Breast revision after capsular contracture requires multiple methods to prevent the problem from recurring. Using new implants, irrigating the implant pocket with strong antibiotic solution, and removing the entire scar capsule are the most commonly accepted approach.
Leading Beverly Hills plastic surgeon Dr. Tarick Smiley has recently posted a Snapchat video of a patient with capsular contracture that caused visible breast asymmetry, with the left implant riding higher than ideal due to the scar capsule pushing it too high on the chest wall.
Scar capsule naturally forms around breast implants or any type of artificial prosthesis; it only becomes a problem when it has thickened or calcified, leading to pain, hardness of the tissue, and deformity. Typically, the symptoms arise in the first few months of surgery, although some patients develop them after several years.
Dr. Smiley performed breast revision after capsular contracture with the creation of a small incision around the lower border of the areola, which was the previous incision site and thus additional scar has been avoided. Then, he removed both implants together with the calcified and thick scar capsule.
While some doctors do not remove the entire capsule when doing revision for capsular contracture, Dr. Smiley believes complete removal can significantly reduce its recurrence—just 4 percent versus 15 percent when the capsule remains inside.
Furthermore, removing the entire capsule allows the implants to settle to a more natural position, which of course results in a more natural breast shape and feel.
After removing the entire capsule, Dr. Smiley is seen irrigating the implant pocket with strong antibiotic solution. Studies have suggested that capsular contracture occurs when bacterial contamination around an implant causes the body to over-react and release copious amounts of collagen fiber.
To further reduce capsular contracture recurrence, Dr. Smiley used a pair of new implants, which he propelled into the pocket with the Keller Funnel, a device that closely resembles an icing bag.
The implant is poured from its sterile packaging into the Keller Funnel, which is then squeezed to propel the implant into its pocket. This implantation process is known to reduce the risk of implant contamination and ultimately lower the risk of capsular contracture.
Capsular contracture is also linked to blood (hematoma) that forms around an implant after surgery and so the celebrity plastic surgeon uses meticulous pocket dissection to control bleeding and minimize risk of complication.
Breast implant replacement surgery requires a highly customized approach to achieve the most natural-looking results possible and to deliver the patient’s cosmetic goals, which she must be able to explain in detail.
Leading Inland Empire plastic surgeon Dr. Tarick Smiley has recently posted a series of videos on Snapchat to demonstrate a patient who had saline implant deflation and thus required replacement.
The before photo shows the right breast looking deflated due to saline implant rupture. The after photo, meanwhile, shows the results of new silicone implants combined with internal lift.
The patient’s right breast appeared smaller than the other side due to saline implant leak. Also, she had moderate breast ptosis (sag) that could benefit from internal lift and implant pocket repair.
To remove both saline implants, Dr. Smiley created a small incision right at the lower border of the areola, which was the location of her previous scars.
Dr. Smiley says a good number of his primary and secondary breast augmentations are performed through the peri-areolar incision technique because the scar blends well into the dark-light skin junction.
When the right breast’s saline implant was extracted from its pocket, it was completely deflated. Dr. Smiley says that full deflation takes about four days, causing the affected breast to look smaller than the other side; however, the leak does not cause any harm since the filler material is saline, i.e., salt and water, which is naturally found in the body.
“The saline is simply absorbed by the body and excreted by the kidney,” the celebrity plastic surgeon says in one of the videos.
Both saline implants were replaced by silicone implants, which are filled with a more cohesive filler material. To ensure that they settle “more naturally,” Dr. Smiley performed internal lift and pocket repair.
Pocket repair was mainly performed by tightening its lateral side, allowing the silicone implant to settle to a more natural position and therefore giving the right amount of fullness along her mid cleavage and upper breast pole; this ancillary technique also prevents excessive lateral bulge (i.e., implant displacement).
During the actual implantation, Dr. Smiley used the Keller Funnel technique in which a cone-shaped disposable device was used to propel the silicone implant into the pocket with just one “squeeze.”
Aside from reducing the operative time, the Keller Funnel device is also known to minimize trauma around the wound. To further promote favorable scar—i.e., it is barely visible at the areola’s border—Dr. Smiley closed the incision in several layers without picking up the outermost layer of the skin.
Only the dermis, which is the deeper layer of the skin, was sutured to ensure that the most superficial layer would receive no or very little tension, which is the key to the most favorable scar possible.
Breast augmentation and cleavage enhancement. Can these two cosmetic goals be achieved, or should the patient accept some compromises and limitations?
Leading Beverly Hills plastic surgeon Dr. Tarick Smiley has recently posted photos on Snapchat demonstrating a patient with bony indentations and wider gap between her small breasts.
With the use of a slightly wider breast implant, Dr. Smiley is able to hide the bony indentations along the patient’s sternum.
To “hide the bony indentations and create a “very soft and natural cleavage,” Dr. Smiley said he used a slightly wider breast implant to “fill in the gap and visible dents.” Nonetheless, he made sure that the horizontal measurement of the implant would still “reflect” the patient’s pre-existing soft tissue coverage to prevent rippling and increased palpability.
“A lot of followers asked if I used fat grafting or injecting to hide the bony indentations. I did not. The right implant design is enough to deliver good results for this patient,” he said.
The patient shown in the picture also received a conservatively sized implant, 400 cc, further reducing the risk of rippling, scalloping, and palpability, problems that plagued overlarge breast implants.
The implants were propelled into their pocket through a peri-areolar incision, meaning a small U-shaped scar was positioned at the lower border of the areola. At three months, it is almost undetectable thanks to meticulous wound closure technique in which no tension was put on the skin.
“That’s why you should always respect the skin. The scar is just three months old and is already unnoticeable. It will continue improving up to 18 months,” Dr. Smiley said.
The patient has been deemed a good candidate for the said incision technique because of the stark color contrast between her areola and the surrounding “normal” skin, making it easier to hide the scar.
Dr. Smiley said he follows a “nine point system of breast perfection” to achieve natural and proportionate-looking breasts.
“The nipple should be right in the middle of the breast, at the most projected part, and should lie at least 2 cm above the inframammary crease. Most of the volume should go to the bottom or lower breast pole, while the upper pole should receive a moderate degree of fullness. The lateral bulge, meanwhile, should not account for more than 10 percent of the total volume,” he explained.
The inframammary fold breast augmentation technique places an incision within the “new” breast crease so the scar blends well into the background. About 50 percent of the breast implant surgeries is performed through this method due to its “simplicity” and direct access to soft tissue layers of the chest.
Hence, the risk of asymmetry is perceived to be lower when the inframammary fold breast augmentation is used compared with other techniques.
In spite of the many advantages of this technique it has one major caveat: the visibility of scar.
The use of Keller Funnel allows Dr. Smiley to shorten the incision, leading to more hidden scar within the breast crease.
Nonetheless, leading Beverly Hills plastic surgeon Dr. Tarick Smiley says certain steps can prevent or at least minimize risk of visible scar, with patient selection being the most important variable.
In Dr. Smiley’s recent videos on Snapchat, he demonstrated a patient he deemed to be a suitable candidate for the incision technique: She had mildly droopy breasts, which resulted in deep folds that could make it easier to hide the scar compared to someone without a prominent crease.
Dr. Smiley says breast implants can give the patient “more symmetry and fullness,” particularly when the implants would “reflect” her anatomy and cosmetic goals.
The patient received silicone breast implants known to provide softer results and more natural contour than saline implants.
Silicone implants are filled with silicone gel, while saline implants contain salt water solution and thus they have a strong predisposition to appear globular and firm once inside their pocket. This is particularly true for patients who are thin or small breasted, meaning they have little soft tissue coverage.
Proper marking prior to the placement of incision and pocket creation is the first step to ensure a well-hidden scar. Dr. Smiley marked the pre-existing inframammary fold and placed a short incision (not longer than 3 cm) slightly above the line.
The incision and its resulting scar are expected to remain on the underside bulge of the breast. (Note: In the first two months of recovery, the implants typically ride higher leading to excessive upper pole fullness; however, this rather unnatural appearance almost always corrects itself as the prostheses settle to their more natural location.)
Aside from proper patient selection, the risk of visible scar was further reduced with the use of Keller Funnel, a device that resembles an icing bag that propels the implant into its pocket with just a few successive squeezes. Not only it reduces the scar length, the amount of trauma around the wound edges is minimized as well, further promoting the best scar possible.
Because the patient’s pre-existing right breast was smaller than the other side, Dr. Smiley used a slightly bigger implant size to improve their symmetry.
And lastly, he closed the incisions in several rows, ensuring that the deeper layers received most of the tension while the skin was spared from “excessive pull,” thus further promoting the most hidden scar.
The top heavy look is one of the most recognizable breast implant effects. Hence, patients who want the natural look always take into account their body frame, particularly their upper body dimension, waist-to-hip ratio, and height when selecting their implant size.
In general, the breast implant size range between 300 and 450 cc provides “smaller” augmentation that suits petite women. Also, going the conservative route favors patients with little soft tissue coverage who are prone to rippling, globular shape, and increased palpability particularly when overlarge implants are used.
Conservative-sized implants also suit athletic patients who typically have low body fat percentage that makes them prone to rippling if overlarge saline implants are used.
Due to the inherent strength of modern breast implants, most patients seeking revision surgery nowadays are not concerned with rupture or leak but want an implant exchange to upsize or downsize, as suggested by a recent survey.
Hence, the breast implant size and its “specific” results on each woman is one of the most important topics during consultation. Leading Beverly Hills plastic surgeon Dr. Tarick Smiley says the patient’s candidness—describing her “bust goals” in precise detail—plays a critical role in the success of breast augmentation.
Of course, it is the surgeon’s responsibility to offer his patients all modalities that will improve their discussion. For instance, some doctors offer sizers that are put inside an unpadded bra to give women an idea on how a specific implant size will look on them.
Some doctors also offer three-dimensional imaging to further improve the discussion regarding the implant size and profile, or how much it projects from the chest wall.
Meanwhile, some studies and surveys have attempted to shed light on the ideal breast size in which individual preferences greatly varied. However, most respondents favored medium-sized breasts, namely, C and D cup.
One study has even suggested that medium-sized breasts that are firm and with a 45:55 ratio, which means most of the volume is in the lower pole, with the nipple serving as the delineating mark, as the most preferred breast appearance.
It is important to note that some patients seek breast implants to enhance their shape or correct the deflated-looking upper breast pole without resulting in significant augmentation.
Breast lift and implants is a “combination” surgery to reshape the pendulous breasts and provide additional volume especially in the upper breast pole, which tends to deflate with aging or following weight loss and pregnancy.
Leading Beverly Hills plastic surgeon Dr. Tarick Smiley has recently posted breast lift and implants before and after photos on Snapchat to illustrate its “contouring and volumizing effects.”
During breast lift with implants, Dr. Smiley always completes one breast before proceeding to the other side. The idea is to create a template for the other breast, leading to more symmetric results.
Prior to surgery, the patient shown in the photos had significantly drooping breasts whose areolar complex, which is the ring of pigmented skin around the nipple, settled below the level of the breast crease and were hugely disproportionate.
With the severity of her breast ptosis, or sagging, Dr. Smiley performed the anchor breast lift, which involved a donut-shaped incision around the areola that extended down the midline to the breast crease. Another incision shaped like a crescent was also created along the base.
The anchor breast lift is also referred to as inverted T lift due to the shape of the incision or scar pattern.
The donut-shaped incision around the areola allowed Dr. Smiley to drastically reduce its size. To achieve good symmetry between the two sides, he used a cookie-cutter device to delineate the new smaller areolar complex.
When making the areolar incision, Dr. Smiley says “it is important not to go too deep in order to preserve the blood supply,” and ultimately “minimize the risk of healing problems and delayed recovery.”
Before and after photos of breast lift with implants
During breast lift, Dr. Smiley elevated the tissue of the lower breast pole with the use of internal sutures, and repositioned the areolar complex higher, ensuring that it would lie approximately at the center of the breast mound. Meanwhile, studies have suggested that the ideal nipple position should be above the breast crease, and there must be a 18-21 cm distance between the nipple and the sternal notch, which is the small dip at the base of the throat.
Afterwards, he positioned the implants beneath the pec muscle, instead of placing them above this anatomical layer. This technique, referred to as submuscular implant placement, reduces palpability and risk of rippling and bottoming out due to the additional padding from the muscle.