast implants are associated with a range of complications, the risk of which increase over time. All breast implants will require removal or replacement at some point in the future.
"Plane change"
Two of the main reasons patients seek revision surgery with Dr Campbell-Lloyd are to address capsular contracture and its consequences, and to undo the functional limitations created by cutting the Pectoralis major muscle and placing an implant in a dual-plane pocket. Dr Campbell-Lloyd believes that the only way to achieve durable results after implant revision is by ensuring that a new implant is placed in a totally new pocket, after performing a complete capsulectomy.
Attempts to modify existing pockets are associated with the early recurrence of complications. In the past, and even now, many surgeons perform revision surgery by simply releasing the contracted scar tissue (capsulotomy) to allow it to expand, or tightening the capsule where necessary for support (using sutures or "heat shrinkage). These techniques fail to manage the basic processes which result in capsular contracture.
Dr Campbell-Lloyd recommends a complete capsulectomy, and conversion to a pre-pectoral pocket in most cases.
Total capsulectomy
Dr Campbell-Lloyd recommends removal of the entire scar capsule from the old implants. This minimises the risk of contracture recurrence, and facilitates other aspects of the surgery including muscle repair. When there is implant rupture, a "total intact" (often incorrectly referred to as "en-bloc") capsulectomy will be performed to contain the rupture during removal.
Pectoralis major muscle repair
Dr Campbell-Lloyd will always repair the Pectoralis major muscle following capsulectomy in a patient who had an original "under the muscle" breast augmentation. Restoring the muscle to its natural position is a key step in creating a stable foundation for any breast implant revision procedure. The muscle repair offers a number of functional benefits.
Internal bra technique
An "internal bra" is the creation of strong supports for the breast using one of two techniques: 1) internal sutures to reconstruct or reinforce the natural boundaries of the breast, and 2) the use of a dissolving mesh to support both the implant and the breast tissue.
The original breast augmentation procedure may have involved deliberate or accidental disruption of the boundaries of the breast. The most common example is the deliberate destruction of the natural crease under the breast (the inframammary fold) by dividing the supporting tissues. This manoeuvre may be a planned step in performing the augmentation surgery as it allows the surgeon to lower the level of the crease (in a properly selected patient) to accommodate a larger implant size. This can however lead to several problems including double-bubble deformity and "bottoming out". Another common example is the inadvertent over release of the inner and outer boundaries of the breast, which can lead to medial displacement/symmastia (effacement of the cleavage; sometimes referred to by patients as "mono-boob") or lateral displacement respectively.
Depending on the specific problems encountered, the internal bra, in conjunction with precise dissection techniques, allows for repair of the previous damage and strong control of the new implant pocket.
Drainless
Due to the techniques Dr Campbell-Lloyd uses, there is no need to use drains for breast implant revision procedures. This allows patients to go home on the day of surgery, and is associated with less pain, with no increase in the risk of fluid collections.
Associated procedures:
Fat transfer & Mastopexy (click for details) are commonly performed as part of breast implant revision procedures.
The reasons some patients consider breast implant revision are identical to the reasons other patients consider explant surgery.
The choice to revise and replace breast implants is deeply personal, as is the original decision to have a breast augmentation. It is vital that in choosing to replace their implants, patients are guided carefully through the complexities of revision surgery. Managing expectations in revision surgery can be difficult due to the enormous number of variables which can influence outcomes.
Implant revision surgery is far more challenging and extensive than primary breast augmentation.
Capsular contracture
All breast implants are surrounding by a scar tissue capsule. If this scar tightens, it may shrink, gradually squeezing the breast implant. Often the implants become almost spherical under the deforming forces of the contracture.
Capsular contracture may be associated with pain, breast shape changes, and increasing firmness of the breast. Capsular contracture is frequently associated with implant rupture, although the relationship may not be causal.
Implant rupture
Ruptured breast implants are common, and very frequently an implant rupture is a silent event. Most patients only find out they have a rupture when they seek investigation of some other complaint, like breast pain. The symptoms that lead to investigation are most commonly related to a capsular contracture, but once the rupture has been identified, many patients erroneously believe that it is the rupture that is the cause of their symptoms.
Patients who have had breast MRI or ultrasound scans will sometimes have findings of silicone in lymph glands. This can be seen in patients with, or without implant rupture. This is suggested to occur most commonly due to the accumulation in lymph glands of microscopic silicone fragments which may be shed by textured implants. This finding is typically of little significance and does not require additional management. Dr Campbell-Lloyd does not support the removal of lymph nodes based on these findings.
In general, implant rupture does not represent a health risk. The ruptured implant is contained within the scar capsule, which prevents leakage of the silicone into the breast tissue. It is very likely that a rupture will have been present for a long time prior to being detected. Implant rupture is far more common with older implants.
More importantly, implant rupture does not represent an urgent indication for revision surgery. Feeling rushed into surgery is a likely cause for dissatisfaction with the outcome of revision procedures.
Changes in the breast over time
Many patients who have cosmetic breast augmentation do so prior to having children. Enlargement of the breast during pregnancy and breast-feeding may lead to stretching of the breast tissues and loss of elasticity, which results in a typical appearance referred to as the “waterfall” deformity (sometimes referred to as "Snoopy" deformity due to the shape). This is a way of describing the breast falling down over the front of the implant, whilst the implant is typically held up by its position under the muscle (and often capsular contracture), creating dissociation between the breast and the implant.
Revision breast surgery is focused on restoring a harmonious relationship between the breast and implant, and may involve mastopexy to elevate the breast, as well as correcting the capsular contracture that often holds the implant in an artificially high position.
Painful implants – whilst often associated with capsular contracture, pain can also occur without any evidence of contracture. Pain may relate to pressure effects of breast implants on nerves, and this is nearly always associated with “under the muscle” or dual-plane placement. Ladies who present with implants that have "fallen" out to the side (typically seen when lying down) may be more likely to experience discomfort in the absence of contracture.
Some patients also experience discomfort, which is best described as a sense of tightness, relating to stretching of the Pectoralis major muscle by the breast implants. This can be a significant issue for physically active women who play sports and engage in weight lifting or functional training.
“Botched” breast augmentation procedures – unqualified or inexperienced surgeons may be responsible for implants which are incorrectly placed, incorrectly positioned & the wrong size. There may be progressive problems leading to pain and cosmetic deformity. Patients who have had poorly performed breast augmentation surgery will often present for correction early after their augmentation procedure.
“Animation deformity ” – the movement of the implant (typically upwards, and outwards) due the effect of the Pectoralis major muscle on the implant is referred to as implant animation. Along with movement of the implant, animation can cause distortion of the breast, a widened and flattened cleavage, and pain.
Dual-plane implant placement requires deliberate release and weakening of a very important muscle.
Cutting the Pectoralis major muscle always creates a serious and permanent change. It may not be obvious at rest, but with movement of the upper body, minor contractions of the muscle can create visible distortion and movement of the implant.
Implant animation can feel very uncomfortable, and some patients will actively avoid movements which involve Pectoralis contraction.
Revising complicated breast implants is far more complex than primary breast augmentation surgery. This is particularly true when multiple procedures (such as implant revision with mastopexy) are performed.
The results of revision surgery may appear unusual early on. It generally takes 3-4 months at least before you can appreciate the final outcome of revision surgery. In that time, the breast will soften and relax, and the surgical planning has to account for this.
Dr Campbell-Lloyd believes very strongly in performing surgery that leaves patients with natural, durable results. We recommend a conservative approach to selecting the size of the new implants, especially when revision surgery is performed with a mastopexy.
In most cases, Dr Campbell-Lloyd recommends downsizing your implants when you have revision surgery. This is a complex topic, and he has written a detailed article on this here.
It is important to understand that using breast implants will always create an ongoing requirement for additional surgery at some stage in the future.
When surgery is performed for capsular contracture, this issue is reliably addressed by performing a total capsulectomy and plane change. However that does not mean that capsular contracture cannot recur in the future.
Also, in spite of complete correction of capsular contracture or cosmetic distortion of the breast, patients who present with pain may not experience resolution of their discomfort after revision surgery.
Depending on the issue(s) being addressed, patients may experience variable degrees of resolution of those issues.
Like all surgery involving breast implants, there are risks (such as infection or bleeding) that can result in one or both breast implants being removed.
All sutures are dissolving sutures, under the skin. A layer of glue is then applied to any incisions. There are no “sticky” dressings applied as this will tend to cause irritation and prevent showering.
After breast implant revision surgery, patients are discharged home with a surgical compression bra which must be worn at all times for the first 4-6 weeks.
Patients are discharged with antibiotic tablets, and pain-relief medications.
Patients are discharged home with detailed instructions. The instructions include emergency contact details for Campbell-Lloyd.
Routine follow-up appointments are made for:
Patients are then seen every 4-6 months as scars fade. Most patients are stable and are discharged at 12-18 months post-op, however we are happy to see any of our patients in an ongoing fashion.
We do not charge for post-op consultations.
There will be some pain. Most patients will experience pain at the incision site in the crease under the breast for the first 7-10 days. Some patients will experience occasional discomforts relating to movement after that time as the healing process continues.
The nature of this surgery is such that patients should expect to require pain relief medication for at least the first 2-3 weeks. Some patients will require simple pain relief (such as Nurofen) for up to 6 weeks as they increase activity.
Internal bra techniques may be associated with some additional discomfort. Patients may experience a tight, "band-like" sensation under the breast associated with the muscle repair and internal bra, which can persist for 2-3 months. This is improved with stretching and the resumption of full activity.
It is vital to maintain a decreased level of activity for 6 weeks after surgery to ensure that the muscle repair is not inflamed or aggravated.
It will take at least 3-4 months for full recovery. Final results can only be appreciated after that time, once scars have softened and relaxed. Scars may only fade after 6-12 months on the breast.
Before & After Photos. Hover mouse cursor to pause slideshow.
