- Monday – Friday
- 9:00 AM – 5:00 PM
Breast revision surgery is performed to improve the results of previous breast surgery. The reason for revision may be relatively straightforward, such as an unfavorable scar or a desire to change implant size, or more complex, involving breast shape, implant position, tissue quality, or several issues at the same time.
One of the most important parts of breast revision surgery is determining what actually needs to be revised.
I think about the breast as several related but separate components: the scar, breast tissue and skin envelope, nipple and areola position, implant, implant pocket, and inframammary fold. A problem with one does not necessarily mean there is a problem with the others.
For example, a patient can have an implant in the correct position but an unfavorable breast shape. Another patient may have an attractive breast shape but an implant that has moved too low or too far laterally. A third may be happy with both the breast and implant but unhappy with a scar.
Revision surgery therefore begins by evaluating each component independently and understanding exactly what the patient would like to change.
Every breast revision consultation begins with understanding what bothers the patient about her current result and what she would like to accomplish with another operation.
I then evaluate:
Previous breast surgery changes the anatomy. Scar tissue, previous pocket dissection, changes in the inframammary fold, stretched skin, and alterations in breast tissue all need to be considered when planning another operation.
The goal is not simply to perform another breast operation. It is to identify the reason for the problem and develop a revision that specifically addresses it.
Breast surgery always creates scars, and most scars improve considerably as they mature. Occasionally, however, a scar may become widened, raised, irregular, depressed, or heal in a way that makes it more noticeable than expected.
If the breast shape and implant position are otherwise satisfactory, scar revision may be the only correction necessary.
This is an important distinction. An unfavorable scar does not necessarily mean the breast itself needs to be reshaped or the implant needs to be changed.
When appropriate, the scar can be revised while leaving the remainder of the breast reconstruction undisturbed.
Sometimes the primary problem is not the implant but the shape or position of the breast tissue and skin.
The breast may have recurrent sagging, stretched lower-pole skin, an elongated shape, nipple or areola asymmetry, loss of upper-breast shape, or another contour issue following previous surgery.
In these situations, revision may involve reshaping the breast tissue and revising the previous breast lift.
The amount of surgery depends on what has changed. Some patients require a relatively limited adjustment, while others need a more complete revision mastopexy.
As with primary breast lift surgery, I consider the quality of the patient’s skin and soft tissues as well as the shape we are trying to create. The goal is not simply to tighten the skin, but to reshape the breast and provide appropriate support for that shape. This is consistent with the tissue-quality and internal-support philosophy already developed on your breast-lift page.
A breast implant sits within a surgically created space called the implant pocket. The dimensions and position of this pocket help determine where the implant sits and therefore have an important effect on breast shape.
Over time, or following previous surgery, the implant may sit:
Importantly, implant malposition can occur after breast augmentation even when a patient has never had a breast lift.
In these patients, the breast tissue and nipple position may be satisfactory. The problem may simply be that the implant pocket is no longer holding the implant where we want it.
Often, yes.
If the breast itself is in a good position and the primary problem is implant malposition, I can often revise the implant pocket internally without adding the external scars of a breast lift.
Depending on the problem, I may tighten part of the existing pocket, release another portion, reconstruct the inframammary fold, change the implant dimensions, or add internal support when necessary.
This can reposition the implant and reshape the breast from the inside while using the patient’s existing breast augmentation incision.
If the breast tissue and skin have also descended, however, correcting the implant pocket alone may not create the desired breast shape. In that situation, an additional breast lift may be necessary.
The important question is therefore not simply, “Does the implant need to be moved?” It is whether the problem involves the implant, the breast, or both.
Every breast implant develops a layer of scar tissue around it called a capsule. This is a normal part of healing.
In some patients, that capsule becomes abnormally tight or firm. This is called capsular contracture.
Capsular contracture can make the breast feel firmer, change its shape, move or distort the implant, create asymmetry, and in more significant cases cause discomfort.
Treatment depends on the severity of the contracture, implant condition, tissue quality, and previous operations.
Revision may involve removing or releasing portions of the capsule, replacing the implant, changing the implant pocket or plane, and using additional internal support when appropriate.
Because capsular contracture can recur, I discuss both the surgical options and their limitations with the patient before deciding on the appropriate revision.
Breast implants are not lifetime devices, and an implant may eventually need to be replaced because of rupture, deflation, age, a change in breast anatomy, or simply because the patient wants something different.
Implant exchange is not necessarily the same operation for every patient.
If the breast shape, implant pocket, and surrounding capsule are satisfactory, replacing an implant may be relatively straightforward.
If the implant has ruptured or the surrounding capsule or pocket has changed, additional surgery may be necessary.
I therefore evaluate not only the implant itself, but also the breast and tissues surrounding it before deciding what needs to be done.
A patient may be completely healthy and have no implant complication but simply decide that she would prefer her breasts to be larger or smaller.
Changing implant size requires more than exchanging one implant for another.
A significantly larger implant may require adjustment of the implant pocket. A smaller implant may leave a pocket or skin envelope that is too large for the new implant.
When downsizing, I evaluate whether the existing breast tissue and skin will contract adequately around the smaller implant or whether pocket tightening, internal support, fat transfer, or a breast lift may also be beneficial.
As on your augmentation page, the implant should be selected according to the patient’s anatomy, proportions, tissue characteristics, lifestyle, and goals rather than volume alone.
In some patients, particularly those with thinner breast tissue, the edge or folds of an implant can become visible or palpable.
This is commonly called implant rippling.
The appropriate treatment depends on why the implant is visible. I evaluate the thickness of the breast tissues, implant type and position, implant pocket, and the areas where additional coverage is needed.
Revision may involve changing the implant, modifying its position, improving the implant pocket, or adding fat transfer to selected areas to provide additional soft-tissue coverage.
Because fat can be placed selectively in different areas and tissue layers, it can be particularly useful when the goal is not to make the entire breast larger but to improve coverage or contour in a specific area. That concept already appears prominently on your fat-transfer page.
Revision after a previous breast augmentation with lift, or augmentation mastopexy, can be more complex because both the breast and the implant have been altered.
The implant may be in the wrong position while the breast tissue remains satisfactory. The breast may have descended while the implant remains appropriately positioned. The inframammary fold may have stretched. The scar may be unfavorable. Or several of these changes may occur together.
This is why I evaluate the implant, pocket, breast tissue, skin envelope, nipple position, inframammary fold, scars, and tissue quality separately.
Depending on the findings, revision may involve pocket reconstruction, implant exchange, revision breast lift, scar revision, fat transfer, internal tissue support, mesh—or a combination of techniques.
The operation should be designed around the specific components that need correction rather than automatically repeating the original operation.
Previous surgery, large implants, stretched tissues, recurrent bottoming out, or poor soft-tissue quality can sometimes make additional internal support helpful during revision surgery.
Depending on the patient’s anatomy, I may use the patient’s own tissue or a surgical mesh or scaffold to reinforce the lower breast and inframammary fold.
In selected patients undergoing breast lift revision, I can preserve de-epithelialized dermal tissue from the lower breast and use it as an internal dermal shelf. This creates another layer of the patient’s own tissue that can help support the lower pole and implant.
For patients with very thin or weak tissues, recurrent implant malposition, or greater mechanical demands, additional mesh reinforcement may sometimes be appropriate.
The goal is not to add support to every revision. It is to determine why the previous breast or implant position changed and provide the amount of support appropriate for that patient’s anatomy. This also creates a natural internal link to your dermal-shelf article.
Breast revision becomes much easier to understand when the individual problems are separated.
A patient may have a good breast shape but poor implant position.
Another may have a well-positioned implant but recurrent breast sagging.
Another may have an unfavorable scar with an otherwise attractive breast.
And some patients have several problems occurring simultaneously.
This is why breast revision surgery is not one operation. Scar revision, breast-shape revision, implant-pocket revision, implant exchange, and treatment of the capsule accomplish different things.
The first step is determining which of those things actually needs to be changed.
For me, successful breast revision surgery begins with diagnosis.
First, I need to understand what the patient does not like about her current breasts and what she wants to achieve. Then I need to determine which part of the previous surgery is responsible for that concern.
I evaluate the breast tissue, skin, scars, nipple position, implant, implant pocket, inframammary fold, capsule, tissue quality, and underlying chest wall individually.
Only then do we decide what needs to be revised.
Sometimes the appropriate operation is relatively limited. Other times several components need to be reconstructed together.
My goal is not to redo everything simply because a patient has had previous surgery. It is to preserve what is working well, correct what is not, and develop the least extensive operation that can predictably accomplish the patient’s goals.
Dr. Afshin Parhiscar is a double board-certified plastic surgeon performing breast revision surgery in Walnut Creek, California, for patients throughout the East Bay, San Francisco Bay Area, and beyond.
With more than 20 years of experience in breast surgery and over 2,500 breast procedures performed, Dr. Parhiscar brings extensive experience in breast augmentation, breast lift, augmentation mastopexy, implant-pocket reconstruction, fat transfer, and revision breast surgery.
Breast revision consultations are individualized and include evaluation of the patient’s previous surgery, current breast shape, scars, implant position, implant pocket, inframammary fold, capsule, skin and soft-tissue quality, asymmetry, and aesthetic goals.
The goal is to understand why the current breast looks or feels the way it does and develop a revision plan that addresses the specific problem while preserving the parts of the previous result that are already working well.
