The patient is now postoperative day 1 after circumferential open capsulotomy, complete open capsulectomy, complete resection of the medial attachments of the pectoralis major muscle and reconstruction with a style 45, 500 cc Natrelle gel implant.  The patient now has perfect symmetry, elevation has been corrected, the inframammary folds are even and a right areolar reduction has been performed to recreate a symmetric size to the nipple areolar complex.

Below is an example of a patient’s significant pectus carinatum with right posterolateral slanting of her chest wall.  She has undergone augmentation mammoplasty procedure by two different surgeons with an unsatisfactory result.  She has inadequate parasternal cleavage with lateral displacement of the implant, especially along the inferomedial portion of her right chest.  In postoperative photos she underwent open capsulotomy medially with an inferomedial muscle release of the pectoralis major muscle and an inferolateral capsulectomy.  The implants were then replaced from moderate profile to extra high profile style 45, 600 cc gel implant, now creating better fullness of the upper pole with a better cleavage.  The patient has worn compressive garments for six weeks.  The incisions are now healing nicely, although there is some redness associated with capillary telangiectasia and this should resolve in the next three months with BioCorneum and vitamin E therapy.

Severe carinatum and reconstruction should only be performed by Board Certified Plastic Surgeons as these are very difficult surgeries in order to regain cleavage, especially with lateral and posterior displaced chest walls.

CASE 2

The above patient presents with silicone gel implants placed 34 years ago.  These are ruptured silicone gel implants that had been placed over one-third of a century ago.  The patient left the implants in and has now noticed increasing pain.  An MRI shows intra and extracapsular ruptured silicone implant and implant material.  She has undergone open periprosthetic capsulectomy, removal of calcified granulomas, silicone calcifications, ruptured silicone gel implant material and subsequently reconstruction with new high profile style 20 Allergan silicone gel implants.  Notice the calcification and hardness of this tissue.  Over years the silicone will calcify with the collagen and create a thickened, hard scar ball, almost the consistency of chalk.  The patient has also developed calcified granulomas with small circumscribed areas of silicone which have become loculated in the tissue.

Notice the hardness of the breasts preoperatively, associated with this thickened calcified scar ball.  The implant shell has pretty much deteriorated as can be seen on this photograph of the ruptured loose gel material being pulled out of the breast.

Patients who have Dow Corning implants should have them removed as soon as possible.  The tendency for them to rupture within originally 10 years was very high and it is unlikely that any of these implants are intact in any women throughout the world.

Her preoperative photos indicate unfortunate complete malposition of the implants.  There is a double-bubble deformity on the left.  The implant is superiorly retropositioned with the skin over-draping the nipple.  She also has an inadequate breast lift on the right from a vertical mastopexy that was performed which was the incorrect operation, thereby creating an inadequate result.  The patient subsequently underwent implant removal and replacement with high profile saline implants with 650 cc.  Open capsulectomies were performed.  The inferior capsules were released on the left.  The implants were dropped down to the correct position and a revision formal mastopexy using the inferior pedicle Wise-pattern technique was accomplished.  Now postoperatively, you can see that the nipple positions are even, the implants are positioned correct, there is no further malposition and she is extraordinarily happy with her results. 

Patients who have gastric bypass surgery through lap bands, Roux-en-Y Gastroplasties, etc., will often require both removal of skin for severe grade 3 ptosis as well as implant placement in order to regain volume.  It is absolutely essential that a Board Certified Plastic Surgeon who specializes in breast reconstruction perform this operation to increase the probability of a successful outcome.

Note on example 1, the nipple areolas are actually quite stretched out.  She had a Benelli lift, around block technique, which simply caused stretching of the areolas with widespread subtle-like scarring.  She is very dissatisfied that the nipple areolas actually did not elevate whatsoever.  Rather, she ended up with widespread areolas and the nipples still in the low position.  The implant is high on the left with scar tissue contracture and is a flat moderate profile showing a very displeasing result.  Her after photo notably shows high profile 600 cc saline implants over-filled to 650 cc, open capsulotomy lowering the left implant and complete revision of the breast lift showing a nicer pattern to the nipple areolar complex, reducing the tension around the areola, allowing for a more rounded shape and less of a sunray appearance.  The vertical scar has actually healed quite nicely as well.

Example 2 indicates a patient who underwent augmentation mammoplasty procedure twice and a breast lift by a different surgeon with severe encapsulation and right double-bubble breast deformity.  Flattening of bilateral breast was extremely unpleasant to the patient.  She also underwent open capsulectomy, replacement with 700 cc high profile saline implants through the periareolar approach and then open capsulotomies high profile implants were used and then the nipple areolar complexes were reduced with a complete formal mastopexy.  The after photo shows a nice rounding shape to the breast, no longer flattening along the inframammary fold.  The nipple areolar complexes are now in the proper position.  The right one has been lowered and there is no further bottoming out.

Breast augmentation mastopexies require tremendous experience in judgment by Board Certified Plastic Surgeons.  Make sure your doctors are specialists in breast augmentation as well as reconstruction and revision when considering this difficult operation.

Dr Linder,

Thank You!  At 60 yrs with 3 surgeries behind me, I was scared to death to try to fix my problem again. From the first phone call with Nellie, ( I luv you Nellie!) she put me at ease and that gave me hope of walking in another office.  Meeting you, sealed the deal. You were so kind and understanding. Very professional to tell me you would ‘help me’ make the decision regarding size according to my body, skin, previous surgeries, etc..I was very, very afraid until I met you and your staff. You ARE a master at revision surgery!!  My boobs are wonderful, Awesome, in fact!!  The whole procedure was something to learn from. Choose the best and you won’t regret it!  Adrianna, I appreciate you!  All your help and kind hug made me cry! Surgery staff, you’re the best!! I will tell everyone, EVERYONE…if you want the best, see Dr Linder!!!!  Again, thank you soooooo much for my 20yr old looking boobies!!!

A.C

California

Note, the pictures of the implant showing complete loss of integrity, probably well over 15 years ago had been ruptured.  Notice the thick, hard calcified shell of the entire exenterated capsule that has been removed, that this is silicone that has bled into the tissue through the capsule and has now caused calcification, hardening and actually loose calcified silicone material within the pocket.�
All Dow Corning implants should be removed.  The integrity of all these shells probably last less than 10 years.  These should be removed as soon as possible, the pockets should be cleaned and all scar tissue and capsule should be exenterated.  Reconstruction with saline or silicone implants can be performed.

Other consultations that day also included mommy makeover, including breast implant lift, tummy tuck and liposculpture of the hips.  These patients present to Beverly Hills from Las Vegas for surgery, including breast augmentation, breast revision, breast lift, breast reduction, liposculpture, and abdominoplasty.

BREAST HYPERTROPHY AND UPPER POLE VISIBILITY

The patient below presents with disproportionately large breast implants that were placed for her body.  The patient had a Benelli round block lift as well as large 500 moderate smooth silicone gel implants placed approximately 10 years ago.  Unhappy with the appearance of the breasts with upper pole rippling, visibility as well as severe hanging and the lateral width is too wide, a better appearance for her body due to the narrowness of her hips, flanks and shoulder would be to use a more tapered implant such as the style 45, 460 cc Allergan gel implant, slightly downsizing in size or volume as well as recreating a complete formal mastopexy using the inferior pedicle Wise-pattern technique.  The patient underwent complete removal and reimplantation with the 460 implants.

Note, her implant was actually ruptured on the right where the shell actually has ooze presenting out of it.  After removing the implants and replacing them with the extra style 45, this greatly reduced visibility of the upper pole rippling.

The formal mastopexy was performed using the inferior pedicle Wise-pattern technique, removing a tremendous amount of skin which led to a greatly enhanced tightening of her breast as can be seen directly on the operating room table just prior to placing the patient’s dressings.

In order to correct severe double bubble deformities, the implants must be repositioned correctly, the skin envelope must be addressed where the nipple areolar complex must be superiorly raised and skin from along the inframammary fold and the vertical limb must be appropriately removed.

Below is a case example of a severe double-bubble breast deformity in which the patient presented status post augmentation mammoplasty procedure 26 years ago through a transaxillary approach which she thought were saline implants.  Intraoperatively, the patient was found to have Becker double lumen silicone gel, internal lumen and saline external lumen implants.  Note, on the photograph the outer layer of saline has actually ruptured and has leaked out through the shell; however, the silicone remains within the intra capsule.  In any case, there is greater underfill of this implant which required reconstruction using style 45, 550 cc extra high profile Natrelle silicone gel implants, open capsulectomy and a secondary formal mastopexy.  Her postoperative photos will be presented on a blog in approximately eight to 12 weeks.

Becker implants have been used for both cosmetic and reconstructive purposes in the past.  I personally do not use these implants.  We either use straight saline or silicone cohesive implants.  The double lumen shall Beck implants have a relatively thin external shell and I have seen a significant number of ruptured Becker implants over the last 15 years.  Patients often do not know what type of implant and what the viscosity of the implants are internally, silicone versus saline, and it is extraordinarily rare that they can remember having these double lumen Becker implants with saline exterior and silicone interior lumens.