The example here shows a patient with complete loss of upper pole fullness, severe ptosis, grade 3, the nipple is well greater than 3 cm below the fold and an implant has been placed under the muscle with a formal lift, removing skin both vertically and along the inframammary fold.  Her postoperative photographs show a nice elevation of the nipple areolar complex. 

This is a four-week photo.  Notice there is still some pink around the areolas and the vertical scars.  This, however, will soften with time.  The position of the areolas shows nice lifting and the nipples are at a direct straight out position.  It is safe to perform both implants and lifts at the same time as long as you find a qualified Board Certified Plastic and Reconstructive Surgeon who specializes in augmentation mammoplasty and mastopexy, understanding the anatomy and blood supply to the nipple to prevent any type of avascular episodes.

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.

Because my practice is so focused on body sculpting of women, including a high emphasis on breast augmentation, breast revision, breast reduction, breast and breast reconstruction, Breast Cancer Awareness Month is extraordinarily important and close to my heart.  I see patients every day in the operating room where I remove tissue and send to pathology at UCLA Medical Center for diagnosis.  Unfortunately, I do detect breast cancers almost annually on patients who have undergone elective surgical procedures.  In fact, we have detected this year alone two different procedures on a capsulectomy and a breast reduction a ductal carcinoma in situ in a stage 1 breast cancer which has required oncological mastectomy with breast reconstruction in both cases.  It is vital that patients who undergo any form of breast biopsy removal or reduction that the tissue be sent to Board Certified Specialists in Pathology so diagnosis of the tissue can be made, realizing that one out of nine women will develop breast cancer at some point in their lives.  Breast Cancer Awareness Month is important for us all to remember that self-breast examination should be done monthly, that mammographies should be done at the age of 40 or at the age of 35 for women who are undergoing any form of breast implant or breast reconstructive surgery as well as breast reduction and breast lift.  Breast cancer awareness includes preoperative mammograms, ultrasounds, MRIs every two to three years for all patients who have silicone gel implants and screening mammography for all women over the age of 48, remembering that breast mammography will save lives and that all tissue specimens should be sent to Pathology for diagnostic purposes in order to detect early stages of breast cancer which can be life-saving.

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.

Patients should be instructed to have MRIs at least every two to three years in order to evaluate the rupture integrity of the silicone gel shell, as well as see their Board Certified Plastic Surgeon annually for an evaluation for scar tissue contracture.

The preop photo shows the patient presenting from Missouri, having undergone three surgeries to correct the severe deformity of her breasts.

The patient presently presents with a double-bubble deformity on the right breast with the implant on the right superiorly retropositioned, as can be seen on her preoperative photograph.  She also has a left severe bottoming out with the implant at too low a position.  The position of the areolar at 6 o’clock to the inframammary fold measures at 13 cm.  This is going to be shortened to 6 cm.  In order to reconstruct this woman’s breasts to regain symmetry and a more normal appearance and natural appearance, a left open capsulotomy was performed superiorly.  A bottoming out procedure with the inframammary skin removed as well as vertical skin in an inverted-T fashion on her last three attempts from other surgeons in the mid-west, she had a vertical lift performed on the left.  However, she never had the inframammary skin removed and therefore severe bottoming out occurred due to inability to address the inframammary fold skin laxity.

On the right breast the implant is superiorly retropositioned as can be seen by the hatch marks on the right upper pole.  In the operating room an open capsulectomy was performed, releasing the capsule circumferentially, removing scar tissue along the parasternal and the lateral inframammary fold as well as the infraclavicular region.  The implant was now nicely dropped down.  Due to her significant asymmetry, a 320 high profile saline implant was placed and filled to 330 on the right with a 350 style 68 high profile Natrelle implant on the left, filled to 380.  This allowed for perfect symmetry.

Finally, a right formal mastopexy revision was performed.  At this time the right nipple areolar complex needed to be raised with skin removed both vertically and along the inframammary fold.

The postop Day 1 photos are shown, which now shows symmetry of the nipple position, the implant on the right has been lowered and the fold distances are even.  We will eventually have future postoperative photos for comparison.

Difficult breast revision surgeries require experienced Board Certified Plastic Surgeons who have dedicated their lives to reconstruction revision of the breast.

Style 15, Allergan/Natrelle silicone gel implant, is a very natural breast implant.  It is a moderate plus profile silicone gel, not too narrow and not too wide.  Advantages include a very natural appearance.  Please see photograph to the left of a 371 moderate plus silicone gel Allergan implant placed in a woman with an ectomorphic body, minimal breast tissue and thin pectoralis muscle development.  The greatest disadvantage, however, is there is still significant visibility, palpability and rippling notable on patients who are this thin with a Style 15, with minimal amounts of body fat and very thin muscles, and with prominent costochondral ribs that are notable, the moderate plus gels do have visibility along the lateral breast and sometimes along the medial breast as well, especially when patients are bending down or bending over.  This should be noted to the patient prior to the operation during consultation and although these are more natural and give a natural upper pole slope, their visibility and rippling can be significant.  In thinner women who desire minimal or less visibility or rippling, I more often prefer either Style 20 or Style 45 extra high profile gels which greatly will reduce the incidence of rippling.  Of course, there will be more upper pole fullness, but when placed under the muscle they still have a somewhat natural appearance as well.