When implants are placed in a submuscular pocket, sometimes patients have animation deformities of the breasts. The implant can appear to move upward and toward the axilla, and a ridge can sometimes be appreciated at the juncture between the lower muscle border and the breast tissue. This can be the result of over release of the medial muscle fibers along the sternum, or overtime with thin soft tissue coverage. This deformity can be treated by moving the implant into a subglandular pocket, adding an ADM (Acellular Dermal Matrix) such as Strattice® (LifeCell) to the lower pole, releasing the muscle from the gland, or performing a split-muscle technique.
Refers to the situation when an implant descends below the breast inframammary fold. This can happen as a result of over dissection of the implant pocket, or over time as the implant pushes below the fold. In this situation the nipple may be pointing upward, and usually the majority of the implant will fall below the horizontal plane situated at the nipple. Correction of this deformity will require possible exchange for a smaller implant, a capsulorrhaphy (capsule repair), and/or inserting an ADM (Acellular Dermal Matrix) for further support along the lower pole.
The body forms a natural barrier of tissue around all implants. When this barrier gets tight around the implant, then this is called a contracture. Clinically, the breast may be painful and the implant will not move freely in the pocket. When this happens the breast implant tends to sit high on the chest. The current theory is that a subclinical infection may develop over time, perhaps with bacteria migrating through the nipple leading to a biofilm of bacteria, potentially irritating the pocket and causing the contracture. It is thought that blood in the pocket at the time of surgery may exacerbate this situation if it happens early. Treatment often requires removal and exchange of the implants, sometimes including a change in the pocket position from subglandular to submuscular or vice a versa, removal of the capsule, and possibly inserting an ADM (Acellular Dermal Matrix) such as Strattice® (LifeCell).
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Double Bubble Deformity
A double bubble can be the result of several different scenarios, each requiring a different surgical technique to repair it. Common causes of a double bubble include: an implant that is too large for the breast, an implant that sits too high on the chest with the gland “falling off” the implant, a tight breast in the lower pole often seen with tuberous deformities, and from a capsular contracture. Correction of this problem is dependent on the cause. If the implant is too large for the base diameter of the breast, a smaller implant can be used or the lower breast pole can be released by making radial cuts in the gland. If the implant sits too high because of inadequate release of the pectoralis muscle, then the muscle can be released a bit more. If the breast is still “falling off” the implant, then a breast lift may be necessary. If the breast is tuberous and the lower pole is tight then radial cuts along the lower breast pole can potentially improve this situation. If a capsular contracture is causing the double bubble, then a capsule excision may help. Of course, variations of all these techniques may be necessary in certain scenarios.
Lateralization of The Implants
When the pocket becomes too large either from over dissection or over time with expansion, the implants can fall off to the sides when the patient is lying down. Treatment of this deformity can be accomplished by performing a capsulorrhaphy (capsule tightening procedure) along the lateral chest wall. This may include the use of permanent or slowly resorbable sutures, reinforcing part of the capsule to itself, or reinforcing the repair with ADM (Acellular Dermal Matrix) such as Strattice® (LifeCell).
This is almost the opposite to lateralization of the implants. This is when the medial or sternal area of the pocket is either over dissected during surgery or over time stretches. The implant migrates toward the sternum and the cleavage becomes crowded or lost. This is more common with subglandular implant placement. Correction of this deformity can be accomplished by creating a submuscular pocket, or performing a capsulorrhaphy, which can include reinforcing the capsule and/or inserting an ADM (Acellular Dermal Matrix) such as Strattice® (LifeCell).
Visibility of the implant through the skin is often a sign of rippling. This is a result of the thin soft tissue covering the implant most often due to the patient being very thin or having undergone many previous breast surgeries. The goal is to provide better soft tissue coverage over the implant if possible. If the implant is in a subglandular pocket, placing it in a submuscular pocket may help. If the implant is saline filled, sometimes over-filling the implant will remove the ridging of the implant and therefore improve the rippling. Usually the goal is to provide more soft tissue coverage so fat grafting can sometimes be helpful, as well as inserting an ADM (Acellular Dermal Matrix) such as Strattice® (LifeCell) over the implant in the rippling areas.
If you would like more information about New York Plastic Surgeon Dr. Wallach and his success with New York City Revision Breast Augmentation procedures, we hope that you will not hesitate to contact our Manhattan offices at (212) 257-3263 or by mail at 1049 5th Avenue, Suite 2D in New York, NY 10028; or using our contact form to request additional details.
Revision Breast Augmentation Frequently Asked Questions
I have rippling of my implants. What causes this?
Rippling is usually caused by the ability to see the natural folds of the breast implant through soft tissue coverage. It is more common in thin patients with thin soft tissue coverage over the implants. Therefore, rippling occurs more when implants are placed in a subglandular pocket than a submuscular pocket. Because a submuscular implant is not completely submuscular, most implants are palpable along the lower pole along the inframammary fold. Since rippling happens when the soft tissue envelope is thin, there are several potential solutions to the problem. If the implants are in a subglandular pocket, changing the pocket position under the muscle will usually cover them better. If the rippling is in the lower pole and the implants are in a submuscular pocket, then sometimes an acellular dermal matrix (ADM) like Strattice may add more coverage to eliminate the rippling. Some surgeons will also perform fat injection into the soft tissue over the implant to thicken the coverage. Additionally, if the implants used are saline filled, sometimes overfilling them may improve the rippling as well.
My breast implants cause pain. Does this mean I have a capsular contracture?
There are many different reasons why patients can have breast pain, and a capsular contracture is just one of the causes. If the cause is due to a capsular contracture, then performing a capsulectomy with implant exchange should improve the pain associated with the tight capsule.
What is a capsular contracture?
The body forms a natural barrier around any type of implant placed in the body. Commonly, this is a soft layer that surrounds the implant and allows the implant to move around easily in the pocket. When the implant pocket becomes tight due to the capsule constricting, the implant can appear tight in the pocket or lose its more natural appearance. Sometimes pain is associated with the capsular contracture. One popular theory of capsular contracture is related to biofilms, which may lead to a subclinical infection and inflammation causing the contracture to develop.
How does one treat a capsular contracture?
There are several techniques to treat a capsular contracture but general principles include performing a capsulectomy, which is a removal of the capsule, and exchanging the implants. Studies suggest that adding an acellular dermal matrix (ADM) like Strattice may reduce a capsular contracture recurrence.
Should my implants be placed above or below the muscle?
The two most common breast implant pocket positions are either submuscular or subglandular. There is a third pocket position that is considered subfascial. The subglandular pocket placement is a reasonable approach for women with a lot of soft tissue coverage over the implant. The advantage to subglandular placement is often less painful than a submuscular pocket placement. It also avoids animation deformities with pectoralis muscle flexion. However, studies suggest a higher risk of capsular contracture, symmastia, and rippling in this position. The advantage of a submuscular pocket is it provides more soft tissue coverage over the implants, less risk of rippling in the upper pole, and a lower rate of capsular contracture. Still, there is often more discomfort after surgery, and there is a higher risk of animation deformities with pectoralis muscle flexion. Both approaches have similar rates of implant palpability in the lower pole. A subfascial method, in my opinion, does not add any more soft tissue coverage than a subglandular approach, and has similar advantages and disadvantages as the subglandular approach.
What happens if I just remove my implants?
Removing breast implants or explantation results vary. If the patient does not have any significant capsule, then removing the implants is straightforward. If there is a tight painful capsule, often the capsule is removed as well. The breast will respond to the implant removal differently in different patients. This depends upon the ratio of natural breast tissue volume to implant, the quality of the soft tissue, and the extent of the surgery. In other words, the final shape is difficult to predict.
What happens if I want smaller implants because my implants are too big?
An implant exchange can be performed to reduce the overall size of the implants. However, the new implant size will affect what may need to be done to the breast gland or skin envelope. For patients with good quality skin and smaller volume changes, an implant exchange may be all that is necessary. For larger differences in volume, a mastopexy may have to be performed. This can be as little as a circumareola lift, which uses an incision around the border of the areola. If the smaller implant results in significantly looser tissues, then the mastopexy technique required may need to be more extensive. This might require using a lollipop incision or even an inverted T incision to adjust for the larger volume differences.
I am unhappy with the implants that were placed and I want bigger ones. When can I get a revision?
Exchanging implants for larger ones usually can be done about four months after the original surgery. It is best to wait for the swelling to dissipate and for the healing to be completed. Whether or not the patient’s anatomy can tolerate a larger implant needs to be evaluated in person during exam.
I have a double bubble. What causes this?
A double bubble is a breast deformity that occurs for several reasons. The first is when the implant drops below the natural inframammary fold or a lower breast crease. This can occur if the pocket was over dissected or by a natural progression of the implant descending into the pocket through a weak inframammary fold. Another cause may be due to placing too large of an implant for the natural breast diameter. In this case, the breast did not expand over the implant and sat on top of it like “the yolk sitting on top of the white of an egg”.
I have a double bubble. How does this get fixed?
A double bubble is exactly as the term states.The implant creates a ridge-like a bubble and the natural breast fold creates the second bubble or ridge. Correcting a double bubble usually requires fixing the implant pocket. If the implant descended below the breast fold, then recreating the breast fold with sutures (performing a capsulorrhaphy) may be sufficient. Some surgeons will add an acellular dermal matrix (ADM) such as Strattice to reinforce the repaired fold. If the implant was too big for the breast diameter, then either the breast gland needs to be scored to allow it to expand around the implant, or a smaller implant needs to be placed.
I think I have bottoming out of my implants. How does one get this fixed?
Bottoming out of an implant is similar to a double bubble in that the implant pocket has gotten larger and the implant has descended below the natural breast fold. If the gland has expanded over the descended implant, then one might not see a double bubble. To correct this problem, a capsulorrhaphy needs to be performed. The lower breast fold needs to be resuspended with sutures. Sometimes an acellular dermal matrix (ADM) like Strattice is used to reinforce the repair. Often a smaller implant is placed because the pocket itself is made smaller.
My implant seems to move into my armpit. What do I do?
An implant that moves into an armpit suggests that the pocket is too large for the implants. A capsulorrhaphy can be performed to repair the pocket and treat the malpositioned implant. This is typically performed with sutures and sometimes an acellular dermal matrix (ADM) like Strattice is used to reinforce the repair.
My implant shape looks funny. How is it fixed?
Unusual breast implant shapes can occur for several reasons. First, a patient can have a capsular contracture, which can distort the shape of the implant. Furthermore, the pectoralis muscle that is released during a submuscular pocket creation can cause the implant shape to change with flexion. Another cause for an odd shaped implant can be due to an implant rupture.
What is symmastia? And why does this happen?
Symmastia occurs when the sternal chest skin lifts up after breast augmentation and allows the implants to potentially move from one side of the chest to the other. This is more common when the implants are placed in a subglandular pocket and when the surgeon tries to produce more cleavage, resulting in an implant malposition.
I think my implant is moving toward the center of my chest and causing a symmastia. How can this be fixed?
Repairing a symmastia is like treating other forms of implant malposition. Commonly, a capsulorrhaphy has to be performed requiring suturing along the medial or sternal pocket. Some surgeons will add an acellular dermal matrix (ADM) such as Strattice to reinforce the repair. If the implants are subglandular, then changing to a submuscular pocket may be worthwhile.
Dr. Wallach is a board-certified plastic surgeon in New York City who specializes in performing cosmetic procedures of the face, breast and body. As one of the cutting edge experts in the field, Dr. Wallach consults on a regular basis with people in the beauty, media, and publishing worlds.