Patients who have undergone breast augmentation will ultimately need to have a second surgery, though it may be 10, 15, or even 20 years after the initial surgery. The reasons can be various ranging from wanting a different kind of implant, wanting a different size implant, or the implant needs to be removed altogether, whether it be patient preference or breast implant illness, capsular contracture or implant malposition.

Whatever the reason, the planning is the same. I like to perform implant selection first. Implant selection is determined by the patient’s goals and desires as well as body measurements. Base width is the number one indicator for breast implant selection. From there, I can determine the volume based on projection. A full or high profile prosthesis will have higher volume than a moderate profile implant. Further considerations will include gel consistency. If the patient wants a more natural appearance, I would recommend a softer gel. If the patient wants more upper pole fullness, I would recommend a more cohesive gel. All current breast implant manufacturers offer different implant thicknesses.

The next consideration is breast tissue consistency.  If the breast tissue is firm or substantial, a two stage approach may be warranted, or a smaller implant selected.

Afterwards, skin envelope is evaluated, in relation to the implant selected.  I use the “C+2” formula to determine soft tissue coverage.  If there is vertical excess (usually less than 3 cm above or below the nipple) then a circumareolar mastopexy (“donut breast lift”) can be performed.  If there is horizontal excess on each side of the midline of the breast, then a circumvertical (“lollipop”) lift needs to be performed.  If there is still vertical excess after planning the lollipop lift, then there will likely be an “inverted T” closure.  I never plan an “anchor” incision as it is usually longer than necessary and furthermore, most patients want to avoid an unsightly scar that can be seen in a low cut dress or from the side.

Once the planning is complete, surgery can begin.  Markings are meticulously performed that delineate the above considerations. A laser level is utilized to ensure symmetric nipple and areola heights.

The first step of the surgery is to remove the old implants.  The implants are inspected for rupture and the capsule is inspected for unusual fluid or capsular contracture.  The pocket is examined and modified as needed to fit the new implants.  That may included tightening (capsulorrhaphy) or opening (capsulotomy) different parts of the pocket.  Occasionally the capsule needs to be removed (capsulectomy).  In those cases a resorbable mesh (internal bra) is important in holding the new implant in place as the body heals.

The new implant is then introduced with a “no touch” technique.  The pocket is bathed in betadine solution and the implant is bathed in triple antibiotic solution.  Its then placed in the pocket with a funnel.  Then the pocket opening is closed.

The next step is to remove all excess skin and tissue as needed.  Skin is removed from around the areola. Skin, fat, and breast tissue are removed from the inferior pole, allowing the breast to be molded and shaped around the implant (in the case of a lollipop or T lift).  Then the breast is closed and the procedure is complete.

The recovery process is basically the same as a breast lift (mastopexy), breast reduction, or breast augmentation.

It will take about 3-4 months for the implants to settle, and up to 12 months for the scars to reach their final appearance.

Possible complications include bleeding, infection, seroma formation, capsular contracture, implant malposition, need for scar revision, changes in nipple sensation, vascular compromise, nipple or areolar necrosis (partial or complete) and implant rupture.  The severe complications are much more uncommon than minor complications.