REVISIONARY SURGERY using a purse string breast lift with implant change for capsular contracture and prosthesis rotational problems

 Background
 Patient Groups
 Patient Concerns and Planning
 Preparing for Surgery
 The Operation
 Recovery
 At Home
 Office Visits and Follow-up
 Outcome and Complications
 Case Histories (Before and After)

BACKGROUND
On occasion following breast augmentation some women can develop scar tissue or implant shifting that presents as stiffness, asymmetry, and sagging of the nipple and areola, despite having a good early result from the primary surgeon. There is a chance that these problems may require secondary surgery. Each patient may have a different sense of the personal impact of these changes, and can request: (1) a change of implants with some treatment of the implant pockets, (2) a change of implants and a breast lift to address any sagging that has occurred over the years, (3) complete bilateral implant removal with a breast lift alone to restore shape, or (4) removal of implants and no additional surgery. Breast augmentation is a highly successful procedure, but does involve some maintenance which in part relates to: (1) the durability of the prostheses that are artificial man-made devices subject to stresses and fatigue as with any structural material, and (2) the numerous physiologic changes occurring in a woman's body as she matures, including weight fluctuations, childbirth, breast feeding, hormonal changes, and natural aging. When patients return to their primary Plastic Surgeon or seek consultation elsewhere and have concerns over internal scarring and shape issues from their Breast Augmentation, it is important for the patient and consulting surgeon to identify how the surgery was originally performed, and the style and volume of implants that were used in the original surgery. Records of the original surgery may be requested to insure that subtle details are not overlooked, when they may impact the secondary surgical intervention.

A breast lift may be necessary in the correction of secondary breast augmentation problems, and since most patients prefer to have their existing implants replaced at the same time, the thought of any new scars may be disquieting. The common approach to secondary breast augmentation requiring a major lift involves a Lollipop or T pattern scar. For lesser degrees of breast sag in the presence of existing implants, many surgeons are incorporating a crescent skin excision, or donut skin excision to provide some skin tightening. By themselves these procedures are used when the nipple needs no more that 1-2 cm of elevation to bring things into better alignment. As the nipple elevation needs to be raised 3-4 cm, some surgeons may perform a more periareolar skin removal and insert a permanent blocking suture to keep the areola from stretching.

When the nipple needs to be raised more than 4 cm, most surgeons recommend a vertical breast lift (Lollipop scar) which leaves a vertical breast scar beneath the areola, or a standard Wise lift leaving an anchor type scar (T scar) down and across the under surface of the breast. Even when a surgeon performs some measures to suspend the breast by creating an internal bra, practically all surgeons use a vertical or T scar for the skin repair component of a lift or reduction. A laser or standard scalpel may be used to create the skin brassiere to tuck inside the breast, but patients are concerned about the amount of scar that is present on the skin, especially when they originally underwent breast augmentation with no other than a tiny skin scar. The idea that to lift the breasts requires the surgeon to add scars to the skin may not be acceptable to all patients.

This Practice has been applying the periareolar purse string breast lift for use in all patients requiring secondary surgery for breast augmentation where a breast lift is required. The nipples can be raised 4 to 9 cm with this method, and it has been used since 1992. While some stretch of the areolae may occur with any purse string periareolar approach, the overall patient satisfaction has been excellent since no other scars were used to lift the breasts. For patients requiring nipple elevation of 1 to 3 cm, this Practice performs a modified Breast Augmentation alone, where no lifting scars, crescent, scars, or donut scars are used. This procedure has been termed a dual-plane breast augmentation or partial over and partial under breast augmentation and can be used in cases of mild ptosis, glandular ptosis, pseudoptosis, and selected cases of moderate ptosis. (SEE BREAST LIFT; CLASSIFICATION OF PTOSIS)

Historically, the surgical treatment for problems related to silicone gel implants has been a benefit offered by some insurance companies, however, in recent years many patients are excluded from coverage for any breast implant-related issues. In selected cases some insurance Payers may permit bilateral implant removal of old silicone gel implants alone, but will decline to offer benefits for any treatment of scar tissue or necessary breast lifting. A number of patients present to our Practice who may have been denied coverage for problems related to breast implants and do not meet the stringent insurance benefit requirements. The use of reduced scar methods for both breast lift and reduction is not new, and fundamental techniques were developed over 30 years ago, but only now are they becoming popular as plastic surgeons gain familiarity with the more exacting technical demands of these procedures. For the prospective patient who returns for secondary breast implant surgery, it may be comforting to know that a breast lift performed simultaneously, may be accomplished with a purse string circular areolar skin approach with no other scarring.