With the recent studies from the FDA in June 2011, findings indicated that women need to replace their saline and silicone implants on the average between 8 and 10 years. Also, there are risks associated with rupture and scar tissue contracture over time. These are specific concepts that we describe to the patients during the consultation and during the preoperative visits. It is important to remember that saline and silicone implants are not lifetime devices, that they will require implant replacement, most notably for rupture of the silicone shell or deflation of a saline implant or hardening associated with scar tissue, referred to as a “capsular contracture.” Saline implants can be diagnosed to rupture clinically as the implant will deflate and the breast will become smaller in size over a relatively short period of time (sometimes 4 to 6 weeks or shorter). Silicone implants on the other hand may undergo a silent rupture in which the shell of the implant may be ruptured or torn with a slow leak of the gel from the shell from within the implant, but this is undetectable until performing an MRI or within the operating room during specific observation of the implant removal.
Patients should be instructed to have MRIs at least every two to three years in order to evaluate the rupture integrity of the silicone gel shell, as well as see their Board Certified Plastic Surgeon annually for an evaluation for scar tissue contracture.
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BEVERLY HILLS PLASTIC SURGERY
Patients who undergo abdominoplasty or panniculectomy procedures should preoperatively be instructed on several precautions in order to prevent undue complications and risks. With any surgery there are risks of bleeding and infection. Bleeding is the most common complication after an abdominoplasty or tummy tuck. This can be greatly reduced by not exerting increased pressure of the abdominal wall thereby not straining the rectus sheath muscles which could lead to suture dehiscence and arterial bleed along the rectus muscle sheath. The outpatients are instructed not to do any heavy lifting or exertion of the abdominal muscles for six weeks postoperatively. They wear an abdominal binder and are instructed also not to take any platelet-inhibiting products, including aspirin, Motrin, Excedrin, or Ibuprofen.
Prevention of infection is the most second common problem of all operations, including abdominoplasty and our patient population is maintained on antibiotics, JP drains are placed and are actively taking fluid out from below the flap, usually between 7 and 10 days. The patients also may not get water on the incision sites until the sutures are finally removed, which may be up to 17 to 21 days. The incision sites are kept dry, Steri-strips are placed in the operating room and are usually removed on day 7 to 10 and the first set of sutures are removed on day 14 with the final set on day 17 to 21. Jackson-Pratt drains are placed in order to reduce seroma formation, a small amount of blood as well as liposuction residual fluid from the tumescent liposuctioning of the iliac crest rolls or hips. Patients are instructed not to return to work until the JP drains are removed. These are not removed until there is at least less than 25 cc per drain, per 24-hour period. At times one drain may be removed at one week while the second may remain in for a few days longer until again there is less than 25 cc per drain. Sutures are never removed presumptuously. We would rather leave them in longer in the subcuticular fashion than take them out too early, which could cause dehiscence of the incision widespread scarring. The patients are also instructed once sutures are removed and there no opening of scabs that they start the Bio Corneum or Kelo-Cote silicone gel spray twice a day for the next three to six months, which may help in reduction of telangiectasia, widespread scarring, keloid or hypertrophic scar formation.
Finally, in general we instruct our patients not to make a final evaluation of the results until at least six months. There is a significant amount of swelling of the abdominal flap, especially the lower abdomen, which can look quite distended and this usually takes at least three months for the swelling to completely resolve. After a six month check, liposuctioning of the lower abdominal flap may be performed in order to smooth it out safely if necessary. Dog-ears may be excised from the hip region. Liposculpturing of the flank region and upper epigastrium can now safely be performed without devascularization of the blood supply to the abdominal flap.
STYLE 45 SILICONE IMPLANTS
The below patient presents with severe bottoming out where the implants have fallen significantly and the height distance from the bottom of the areola to the inframammary fold is greater than 13 cm. The patient is a model and declines to have scars throughout her breasts other than the periareolar incision which she previously had.
Using a style 45, high profile, cohesive silicone Allergen gel implant, we were able to reposition the nipple areolar complex without actually moving the areola by releasing the capsule along the infraclavicular, parasternal and lateral anterior axillary line, replacing the moderate silicone gel implants with a new style 45 cohesive gel implant. This patient has achieved both increased fullness to the upper pole of her breast as well as the nipple areolar complex is now centralized more into the middle of her breast. With certain cases such as this, correction of severe bottoming out can be performed without the use of mastopexies or internal capsulorrhaphies by simply replacing the low or moderate profile saline or silicone implants with the new style 45 cohesive Allergen gel implants.
Right double-bubble left bottoming out
The preop photo shows the patient presenting from Missouri, having undergone three surgeries to correct the severe deformity of her breasts.
The patient presently presents with a double-bubble deformity on the right breast with the implant on the right superiorly retropositioned, as can be seen on her preoperative photograph. She also has a left severe bottoming out with the implant at too low a position. The position of the areolar at 6 o’clock to the inframammary fold measures at 13 cm. This is going to be shortened to 6 cm. In order to reconstruct this woman’s breasts to regain symmetry and a more normal appearance and natural appearance, a left open capsulotomy was performed superiorly. A bottoming out procedure with the inframammary skin removed as well as vertical skin in an inverted-T fashion on her last three attempts from other surgeons in the mid-west, she had a vertical lift performed on the left. However, she never had the inframammary skin removed and therefore severe bottoming out occurred due to inability to address the inframammary fold skin laxity.
On the right breast the implant is superiorly retropositioned as can be seen by the hatch marks on the right upper pole. In the operating room an open capsulectomy was performed, releasing the capsule circumferentially, removing scar tissue along the parasternal and the lateral inframammary fold as well as the infraclavicular region. The implant was now nicely dropped down. Due to her significant asymmetry, a 320 high profile saline implant was placed and filled to 330 on the right with a 350 style 68 high profile Natrelle implant on the left, filled to 380. This allowed for perfect symmetry.
Finally, a right formal mastopexy revision was performed. At this time the right nipple areolar complex needed to be raised with skin removed both vertically and along the inframammary fold.
The postop Day 1 photos are shown, which now shows symmetry of the nipple position, the implant on the right has been lowered and the fold distances are even. We will eventually have future postoperative photos for comparison.
Difficult breast revision surgeries require experienced Board Certified Plastic Surgeons who have dedicated their lives to reconstruction revision of the breast.