Breast revision for capsular contracture requires meticulous procedures to prevent the complication from recurring. The core guideline is to eliminate the bacteria, which are believed to cause the body to react and release a thick biofilm or scar capsule that causes hardness and asymmetry of the breast.
Leading Beverly Hills plastic surgeon Dr. Tarick Smiley has recently demonstrated breast revision for capsular contracture on his Snapchat. The surgery involved a patient with silicone implants she had for eight years; these were implanted by a different doctor.
Dr. Smiley irrigates the implant pocket with strong antibiotic solutions to kill microorganism known to cause low-grade bacteria, which is linked to increased risk of capsular contracture.
The patient’s left breast appeared constricted and “high-riding” due to the thick fibrous scar tissue, while the right side had no such problem. Dr. Smiley said that about 98 percent of capsular contracture affects only one side due to unknown reasons.
Every time an implant—e.g., breast implant and pacemaker—is placed, the body makes a layer of tissue called capsule. Dr. Smiley said this is an auspicious natural process that prevents implant malposition.
He said that the only time that the capsule is considered capsular contracture is when it becomes too copious and “problematic,” leading to hardness of the breast, asymmetry and unnatural contour (narrow and constricted base), and a varying degree of pain and discomfort with arm motion.
The celebrity plastic surgeon cited medical literature suggesting that the risk of capsular contracture in primary breast augmentation is around 5 percent, and may reach as high as 33 percent in revision surgery.
Dr. Smiley said that irrigating the breast pocket with strong antibiotic solution reduces the capsular contracture rate by “killing the microorganism.” According to several studies, low-grade bacteria may cause the copious production of fibrous tissue, but not enough to cause an infection.
To further reduce the capsular contracture rate in primary and revision breast augmentation surgery, Dr. Smiley emphasized the importance of using brand new implants and removing the entire scar capsule, instead of just incising or eliminating some parts.
In addition, Dr. Smiley said that placing the implants beneath the muscle than above this layer (with only the breast tissue enveloping the prostheses) further minimizes the risk of capsular contracture. The theory is that the reduced contact between the implant surface and the tissue known to harbor staph bacteria, and the constant massage provided by the pec muscle preclude the formation of copious scar tissue.
During a secondary liposuction surgery of the same area, plastic surgeons deal with more challenges due to the scar tissue created by the previous surgery.
Scar tissue forms within the fatty layer that has been previously suctioned through a liposuction cannula, a slender steel probe attached to a vacuum pump. Hence, during a revision surgery the area is very “tough,” making it more difficult to move the instrument back and forth.
A secondary liposuction surgery is performed to correct the unsightly rolls and contour irregularities caused by a previous liposuction. Afterwards, the patient receives BBL surgery.
Leading Beverly Hills plastic surgeon Dr. Tarick Smiley has recently posted a series of videos on Snapchat to demonstrate a female patient who underwent secondary liposuction surgery that was shortly followed by Brazilian butt lift or BBL.
In standard liposuction the fats are discarded, but in BBL they are “re-used” in order to improve the volume and contour of the buttocks and hips, thus obviating the need for synthetic implants.
Dr. Smiley said the patient previously had botched liposuction of the back done by another surgeon, leading to the appearance of rolls and contour irregularities.
The celebrity plastic surgeon corrected the botched results by using liposuction microcannula, which has a narrower diameter compared to the standard design. With this technique, he was able to remove small bits of fat, as opposed to large chunks, leading to smoother results.
The use of microcannula also favored the patient because of the internal scar tissue in her back.
To further ensure smooth and natural results, Dr. Smiley preserved a thin layer of fat beneath the skin.
“Liposuction is not about removing all fats. What is more important is to preserve a smooth skin surface, which is only possible when you leave a carpet of fat beneath the skin,” he said in a previous Snapchat video.
Because the patient also requested for BBL and thus required large volume liposuction, Dr. Smiley also used the axilla (armpit area), bra rolls, anterior abdomen, thighs, and knees as donor sites.
The patient also requested for “wider and curvier hips,” Dr. Smiley said he allocated a large portion of the purified fat into the area.
It should be noted that most patients will need 600-900 cc of purified fat (after removing all the impurities such as the oil and blood inadvertently collected during liposuction) to see a noticeable difference. But for more impressive results, some may even need up to 1,200 cc.
The reasons for having a revision breast augmentation can range from the desire for an “upsize” or “downsize,” improvement of the breast shape and symmetry, and to implant-related issues.
Leading Beverly Hills plastic surgeon Dr. Tarick Smiley has recently posted a series of Snapchat video showcasing a patient seeking revision breast augmentation to correct these three aesthetic issues:
The laser reveals the significant asymmetry between her breasts, particularly in terms of her submammary fold placement.
- Asymmetric breast fold. The right breast has its submammary crease settling lower compared to the other side due to implant sagging. Dr. Smiley said repairing the implant pocket during a revision surgery, along with correct implant selection, can solve this problem.
- Lack of upper pole fullness. The bottoming out of the right implant has an inverse effect on the upper breast pole as it now lacks fullness (only 10-15 percent of the total breast volume). Dr. Smiley said the aim is to allocate at least 30 percent volume to this area, resulting in a more natural, youthful appearance.
- Desire for bigger implants. The patient has expressed her desire for bigger implants without resulting in a top-heavy or unnatural look. Smiley said that physical exam is the first and most critical step to ensure that the surgery can achieve such goal.
During breast exam, Dr. Smiley measured the base of the breast and told the patient that her anatomy would only allow implants whose width is not more than 13 cm due to her narrow chest. Going beyond the anatomy, he warned, can lead to a myriad of problems such as uniboob appearance, excessive lateral bulge, implant wrinkling, and other telltale signs of the surgery.
One possible way to create a bigger appearance without resulting in the aforementioned problems is to use high profile implants, which offer the most forward projection—i.e., they stick out more from the chest wall—relative to their [narrow] width.
To further promote natural results, the patient is deemed as a good candidate for silicone breast implants, which are noted for their more natural feel and shape than saline implants.
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.
It is important to note that the latest plastic surgery trends should not supersede patient safety and satisfaction. Therefore, the goal of any prudent plastic surgeon is to enhance one’s appearance based on her “realistic” goals and, of course, within the safe limit.
Dr. Tarick Smiley, who is the medical director of the renowned California Surgical Institute, has explained some of the latest plastic surgery trends in Beverly Hills.
Thanks to recent improvements in fat transfer—allowing most of the grafts to persist long term—buttock augmentation is now more commonly performed with the use of the most natural material available—i.e., the patient’s very own fat.
In 2016, board-certified plastic surgeons performed about 18,000 buttock augmentations via fat transfer, a 26 percent increase from the previous year. The growing popularity of this procedure, also dubbed as Brazilian butt lift, is attributed to curvy celebrities like Kim Kardashian, Jennifer Lopez, and Beyonce Knowles.
- Sayonara to the over-inflated breasts
In the past decade, a good number of breast augmentation patients sought for an over-inflated chest appearance (e.g., DD and E cup). But with more women today following a healthier and more active lifestyle, it is not surprising that they now gravitate towards smaller “improvements.”
With smaller breast implant sizes, the results generally appear more natural and proportionate. In addition, they do not interfere with the patient’s active lifestyle.
“Instead of simply augmenting the breasts, most patients today want something more, but subtle. They desire for a more natural appearance and so they are also focused on improving their breast shape. Therefore, implants are now typically combined with some type of breast lift,” says Dr. Smiley.
In the past, facelift received notoriety due to its unnatural effects—flat cheeks, lateral skin pleating, overly tight face, and weird brow position. However, things have changed when surgeons started recognizing that simultaneous procedures like fat transfer, neck lift, and eyelid lift can make a huge difference.
Dr. Smiley typically combines facelift with fat transfer—a method dubbed as three-dimensional facelift—to achieve a more natural, more youthful result.
To further achieve natural results, Dr. Smiley highlights the importance of the correct vector of pull. In his previous Snapchat video posts, he demonstrates how pulling the skin at a 45 degrees angle can restore the softness of the cheeks (as opposed to making them flat and gaunt) and provide impressive rejuvenating effects.
- Quick fix facial procedures
Some patients, particularly men, deter the idea of surgery and the ensuing recovery and so they resort to Botox, dermal fillers, and Kybella injection (i.e., double chin eliminator).
According to a survey conducted by the American Board of Plastic Surgery, about 7 million Botox injections, and 2.6 million dermal fillers were performed last year alone.
Simply put, one of the latest plastic surgery trends favor non- or minimally invasive methods.