Breast Implant Revision or Replacement

Dr. Bob Basu: The primary concerns of patients seeking revision surgery, it's so diverse, and I'll give you a couple of examples. Some patients come in wanting to go bigger. They feel they've lost volume after having kids. So they had their first time augmentation before kids, and now they've had kids and they've lost volume. Some of the patients have now not only lost volume, but now they have loose skin and they have rippling. They have the old generation implants or they have the older saline implants so they do want an upgrade.

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Dr. Bob Basu: Our topic today is breast augmentation revision or breast implant replacement. And on this podcast, we answer questions submitted by patients. Our question is from Kathi, who is originally from Pasadena, Texas, but now lives in Austin.

Kathi: Hi Dr. Basu. My name is Kathi. I'm 65 years old, hairdresser. I have had surgery and stuff. So I've had my boobs done, I've had the facelift, brow lift, you name it. I've been thinking about doing a revision on my augmentation. I want this to be my last one at 65. I'd like to know how much this is going to cost, what's the recovery. How many of these kinds of breast surgery have you done? And thank you for answering my question.

Dr. Bob Basu: Well Kathi asks, there's a couple of questions embedded in her question so I'm going to try to unwrap this as best as possible. First, revision surgery, it's not a one size fits all. And when I first visit with a breast implant revision surgery consultation, before I've even done the exam, I tell them that revision surgery can be as simple as an implant exchange to upgrade your implants, it can be more such as an implant exchange with a skin tightening procedure or a breast lift of some form, whether that be a limited scar lift or a full lift mastopexy, but it can be even more complicated and more complex where we need to provide much needed support to the breasts using a technique called an internal bra technique, which I do regularly.

Now, Kathi asked me how many of these breast surgeries, revisional breast surgeries, I do. I would say 50% of all my breast cases, and I do a lot of breast surgery, are revisional procedures. So on a weekly basis, I'm probably performing three to six revisional breast cases on average per week now for the past what 16, 17 years. So based on that experience, and I love doing revision breast surgery, in fact, I co-edited a textbook on cosmetic breast surgery in which several of the chapters were dedicated to different revisional techniques. Every revisional surgery, every patient is unique and it's important to address individual concerns and their history and past surgical history. Some patients may have had multiple breast surgeries in the past, some patients may be looking at their first redo.

The primary concerns of patients seeking revision surgery, it's so diverse, and I'll give you a couple of examples. Some patients come in wanting to go bigger. They feel they've lost volume after having kids. So they had their first time augmentation before kids, and now they've had kids and they've lost volume. Some of the patients have now not only lost volume, but now they have loose skin and they have rippling. They have the old generation implants or they have the older salient implants so they do want an upgrade.

Some patients come in and they feel they're too big now. They want to downsize or they're done with implants and they want to see if they can get a smaller, more petite result that's more proportionate using their own tissue. Some patients come in complaining that their implants are falling to the side or they're just sagging too low and they want to restore upper pole volume. And I'll even see patients that are done with implants, either they're concerned about scar tissue from the implants or some health-related concern with implants, and they just want their implants out. Some patients choose not to have implants. Some patients choose to just restore their breast volume using their own fat using a novel technique of fat transfer for the breast. So what are the primary concerns of revision surgery of patients? Again, it's not a one size fits all.

There are two major categories of implants. There's the old-school saline implants, which are saltwater bag implants that are filled into a silicone gel bag, and there's the new generation silicone gel, also known as gummy bear implants. Now they're both good options, there's pros and cons. We offer both. But I will tell you, and we do a lot of augmentations and implant surgery on a weekly basis, categorizes of what's called an Allergan Black Diamond provider for breast implant, based on our breast implant volumes, which places our implant practice in the top one to two percent of implant practices in the country.

And based on that experience level, I will tell you that although we offer both saline and silicone gel or gummy bear implants, we really are a 99.9% silicone gel or gummy bear implant practice. And here's the reason why, most of my patients are moms or professionals and everyone's different in terms of what they want in terms of size and volume. But the common denominator of my patient population is they want that natural look and feel. And the overwhelming advantage of the smooth silicone gel, gummy bear implants is that, number one, they're softer. I believe compared to the same CC of saline they're lighter, and you don't get the rippling effect that you can get from saline implants. And so therefore my patients gravitate towards what's called the silicone gel, also known as the gummy bear implants.

So around the country, if you talk to the implant manufacturers, and we'll give you a gauge of what's being ordered from industry, there has been a trend towards smaller sizes. Now we're in Houston, Texas. Everything's bigger in Texas. We're not necessarily seeing that as much, but what I am seeing is an increase in patients opting for implant removal, and I think that has to do with those patients that have had textured implants. There's been concerns about this rare condition called Breast Implant Associated ALCL. It is a very, very rare form of lymphoma that's been connected to old textured implants. In fact, textured implants were actually recalled. Now, if you have textured implants, I don't want you to think you have to have those implants removed, but it's important to do monthly self exams, and if you feel something different, you see something different, go see your physician or surgeon.

The other concern with implants is this rare, rare collection of symptoms called Breast Implant Illness. And some patients feel that they're having some health-related issues due to their implants, they want to live life without implants, and that's a personal decision. We do help those patients as well, too.

I have seen an increase in patients wanting breast enlargement using their own tissue, meaning fat transfer. It's a great technique because you're really putting your excess fat to good use. Now patients come in and when they talk to my patient consultants, they think a fat transfer for the breast is basically the same as an implant augmentation but what they don't realize is that fat grafting to the breast, although you're not using an implant, takes longer time to do. Number two, you have to do liposuction of an entire different body part so you're treating another area that has its own associated recovery. And number three, there are inherent limitations of how full you can make your breasts with one session of fat transfer.

So for a patient that has an A cup that wants to get a nice full C or a D cup, one session of fat transfer is not going to do it. And here's the reason why, you can only effectively transfer about say 200, maybe 250 CCs of volume in each breast at a maximum any given session. And the reason why there's that limitation is that if you add more fat, fat's just not going to survive. It'll dissolve away. So there's a minimal amount of fat that we can transfer with a fat that's going to stick around.

And so fat transfer for the breast is a really good option for someone that wants a very conservative augmentation. We're talking about they want to go fuller by about a half cup size, maybe at most a cup size, that's it. But if you're looking for a full augmentation, maybe going from an A cup to C cup or A cup to D, you want to go big or go home, fat transfer is not a good option because you're going to need multiple surgeries and the costs just skyrocket at that point. Whereas you can achieve that result with just a one hour procedure, such as a breast augmentation with an implant.

I would say that a patient that's seeking a very conservative augmentation will be happy with fat transfer for the breast. And number two, remember, you have to have enough fat. Everyone thinks they're great donors, but you have to have enough fat from somewhere else on your body to make it worthwhile. So typically if I had to describe a body type, it's someone that wants a very conservative augmentation that has some voluptuousness, some curves where we can harvest fat. If you're too thin, you're too fit, you are not a candidate for fat transfer for the breast.

So let's step back for a second. The internal bra technique is very different than just an augmentation with a lift. In many of my consults that I have with patients, I ask them, whenever you do an augmentation, you do an augmentation with a lift, or you're doing a lift by itself. What is it that holds up the breast when you're doing these procedures? And the answer to that question is it's your tissue quality. Some patients have great tissue and some patients have really weak tissue. Who has weak tissue? Patients who've lost weight, patients who've had post-pregnancy changes from breastfeeding, or patients that are just born with weak tissue, it's the genetics that they have. So if the tissue is weak, even if you do an augmentation and lift, you're going to get some recurrence of sagging because the tissue is not strong enough to hold up the implant.

So when patients want more upper pole volume, they want that rounded look, they want their cleavage to sit a lot higher. And when they want that and their tissue is weak, it's too weak to give them that result. We have to do something else besides using their tissue to give them the added support. So when patients want that push-up bra look without wearing a bra, that's where the internal bra technique comes into play.

So in the internal bra technique, we're using something else besides the patient's own tissue. That something else that I like to use is a material called GalaFLEX, and I'll get back to that in a second. Other surgeons like to use other materials for support. I use that material to recreate the effect that the cup of a push-up bra does on your breast. It gives you much needed added support to your implant.

Now, my preferred technique for the internal bra technique is to utilize a material called GalaFLEX. It's called a GalaFLEX surgical mesh. Now I tell patients this is not the surgical mesh that you hear about in abdominal hernia surgery or OB/GYN surgery for bladder suspension procedures. That's not what it is. What this is, although it's called a surgical mesh, it is made out of a suture material that's been around for decades and that suture material slowly dissolves over time, we're talking to 18 to 24 months. As that suture material dissolves, your own collagen grows into it, strengthening and providing strength and support. So the GalaFLEX is basically anchored to your chest wall, the bottom edge of the GalaFLEX, and the upper edge of the GalaFLEX is then anchored to your muscle. So I want you to think of it as creating a hammock or a push-up bra effect supporting your implant that's under the muscle. That's how we get that added support.

So in cases of the internal bra technique, we're no longer depending on your skin, which may be weak, may have stretch marks from weight loss, having kids. We're no longer depending on your skin to hold up your breast implant achieving upper pole volume, we're depending on the GalaFLEX. And I can tell you I've been doing internal bra techniques for almost 12, 13 years, I don't have a single recurrence because this technique works. Now I've used different materials in the past. We've evolved our technique, but with GalaFLEX I've had outstanding outcomes for my patients. My patients are very, very happy.

Now, patients need to understand that the internal bra technique is not an augmentation lift. In the internal bra technique, I am re-engineering your breast. I'm oftentimes raising your folds position, actually raising the footprint of your breast on your chest wall, and we're addressing volume with an implant and we're tightening your skin likely with a lift, and we're talking about lateral position, upper pole position. There's a lot of variables that we're managing with the internal bra technique, so this is complex surgery that a lot of surgeons don't do because of the complexity of it. I wrote a chapter on the internal bra technique in my textbook recently, which I like to share with my patients when they come for consultation. And it's a very powerful technique.

So Kathi, what I would tell you is that revision surgery is not one size fits all. You could be as simple as an implant exchange, you could be more complicated and need an internal bra technique. So to answer your question really requires a formal consultation and a physical exam. Number two, it requires you and your surgeon to be on the same page on where you're trying to go and what are your cosmetic goals? And I know it's hard to communicate sometimes those cosmetic goals, so what I encourage patients to do is to their consult, bring me some wish photos, wish pics. You can get those photos from my website. I have hundreds of before and after photos for breast implant surgery, or you can get those photos from a model from Instagram or a magazine. Maybe there's a result that you've seen that you'd love to emulate.

That gives me a really good idea of where you're trying to go so then I can develop a plan to try to get you there as best as possible, or I may need to tell you that we can't get you there. But that's really important to have that discussion before you embark on any revision surgery.

The last thing I wanted to comment on your question was you want this to be absolutely your last breast surgery, and I'm not so sure that is possible because although implants are very, very safe medical devices, no medical device lasts forever. The old saying is that implants need to be revised and replaced every 10 to 15 years, I think that's somewhat of a myth because I have plenty of patients that I have operated on from 16, 17 years ago and they come back for other things like Botox, and they're happy with their breasts still.

Now, typically I prepare patients that you may need a revision surgery in 10 to 15 years, but the real reason for revision surgery is purely cosmetic. So I'm hopeful that you're leading a healthy lifestyle and you're going to be with us for another 30 years. And so will you need a revision surgery after 65? If you opt for implants, you may need a revision surgery to make your breasts look and feel their best, and so I just want to set that expectation that I know you want this to be your last surgery and I understand that, but let's be realistic. No medical device lasts forever. You may need revision surgery in the future.

And so I think the first starting point to determine what the cost would be would be to call and speak to our expert patient consultants who can start walking you through the process in an extensive dialogue about what your challenges and concerns are and where you want to go. And ultimately it requires a consultation to determine what we actually need to do so we can give you the most accurate information.

If you'd like to learn more about revision breast surgery, I encourage you to visit our website. We have hundreds of breast implant before and after cases of my actual private patients who have given consent to share their results on our website, and our website again is basuplasticsurgery.com. And you can also find us on Instagram at Basu Plastic Surgery.

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