Breast implant removal with smaller replacement can pose some challenges such as risk of sagging appearance and poor breast contour, although with close attention to details great results can be achieved.
Recently, leading Los Angeles plastic surgeon Dr. Tarick Smiley has performed a surgery on a woman with 500 cc silicone implants who wanted them replaced with 270 cc, which could slash her breast size by almost half.
The patient asked for breast implant removal immediately followed by replacement. But since the new implants were significantly smaller than the old ones, a simultaneous breast lift was performed to maintain natural breast contour.
Due to the significant downsize, she was deemed as a good candidate for a simultaneous breast lift. Without this procedure, her implants would settle too low, resulting in a drooping appearance and deflated-looking upper breast pole.
To remove the old implants along with their scar capsule, Dr. Smiley created a small incision within the breast crease (submammary fold), which would result in a well-concealed scar. He then replaced them with a new pair of smaller implants.
Next, he performed a standard breast lift in which the incision pattern ran around the areola, which was extended downward towards the crease and then across the base of the breast. This would result in an inverted T or anchor-shaped scar that is expected to blend into the background 1-2 years postop.
For long-lasting effects, breast lift should not just be about skin tightening and resection. After all, its elasticity makes it susceptible to the effects of gravity and aging. Hence, the celebrity plastic surgeon creates a more resilient support by remodeling the deeper tissue.
The use of “deep tissue work,” according to Dr. Smiley, also allows the surgeons to elevate some of the tissue of the lower breast pole, resulting in additional upper pole fullness. According to studies, the most preferred breast shape has a 45:55 upper to lower pole ratio (resembling a teardrop shape).
To further promote youthful and natural-looking results, the new position of the nipples should be horizontally and vertically aligned with each other.
Furthermore, tightening the deeper tissue allows the skin to receive no or very minimal tension, which is the key to good healing and “nice looking scars,” says Dr. Smiley.
Revision tummy tuck is generally more complex than the initial surgery due to the presence of old incision lines and scar tissue. Oftentimes, the patients also have some type of navel deformity, contour asymmetry, and residual excess skin, says leading Beverly Hills plastic surgeon Dr. Tarick Smiley.
Dr. Smiley has recently posted a series of Snapchat videos to demonstrate revision tummy tuck performed on a male patient.
A few years ago the patient underwent tummy tuck performed by a different surgeon. But instead of achieving a more masculine physique, the surgery left him with unnatural-looking navel (too big and round), visible asymmetry along his flanks, and high-riding and indented scars.
Aside from revision tummy tuck, the patient also asked for a simultaneous breast reduction to make his chest area congruent with the abdomen.
To conceal the high-riding tummy tuck scar beneath the patient’s underwear, Dr. Smiley created a new incision line (hip to hip) that was positioned very low that it settled within the groin and pubic hairline.
Through the new incision placement, he was also able to eliminate the appearance of indented scar by removing the residual loose skin. Furthermore, he removed more skin along the right flank to eliminate the contour irregularity.
Meanwhile, the celebrity plastic surgeon also performed navel repair, particularly with the intent to reduce its size and change its shape. He said that a natural-looking belly button has a more vertically oriented contour, as opposed to having a perfectly circular shape.
During navel repair, he placed the incision inside the belly button’s rim so the scar will remain imperceptible.
Afterwards, all the incisions were closed by multiple rows of stitches to promote the best scar possible. The skin, meanwhile, was not picked up by any suture and instead a surgical tape held its edges together to reduce superficial tension.
“The key to faded and favorable scar is to eliminate most of the tension on the skin,” says Dr. Smiley.
Dr. Smiley also injected Exparel directly into the abdominal muscle; this is a long-acting numbing medication that works for up to four days, thus allowing the patient to avoid or at least limit his use of narcotic pain relief.
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.