Causes Behind Breast Implant Revision Surgery

Once the breast implant is in place, as normal part of the healing process, the body forms a tissue capsule (aka barrier of scar tissue) around the implant. The body forms a capsule like this around any object it recognises as foreign as a protective measure. The tissue capsule around the implant is usually soft or slightly firm but not noticeable, and it helps to keep the implant in place. In a small number of patients, however, this capsule of scar tissue tightens, becomes unusually hard and starts to contract around the implant and in severe cases distort the shape of the breast and even cause pain. This is called Capsular Contracture. As the capsule starts to contract around the soft implant, the breast implant starts to feel firm and gradually looks rounder, usually becomes pulled upward.

The severity of capsular contracture is rated using a grading system known as The Baker System. It includes four types.

Baker type I – Breast feels soft with no obvious capsule, no treatment required.

Baker type II – The breasts will usually appear normal in shape but feel somewhat firm to the touch.

Baker type III – The breasts will be firm to the touch and appear abnormal, e.g., they will be overly round, hard-looking and the nipples may be misshapen.

Baker IV – In addition to the symptoms in type III, patients also experience breast soreness; their breasts will often be tender and painful to the touch.

In Types I and II Capsular Contracture, I normally advise my patients to massage their breast using a specific compression technique to try and break the capsule and prevent it from developing further. Proper technique, adequate duration and frequency are key for this method to work.

In Types III and IV capsular contracture, treatment is usually surgical, in the form of capsulectomy, entire removal of capsule and the implant. Ideal scenario would be to allow the breast tissue to recover for a few months before re-augmentation. However, in most cases patients choose to re-augment at the same time as the capsulectomy procedure.

Prevention is key with all types of complications; however, we still do not know the actual causes behind capsular contracture, there are many discussions and opinions surrounding this matter, but none has been proven yet. While it’s impossible to prevent capsular contracture from occurring, there are ways to lower the risk. This is something that your plastic surgeon should discuss with you at your consultation.

Sometimes following a breast implant surgery, patients may feel and see the wrinkles and rippling (folds) of the breast implants under their skin which may feel uncomfortable and gives the breasts an unnatural appearance. Unfortunately, this may be inevitable, especially following pregnancy or significant weight fluctuations as wrinkling and rippling occurs when the breast tissue is stretched, the implant pocket is enlarged and there isn’t enough breast tissue between the implants and the skin.

Most common reasons for wrinkles and rippling are:

• Poor tissue coverage of the implants – This usually happens for sub-glandular implant placement in patient with insufficient breast tissue to cover the implants. In these patients, the wrinkles and rippling and be felt or be visible along all sides of the implant. For these patients, appropriate size implants should be placed behind the muscle which covers the upper and inner poles of the implant and they won’t see of feel any ripples or wrinkles along these areas. However, they may still see and feel the edge of the implants on the lower and outer sides of the breast, as these sides are not covered by the muscle.
• Patients with sub glandular placement, who start out with a more generous amount of breast tissue are much less likely to experience wrinkling and rippling. However, as the implants do not have the support of the muscle, gravity and weight of implants, will result in faster stretching of skin and breast tissue causing visible wrinkling and rippling on the upper and inner poles of the breast, particularly following pregnancy and weight fluctuations.
• Capsule around the implant is too loose – Sometimes, the capsule that forms naturally around the inserted breast implant might be larger than the implant itself, causing the implant to be drooping inside the capsule. When this happens, waves will form on the implant, which in turn results in visible wrinkles and rippling.
• Round implants – wrinkles and rippling are more common in round implants than in anatomical (tear shaped) implants due to round implants being less cohesive.
• Underfilled/Overfilled saline breast implants – When saline implants are underfilled or overfilled below or beyond the manufacturer’s recommended amount, it may cause the edge of the implants to wrinkle or pull to create ripples.

It’s important to note that the quality of the skin, significantly influences the shape of the breasts and the likelihood of developing wrinkles and rippling. Even though breast skin contains special elastic fibres, there is natural and hereditary variation in the amount of elasticity and thickness of each person’s breast skin, which affects the overall appearance of the breasts.

It is important to understand that any patient may experience wrinkling and rippling problems at some point following surgery, however the risk can be significantly reduced if:

• Appropriate implant size is chosen – large implants always increase the risk for wrinkling and rippling.
• Implants are placed in appropriate pocket – i.e. placing the implants submuscular in patient with little to no breast tissue to cover the implant
• Patient maintains same weight following surgery – by losing weight, means also lose breast tissue resulting in the implants coming closer to the skin.
• Complete one’s family prior to undergoing surgery – pregnancy and breast feeding will result in stretching of breast tissue and implant pocket, and many times in significant breast size fluctuations.

Treatment of wrinkles and rippling varies depending on the severity and cause of the condition. In some instances, the condition can be improved by simply gaining some weight, whereas other cases require surgical intervention, involving one or a combination of the following procedures: changing implant size, swapping the placement of implants from sub glandular to sub-muscular and an uplift. Fat transfer from the hips, thighs or stomach to the breast is also another option to make wrinkles and rippling less noticeable, however, this wouldn’t be suitable for all patients.

Your surgeon should discuss the best treatment options for you, during your consultation.

Breast implants are not life-time devices and need to be replaced at some point in time, regardless of the type or brand of the implants. Some manufacturers state a time limit on the lifespan of their implants, whereas others provide lifetime warranty. None of these statements confirm how long the implants really last. In some patients, implants may rupture within the first few years of the implantation whereas for others their implants may last much longer without experiencing any issues.

Implant rupture can be intracapsular or extracapsular. Intracpasular rupture means that the implant has ruptured inside a tissue capsule, meaning that it is “contained”, normally does not show any symptoms until later stage. Extracapsular rupture on the other hand is where the silicone has broken through the tissue capsule and this can more easily be detected at the early stage to visible symptoms.

When an implant ruptures, the most apparent sign is that the breast becomes firm and swollen (doubles in size), remains swollen for about a week then returns to normal size. Other symptoms may include tenderness in outer breast, lump in breast or armpit and noticeable breast asymmetry.

There is another term associated with implant leakage, “Silent Leakage”, this refers to microdroplets of silicone penetrating through the implant shell and the tissue capsule, despite them being intact.  This process can normally take years and the silent leakage becomes apparent when the microdroplets of silicone forms small lump(s) in the breast or the lymph nodes located in the armpit.

Causes of leakage and rupture may include:

• Natural wear and tear
• Punctures following a breast biopsy
• Trauma that may result from an accident or a violent impact against your chest
• Manufacturing fault – small, unavoidable imperfections in the silicone shell of the implant

It is important to remove a ruptured implant soon after rupture is confirmed, particularly if it is an extracapsular rupture. Any delays will increase the risk of the silicone migration. However, due to various reasons, patient may not be able to undergo surgery as soon as she’d like to and, in these instances, it is crucial to wear an extra high impact sports bra, day and night, avoid putting any pressure over the chest area and stop any strenuous activity or sports until the ruptured implant have been removed or replaced.

I offer my patients with breast implants complimentary annual checks, I believe it is important to check your breasts regularly, regardless of having implants or not. During these appointments I show them how to examine their breasts once a months and what symptoms to look our for in terms of implant related complications. If patients show no symptoms or issues, as a routine I refer them for some type of scan every 3-4 years to check the integrity of their breast implants. 

Bottoming out is a complication that occurs when there there’s no adequate support and implant slides too low in the breast tissue, increasing the distance between the nipple and the breast fold. From the front, the nipple appears to be too high on the breast. If looked from the side, the nipple appears to be pointing upwards due to the increased distance between it and the breast fold.

Reasons for bottoming out of implants may include:

• Weak Tissue – tissue laxity, caused by, natural ageing, weight fluctuations, pregnancy, breast feeding and other hormonal changes impacting the breast tissue.
• The surgeon placing the breast fold too low – during the augmentation, your plastic surgeon may disrupt the inframammary fold that’s attached to the rib cage (causing no support for your implant).
• The implant pocket is over dissected – if the pocket that contains your implant is cut too large, then the implant may push downwards from the inside.
• Implants too large for the patient’s frame – in cases where implants are too heavy for the patient’s body, they may push down under the breast fold.

In addition to the above, smoking, high concentration of breast fat and not supporting the breasts while exercising or being active, can also increase the risk for developing Bottoming Out.

The only treatment option to correct bottoming out, is surgery. The corrective surgery normally involves re-creating the breast implant pocket and many times combined with an uplift. In some cases, the correction process may be completed in 2 stages:

1. Remove the implants, and if necessary, re-adjust/repair the breast pocket and allow the breast tissue to heal over 6-9 months.

Once breast is settled and healed, re-augment using an appropriate size implant and suitable placement. Sometimes an uplift will also be necessary to remove excess skin.

Following Breast augmentation, implants may appear to be sitting slightly too high and to have too much fullness in the upper half, especially when implants are placed sub-muscular or dual plane. This is completely normal, and It takes time for the muscle and tissue to relax and allow the implants to settle in place. The healing period and the settling of breast implants, varies between individuals and is determined by their chest anatomy.

However, sometimes the implants are placed too high in the breasts, or patient may develop complications which may result in implants looking unnatural and high on the upper pole of the breast. This condition is known as “high riding” and can only be corrected with surgical intervention.

Reasons for High Riding implants may include:

• Inadequate muscle release
• Poor pocket development
• Early capsule formation
• Patient has a strong muscle
• Rough textured implants – Attachment of breast tissue to surface of breast implant.

Surgery to correct High Riding implants and to achieve a more natural looking breasts may involve release of the muscle, increasing the size of the implant pocket, excising the capsule.

“Double bubble” occurs when an implant or natural breast tissue drops down below the breast fold (inframammary crease), creating an unnatural indentation or line across the lower pole of the breast; causing the appearance of two breasts, from the profile. This condition is more visible when the arms are lifted above the head. Fortunately, double bubble is a relatively rare complication which may occur at any time after breast augmentation surgery and it is treatable in most cases.

Causes of Double Bubble may include:

• Incorrect breast implant placement– Double bubble occurs when a patient that has sagging breast tissue and is indicated for a subglandular implant placement but instead undergoes a submuscular placement. This results in a full upper breast pole but with low hanging breast tissue giving the appearance of a second hanging breast.
• Pregnancy – Following pregnancy, the breasts become larger, the natural breast tissue sags, but the implants remain where they were originally placed.
• Oversized implants relative to your size– When implants are too big and heavy for the chest wall it causes skin and supporting breast tissue to stretch and settle or migrate below the natural breast fold.
• Patient has tuberous breast deformity
• Sagging of Natural breast tissue – Ageing causes natural sagging of the breast tissue, but the implants remain where they were originally placed,
• Natural breast fold is too high – This means the distance between the nipple and the breast fold is too short and as a result, a new lower fold is created but there is a visible groove between the nipple and the new lower fold.
• Patient develops capsular contracture – scar tissue build-up and hardening of the fibrous capsule surrounding the implant
• Scarring is present from previous breast surgeries

It should be noted that Double Bubble is rare and many patients with similar scenarios as above, may not develop this problem.

Sometimes treatment may not be necessary, and the double bubble will resolve on its own. In some cases, your surgeon may advise you to wait for up to a year after your breast augmentation to see if it improves on its own, before making a decision to undergo further surgery to correct it.

If surgical intervention is required then it can involve, one or a combination of the following: a breast uplift (mastopexy), changing size and/or placement of implant and adjusting the breast fold.

The right way of handling / correcting Double Bubble depends on the cause, patient’s current anatomy and how long after surgery this occurs. Your surgeon should discuss the best treatment options for you, during your consultation.

Symmastia also known as “uniboob” is a relatively rare implant complication that occurs when the skin and muscle between the breasts over the sternum (breastbone) detaches and the two pockets of tissue that hold the breast implants come together to form one pocket. This causes one or both implants to shift toward each another, creating the appearance of a single large breast.

Although very rare, symmastia can sometimes be congenital, meaning you’re born with it but in most cases it is a complication of breast implant surgery where implants used are too big or too wide for your body, you have pre-existing deformities of the chest wall or that your implants were positioned incorrectly or using poor technique.

It’s often difficult to correct symmastia and it may require more than one surgery.

BIA-ALCL is an extremely rare and highly treatable type of non-Hodgkin’s lymphoma, a cancer of the cells of the immune system, that can develop around breast implants. It is important to note that even though BIA-ALCL is found in the breasts of some women with breast implants, it is not breast cancer. BIA-ALCL develops in the fluid around breast implant and is usually contained by the fibrous capsule around implants it does not develop in the breast tissue.

To date, no specific causal factors for BIA-ALCL have been identified. However, it does appear that textured implants (specifically the rougher textured) are associated with more cases of BIA-ALCL than smooth implants.

Common Symptoms include persistent swelling of the breast, tenderness, overlying skin rash and fluid accumulation around the implant. It can also present as a lump in the breast or armpit. For any patient experiencing these or any symptoms, they should see their plastic surgeon for evaluation and diagnosis.

BIA-ALCL is extremely rare and no different to any other implant related complications and is treated with the removal of both breast implants and the capsule around them (total capsulectomy) from both breasts. If patient wishes to re-augment her breasts, this can be done 12 months after the implants and capsules have been removed.

For Up-to-date information about BIA-ALCL visit:

MHRA – Medicines and Healthcare products Regulatory Agency (UK)

FDA – Food and Drug Administration (USA)

BAPRAS – British Association of Plastic, Reconstructive and Aesthetic Surgeons

Think about the change you want to see, then research and find out as much information as possible about the treatment, being precise about what you want and, above all, be open to all your wishes not being achievable.

Find a qualified plastic surgeon experienced in Breast Surgery, making sure that he or she is board certified. Also look for “genuine” reviews and feedback from previous patients.

Have consultations with at least 2 or 3 qualified and experienced plastic surgeons, just to have something to compare and cross-check.

Be honest about your medical history and discuss all aspects of the surgery with the plastic surgeon. Do not be afraid to ask questions, since it is important to know the risks involved and feel comfortable with the person who will be carrying out the surgery.

The plastic surgeon should be able to explain why he/she recommends a certain type of treatment option or technique, as with all cosmetic surgery, the type of technique used depends on many factors involving the patient’s indication for treatment, anatomy and lifestyle, and a treatment plan should be tailored to suit the specific needs of the patient.

Thoroughly Research the type of breast implants offered to you. Find out information about the implant manufacturer, how long the implants have been on the market, their track record and what type of guarantees comes with the implants.

Find out what type of care is offered Before, During, and especially After the surgery as after-care can be just as important as the surgery itself. So make sure you know who to contact and how you will be looked after, especially if there are any complications or problems following your surgery.

Find out where the surgery will be performed, as this can have major implications on safety during the operation and the occurrence of possible risks and complications.

Last but not least, “COOL OFF” before you Commit. Cosmetic Surgery should not be taken lightly, as it is after all surgery. Take your time and reflect on all aspects of the Breast Surgery, and make sure you understand all the implications involved before you make an informed decision to proceed.