Complications Requiring Breast Revision Surgery
“Breast Implant Malposition”
Implant malposition is defined as a breast implant that is sitting on the patient’s chest wall in the wrong location. The implant can either be too high or too low, the implants can be too wide (or far apart), or too close together.
The original operating surgeon placing the implants in the wrong location almost always causes the problems. Breast implants don’t usually move on their own unless the patient develops a capsular contracture, or tight scar tissue, around the implant. This scar tissue would cause the implant to move up vertically on the chest. There are many causes for breast implant malposition. The ones we see most commonly in our practice are that the original surgeon did not taken the time, or have the expertise, to locate the implants precisely on the patient’s chest. This normally results in one or both implants that are too high or too low. If only one implant is in the wrong position the breasts look lopsided, which is frequently the situation.
The ideal location for a perfectly placed breast implant is to center the implant directly beneath the center of the nipple in non-drooping breasts. When the implant is placed on the top of the muscle, the lower edge of the implant should be placed at the breast fold, or crease, under the breast. Even if the distance from the nipple to the crease is short, the weight of the implant will lengthen this distance over time. Rarely, the surgeon may need to lower this crease slightly to center the implant at the time of the original operation, but this is hardly ever necessary. If a surgeon does not take the time to locate the breast fold precisely, it can result in an implant location this is either too high or too low. A good surgeon will mark the breast fold exactly where it should be with the patient in the standing position before the patient is taken to the operating room. Some surgeons will try to estimate and mark the breast crease location after the patient is lying down and asleep. This never works properly since the patient must be standing in order to accurately judge the proper location of the existing breast tissue and the breast crease.
To properly reposition an implant on top of the muscle that is too high or too low requires additional corrective surgery. The surgeon can lower a pocket that is too high to match the other side by surgically opening the pocket slightly more. If the pocket is too low, the surgeon can place stitches at the bottom of the pocket to close it and match the opposite side.
The ideal location for implants that are placed under the muscle is slightly different. Our practice universally sees patients from other surgeons with implants under the muscle that ride too high. This is because in order to get the implant properly placed at the breast crease, the surgeon must cut, or detach, the small slips of the breast muscle that are attached to the 5th and 6th ribs. This procedure typically adds 20 to 30 minutes to the operation and some surgeons are reluctant to spend the additional time to perform this extra step. If this muscle detachment is not done the implants will invariably ride too high. The muscle is in effect holding the implant up permanently, almost like an internal bra. This can be corrected by having the patient wear an elastic band above the top part of the breast pushing the implants lower, together with the use of muscle relaxant medication over a 3 to 6 month period in an attempt to stretch the muscle slips. This non-surgical approach works about 25% of the time, with the majority of cases requiring additional surgery to detach the uncut muscle fibers at the 5th and 6th rib to reposition the implant lower.
Sometimes one will see patients where the implants are too wide apart. This is usually caused when implants are placed under the muscle and the patient’s breastbone is wide to begin with. There is a tendency for the muscles to push the implants to the side in the first 6 months after surgery, but the muscle will eventually stretch out and more cleavage will develop, providing the original surgeon did not over dissect the breast implant pockets too wide. This can sometimes be corrected by placing stitches at the outside edges of the breast implant pockets to close them down and push the implants back towards the center for more cleavage. Another viable option is to move the implants to a position on top of the muscle for better appearance and more cleavage. This may increase the appearance of implant rippling, which can be seen through the skin in very thin patients.
Rarely, we see patients with implants too close together. This problem is uniformly caused by over dissecting the pocket too close to the middle of the breastbone with the implants on top of the muscle. It can also be caused by accidentally cutting the attachment of the breast muscle at the breastbone when the implants are under the breast muscle. This is a very difficult problem to fix and most of the time corrective surgery can result in some improvement, but not a perfect repair.
As you can see from our discussion, implant placement is of paramount importance in achieving as close to a perfect result as possible. It requires a surgeon to take the proper approach to planning, marking and performing the operation. Although breast augmentation is an extremely popular operation, it requires a skilled surgeon with a lot of experience to get it right. If you are dissatisfied with the positioning of your breast implants for any reason, give us a call. There is a good chance that we can help you.
Please contact our office if you are from outside the Southern California area for a preliminary telephone conversation with Dr. Moser personally to ascertain if an in-person consultation would be helpful to you.