Stuart. A. Linder, M.D., F.A.C.S. is a Beverly Hills plastic and reconstructive surgeon specializing in breast augmentation, liposuction, tummy tuck, and more.
Dr. Linder is certified by the American Society of Plastic and Reconstructive Surgeons and is a diplomate of the American Board of Plastic Surgery (ABPS).
*All images are models
Anatomical implants are not recommended.
Oftentimes they are positioned correctly in the operating room, but will become malpositioned after the surgery. Anatomical implants come in saline, silicone and gummy bear round implants which can increase the odds of having a rotational deformity. Even as little as 5º shift in the implant can lead to a misshapen breast.
Any of these problems can lead to a double bubble deformity, bottoming out of the implant or rotational problems.
Bottoming out can occur through technical surgical problems or overtime.
Correction of bottoming out can be difficult, especially in patients who have had multiple revisions or reconstruction. In order to repair bottoming out, it may require suturing the inframammary fold capsule upward, strips of capsule can be taken and the capsule can then be plicated superiorly.
Larger implants may lead to bottoming out more quickly.
Capsular contractures are one of the most common causes of patients requiring breast revision surgery.
The capsule is formed with three elements - collagen, fibroblast and blood vessels. The capsular contracture may be associated with micro contamination and staphylococcus aures or staphylococcus epidermis. Removal of the capsule often will occur with the replacement of the implant concurrently. Patients with Baker IV capsular contracture may require open capsulectomy and circumferential open capsulotomy.
A capsulectomy is removal of the scar tissue around the implant, either above or below the muscle. A capsulotomy is simply circumferential release of the capsule, allowing more space and volume for the implant to occupy, reducing the pincushioning effect of the constriction. All capsule specimen tissue should be sent to Pathology for diagnostic purposes in order to investigate possible cancer. Patients who have had capsular contracture are at a higher rate for recurrent capsular contracture, both with silicone and saline implants. Silicone implants have a higher incidence of capsular contracture than saline due to micro porous silicone leakage and calcification.
|Grade I||Grade II||Grade III||Grade IV|
|A soft capsule around the implant without scar tissue or visible distortion||Palpable hardening around the implant||Able to be felt and visible distortion of the implant||Palpable, visible distortion, with hardness and coldness to the breast with a deformity.|
Double bubble deformity occurs when the implant has risen and the skin now over-drapes the breast.
Correction requires three elements:
This will allow for complete correction of a double-bubble deformity. Double bubbles are often associated with severe encapsulation, most often Baker III or Baker IV capsular contractures. There is deformity of the implant with malpositioning of the implant.
The transaxillary approach may lead to inaccurate release of the parasternal and the inframammary attachment of the pectoralis major muscle which automatically sets you up for a pincushioning effect of superior retro positioning of the implant right from the start and a double-bubble deformity.
Our practice sees a lot of issues with malpositioning of their implants. These surgeries in general require either capsulectomies, capsulotomies or capsulorrhaphies with retightening of the capsule internally in order to reshape the pocket. This may require an AlloDerm or a Strattice Graft material if there is an inadequate amount of thinned out capsule.
Cleavage is often a problem with patients who have undergone surgery to transaxillary and transumbilical approach. Without precise release of the parasternal muscles or over-resection of the lateral breast pocket, the implants may be laterally displaced, patients present desiring cleavage and therefore the implants are changed to high profile and the capsule laterally may need to be tightened.
Ruptured implants are extremely common as Dr. Stuart Linder specializes in breast revision procedures.
Any patient with a ruptured implant should undergo surgery as soon as possible, as scar tissue contracture will continue and can progressively constrict the entire pocket with increased scar tissue in order to close the space.
We recommend our patients have surgery within 14 days of detection.
|MRI Required||How To Detect||Average Implant Lifespan||FDA Approved|
|Saline||No||Read More||10 Years||Yes|
|Silicone||Yes||Read More||10-12 Years||Yes|
|Polyurethane||Yes||Read More||No Longer Used||No|
Size change is dependant upon the volume. High volume saline implants are tapered implants that will give you more AP projection and volume and less lateral fullness which is very, very useful for patients of all ages, especially women in their 40s and 50s.
These patients often may have been ectomorphic in build with thick breast tissue and muscle and therefore they were limited as to how large they can go on the original augmentation; however, after stretching out over one to two years, tissue expansion is allowed for now more occupied space and a larger implant can now be placed safely.
Implant exchange is associated with patients desiring larger or smaller volume implants. As patients age into their late 40s and 50s, they often desire smaller implants in order to feel less heavy and matronly. Saline exchange or silicone exchange may require a secondary procedure with the skin in order to tighten it if there is significant volume and skin laxity has occurred.
Concurrent implant exchange and mastopexy is a very frequent operation in my surgical practice. Patients may desire to change saline implants to silicone of silicone implants to saline. This is user-friendly and also depends upon the amount of breast tissue that the woman has to start with.
Symmastia is one of the most difficult problems to correct.
It is when the implant is crossed over the sternum. This is usually associated with a technical error of the original surgeon. The midline should never be crossed in any patient. Symmastia repair may require capsulorrhaphies and/or inlay grafting of Strattice or AlloDerm. Using a high profile saline and a spacer which narrows the implant diameter and opening the lateral pocket, may also be useful for reduction of symmastia.
The low profile implants are the most difficult to use with symmastia due to the wide diameter and changing to high profile saline and silicone will help to reduce the effect of symmastia.
Breast revision costs will vary per patient.
This includes surgeon’s fee, operating room fees, implant cost and anesthesia fees. The surgeon fee can include cosmetic and reconstructive revisions, and may be covered by insurance.
*Final cost will be determined by your plastic surgeon
|Anatomical||Bottoming Out||Capsular Contracture||Double Bubble Deformity||Positioning Issues||Size Change||Symmastia||Ruptured Implants|
|Rarely||Rarely||Read More||Read more||Rarely||Never||Rarely||Usually|
*This differs per policy and state. Consult with your surgeon.
Breast revisions should be performed under general anesthesia with a board certified anesthesiologist.
All anesthesia is performed by Dr. Charles Hoffman.
Laryngeal mask airways can be used in the majority of the patients. However, those who have a history of reflux or gastroesophageal disease are usually better candidates for endotracheal tube intubation. This should be discussed with your Board Certified Anesthesiologist.
|Preoperative||Patient is started on an intervenous antibiotic (Ancef, Cipro and Vancomycin).|
|Surgery||A typical revision surgery takes between 90 - 120 minutes.|
|Recovery Room||At least one hour. This is a requirement of federal law in Medicare.|
|After Surgery||Patient is sent home with a Bias wrap and gauze in place. No heavy lifting or raising the arm above the shoulder for three weeks.|
|All dressings are removed and replaced with a Linder Bra.|
(up to Day 14)
|Patient returns to work depending upon the extent of the revision.|
|Dressings are then changed two to three times a day.
|Patient returns for suture removal.|
|Position of implant evaluated.|
|6 - 8 Weeks||Resuming regular exercise usually occurs.|
|10 - 16 Weeks||Photographs of postoperative results.|
|Continued Treatment||Incision sites are often treated with Vitamin E or Bio corneum silicone gel spray. In order to reduce scarring use twice a day for three to six months.|