Breast implant exchange surgery

It's not uncommon for women who have already had a breast augmentation some years ago to come and consult with us about an implant exchange. Most commonly, this is for reasons of wanting a different size; most often a little bit larger, sometimes a little smaller. People do change their minds about the look they want, compared to their original implant choice, and we understand that.

In situations like these, where the breast is soft (doesn't have capsular contracture) and the pocket where the implant sits is in good shape, we can do what's termed a "simple" implant exchange surgery.

This involves helping the patient select the desired new size and shape, and going to surgery to replace the older implants. There's definitely a skill to selecting the new implant - and we've got a few little tricks for this!

With the resurgence in popularity of silicone gel implants, many women who first had breast implant surgery back in the "saline-only" era often consider switching to silicone gel implants. Here at our Orlando practice, four out of five patients who have experienced both types of breast implants tell me that they far prefer the gel implants. Gel implants also help to reduce wrinkle and ripple problems in the slender patient with saline implants. Using a different implant shape can also be a helpful suggestion. This keeps the implant width proportional to the patient's frame, but allows more (or less) fill up front, where most patients want it.

At surgery, we can typically use the same surgical incision - so there are no new scars. And if the old scar has widened out, we get a chance to revise it during surgery, and hopefully get a nicer looking scar.

Most women are pleasantly surprised: the recovery from a "simple" implant exchange is usually very easy, with little pain, bruising or swelling. Since the pocket for the implant is already present, and only few small adjustments need to be made to the tissue pocket, the recovery is much quicker.

More complex implant exchange surgeries involve the correction of tissue stretch or pocket expansion, or the correction of scar tissue / capsular contracture issues. As the name suggests, these surgeries are much more involved. But that's a topic for another day. Cheers!!

Choosing the right breast implant shape

Back in the dark ages, plastic surgeons recommended breast implants based only on their total volume.

Now, most modern surgeons realize that it is important to measure the patient's rib cage width, and match the width of the implant to the width of the patient, in order to obtain a result that looks attractive, proportional, and avoids an overly wide cleavage gap or excessive lateral (side) fullness.

In addition to picking the right size, there are several choices of implant shapes available. These are called "profiles" by the manufacturers. Choosing the right profile makes a major difference in the final appearance of the breast shape.

Many patients are unaware of these possible choices before their consultation with us, and have only thought about the number of cc's in the implant or the cup size they want. A useful question to consider is "How much fullness do you like in the upper part of the breast?" Someone who want a lot of fullness will pick a different implant than someone who just wants a little.

The most popular profile (implant shape) in our practice, whether it be silicone or saline filled, is a medium profile implant. About 70% of our patients choose this shape. It gives an attractive fullness in the upper part of the breast, but not "too much" for most people's taste. I call this the "Victoria's Secret catalogue model" look, and the proportions work well for most average frame patients.

The second most popular profile is the "high profile" implant. It gives more roundness and fullness in the upper part of the breast. For women that have a narrow ribcage and still want a generous implant volume, the high profile shape is worth considering. For women that want a larger, fuller implant without going to a wider implant, sometimes switching from a medium profile to a high profile implant is also a useful option. About 20%-25% of our patients choose this shape. But it's a "love-it-or-hate-it shape"; some women think it looks a little too overdone or obvious, especially in the larger sizes, while some women find it sexy and attractive. It's all personal taste.

The low profile implant is the third choice. It works for women that have a broad ribcage, but for whom the other profiles would give an implant volume that would be excessively big. It's a more conservative and "natural" look, and gives less projection or upper pole fullness compared to the other two profiles.

While some surgeons strongly recommend high profile implants for women considering a combination breast augmentation / breast lift surgery, I do not insist that women make that particular choice. It is true that a higher profile implant has a greater arc length over its highly curved surface, and so it fills up more loose skin compared to the lower profile implants. However, the patient may not want the size or shape that a properly selected high profile implant gives. I think its more important to the final result to pick the implant size and shape that the patient wants first, and then tailor the mastopexy around that as needed. In my opinion, this is much more likely to make the patient happy in the long run.

In our experience, there's no substitute for proper measuring, followed by trying on actual implant sizers in a sports bra and T-shirt. Once women see how it looks in the mirror, it's amazing how rapidly they are able to sort out the many different choices. Once they see the look they prefer, most women know it almost immediately! It's kind of like trying on shoes: you know if they fit or not.

Ripples and breast augmentation

One of the frustrating problems that can sometimes occur after breast implant surgery is known as "rippling" - an irregular wavy look or feel to the breast. This is caused by a combination of factors, related to the physical properties of the implant, the patient's own soft tissue and how it may have changed over time, and the choice of implant pocket design ("over vs. under").

Plastic surgeons generally divide these problems into 2 main categories, based on why they've happened.
1. Shell rippling
2. Traction rippling

Shell rippling is the most common problem of this kind I see, and is the topic for today. (I'll discuss traction ripples in a later blog.) The classic scenario is with a subglandular ("over") saline-filled implant in a slender woman who doesn't have very much tissue coverage over the implant. Typically, the breasts looked OK for a period of time, and then, ripples started to show up later.

The usual way to improve this situation is to operate, and get more tissue coverage over the implant, by converting it to a sub-pectoral position. This move significantly improves ripples in the upper portion of the breast - which is the area most exposed by low neckline fashions. The other solution is to change the saline implant to a silicone gel implant, which has been shown in studies to have a ripple rate of approximately 1%, as opposed to the ripple rate of saline implants, at about 10%. I usually prefer to use both methods - getting muscle coverage over a gel implant. It works well to fix this problem.

Shell ripples occur for several reasons: they have to do with the tendency of the elastomeric implant shell to want to fold in on itself, the amount of fill in the implant, the viscosity of the fill material in the implant, and the pressure applied by the surrounding soft tissue. They are disguised by the amount of soft tissue thickness over the implant. Often, with the passage of time, there is thinning out of the breast tissue adjacent to the implant, and implants that were adequately covered early post-op may become more obviously rippled over time.

Saline implants, having the lowest viscosity filler, will ripple the most. Currently available silicone gel implants, having a moderate viscosity filler, ripple a lot less. The "form stable" gummy bear implants, with their high viscosity silicone filler, should ripple even less than the current generation of gel implants. Early data from Europe seems to support this concept.

Women interested in saline implants often ask about the concept of "over-filling", which is just adding more saline solution in the implant bag, beyond the manufacturer's recommended range. There are pro's and con's to this approach. Certainly, more fluid will reduce some of the emptiness and collapse of the implant shell seen when the saline implant is in the vertical position. It also makes the implant larger, rounder, less natural looking, and a little more firm. It also potentially voids the manufacturer's warranty. If you over-do the over-filling, you start to see a new type of wrinkling - tension bands around the equator of the implant. So overfilling is only partially helpful- and as we've discussed, it only addresses one of the multiple factors that are involved with ripple formation.

The soft tissue pocket is also important. If there is a significant amount of capsular contracture, the soft tissue envelope may actually distort the shape of the implant, and cause it to fold on itself. This can cause a knuckle-like point to occur in the implant, which patients may be able to feel through the skin. Implant folds can lead to early implant failure. So, when you are fixing ripple issues, any capsule issues will need to be addressed surgically as well.

Take home message: ripples are related to the combination of thin soft tissue coverage, combined with the engineering limitations of the current generation of breast implant devices. If you are slender up top, and can feel or see your ribs on the side of your rib cage, you should give some thought to sub-pectoral implant placement of a gel implant, if you want to do everything currently possible to minimize your risk of ripple issues post-op.

For some ultra-skinny women, even sub-pectoral gel implants will have some ripples. While weight gain would help, very few women want to hear that they should gain a few pounds! Here, our treatment options are limited - placement of a layer of alloderm or strattice (very expensive), fat grafting to the breast (technically difficult), or perhaps injections of commercially available fillers. It remains to be seen whether the new generation of form-stable breast implants will be a good answer or not for this group of patients.

Saline breast implants: pros and cons

Today's chapter is about saline breast implants.

Prior to 2006, saline implants were the most commonly used implant in the U.S. Now, with FDA re-approval of the silicone gel implants, that figure has fallen significantly, down to about 20% in our practice.

Here are the more common reasons that my patients give for picking a saline-filled breast implant.

1. Cost. Saline implants aren't as expensive.

2. Adjustability. For women with major breast asymmetry issues, the adjustability of the size of a saline implant at the time of surgery can be helpful to fine-tune the correction of volume differences between the two breasts. Essentially, we can "put a little more" on the smaller side. With silicone gel implants, the implants are not adjustable - so one has to go to the next size implant, a difference of 25-30 cc.

3. No need for follow-up scans. When a saline implant leaks, the saline is simply absorbed by the body. The implant deflates quickly - and making the diagnosis of an implant deflation is easy, without requiring fancy diagnostic tests. There are no recommendations for follow-up MRI scans, as there are with the gel filled implants.

4. Lingering anxiety about silicone gel. Despite the large number of carefully performed, large-scale scientific studies disproving many of the "urban legends" about health issues and silicone, some women are just more psychologically comfortable with the saline option.

5. Age. If you are younger than 22 years old, silicone gel implants may not be available under the FDA guidelines, unless you happen to have other issues, like rib cage asymmetry, scoliosis, and so forth.

6. Wanting the "very rounded" look. This can be achieved, if desired, by over-inflation of a saline implant, creating a more spherical shape and increased upper breast fullness.


Disadvantages of saline implants:

These were discussed in the previous blog chapter, during the discussion of silicone gel implants. The main issues are:
- a less realistic "feel" to the breast

- higher percentage of ripple / wrinkle issues, particularly in slender women.

While some surgeons will try to over-fill the implant in an attempt to reduce ripples, that may cause a different set of problems, such as creating excessive roundness of the upper breast, causing excessive firmness, or creating tension bands around the edge of the implant. Over-filling also potentially voids the manufacturer's warranty.

The choice of implant - the size, the shape, and the type of fill - are all issues that we discuss at the time of a consultation. Hopefully, the information in this blog will help you to become a more "informed patient" prior to your consultation and surgery, and will answer some preliminary questions for you.

Silicone breast implants: pros and cons

A very common question during augmentation consultations is about the various advantages and disadvantages of silicone breast implants and saline breast implants.

In this chapter of PSB- the Plastic Surgery Blog, we'll talk about silicone breast implants. The next installment will discuss saline breast implants.

Currently, about 80% of our patients select the silicone gel implants.

Safety data:

The FDA thoroughly looked at the scientific data, prior to allowing silicone breast implants back on the market for general cosmetic uses in 2006. The "blue-ribbon" panel of experts from multiple different fields of medicine agreed that, based on current scientific studies:

a) there is no increase in the risk of breast cancer due to the use of silicone breast implants, and

b) there is no increase in the rate of developing "auto-immune" or connective-tissue diseases like scleroderma, lupus or rheumatoid arthritis due to the use of silicone breast implants.


That being said, no implant is perfect.

Just like any man-made device, the implant, whether it is saline-filled or silicone gel filled, will eventually get old, become brittle, develop a small crack in the flexible outer shell, and leak. Implants don't last forever. At some point, a second surgery will be required to swap out the implants for a new pair.

Also, implants (both saline and silicone) do get in the way of seeing tissue clearly with a mammogram, as the implant hides some of the breast tissue. This problem is worse when the implants are above the muscle, and somewhat better when they are behind the pectoral muscle.

Lastly, an implant can become firmer than desired, due to the development of capsular contracture. This may require more surgery to fix, and currently, it's impossible to predict ahead of time whether this problem will happen for a particular patient, or not.

Advantages of silicone breast implants:

1. "the feel" - Most of my patients like the way the silicone breast implants feel. Simply put, they feel very similar to real breast tissue, and do not have the "water balloon" feel that the saline implants have. This, for most patients, is the deciding factor.

2. Less chance of ripples & wrinkles - Particularly in slender women, one of the main drawbacks of saline implants is that any wrinkling in the implant may show through the skin, causing visible ripples, particularly with leaning forward. This can happen even with the implants behind the muscle, and even if the implants are filled to the correct volume. Studies show that rippling occurs in about 10% of patients with saline implants, but only about 1% of silicone breast implants. Patients who are thin enough to feel their ribcage on the side of their chest are particularly prone to rippling problems. Switching to silicone implants often fixes the problem for patients with ripples in their saline implant (unless you are super-skinny!)

3. Works better for women with rib cage irregularities - Silicone gel implants seem to drape more smoothly over rib cage asymmetries due to scoliosis or pectus excavatum (sunken chest).

4. Less tissue stretch - Over time, the saline implants seem to have a slightly higher rate of stretching out the skin and soft tissues of the breast, compared to gel implants. This can result in pocket expansion, bottoming out, or ptosis (droop) of the breast.


Disadvantages of silicone breast implants:

1. More expensive than salines.

2. FDA recommendations for follow-up MRI's - As we discussed in an earlier blog chapter, MRI's are recommended at years 3, 5, 7 and so on. This can get expensive.

3. Trickier to tell if you have a deflation - Unlike saline implants in which a deflation is very obvious in a few days, it's more difficult to tell if there s a leak in a gel implant by simply looking at the breast. Usually, some sort of scan - like a breast ultrasound or MRI - is needed in order to make the diagnosis.

4. In the event of a leak, additional surgery is needed - Current recommendations call for a capsulectomy to be performed for most patients with a leaking gel implant. While this is a routine operation for most plastic surgeons, it does represent more surgery than the simple "switch-out" procedure that would be performed for a deflation in a saline implant.

5. May need a somewhat longer incision that the saline implant. Saline implants can be rolled up while still deflated, and placed into the breast through a small incision, and inflated after positioning. This drawback will become even more significant when the new generation "form-stable" or 'Gummy Bear" silicone implants are introduced to the U.S. market, as these require a 5-6 cm. incision.


Overall, patients are very satisfied with breast augmentation, regardless of whether saline or silicone breast implants are used. They recommend it to their friends, co-workers and family. It's the #1 most popular surgical procedure both in our practice, and nationwide. While you can usually get a good result with both kinds of implants, certain individual situations may make the choice of a particular type of implant better than the other.