Breast Revision with ADM or Mesh
Augmentation Revision encompasses a wide variety of things from relatively simple things to very complex. The most common reason for revision breast augmentation is capsular contracture or an apparent hardening of the breast implant due to scar tissue developing and tightening around the breast implant. Another common reason for revision breast augmentation is implant malposition which is when one or both implants appear to be positioned too high, too low, too close together or too far apart. Less common reasons for revision include a personal decision for a change in size, sometimes bigger and sometimes smaller. Sometimes the breast itself has aged or drooped such that it is the breast itself than needs some surgical help to correct the signs of aging. Although modern breast implants are FDA approved, well made, and very durable, they will not necessarily last forever and will eventually wear out and need replacement or just removal. The risk of implant failure varies with the exact device and the lifestyle of the women. As a general rule of thumb, at 10 years, the risk of an implant having ruptured is about 10%
The generally most recommended surgery for capsular contracture is a “site change.” “Site change” can include several different options. One common option includes a capsulectomy where most or all of the scar tissue (“capsule”) is removed and generally a new implant is then placed in this new virginal space but same anatomical plane either subglandular or subpectoral. A related option is, after the capsulectomy, to place a new implant in a new virginal space but in a different anatomical plane, thus switching from subglandular to subpectoral or, visa versa, subpectoral to subglandular. In many cases, these operations may include the addition of a piece of lining material known as “acellular dermal matrix (ADM)” which many surgeons believe helps prevent the recurrence of capsular contracture. A very similar option is known as the “Neosubpectoral,” “Neopectoral,” or “Neopocket.” It follows the same principles as a capsulectomy and site change, but instead of removing the capsule, the old capsule space is closed off after the implant is removed and a new space is created from scratch in one new plane or another, most commonly in a new subpectoral (“neosubpectoral”) space with or without ADM.
Malpositions are generally treated somewhat differently and usually do not require a capsulectomy but rather do require a pocket repair which may mean a “capsulotomy” where the implant space is opened on one or more sides, a “capsulorrhaphy” where the implant space is sutured or sewn to close off one or more sides, a neopocket technique where the old space is closed off completely and a new better shaped space is created in front of the old space, or a capsulorrhaphy/neopocket technique reinforced with “acellular dermal matrix (ADM).” In correcting implant malpositions, the existing implant may be reused and may not necessarily need to be replaced with a new implant.
Ptosis describes the degree to which the breast has drooped. In many cases, as women age, their breast will droop such that the skin and nipple need to be lifted and rearranged to restore a more youthful appearance. This may be done as an isolated procedure or in conjunction with another type of revision.
Revision surgery for size change, implant removal or replacement either electively or for rupture may be very simple, or more complicated and include some aspects of capsulectomy, capasulorrhaphy, neopocket, and ADM surgery depending on the circumstances.
It is especially important when contemplating revision breast implant surgery to find a highly skilled plastic surgeon with demonstrated experience in revisions because the risk of needing a 2nd revision is generally twice as high as needing a 1st revision, a testament to the difficulty of correcting implant-related problems as compared to a primary breast augmentation.
The risk of having revision surgery after a breast augmentation is roughly 20% at 10 years. Many of the reasons for revision are simple and unrelated directly to the implant, for example a simple size change either bigger or smaller. But in some other circumstances, a revision requires some sort of repair work either to replace or reinforce tissues.
In the case of capsular contracture, the existing implant scar and space is either removed or closed off and a new space is created to receive the implant. At the time of this surgery, the new space is raw and unlined by any scar tissue. The earlier practice was to allow a new and hopefully “friendlier” scar- capsule to form, but more recently another option has gained popularity, and that is lining the new space in whole or in part with an acellular tissue dermal graft known as “Acellular Dermal Matrix” or “ADM.” The principle here is similar to that in dealing with a thermal skin burn or dealing with bad scarring after a burn. The “ADM” allows the creation of a healed wound with minimal scarring or scar capsule in the case of breast implants. The published data on this procedure is very encouraging with correction of capsular contracture with the help of “ADM” reported occurring in well over 90% of cases.
Ironically, Acellular Dermal Matrices (ADM) have also been shown to be helpful in reinforcing weak tissues. In cases of implant malposition, tissue thinning, “bottoming out” (stretch deformities), ADM can be used to reinforce fold repairs (capsulorrhaphies), site changes from subglandular to subpectoral (“dual-plane conversions”), mastopexies, and site changes from subpectoral to subglandular for excess animation deformities. In each of these situation, the ADM reinforces a repair or reinforces the soft tissue cover with either a strip of ADM in the case of a fold repair, or a sheet of ADM in the case of a site change or mastopexy.
Whereas ADM is preferred by many experienced plastic surgeons when dealing with capsular contracture, there is some interest in using synthetic mesh for some types of reinforcement procedures where the creation of scar by using mesh may not be a negative.