Revisional Breast Surgery in San Francisco Bay Area, Oakland and Walnut Creek
Approximately 50% of women will request revision breast surgery at some point after breast augmentation and even a greater number after breast reconstruction.
Why is this? Clearly scar tissue around the implant, called a ‘capsular contracture,’ is the most important cause. Other common causes include, implant mal-position, breast and/or nipple/areola asymmetry with or without size discrepancy, breast pain, rippling, desire for greater or lesser volume, replacement of an aged implant and anxiety regarding potential side effects including constitutional ‘disease’ with implantation.
Breast Implant Replacement
Implant replacement is recommended by the FDA every 10 yrs after silicone gel augmentation or reconstruction. The reason for this is that there is insufficient data to support that the newest so called ‘gummy bear’ or ‘cohesive gel’ implants will not rupture over a lifetime. Older data suggests that after 10 years, the shell, which holds the silicone, becomes more prone to fracture.
Capsular contracture is thought to have at least 2 important causes: the presence of skin bacteria with a bio-film over the implant and the relative lack of vascularity to the tissue surrounding the implant. Vascularisation is necessary to sterilize the surface , in a biological sense, once bacterial colonization occurs and to allow adherence to the surrounding tissue. Previous literature suggested that the use of textured implants, which supports vascular in-growth, results in lower rates of capsular contracture. Almost all aspects of implantation are controversial, regarding exactly what leads to capsular contracture: the irrigation fluids, with or without betadine iodine and / or antibiotic irrigation, the use of a ‘no touch technique’, the placement of a drain and smooth versus textured implants. However, there is no question that implantation within 6 months of pregnancy holds a higher risk of capsular contracture and is also associated with milk discharge after implantation.
Biologic materials, called ‘dermal substitutes (DS)’, have been in clinical use since approximately 2007 to provide an additional coverage over the implant during breast reconstruction. These sheets of dermis provide a better contour to the outside, with reduced presence of rippling, as well as reduced extrusion of the implants particularly when the skin flaps are thin and tight following mastectomy. The very important incidental finding is that the rate of capsular contracture following placement of a breast expander and or implant and following removal of a symptomatic capsule is significantly reduced if the expander /implant is covered by a dermal substitute. Implicit to this, is the need to maintain adequate broad spectrum antibiotic coverage in the peri-operative period in order to maintain an environment in which the bacteria are not allowed to continue to colonize the implant pocket during the period of time needed to incorporate the dermal layer within the body by vascular in-growth.
The feature of reduced capsular contracture rates with a DS wrap is even more evident in women who undergo irradiation before, during and after implantation including the use of a 2 stage: expander then implant. As a result of this finding, the doctrine ‘do not implant an irradiated chest wall’ no longer applies, providing that the expander/implant has a DS wrap.
DSs impede capsular contracture, add structural support, smooth surface contour and protect sub-surface layer from extrusion. Because of these 4 features, dermal substitutes have gained popularity, rapidly and world-wide, not only for breast reconstruction but also for revision breast augmentation.
Implant Repositioning
Internal mastopexy of the implant pocket is used to correct implant mal-position: for example if the implants are too close together: termed ‘symmastia’, too low or ‘bottomed out’ or too lateral and lack of medial cleavage. Nipple mal-position is often related to the implant mal-position. It follows that by correcting the implant position, the nipple position can also be corrected. Implant mal-position traditionally has utilized sutures between the front and back of the capsule to narrow the pocket in the desired size and shape. However, long-term results are often disappointing, since the sutures may fail and/or the pocket simply widens again. The reinforcement of the pocket by suturing a crescent shaped sheet of DS on the inner surface of the internal mastopexy adds considerable strength to the repair and has significantly improved the success of internal mastopexy. Because of this, the need to create a so-called ‘neo-implantation pocket’, that is to make a new pocket over the old one or remove the old one and then suture the 2 raw surfaces around the previous capsule is usually not necessary.
DS’s can be be divided into 3 groups:
- Human Acellular Dermis: Alloderm ( LifeCell ), Allomax ( Davol ) and Flex AD ( Ethicon )
- Porcine Acellular Dermis: Strattice ( LifeCell) , Permacol ( Covidien ), Surgimend ( TEI Biosciences ), Collamend ( Davol ), XenMatrix ( Brennon Medical )
- Porcine Small Intestine Submucosa: Surgisis ( Cook medical ) and FortaGen ( Organogenesis )
Each product may have subtle features favoring or not favoring it’s clinical application.
Cross-linking has been purported to favor resistance to native collagenase degradation of a DS, which in term leads to continued strength. On the other hand, non cross-linking favors stretch and early vascular ingrowth, which favors early incorporation and is helpful in a relatively poorly vascularized bed or where wound colonisation is in question, such as Alloderm. There are specific individual features for each type DS regarding: transportation, i.e. Alloderm, must be frozen, the relative inelasticity and initial strong support such as Strattice and Allomax, long term strength such as Permacol, which is cross-linked versus Xenmatrix which is not cross-linked. Other technical differences include the need to hydrate such as Alloderm, Allomax and Collamend versus no hydration such as Flex HD and Permacol.
Implant Replacement Cost
Finally, there is the issue of cost. Alloderm is the most expensive of the DS products. Typically, insurance carriers will pay for the use of a DS during breast reconstruction. However, in a strict fee for service setting, such as independent out-patient surgery center, the cost must be taken from the pre-set facility fee and typically this is not affordable. It is therefore usual that DS’s are placed in a hospital setting where the individual product can be charged to the insurance carrier in addition to the other facility fees.
Visit our Revisional Breast Surgery Gallery for more before and after images.
