A 37-year-old African American female presented with a ruptured implant. The ruptured implant was a lower profile saline and was about ten years old. During the consultation, we discussed not only removing the implants but also what her goals were after her breast revision surgery. After setting the expectation, we decide to replace the old implants with high profile 425cc saline implants and overfill them to 465cc.
As you can see from the 7-week postop photos, she looks great in her clothing and she is very pleased with her size and shape.
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Becker Breast Implant Removal
Recently, I had the opportunity to surprisingly operate on a patient who had a Becker double lumen ruptured implant. This patient is a 52-year-old middle eastern female status post augmentation mammoplasty silicone gel implants per, with no identifiable records or patient’s accountability as to the type or size of her implants.
Intraoperatively, it was identified to be double lumen bilateral ruptured silicone and outer lumen saline ruptured implants. Please see the photographs showing the ruptured Becker implant. These are very unusual implants that were placed three decades ago. There are very few of them still remaining in women throughout the world and it was a surprise finding in the operating room. This patient desired to have the implants removed completely with explantation without reimplantation and drainage tube placement. She also underwent breast mastopexy lift in order to reconstruct the shape of her breasts after losing a significant portion of her volume.
Becker implants were double lumen implants placed many years ago. They had silicone inner lumen with an external secondary compartment of salt water. The majority of these implants have been removed over the last 15 to 20 years and the few residual that are found require bilateral double lumen implant removal with removal of capsules often with calcification from leakage silicone.
This is a case example of a patient who presents with a ruptured silicone implant who had a breast augmentation only four years ago. She presents with severe Baker IV capsular contracture with a very hardened right breast with severe scar tissue hardening. Interestingly, she denies any incidents of trauma to her breast whatsoever nor heavy workout or exertion. In the operating room, immediately upon opening the incision and entering into the breast pocket through the capsule, loose silicone was identifiable. The posterior portion of the implant was largely torn with loose silicone throughout the pocket.
Patients who undergo silicone implants should simply have MRIs every three years. Often asymptomatic, patients may still have a tear within the shell of the implant that is not obviously identifiable clinically. This patient did have severe scar tissue with a Baker IV capsule which indicated that there may have been some trauma that she however was unaware of, which could have been associated with the posterior rupture of the silicone gel implant. MRIs are very sensitive for ruptured silicone gel implants and should be performed at least every three years per guidelines of the FDA.
HIGH PROFILE IMPLANTS
This is a case study with a patient that I personally performed a breast augmentation 15 years ago on. She has developed a right ruptured implant and some bottoming out over the last15 years. At the time, only low profile implants were available. Low profile 390 cc saline implants were used. Scar tissue was also found in the upper pole of the breast causing inferior displacement of the implants.
The patient desired fuller breasts in order to regain upper polefullness and decrease lateral width. A high profile saline exchange was performed. Notice the postoperative day one result. This shows upper pole fullness, excellent cleavage, and there is no further widening of the bag; however, the nipple areolar complexes are now situated centrally in the breast and the bottoming out has been completely corrected without any form of inferior capsulorraphy or any skin excision. Simple reducing the low profile flat to a high profile saline, opening up the superior capsule through the inframammary approach, has allowed for an excellent result of centralization of the nipple areolar complex and complete abolishment of the bottoming out.
We perform breast augmentations weekly. Both saline and silicone gel implants are used in our Beverly Hills Surgery Center. Interestingly, this is a case example of a silicone gel implant bleed.
The patient underwent augmentation mammoplasty with silicone textured implants under the muscle by a different surgery approximately 13 years ago. Although the MRI does not show specific rupture of the implant and that the shell of the implant is intact, upon removal of the implant there is significant silicone gel bleed. What that simply means is there are micro pores within the shell of the silicone implant that actually bleed small droplets of silicone. Examination of the implant, as can be seen by the photographs, shows this light silicone layer external to the shell. Upon pressing on it with your finger, a small amount of silicone appears to be cohesive and sticky and it appears there are small micro droplets throughout the shell. Silicone gel bleed is the usual process of all silicone implants over time. The silicone gel bleed does increase risk of capsular contracture, calcifications, hardening and scar tissue formation. Silicone gel bleed over time can lead to both intra and extracapsular spread of the silicone, with spread furthermore to lymphatics, including the axillary lymph nodes.
The general message from this blog is that simply because your silicone implants do not show a specific rupture on MRI, does not mean there is not bleed and silicone leakage external to the implants. As a result, I still believe that implants should be replaced every 10 to 15 years in order to reduce the silicone bleed and its consequences, including capsular contracture, calcification, calcified granulomas and scar tissue formation.
This is an excellent case example of a patient who left her saline implant in her chest for over two years. For some reason she declined to have the implant replaced until now that it has become painful. This is an obvious rupture on clinica examination. Mammogram also showed scar tissue contracture with complete deflation of the left saline implant.
I recommend that these implants be replaced within four weeks after a rupture in order to reduce scar tissue contracture that will certainly occur.
In any case, the patient underwent surgery through a previous periareolar incision. The implant was removed. Scar tissue was then completely released and exenterated through an open capsulectomy, releasing scar tissue circumferentially around the pocket and the implant was then reconstructed using a style 68 high profile Natrelle 400 cc saline implant.
Patients with ruptured saline implants simply should have them replaced, no different than a blown out tire on a car, this needs to be replaced as soon as possible in order to reduce scar tissue which will make it more difficult to regain a symmetric appearance in the future.
This case example is of a patient with a 42-year-old ruptured Heyer-Schulte silicone gel implant placed back in the late 1960s. This is a 78-year-old White female who presents with severe capsulitis, mastitis, ruptured silicone implants and symptoms of possible rheumatoid arthritis. She was referred by her rheumatologist for removal of her ruptured silicone implant, implant material with breast mastopexy lift, reconstruction and drainage.
Intraoperative photo of the ruptured implant shows a posterior patch notable on a complete dissolved shell with loose, smooth silicone gelatinous material. The Heyer-Schulte implants were the first United States manufactured saline implants back in 1968. Heyer-Schulte implants initially manufactured the polyurethane silicone gel prosthesis with an internal Y-shape baffle called the Natural Y Prosthesis. Heyer-Schulte later introduced multiple single lumen gel implants in the early 70s. These implants notably had a thinner shell. These implants were removed with complete dissolving of the majority of the shell with calcifications within the capsule and scar tissue formation throughout the breast. The Heyer-Schulte implants have had data on shell thickness and gel characteristics that were not initially available by the company. Dorne reported weights of average silicone gel molecular weight to be 83,500, significantly higher than the modern Silastic II silicone gels of 55,000 molecular weight. It is very rare to find patients with Heyer-Schulte silicone implants. These implants on most patients have been removed and replaced decades ago or the patients are now deceased.
These are the oldest silicone implants in my person practice of 16 years that I have had the chance to remove. The patient is now postoperative three weeks and the implants have been removed with a full breast lift and drains removed. Postoperative photos will be present in a following blog.
The video shows an interesting case with the patient presenting with burning in her right breast. Her implants are approximately 14 years old. They were experimental style 45 smooth 400 cc Allergan gel implants. The patient presents to the office with increasing pain with a sloshy feeling in her right breast. An MRI would have been useful; however, it was obvious on clinical examination that there was complete rupture of the implant and you can feel softening of the right lower pole of the breast with complete collapse of the upper pole. Intraoperatively, notice on the video that the implant is completely dissolved of the shell of the anterior surface and that by pulling the implant out there is a yellowish tint to the silicone associated with increased chronic protein which creates a darker yellowish appearance to the implant.
Ruptured silicone implant surgery should only be performed by Board Certified Plastic and Reconstructive Surgeons with experience of the chest anatomy to maintain good vascular blood supply and reconstruct the breast in a standard that is consistent with the American Board of Plastic and Reconstructive Surgery.
Patients in my practice present with both acute and chronic seromas status post blunt trauma to the chest after a breast augmentation procedure. The seroma is simply a water serous fluid that the body creates after a tear in the capsule. Capsular tear may lead to this fluid accumulation which can differ in size, between medium and small seromas. Small seromas may resolve with a few weeks over time. Moderate to large seromas may however settle for several months and may require surgical intervention with exploration of the breast, evacuation of the seroma, antibiotic irrigation and possible JP drain placement, if necessary, due to inflammation of the pocket. Seromas can be found in any pocket, including breast augmentation, subpectoral or subglandular pockets, or an abdominoplasty cavity in which there is extensive dissection over the abdominal muscles leading to a large free space that can be filled with fluid. The diagnosis of a seroma is normally associated with an enlargement of the breast with fluid shifts within the breast itself. It can be diagnosed either clinically for large and medium size seromas or can be determined by ultrasound for smaller seromas. Seromas should be differentiated from hematomas which are often associated with ecchymosis and staining from hemosiderin deposition of the skin over time. The diagnosis of a seroma is also consistent with blunt trauma, including motor vehicle accidents or whiplash accidents from a seatbelt which leads to a tear of the capsule and serous fluid formation. Seromas that are not drained, over time may lead to capsular contracture with resorption of the serous fluid back into the capsule causing thickening, hardening and scar tissue formation. The treatment options for small seromas can include conservative management, ice compression, antibiotics, aspiration and compression garments, including the Dr. Linder Bra. Medium to large seromas should undergo, under general, exploration with possible drain placement if necessary.
||The video provided shows a patient status post motor vehicle accident with a 700 cc clear straw-colored seroma that was found under exploration of her breast under general anesthesia. Notably, she had scar tissue contracture along the medial breast requiring open periprosthetic capsulectomy. Implant was replaced after copious irrigation with antibiotic irrigant, including gentamicin and Bacitracin and a 7 mm JP drain was placed in order to reduce recurrence of serous fluid. It is controversial when not to place a Jackson-Pratt drain. Patients who have small seromas that do not show any further evidence of fluid accumulation or acute inflammation or bleeding do not always need a drain. Do remember that drains can be a portal for infection, staph, strep, MRSA, E-coli, pseudomonas and other types of bacterium, especially when a prosthetic device such as an implant is found within the breast cavity. Therefore, it is important to weight the risk of a drain with the risk of recurrence of fluid if there is active inflammation.
In this patient specifically due to the scar tissue contracture and acute inflammatory response, JP drains were subsequently placed in the pockets. Seromas are very commonly associated with trauma. Trauma can be as simple as lying on her chest, lying on your side at night during sleep or a heavy workout with a tear in the capsule. It can also be associated with severe blunt trauma, including assault or a motor vehicle accident with seatbelt whiplash.
Board Certified Plastic and Reconstructive Surgeons are able to diagnose and treat these seromas accordingly.
Patient presents recently with a 25-year-old ruptured Silimed silicone implant notable on MRI is extravasation of both intra and extracapsular rupture. Patient presents clinically with painful breast deformity, Baker IV capsular contracture, double-bubble breast deformity with ruptured silicone mastitis.
The video shows the patient’s implant being removed with the silicone material as loose globular amounts of small droplets of silicone rather than a smooth viscous silicone liquid. These implants are 25 years old and are no longer available in America. The Silimed Biocel textured implants in my experience have a high rupture rate. Notice the textured coating of the silicone shell with the calcifications and white plaque shown throughout the shell. Notice half of the implant has lost its integrity and that the free silicone is identifiable throughout the breast. Patients who present with ruptured Biocel silicone textured implants should have them removed. Notice open capsulectomy silicone material exenteration is required and reconstruction with either silicone or saline implants can be performed. These Allied Biocel Silimed textured implants are rare and I only see these a few times a year in my busy revision reconstructive practice due to its rarity.